,,extraction ,,of ,,the ,,teeth4 ,,extraction ,,of ,,the ,,teeth ,,by ,j4 ,f4 ,,colyer1 ,l4,r4,c4,p41 ,m4,r4,c4,s4 ,l4,d4,s4 ,dental ,surgeon and ,lecturer on ,dental ,surgery to ,charing ,cross ,hospital3 ,assistant ,dental ,surgeon to the ,dental ,hospital of ,london ,london3 ,,claudius ,,ash ,,sons1 ,,limited1 #e1 #f1 #g1 #h ,,and #i1 ,,broad ,,street1 ,,golden ,,square1 ,w4 #ahif ,,contents4 ,,chapter ,i4 ,,page ,,the ,,general ,,principles ,,of ,,extraction ,,of ,,the ,,teeth #a ,,chapter ,,ii4 ,,the ,,extraction ,,of ,,individual ,,teeth #ai ,,chapter ,,iii4 ,,the ,,extraction ,,of ,,misplaced ,,teeth #df ,,chapter ,,iv4 ,,the ,,use ,,of ,,an,,sthetics ,,during ,,extraction ,,of ,,the ,,teeth #ef ,,chapter ,v4 ,,difficulties1 ,,complications1 ,,and ,,sequel ,,of ,,extraction ,,of ,,the ,,teeth #fc ,,index #if ,,extraction ,,of ,,the ,,teeth4 ,,chapter ,i4 ,the ,general ,principles of ,extraction of the ,teeth4 ,as an operation1 extraction of teeth is fortunately becoming more rare1 but even now large numbers are needlessly sacrificed1 in many cases owing to ignorance on the part of the patient of the value of the teeth1 at times to lack of knowledge on the part of both operator and patient of the modern methods of conservative dentistry4 ,with the assistance of antiseptics in the treatment of root-canals1 and the increase in knowledge of the methods of filling and crowning teeth1 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 useful1 with the exception of-- 7#a7 ,those teeth whose roots are much shortened by absorption4 7#b7 ,those teeth from which the alveolar process has disappeared to such an extent as to leave them quite loose2 and 7#c7 ,those teeth attacked with chronic periodontitis1 which1 in spite of treatment1 tends to become worse4 ,special circumstances naturally alter cases2 for instance1 with patients the subjects of nervous prostration1 or feeble in health1 a lengthy operation is often contra-indicated1 and under such conditions extraction may be preferable to the lengthy and tedious processes of conservative treatment4 ,another indication for extraction is in cases of teeth setting up or aggravating ulceration of the tongue1 lips1 or other soft parts of the mouth4 ,teeth fractured in a longitudinal direction should generally be removed1 and the same rule applies to those which are so misplaced as to be incapable of being brought into the normal arch4 ,in crowded conditions of the teeth extraction is often called for1 and under such circumstances is really conservative treatment4 ,if extraction be determined upon1 a careful examination of the tooth to be removed should be made4 ,this will allow some idea to be formed of the amount of sound tissue present1 and also of the force which will be necessary for the dislodgment of the tooth4 ,in the case of roots1 the edges must be defined1 and for this purpose a blunt probe1 similar in pattern to that shown in fig4 #a will be found useful4 ,illustration3 ,,fig4 #a4 ,instruments4--,the instruments in general use for the removal of teeth are forceps and elevators4 ,the ,forceps is an amplified pair of pincers or pliers4 ,it is made up of three parts1 namely1 the blades or portions beyond the joint which are applied to the tooth1 the joint itself1 and the handles4 ,forceps should be made of fine steel1 should be light and yet strong enough to withstand without bending any strain that may be put upon them4#a ,the blades should be shaped to fit the tooth they are intended to remove1 and they should be clear of the crown when applied4 ,on longitudinal section a blade should present a thin wedge-shaped appearance4 ,two kinds of joints are met with4 ,in the first variety one half of the forceps passes through a slot in the other1 the two being held together by a rivet passing through the centre 7fig4 #b74 ,in the second variety 7fig4 #c7 the two halves are held together side by side by a screw or pin which takes the entire strain4 ,most forceps of ,english manufacture are made on the latter plan1 which has the advantage of permitting the instrument to be easily cleaned2 it also allows a slight lateral movement of the two halves--a point of some practical importance4 ,it is urged against this style of joint that it is weak2 in practice1 however1 this is not found to be the case4 ,illustration3 ,,fig4 #b4 ,illustration3 ,,fig4 #c4 ,the handles should be of a size and shape to lie comfortably in the palm of the hand1 and should be in such relation to the blades that when the latter are applied in the direction of the long axis of the tooth1 the handles clear the lips4 ,as a general rule1 in forceps designed for the removal of the anterior teeth in the maxilla1 the blades and handles are in the same line 7fig4 #d71 ,illustration3 ,,fig4 #d4 ,illustration3 ,,fig4 #e4 while for the upper back teeth the handles form a curve of greater or less extent with the blades 7fig4 #e74 ,in forceps for the lower teeth the blades are bent down from the handles to an angle of nearly ninety degrees4 ,in one class1 namely1 the hawk's-bill1 when the blades are applied to the tooth the handles are at right angles to the line of the arch 7fig4 #f71 while in other classes the handles are in line with the arch 7fig4 #g74 ,illustration3 ,,fig4 #f4 ,illustration3 ,,fig4 #g4 ,the manner of holding forceps is shown in figs4 #h1 #i1 #aj4 ,the handles should rest comfortably in the palmar surface of the hand1 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 advantage4 ,the thumb placed between the handles acts as a regulator to control the