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.

EXTRACTION OF THE TEETH.

CHAPTER I.
———
The General Principles of Extraction of the Teeth.

(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.

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.

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),

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).

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.

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.

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.

The Screw (fig. 14) is an instrument which on rare occasions is useful for the removal of deep seated roots.

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.

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

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.

CHAPTER II.
———
The Extraction of Individual Teeth.

(1)UPPER TEETH.—For the removal of teeth in the maxilla the patient should be placed at such a level that the arm of the operator can, if necessary, embrace the head of the patient with comfort. The operator should stand at the right side of the patient, and slightly in front, the first finger and thumb being placed on either side of the alveolus (fig. 16). In the event of the patient becoming restless, the arm should be shifted so as to encircle the head and hold it firmly.

(a) Upper Incisors.—The roots of both the upper central and lateral incisors are usually cone shaped, the anterior surface being the arc of a greater circle than that of the posterior. Forceps for the removal of these teeth ought therefore to have the blades made in a corresponding manner (see fig. 17). The lateral incisor is smaller than the central, and has at times a root somewhat flattened. In removing upper incisors the posterior blade is applied first, care being taken to

see that the edge of the instrument passes between the gum and the tooth. To dislodge these teeth a firm inward movement should be made in a direction towards the palate, this movement being followed by one in an outward direction. If this fails to dislodge the tooth from its attachments, a firm rotary motion, first to the right and then to the left, may be tried (the amount of rotation necessary being only about an eighth of the circle represented by the circumference of the root). Rotation is generally recommended in the first instance for the extraction of these teeth, but the inward movement is, I think, best, the teeth yielding more readily and with less laceration of the soft tissues.

The extraction of the roots of these teeth does not as a rule present much difficulty. When moderately sound the instrument shown in fig. 17 may be used, but in those instances where the root is much decayed, and lies well below the gum margin, a rather finer pair will be found more serviceable. The manner of removal is similar to that used when the crown is standing.

(b) Upper Canines.—These teeth, like the incisors, are single rooted, but the difference between the curve of the anterior and posterior surfaces is greater. The roots too are much longer, more firmly implanted, and hence require more force in their removal. Forceps similar in pattern to those used for incisors may be used, the severance of the tooth from its attachments being brought about by force applied in an inward, followed by an outward, direction. The root being more or less three sided, rotation cannot well be adopted.

The roots of canine teeth are to be removed in the same manner as that adopted for the whole tooth.

(c) Upper Bicuspids.—The first bicuspid has usually one root flattened and more or less longitudinally grooved on its mesial and distal surfaces. If this grooving is much marked, it results in a greater or less division of the root into two slender terminations. Whether such bifurcation exists or not can seldom be determined before operation and would not modify the method adopted, but the tendency to this variation should be borne in mind and the lateral movement be very gently applied. The internal and external surfaces of the root are for all practical purposes of equal curvature.

The second bicuspid has usually only one root, which is not so flattened in the antero-posterior diameter as the first. There is also not the same tendency to grooving or bifurcation of the root as there is in the first bicuspid.

The blades of forceps for the bicuspids should be equal segments of the same circle; they should also be bent at an angle with the handles, so that the latter may clear the lower lip. The forceps shown in fig. 18 is a useful pattern. In removing an upper bicuspid, the inner blade of the forceps should be applied first. For severing the tooth from its attachments a slight inward movement should first be made, followed by an outward one. If this fails to cause the socket to yield, the inward movement may again be made, followed by an outward one, and repeated if necessary. The removal of the tooth from its socket is to be carried out by force applied in a downward and outward direction. It is well to remember that the force applied to the inward should always be slight compared to that used in the outward direction. The removal of bicuspid roots is carried out in a manner similar to that for the whole tooth.

(d) Upper Molars.—The first upper molar has three roots, one internal towards the palate (palatine), and two external (buccal); of the three the palatine is the largest, sub-cylindrical in form, and often curved. The two buccal roots are placed in an anterior and posterior position, the latter being in a plane internal to the anterior one; both these roots are somewhat flattened, and of the two the anterior is the larger. The roots of the second molar are similar in shape to the first, but are usually smaller. The third molar, when normal, has three roots, but very frequently these are all fused together so as to form an abrupt tapering cone, the point of which is often curved.

