EXTRACTION OF THE TEETH.
EXTRACTION OF THE TEETH
BY
J. F. COLYER, L.R.C.P., M.R.C.S. L.D.S.
_Dental Surgeon and Lecturer on Dental Surgery to Charing Cross Hospital:
Assistant Dental Surgeon to the Dental Hospital of London_
London:
CLAUDIUS ASH & SONS, LIMITED,
5, 6, 7, 8 AND 9, BROAD STREET, GOLDEN SQUARE, W.
1896
CONTENTS.
CHAPTER I. PAGE
THE GENERAL PRINCIPLES OF EXTRACTION OF THE TEETH 1
CHAPTER II.
THE EXTRACTION OF INDIVIDUAL TEETH 19
CHAPTER III.
THE EXTRACTION OF MISPLACED TEETH 46
CHAPTER IV.
THE USE OF ANÆSTHETICS DURING EXTRACTION OF THE TEETH 56
CHAPTER V.
DIFFICULTIES, COMPLICATIONS, AND SEQUELÆ OF EXTRACTION OF THE TEETH 63
INDEX 96
EXTRACTION OF THE TEETH.
CHAPTER I.
The General Principles of Extraction of the Teeth.
As an operation, extraction of teeth is fortunately becoming more rare,
but even now large numbers are needlessly sacrificed, in many cases
owing to ignorance on the part of the patient of the value of the teeth,
at times to lack of knowledge on the part of both operator and patient
of the modern methods of conservative dentistry. With the assistance of
antiseptics in the treatment of root-canals, and the increase in
knowledge of the methods of filling and crowning teeth, it is now
possible to retain many which would in former days have been
extracted--indeed it may be said with truth that all teeth and many
roots are capable of being saved and rendered useful, with the exception
of--
(1) Those teeth whose roots are much shortened by absorption.
(2) Those teeth from which the alveolar process has disappeared to such
an extent as to leave them quite loose; and
(3) Those teeth attacked with chronic periodontitis, which, in spite of
treatment, tends to become worse.
Special circumstances naturally alter cases; for instance, with patients
the subjects of nervous prostration, or feeble in health, a lengthy
operation is often contra-indicated, and under such conditions
extraction may be preferable to the lengthy and tedious processes of
conservative treatment. Another indication for extraction is in cases of
teeth setting up or aggravating ulceration of the tongue, lips, or other
soft parts of the mouth. Teeth fractured in a longitudinal direction
should generally be removed, and the same rule applies to those which
are so misplaced as to be incapable of being brought into the normal
arch. In crowded conditions of the teeth extraction is often called for,
and under such circumstances is really conservative treatment.
If extraction be determined upon, _a careful examination of the tooth_
to be removed should be made. This will allow some idea to be formed of
the amount of sound tissue present, and also of the force which will be
necessary for the dislodgment of the tooth. In the case of roots, the
edges must be defined, and for this purpose a blunt probe, similar in
pattern to that shown in fig. 1 will be found useful.
[Illustration: FIG. 1.]
=Instruments.=--The instruments in general use for the removal of teeth
are forceps and elevators. _The Forceps_ is an amplified pair of pincers
or pliers. It is made up of three parts, namely, the blades or portions
beyond the joint which are applied to the tooth, the joint itself, and
the handles. Forceps should be made of fine steel, should be light and
yet strong enough to withstand without bending any strain that may be
put upon them.[1] The blades should be shaped to fit the tooth they are
intended to remove, and they should be clear of the crown when applied.
On longitudinal section a blade should present a thin wedge-shaped
appearance. Two kinds of joints are met with. In the first variety one
half of the forceps passes through a slot in the other, the two being
held together by a rivet passing through the centre (fig. 2). In the
second variety (fig. 3) the two halves are held together side by side by
a screw or pin which takes the entire strain. Most forceps of English
manufacture are made on the latter plan, which has the advantage of
permitting the instrument to be easily cleaned; it also allows a slight
lateral movement of the two halves--a point of some practical
importance. It is urged against this style of joint that it is weak; in
practice, however, this is not found to be the case.
[Illustration: FIG. 2.]
[Illustration: FIG. 3.]
The handles should be of a size and shape to lie comfortably in the palm
of the hand, and should be in such relation to the blades that when the
latter are applied in the direction of the long axis of the tooth, the
handles clear the lips.
As a general rule, in forceps designed for the removal of the anterior
teeth in the maxilla, the blades and handles are in the same line (fig.
4),
[Illustration: FIG. 4.]