amount of pressure of the blades upon the tooth4 ,as a precaution it is well to have the ball of the thumb well between the handles1 so that the pressure is counteracted not only by the soft tissues1 but also by the terminal bony phalanx of the thumb4 ,if this precaution be not observed1 any sudden crushing of the tooth may be accompanied by a severe and very painful contusion of the operator's thumb4 ,illustration3 ,,fig4 #h4 ,mode of holding forceps for the removal of upper teeth4 ,the ,elevator consists of two parts--the handle and the blade4 ,the former1 usually made of wood or ivory1 is about four inches in length and of a shape suitable to allow a firm grip being obtained of it by the hand4 ,the blade is made of fine steel1 and is about two inches long4 ,elevators are of two varieties1 straight and curved4 ,in the first form the blade is thin1 about one-fifth of an inch in breadth1 one surface being made convex and the other flat4 ,the point of the blade may be rounded as shown in fig4 #aa1 or spear-shaped1 as shown in fig4 #ab4 ,illustration3 ,,fig4 #i4 ,mode of holding lower 8hawk's bill0 pattern forceps4 ,illustration3 ,,fig4 #aj4 ,mode of holding forceps of pattern shown in fig4 #cj4 ,in the curved variety1 the terminal half inch of the steel portion of the instrument is bent at an angle with the shaft of the instrument 7fig4 #di74 ,the edge of the blade of an elevator should always be kept sharp4 ,the method of holding an elevator is shown in fig4 #ac4 ,the handle should rest comfortably in the palm of the hand1 the first finger lying along the blade and being brought near the point so as to prevent the instrument slipping4 ,when using the elevator for the removal of teeth on the right side of the mandible1 the finger should lie along the curved side of the blade1 and on the flat side when extracting teeth on the left side4 ,illustration3 ,,fig4 #aa4 ,the ,screw 7fig4 #ad7 is an instrument which on rare occasions is useful for the removal of deep seated roots4 ,illustration3 ,,fig4 #ab4 ,after being used1 instruments of every kind should be freed from all foreign matter and then carefully sterilised4 ,the next point which demands attention is the position of the operator and patient4 ,the chair should be placed before a good light1 and if a proper dental chair is not to hand an ordinary arm chair may be utilised2 failing this1 two ordinary chairs may be placed back to back1 on one of which the left leg of the operator should be raised to form a rest for the patient's head4 ,the patient should be placed in such an unconstrained position as will allow the operator to exert all necessary movements with freedom4 ,illustration3 ,,fig4 #ac4 ,illustration3 ,,fig4 #ad4 ,the operator should place himself so as to use his force to the greatest advantage4 ,his left arm may be utilised1 if necessary1 for steadying the movements of the patient's head1 while the fingers of the left hand can be employed-- 7#a7 ,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 neighbours2 7#b7 ,to support the mandible2 7#c7 ,to grasp the alveolus and so allow some idea to be gained of the effect of the force employed4 ,the special positions for the removal of different teeth will be described in chapter ii4 ,it may be advantageous1 before describing the steps of the operation of extraction1 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 out4 ,if the teeth be examined it will be noticed that they are capable of division into-- 7#a7 ,teeth with single1 rounded tapering roots2 7#b7 ,teeth with single roots more or less irregularly flattened or curved2 7#c7 ,teeth with multiple roots4 ,under 7#a7 are included the upper incisors 7temporary and permanent7 and the lower bicuspids2 7#b7 the lower incisors and canines 7temporary and permanent71 and also the upper canines and bicuspids2 7#c7 the upper and lower molars 7temporary and permanent7 and frequently the first upper bicuspids4#b ,the shape of the roots1 as we shall subsequently find1 has an important bearing upon the manner in which force is to be applied when severing them from their attachments4 ,a correct acquaintance with the disposition of the alveoli of the teeth is of importance for skilful and successful operating4 ,fig4 #ae gives a general idea of the appearance of the alveoli1 but it is needless to say that a full knowledge can only be really obtained by a careful study of the bones themselves2 by this means1 too1 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 socket4 ,the points to be specially noted in the maxilla are the thinness of the outer alveolar wall as compared with the inner1 the prominence of the canine socket1 and the cancellous character of the bone in the region of the third molar4 ,in the mandible the outer alveolar border will be seen to be thinner than the inner1 with the exception of that portion in the region of the ,illustration3 ,,fig4 #ae4 ,from the 8,american ,system of ,dentistry40 third1 and often of the second molar2 another fact worthy of attention is that at the posterior portion of the socket of the third molar the bone is moderately dense4 ,when performed with forceps the operation of tooth extraction may be divided into three stages3-- 7#a7 ,adaptation of the forceps to the tooth4 7#b7 ,destruction of its membranous connections with1 and dilatation of1 the socket4 7#c7 ,removal of the tooth from the socket4 ,in the initial stage the first step is the application of the blades1 and1 in this connection1 care must be taken to see that the points pass between the gum and the tooth1 and also