Owing to the disposition of the roots different forceps will be required for the removal of upper molars on the right and left side. Of the blades, the outer or buccal should possess two grooves, the anterior being the broader and placed in a more external plane. This blade should also have a slight projection between the grooved surfaces to adapt itself to the space between the buccal roots. The inner or palatal blade should possess only one groove. A well-made pair of upper molar forceps should fit the neck of a first upper permanent molar accurately. The blades should be bent at an angle with the handles, so that when in use the latter may clear the lower lip (fig. 19). The palatine blade should be applied first, and in bringing the outer blade into place the point should be kept over the groove on the buccal side of the tooth, as this groove is a guide to the space between the outer roots. To sever these teeth from their attachments force must be applied first slightly inwards and then outwards, the movements being repeated if necessary, the removal of the tooth from the socket being carried out by exerting force in a downward and outward direction. Too much outward movement leads to undue bending or fracture of the external alveolar plate.

In removing the third molars it is advisable not to have the patient’s mouth opened to the fullest extent, as the tension of the tissues of the cheek will thereby be lessened and a clearer view of the outer side of the tooth thus gained. The application of the forceps is of the utmost importance, as one is liable, unless care is taken, to include some of the soft tissue between the blades and the tooth and so cause a painful laceration. Force applied inwards and then outwards is generally sufficient to loosen these teeth, their removal being carried out by a downward and outward movement.

Forceps similar to those shown in fig. 19 may be used for the removal of the third molars, but most operators use patterns the blades of which are similar segments of the same circle (fig. 20).

There is an abnormality of the upper molars which may with advantage be mentioned here. In this deformity the posterior buccal root is situated in a plane much internal to the anterior—in other words, it is an exaggeration of the normal arrangement. Such teeth have been termed by Mr. Booth Pearsall “oblique rooted” (fig. 21). The abnormality is met with most frequently in the third molar, sometimes in the second, rarely in the first. The difficulty encountered in extracting these teeth is that the outer blade of the forceps tends to slip round. Oblique-rooted teeth can at times be diagnosed by noting an undue prominence of the alveolus over the anterior buccal root, and are best removed with forceps similar to that shown in fig. 20.

In cases where a portion of the crown remains and the decay extends well below the gum on either the palatal or buccal side, ordinary molar forceps should be discarded and root forceps employed; useful patterns are shown in figs. 18, 22 and 23. The removal of teeth in this condition is carried out as follows, and for the sake of description it will be supposed that the decay extends deeply on the palatine side. One blade of the forceps should be first applied to the buccal side of the tooth and to the root which is considered the stronger; the inner blade should then be applied to the palatine root care being taken to insinuate it between the alveolus and the root. The forceps should then be pushed well upwards until a firm hold of the root is obtained. A firm inward movement should then be made, as this will allow the inner blade to pass still higher up the palatine fang and insure steadiness should the blades tend to ride upon the surface of the root. An outward movement should next be made, but to nothing like so great a degree as that used in extracting molars with the whole of the crown standing. This inward and outward movement is to be repeated until the tooth is freed, the force being principally applied in the inward direction.

When the more extensive decay has taken place on the buccal side the order of proceeding is slightly different. The first blade to be applied should be the palatine, the outer blade being closed upon whichever of the buccal roots is considered the stronger.

The extractive force should be applied first outwards and then inwards, these movements being repeated if necessary, the principal force being outwards, as the object in view is to prevent the instrument slipping off the more decayed side.

When a molar is so decayed that but little of the crown remains, but all the roots are still united, root forceps are indicated. In such a case the inner blade is to be applied to the palatine root first, the outer blade being closed upon the stronger of the buccal fangs. Inward followed by outward movement should be employed, the point to bear in mind being to use force towards the side of the tooth which is considered the weaker. In the majority of such cases the three roots come away together, but even if this does not happen, one or perhaps two will be removed, the remainder being subsequently removed with but little difficulty.

In cases where the resistance presented by the roots is very great and an unsuccessful attempt has been made with ordinary root forceps, an instrument with a buccal blade similar to that shown in fig. 24 may be used. The inner blade is first applied, the outer one being brought so as to come, if possible, into the space between the buccal roots. A firm hold of the roots having been gained, an attempt to extract should be made by force applied in an inward and outward direction; this failing, sufficient pressure should be put upon the handles to split the roots asunder. The sharp outer blade of the forceps will then pass between the divided buccal roots on to the palatine root, which can thus readily be brought away. A pair of ordinary upper root forceps should be employed for removing the buccal roots.

If all the three roots of a molar are separate, their extraction presents but little difficulty, a slight rotary movement generally sufficing.

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