[Illustration: FIG. 5.]
while for the upper back teeth the handles form a curve of greater or
less extent with the blades (fig. 5). In forceps for the lower teeth the
blades are bent down from the handles to an angle of nearly ninety
degrees. In one class, namely, the hawk’s-bill, when the blades are
applied to the tooth the handles are at right angles to the line of the
arch (fig. 6), while in other classes the handles are in line with the
arch (fig. 7).
[Illustration: FIG. 6.]
[Illustration: FIG. 7.]
The manner of holding forceps is shown in figs. 8, 9, 10. The handles
should rest comfortably in the palmar surface of the hand, and in such a
manner that the end of one handle rests between the thenar and
hypothenar eminences--a portion of the hand where force can be applied
with advantage.
The thumb placed between the handles acts as a regulator to control the
amount of pressure of the blades upon the tooth. As a precaution it is
well to have the ball of the thumb well between the handles, so that the
pressure is counteracted not only by the soft tissues, but also by the
terminal bony phalanx of the thumb. If this precaution be not observed,
any sudden crushing of the tooth may be accompanied by a severe and very
painful contusion of the operator’s thumb.
[Illustration: FIG. 8.
Mode of holding forceps for the removal of upper teeth.]
_The Elevator_ consists of two parts--the handle and the blade. The
former, usually made of wood or ivory, is about four inches in length
and of a shape suitable to allow a firm grip being obtained of it by the
hand. The blade is made of fine steel, and is about two inches long.
Elevators are of two varieties, straight and curved. In the first form
the blade is thin, about one-fifth of an inch in breadth, one surface
being made convex and the other flat. The point of the blade may be
rounded as shown in fig. 11, or spear-shaped, as shown in fig. 12.
[Illustration: FIG. 9.
Mode of holding lower “hawk’s bill” pattern forceps.]
[Illustration: FIG. 10.
Mode of holding forceps of pattern shown in fig. 30.]
In the curved variety, the terminal half inch of the steel portion of
the instrument is bent at an angle with the shaft of the instrument
(fig. 49). The edge of the blade of an elevator should always be kept
sharp.
The method of holding an elevator is shown in fig. 13. The handle should
rest comfortably in the palm of the hand, the first finger lying along
the blade and being brought near the point so as to prevent the
instrument slipping. When using the elevator for the removal of teeth on
the right side of the mandible, the finger should lie along the curved
side of the blade, and on the flat side when extracting teeth on the
left side.
[Illustration: FIG. 11.]
_The Screw_ (fig. 14) is an instrument which on rare occasions is useful
for the removal of deep seated roots.
[Illustration: FIG. 12.]
After being used, instruments of every kind should be freed from all
foreign matter and then carefully sterilised.
The next point which demands attention is the =position of the operator
and patient=. The chair should be placed before a good light, and if a
proper dental chair is not to hand an ordinary arm chair may be
utilised; failing this, two ordinary chairs may be placed back to back,
on one of which the left leg of the operator should be raised to form a
rest for the patient’s head. The patient should be placed in such an
unconstrained position as will allow the operator to exert all necessary
movements with freedom.
[Illustration: FIG. 13.]
[Illustration: FIG. 14.]
The operator should place himself so as to use his force to the greatest
advantage. His left arm may be utilised, if necessary, for steadying the
movements of the patient’s head, while the fingers of the left hand can
be employed--
(1) To keep the cheek and other soft parts away so as to obtain a clear
view of the tooth to be extracted and its immediate neighbours;
(2) To support the mandible;
(3) To grasp the alveolus and so allow some idea to be gained of the
effect of the force employed.
The special positions for the removal of different teeth will be
described in chapter ii.
It may be advantageous, before describing the steps of the operation of
extraction, to refer briefly to a few =points in the anatomy of the teeth
and jaws= which have a direct bearing upon the manner of carrying it out.
If the teeth be examined it will be noticed that they are capable of
division into--
(1) Teeth with single, rounded tapering roots;
(2) Teeth with single roots more or less irregularly flattened or
curved;
(3) Teeth with multiple roots.
Under (1) are included the upper incisors (temporary and permanent) and
the lower bicuspids; (2) the lower incisors and canines (temporary and
permanent), and also the upper canines and bicuspids; (3) the upper and
lower molars (temporary and permanent) and frequently the first upper
bicuspids.[2]
The shape of the roots, as we shall subsequently find, has an important
bearing upon the manner in which force is to be applied when severing
them from their attachments.
A correct acquaintance with the disposition of the alveoli of the teeth
is of importance for skilful and successful operating. Fig. 15 gives a
general idea of the appearance of the alveoli, but it is needless to say
that a full knowledge can only be really obtained by a careful study of
the bones themselves; by this means, too, some idea of the strength of
different portions of the alveolar borders can be obtained--a matter of
some moment when applying force in the process of removing a tooth from
its socket. The points to be specially noted in the maxilla are the
thinness of the outer alveolar wall as compared with the inner, the
prominence of the canine socket, and the cancellous character of the
bone in the region of the third molar. In the mandible the outer
alveolar border will be seen to be thinner than the inner, with the
exception of that portion in the region of the
[Illustration: FIG. 15.