that they are applied parallel with the long axis of the root4 ,it is1 as a rule1 best first to apply the blade on the side of the tooth most obscured from view1 and then lightly to close the other upon the opposite side4 ,the blades should then be forcibly pressed upwards or downwards1 as the case may be1 in the direction of the apex of the root2 a slight rotary or wriggling motion will often be found of assistance in the process4 ,this 8pressing0 movement should be continued until a firm hold of the root has been obtained--a point of great importance1 as upon it the successful removal of the tooth in a large measure depends4 ,the handles should next be firmly closed1 so as to give the blades a good grip1 and the amount of pressure applied should be such1 that when movement has commenced the blades do not ride upon the surface of the root4 ,the amount of pressure to be applied must naturally vary according to the character of the tooth to be removed1 and the resistance offered by the alveolar process4 ,the thumb placed between the handles of the forceps1 as previously pointed out1 should counteract the pressure applied to the root and prevent crushing1 which1 should it occur1 may make the subsequent removal very difficult4 ,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 direction4 ,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 structures1 and at this point it need only be remarked that rotary motion is alone admissible in the case of teeth possessing a single conical root4 ,the final stage is carried out by exerting extractive force in the direction of the long axis of the tooth1 and also in that of least resistance2 the latter is determined by a knowledge of the anatomy of the alveolar border1 and by the sensation conveyed to the hand through the forceps4 ,the removal of a tooth with a straight elevator is accomplished in the following manner4 ,the blade1 with the flattened surface towards the tooth to be removed1 is inserted between the root and the alveolus1 the instrument being kept as far as possible parallel with the anterior surface of the crown4 ,the blade is then forced downwards so as to reach the root at as low a point as possible2 the handle of the elevator is then rotated away from the direction in which the tooth is to be removed4 ,this has the effect of both raising the tooth in its socket and displacing it in the required direction4 ,one such movement of the instrument rarely suffices for the removal of a tooth1 a second1 and sometimes a third grip1 each time nearer to the apex of the root1 having to be obtained4 ,the method of using a curved elevator will be described in dealing with the removal of the roots of lower molar teeth4 ,the wound resulting from the removal of a tooth is a lacerated one1 and heals by 8granulation40 ,the socket immediately after the operation becomes filled with coagulated blood1 which is eventually replaced by granulation tissue1 followed at a later period by the formation of loose cancellous bone4 ,a varying amount of absorption of the alveolar border always follows the removal of a tooth1 the continuity in the surface of the gum being restored by ordinary cicatricial fibrous tissue4 ,the wound is best treated by keeping the parts carefully cleansed as far as possible from all foreign matter1 and for this purpose an antiseptic mouth-wash#c should be used several times a day4 ,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 part4 ,from the wound caused by the removal of a lower tooth such is not the case1 and should suppuration take place the socket must be frequently syringed with some antiseptic solution1 and if necessary1 packed4 ,the ,extraction of the ,temporary ,teeth4--,although the actual details of the extraction of the temporary teeth do not differ from those of the permanent teeth1 there are1 nevertheless1 one or two points to which attention may with advantage be directed4 ,first and foremost1 a child should not be deceived1 and if it is necessary to extract a tooth1 the child should be told and not taken unawares4 ,when1 too1 a child resists having a tooth removed1 the operation must not be forcibly carried out1 for by a little patience and moral suasion on the part of the operator1 the better side of a child's nature can generally be gained4 ,it should also be remembered that ansthetics are quite as needful for the extraction of the temporary as the permanent teeth1 the pain to be borne by a child being quite as great as that to be endured by an adult4 ,,chapter ,,ii4 ,the ,extraction of ,individual ,teeth4 7#a7,,upper ,,teeth4--,for the removal of teeth in the maxilla the patient should be placed at such a level that the arm of the operator can1 if necessary1 embrace the head of the patient with comfort4 ,the operator should stand at the right side of the patient1 and slightly in front1 the first finger and thumb being placed on either side of the alveolus 7fig4 #af74 ,in the event of the patient becoming restless1 the arm should be shifted so as to encircle the head and hold it firmly4 7a7 ,upper ,incisors4--,the roots of both the upper central and lateral incisors are usually cone shaped1 the anterior surface being the arc of a greater circle than that of the posterior4 ,forceps for the removal of these teeth ought therefore to have the blades made in a corresponding manner 7see fig4 #ag74 ,the lateral incisor is smaller than the central1 and has at times a root somewhat flattened4 ,in removing upper incisors the posterior blade is applied first1 care being taken to ,illustration3 ,,fig4 #af4 see that the edge of the instrument passes between the gum and the tooth4 ,to dislodge these teeth a firm inward movement should be made in a direction towards the palate1 this movement being followed by one in an outward direction4 ,if this fails to dislodge the tooth from its attachments1 a firm rotary motion1 first to the right and then to the left1 may be tried 7the amount of rotation necessary being only about an eighth of the circle represented by the circumference of the root74 ,rotation is generally recommended in the first instance for the extraction of these teeth1 but the inward movement is1 ,i think1 best1 the teeth yielding more readily and with less laceration of the soft tissues4 ,the extraction of the roots of these teeth does not as a rule present much difficulty4 ,when moderately sound the instrument shown in fig4 #ag may be used1 but in those instances where the root is much decayed1 and lies well below the gum margin1 a rather finer pair will be found more serviceable4 ,the manner of removal is similar to that used when the crown is standing4 ,illustration3 ,,fig4 #ag4 7b7 ,upper ,canines4--,these teeth1 like the incisors1 are single rooted1 but the difference between the curve of the anterior and posterior surfaces is greater4 ,the roots too are much longer1 more firmly implanted1 and hence require more force in their removal4 ,forceps similar in pattern to those used for incisors may be used1 the severance of the tooth from its attachments being brought about by force applied in an inward1 followed by an outward1 direction4 ,the root being more or less three sided1 rotation cannot well be adopted4 ,the roots of canine teeth are to be removed in the same manner as that adopted for the whole tooth4 7c7 ,upper ,bicuspids4--,the first bicuspid has usually one root flattened and more or less longitudinally grooved on its mesial and distal surfaces4 ,if this grooving is much marked1 it results in a greater or less division of the root into two slender terminations4 ,whether such bifurcation exists or not can seldom be determined before operation and would not modify the method adopted1 but the tendency to this variation should be borne in mind and the lateral movement be very gently applied4 ,the internal and external surfaces of the root are for all practical purposes of equal curvature4 ,the second bicuspid has usually only one root1 which is not so flattened in the antero-posterior diameter as the first4 ,there is also not the same tendency to grooving or bifurcation of the root as there is in the first bicuspid4 ,the blades of forceps for the bicuspids should be equal segments of the same circle2 they should also be bent at an angle with the handles1 so that the latter may clear the lower lip4 ,the forceps shown in fig4 #ah is a useful pattern4 ,in removing an upper bicuspid1 the inner blade of the forceps should be applied first4 ,for severing the tooth from its attachments a slight inward movement should first be made1 followed by an outward one4 ,if this fails to cause the socket to yield1 the inward movement may again be made1 followed by an outward one1 and repeated if necessary4 ,the removal of the tooth from its socket is to be carried out by force applied in a downward and outward direction4 ,it is well to remember that the force applied to the inward should always be slight compared to that used in the outward direction4 ,the removal of bicuspid roots is carried out in a manner similar to that for the whole tooth4 ,illustration3 ,,fig4 #ah4 7d7 ,upper ,molars4--,the first upper molar has three roots1 one internal towards the palate 7palatine71 and two external 7buccal72 of the three the palatine is the largest1 sub-cylindrical in form1 and often curved4 ,the two buccal roots are placed in an anterior and posterior position1 the latter being in a plane internal to the anterior one2 both these roots are somewhat flattened1 and of the two the anterior is the larger4 ,the roots of the second molar are similar in shape to the first1 but are usually smaller4 ,the third molar1 when normal1 has three roots1 but very frequently these are all fused together so as to form an abrupt tapering cone1 the point of which is often curved4 ,illustration3 ,,fig4 #ai4 ,owing to the disposition of the roots different forceps will be required for the removal of upper molars on the right and left side4 ,of the blades1 the outer or buccal should possess two grooves1 the anterior being the broader and placed in a more external plane4 ,this blade should also have a slight projection between the grooved surfaces to adapt itself to the space between the buccal roots4 ,the inner or palatal blade should possess only one groove4 ,a well-made pair of upper molar forceps should fit the neck of a first upper permanent molar accurately4 ,the blades should be bent at an angle with the handles1 so that when in use the latter may clear the lower lip 7fig4 #ai74 ,the palatine blade should be applied first1 and in bringing the outer blade into place the point should be kept over the groove on the buccal side of the tooth1 as this groove is a guide to the space between the outer roots4 ,to sever these teeth from their attachments force must be applied first slightly inwards and then outwards1 the movements being repeated if necessary1 the removal of the tooth from the socket being carried out by exerting force in a downward and outward direction4 ,too much outward movement leads to undue bending or fracture of the external alveolar plate4 ,illustration3 ,,fig4 #bj4 ,in removing the third molars it is advisable not to have the patient's mouth opened to the fullest extent1 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 gained4 ,the application of the forceps is of the utmost importance1 as one is liable1 unless care is taken1 to include some of the soft tissue between the blades and the tooth and so cause a painful laceration4 ,force applied inwards and then outwards is generally sufficient to loosen these teeth1 their removal being carried out by a downward and outward movement4 ,forceps similar to those shown in fig4 #ai may be used for the removal of the third molars1 but most operators use patterns the blades of which are similar segments of the same circle 7fig4 #bj74 ,illustration3 ,,fig4 #ba4 7a7 ,normal upper first permanent molar4 7b7 ,oblique rooted upper first permanent molar4 7c7 ,normal upper second permanent molar4 7d7 ,oblique rooted second permanent molar4 ,there is an abnormality of the upper molars which may with advantage be mentioned here4 ,in this deformity the posterior buccal root is situated in a plane much internal to the anterior--in other words1 it is an exaggeration of the normal arrangement4 ,such teeth have been termed by ,mr4 ,booth ,pearsall 8oblique rooted0 7fig4 #ba74 ,the abnormality is met with most frequently in the third molar1 sometimes in the second1 rarely in the first4 ,the difficulty encountered in extracting these teeth is that the outer blade of the forceps tends to slip round4 ,oblique-rooted teeth can at times be diagnosed by noting an undue prominence of the alveolus over the anterior buccal root1 and are best removed with forceps similar to that shown in fig4 #bj4 ,in cases where a portion of the crown remains and the decay extends well below the gum on either the palatal or buccal side1 ordinary molar forceps should be discarded and root forceps employed2 useful patterns are shown in figs4 #ah1 #bb and #bc4 ,the removal of teeth in this condition is carried out as follows1 and for the sake of description it will be supposed that the decay extends deeply on the palatine side4 ,one blade of the forceps should be first applied to the buccal side of the tooth and to the root which is considered the stronger2 the inner blade should then be applied to the palatine root care being taken to insinuate it between the alveolus and the root4 ,the forceps should then be pushed well upwards until a firm hold of the root is obtained4 ,a firm inward movement should then be made1 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 root4 ,an outward movement should next be made1 but to nothing like so great a degree as that used in extracting molars with the whole of the crown standing4 ,this inward and outward movement is to be repeated until the tooth is freed1 the force being principally applied in the inward direction4 ,illustration3 ,,fig4 #bb4 ,illustration3 ,,fig4 #bc4 ,for the removal of roots towards the back of the mouth4 ,when the more extensive decay has taken place on the buccal side the order of proceeding is slightly different4 ,the first blade to be applied should be the palatine1 the outer blade being closed upon whichever of the buccal roots is considered the stronger4 ,the extractive force should be applied first outwards and then inwards1 these movements being repeated if necessary1 the principal force being outwards1 as the object in view is to prevent the instrument slipping off the more decayed side4 ,when a molar is so decayed that but little of the crown remains1 but all the roots are still united1 root forceps are indicated4 ,in such a case the inner blade is to be applied to the palatine root first1 the outer blade being closed upon the stronger of the buccal fangs4 ,inward followed by outward movement should be employed1 the point to bear in mind being to use force towards the side of the tooth which is considered the weaker4 ,in the majority of such cases the three roots come away together1 but even if this does not happen1 one or perhaps two will be removed1 the remainder being subsequently removed with but little difficulty4 ,in cases where the resistance presented by the roots is very great and an unsuccessful attempt has been made with ordinary root forceps1 an instrument with a buccal blade similar to that shown in fig4 #bd may be used4 ,the inner blade is first applied1 the outer one being brought so as to come1 if possible1 into the space between the buccal roots4 ,a firm hold of the roots having been gained1 an attempt to extract should be made by force applied in an inward and outward direction2 this failing1 sufficient pressure should be put upon the handles to split the roots asunder4 ,the sharp outer blade of the forceps will then pass between the divided buccal roots on to the palatine root1 which can thus readily be brought away4 ,a pair of ordinary upper root forceps should be employed for removing the buccal roots4 ,if all the three roots of a molar are separate1 their extraction presents but little difficulty1 a slight rotary movement generally sufficing4 ,in all cases where there is a fear of a molar fracturing1 root in preference to ordinary forceps should be used4 ,illustration3 ,,fig4 #bd4 7#b7 ,,lower ,,teeth4--,for the removal of lower teeth the patient should be placed on a low level1 the head being kept a little forward and the chin depressed4 ,the position of the operator will naturally differ with the tooth to be removed ,illustration3 ,,fig4 #be4 and also with the instrument to be used4 ,with teeth on the right side1 when hawk's-bill pattern forceps or