From the “American System of Dentistry.”]
third, and often of the second molar; another fact worthy of attention
is that at the posterior portion of the socket of the third molar the
bone is moderately dense.
=When performed with forceps the operation of tooth extraction may be
divided into three stages:--=
(1) Adaptation of the forceps to the tooth.
(2) Destruction of its membranous connections with, and dilatation of,
the socket.
(3) Removal of the tooth from the socket.
In the initial stage the _first step_ is the application of the blades,
and, in this connection, care must be taken to see that the points pass
between the gum and the tooth, and also that they are applied parallel
with the long axis of the root. It is, as a rule, best first to apply
the blade on the side of the tooth most obscured from view, and then
lightly to close the other upon the opposite side. The blades should
then be forcibly pressed upwards or downwards, as the case may be, in
the direction of the apex of the root; a slight rotary or wriggling
motion will often be found of assistance in the process. This “pressing”
movement should be continued until a firm hold of the root has been
obtained--a point of great importance, as upon it the successful removal
of the tooth in a large measure depends. The handles should next be
firmly closed, so as to give the blades a good grip, and the amount of
pressure applied should be such, that when movement has commenced the
blades do not ride upon the surface of the root. The amount of pressure
to be applied must naturally vary according to the character of the
tooth to be removed, and the resistance offered by the alveolar process.
The thumb placed between the handles of the forceps, as previously
pointed out, should counteract the pressure applied to the root and
prevent crushing, which, should it occur, may make the subsequent
removal very difficult.
The _second stage_--the destruction of the membranous attachments and
dilatation of the socket--is accomplished by employing force in either a
rotary or a lateral direction. The movement to be employed depends upon
the form of the root or roots to be removed and the resisting strength
of the surrounding hard structures, and at this point it need only be
remarked that rotary motion is alone admissible in the case of teeth
possessing a single conical root.
The _final stage_ is carried out by exerting extractive force in the
direction of the long axis of the tooth, and also in that of least
resistance; the latter is determined by a knowledge of the anatomy of
the alveolar border, and by the sensation conveyed to the hand through
the forceps.
=The removal of a tooth with a straight elevator= is accomplished in the
following manner. The blade, with the flattened surface towards the
tooth to be removed, is inserted between the root and the alveolus, the
instrument being kept as far as possible parallel with the anterior
surface of the crown. The blade is then forced downwards so as to reach
the root at as low a point as possible; the handle of the elevator is
then rotated away from the direction in which the tooth is to be
removed. This has the effect of both raising the tooth in its socket and
displacing it in the required direction. One such movement of the
instrument rarely suffices for the removal of a tooth, a second, and
sometimes a third grip, each time nearer to the apex of the root, having
to be obtained.
The method of using a curved elevator will be described in dealing with
the removal of the roots of lower molar teeth.
=The wound resulting from the removal of a tooth= is a lacerated one, and
heals by “granulation.” The socket immediately after the operation
becomes filled with coagulated blood, which is eventually replaced by
granulation tissue, followed at a later period by the formation of loose
cancellous bone.
A varying amount of absorption of the alveolar border always follows the
removal of a tooth, the continuity in the surface of the gum being
restored by ordinary cicatricial fibrous tissue.
The wound is best treated by keeping the parts carefully cleansed as far
as possible from all foreign matter, and for this purpose an antiseptic
mouth-wash[3] should be used several times a day. From the wound
resulting from the extraction of an upper tooth the discharge drains
away in a natural manner owing to the orifice being the most dependent
part. From the wound caused by the removal of a lower tooth such is not
the case, and should suppuration take place the socket must be
frequently syringed with some antiseptic solution, and if necessary,
packed.
=The Extraction of the Temporary Teeth.=--Although the actual details of
the extraction of the temporary teeth do not differ from those of the
permanent teeth, there are, nevertheless, one or two points to which
attention may with advantage be directed. First and foremost, a child
should not be deceived, and if it is necessary to extract a tooth, the
child should be told and not taken unawares. When, too, a child resists
having a tooth removed, the operation must not be forcibly carried out,
for by a little patience and moral suasion on the part of the operator,
the better side of a child’s nature can generally be gained. It should
also be remembered that anæsthetics are quite as needful for the
extraction of the temporary as the permanent teeth, the pain to be borne
by a child being quite as great as that to be endured by an adult.