elevators are used1 the operator should stand behind and to the right of the patient1 the left arm being brought round the patient's head4 ,the thumb of the left hand should be placed on the inner side and the first finger on the outer side of the alveolus of the tooth to be removed1 and the three remaining fingers under and supporting the chin4 ,in placing the fingers in the mouth1 care should be taken to keep the wrist well down so as not to impede the entrance of light 7fig4 #be74 ,illustration3 ,,fig4 #bf4 ,when removing the anterior teeth or those on the left side of the mouth1 the operator should stand on the right side and slightly in front of the patient4 ,the left hand should be placed as follows3 the second finger on the lingual side1 and the first on the labial side of the alveolus of the tooth to be extracted1 the thumb being placed under the chin 7fig4 #bf74 ,when employing forceps of the straight pattern shown in fig4 #cj1 the operator should stand as shown in fig4 #bf1 but it will be found difficult to place the fingers of the left hand on either side of the alveolus1 indeed they can only well be used for retracting the cheek and supporting the jaw4 ,in removing teeth from the lower jaw1 the operator should be careful1 in raising the tooth from the socket1 to guard against a sudden separation of the tooth from its attachments which might result in damage to the upper teeth4 ,illustration3 ,,fig4 #bg4 7a7 ,lower ,incisors4--,these teeth each have a single root which is much flattened laterally4 ,for their removal1 forceps similar to those shown in fig4 #bg should be used1 the blades being equal segments of the same circle4 ,the lingual blade should be applied first1 the loosening movement being made by taking the tooth slightly inwards and then outwards1 the final extractive force being upwards and outwards4 ,the removal of lower incisor roots is carried out in a similar manner4 7b7 ,lower ,canines4--,the lower canines have normally one root1 which is flattened laterally4 ,in comparison with the incisors1 the root is stronger and longer4 ,the removal of a lower canine is carried out in a manner similar to that employed for a lower incisor1 but as the tooth presents more resistance1 a greater amount of force is usually required4 7c7 ,lower ,bicuspids4--,the lower bicuspids have normally one root which is conical in shape4 ,in the first bicuspid the conical shape of the root is not so marked as in the second1 the outer aspect being the arc of rather a larger circle than the posterior4 ,forceps similar to those shown in fig4 #bg may be used1 the blades for all practical purposes being equal in size and shape4 ,the lingual blade of the instrument should be applied first1 the severing of the tooth from its attachments being carried out by a slight rotary movement around the long axis of the tooth first in one direction and then in the other2 should this not succeed1 a slight inward followed by an outward movement may be tried1 the tooth being raised from its socket by force applied in an upward and slightly outward direction4 ,the roots of lower bicuspids are to be removed in a manner similar to that required for the extraction of a whole tooth4 ,when the root lies much below the level of the gum the extraction is often troublesome owing to the difficulty in gaining a hold with the blades of the forceps2 in such cases1 if an attempt with forceps has failed1 the straight elevator may be employed4 ,illustration3 ,,fig4 #bh4 7d7 ,lower ,molars4--,lower molars have two roots1 placed anteriorly and posteriorly4 ,the roots are much flattened and have a tendency to curve backwards1 this being well marked in the second and especially so in the third molar2 a fusion of the two roots is at times met with in the second and frequently in the third molar4 ,a section of a lower molar at the neck shows both the buccal and lingual aspects to be composed of two segments of a circle touching each other at one extremity2 the anterior segment being slightly the larger 7fig4 #bh74 ,each blade of the forceps used for these teeth should possess two grooves1 ,illustration3 ,,fig4 #bi4 ,illustration3 ,,fig4 #cj4 separated by a projection which fits into the division between the anterior and posterior roots2 for all practical purposes the blades may be made of the same size1 so that one instrument will suffice for both sides of the jaw4 ,the instrument best adapted for the removal of these teeth is shown in fig4 #bi1 though some operators prefer the shape illustrated in fig4 #cj4 ,the advantages of the former over the latter may be briefly summed up as follows3 7#a7 ,a clear view of the tooth and its surroundings can be obtained during the whole period of removal4 7#b7 ,force can be applied with greater advantage4 7#c7 ,the alveolus can be easily embraced by the fingers1 or by the finger and thumb of the left hand4 7#d7 ,in removing the tooth from the socket a slight backward movement can be employed4 ,one disadvantage of shape fig4 #bi is that it is difficult to employ much inward movement1 and therefore1 for teeth lying inwards1 namely1 with the crown directed towards the tongue1 hawk's-bill-shaped forceps cannot easily be used4 ,another disadvantage is that the extent of inward movement is limited by the proximity of the upper teeth1 and in case of trismus it is often better to use straight forceps 7fig4 #cj74 ,in cases where there are also much swelling and rigidity of the cheek the straight forceps cause less inconvenience to the patient4 ,in removing lower molars with forceps1 the inner blade should be first applied and then the outer1 care being taken to get the points of the blades between the interspace of the roots4 ,for severing these teeth from their attachments1 a slight inward movement should be first made1 followed by one well outwards1 this inward and outward movement being repeated if necessary4 ,the removal of the tooth from its socket is carried out by force used in an upward and outward direction4 ,the upward force exerted upon lower teeth should always be well under control1 as not infrequently the resistance is very suddenly overcome1 and1 if such precaution is not taken1 there is danger of striking the upper teeth with considerable force4 ,illustration3 ,,fig4 #ca4 ,as previously pointed out1 the roots of these teeth are at times curved a little backwards so that it is often needful in removing the teeth from their sockets to twist the forceps in a curved direction backwards4 ,in the removal of the second molar too much outward movement is not permissible1 as the outer alveolus is often very dense4 ,the third molar is best removed with a straight elevator4 ,a glance at the illustration of this tooth 7fig4 #ca7 will show that the roots have a well-marked curve backwards1 in addition to which the bone forming the socket of this tooth is stronger than is the case with the anterior molars4 ,the removal of the third molar has therefore to be accomplished by using force in a direction upwards and backwards1 in other words1 in a curve similar to the arc of the circle formed by the roots4 ,this movement cannot well be carried out with forceps1 but is easily accomplished with the elevator as follows 7it being assumed that the second molar is in place73--,hold the elevator as shown in fig4 #ac1 and insert the blade between the anterior surface of the root and the alveolus1 keeping the flattened side of the instrument as far as possible parallel with the root surface4 ,then force the blade downwards in a direction towards the apex of the root2 following this1 rotate the handle away from the direction in which the tooth is to be moved4 ,this has the effect of both raising the tooth in its socket and displacing it backward4 ,the edge of the elevator which is to be brought into contact with the surface of the root should be sharp so as to cut somewhat into the cementum4 ,should this prove insufficient the handle should again be raised and the flattened surface of the instrument brought parallel with the anterior surface of the root and the extractive movement repeated until the tooth is completely raised from its socket4 ,in using the elevator1 especial care must be taken to protect the tongue with the fingers or thumb of the left hand1 so as to prevent a slip1 which might result in puncture of the tongue1 or of the operator's finger4 ,with the third lower molar there is a tendency for the gum to adhere tenaciously to the posterior part of the neck of the tooth4 ,when this happens it is better to simply raise the tooth from its socket with the elevator or forceps1 as the case may be1 and then cut the gum away with a curved pair of scissors4 ,by this method a severe laceration of the gum may at times be avoided4 ,when the third molar is isolated owing to the absence of the second molar1 the elevator may still be employed for its removal1 on the right side the first finger1 and on the left side the thumb of the left hand being used as the fulcrum4 ,in such cases1 however1 many operators prefer to use ordinary lower molar forceps4 ,the removal of lower molars when a portion of the crown is standing1 but the decay has progressed below the gum on either the buccal or the lingual aspect1 is carried out with root forceps of shape shown in fig4 #bg4 ,a condition similar to this in upper molars and the method indicated for their removal were referred to on page #bg4 ,the principles enumerated there apply equally to the removal of lower molars1 so that it will not be necessary to repeat them4 ,the main points to bear in mind are1 to apply the blades of the forceps to the stronger root1 and to use the principal force in the direction of the weaker wall4 ,where the roots of molars are still united1 root forceps should be used1 the blade being first applied to the lingual surface of the stronger root4 ,a firm hold having been obtained1 the root may be removed by employing force in a manner similar to that employed with ordinary molar forceps4 ,in this way both roots will usually come away together4 ,if1 however1 only one root is extracted1 the remaining one can easily be removed1 either with the same forceps or a curved elevator4 ,the curved elevator 7fig4 #di7 may be employed either by placing it against the root1 and so forcing it into the socket of the root already removed1 or by placing the blade in the socket of the extracted root1 forcing the point of the instrument through the intervening bone and then elevating the remaining root4 ,with roots of lower molars which present great resistance1 forceps with cutting blades may be used 7fig4 #cb74 ,the blades are inserted on the lingual and buccal aspects of the arch in such a manner that the points pass into the space between the roots4 ,the handles are then closed and an attempt is made to remove the roots in the ordinary way1 but should this prove unsuccessful the handles must be forcibly closed1 so as to divide the roots which can then1 as a rule1 be removed with ordinary root forceps4 ,the value of splitting roots in a case similar to that shown in fig4 #cc is apparent1 for1 as will be seen1 it allows each root to be removed in the line of its inclination4 ,illustration3 ,,fig4 #cb4 ,in those cases where the roots are separated their removal is carried out with root forceps1 an inward and outward movement being usually sufficient4 ,the roots of third molars are best removed with a straight elevator4 ,the modus operandi is similar to that used in extracting the whole tooth4 ,illustration3 ,,fig4 #cc4 7a7 ,lower molar with divergent roots4 7b7 ,the dotted lines show the direction in which the root can be removed if the tooth is divided as suggested in the text4 ,at times the lower molar teeth are much tilted in such a way that the crown surface stands towards the tongue4--,under such conditions their removal is best carried out with instruments of the pattern shown in fig4 #cj1 since the handles of forceps of the hawk's-bill pattern when applied would come in contact with the upper teeth1 and thus impede the inward movement which is so necessary for the removal of teeth in this position4 ,the ,temporary ,teeth4--,for the removal of upper incisors and canines1 a small pair of straight forceps of the pattern shown in fig4 #cd should be used4 ,the first upper temporary molars are best removed with a pair of forceps like fig4 #ce4 ,the lower incisors and canines require a small pair of hawk's-bill forceps similar to the shape shown in fig4 #bg4 ,for the lower temporary molars1 a small pair of forceps similar to that illustrated in fig4 #bi should be used4 ,illustration3 ,,fig4 #cd4 ,illustration3 ,,fig4 #ce4 ,in removing the temporary teeth1 care must be taken not to drive the forceps up too high1 for fear of injuring the permanent teeth2 this is more especially to be noted in connection with the temporary molars1 as the roots of these teeth practically embrace the crowns of the bicuspids4 ,generally speaking1 if a temporary molar fractures in the attempt to remove it1 the portion of tooth remaining in the jaw should be left alone unless it can be brought away quite easily4 ,illustration3 ,,fig4 #cf4 ,roots in the condition shown in fig4 #cf are best removed with an elevator as follows3 the thumb of the right hand being placed on an adjacent tooth so as to gain a hold1 the point of the elevator should be placed below the end of the root and force applied4 ,in a few cases it may be necessary to cut the gum with a lancet before using the elevator4 ,small pieces of the temporary teeth which persist and become wedged in between the permanent teeth can be best removed with an excavator or a similar suitable instrument4 ,,chapter ,,iii4 ,the ,extraction of ,misplaced ,teeth4 ,nothing1 perhaps1 tests the skill of a good operator more than the extraction of a misplaced or impacted tooth1 and although it is impossible to give anything like a complete list of the various malpositions met with1 those most commonly seen will be mentioned1 and the usual method for removing such teeth indicated4 ,illustration3 ,,fig4 #cg4 7a7 ,upper ,central ,incisors4--,an irregularity of this tooth calling for removal is shown in fig4 #cg4 ,the extraction is best carried out with an instrument similar to that shown in fig4 #ch1 the fine inner blade being applied on the palatal side and the broad blade on the labial4 ,extractive force should be applied principally in the outward direction1 and if this is not sufficient1 slight rotary movement should be tried4 ,in cases where there is less room between the approximal teeth1 the projecting tooth may be removed with a pair of straight forceps 7fig4 #ag71 the blades being applied to the mesial and distal aspects of the root4 ,the blades should not be driven very far up1 and the loosening of the tooth should be accomplished by slight rotary motion1 in using which care should be taken to avoid loosening the approximal teeth4 ,illustration3 ,,fig4 #ch4 7b7 ,upper ,lateral ,incisors lying internal to the arch1 as shown in fig4 #ci1 can be removed with the forceps shown in fig4 #ch1 by placing the fine blade on the labial and the broad blade on the palatal side of the tooth4 ,extractive movement should be made inwards1 followed by very slight outward movement2 this failing1 rotation should be tried1 but as pointed out on a previous page1 this form of movement is not so suitable for lateral incisors as for centrals4 ,illustration3 ,,fig4 #ci4 7c7 ,upper ,canines placed high in the arch1 as shown in fig4 #dj1 may be extracted with a straight pair of forceps 7fig4 #ag71 the blades being placed on the mesial and labial aspects of the root4 ,extraction of such teeth is very difficult4 ,slight but firm rotation may first be tried2 if this fails to loosen the tooth1 slight lateral movement may be attempted1 the force being applied towards and then away from the median line of the mouth4 ,illustration3 ,,fig4 #dj4 ,illustration3 ,,fig4 #da4 7d7 ,upper ,bicuspids misplaced1 as shown in fig4 #da1 can be removed with forceps1 as shown in figs4 #ah and #bb1 the blades being applied on the anterior and posterior aspects of the tooth4 ,force should be applied in a backward and forward direction1 the movements being repeated and persevered with until the tooth is loosened in its socket4 ,illustration3 ,,fig4 #db4 ,illustration3 ,,fig4 #dc4 ,a bicuspid placed as shown in fig4 #db can be removed with forceps similar in form to those depicted in figs4 #ah and #bb1 with the outer blade strong but narrow4 ,the extractive movement should be made mainly in an inward direction4 ,illustration3 ,,fig4 #dd4 7e7 ,lower ,central ,incisors placed similarly to that shown in fig4 #dc may be removed with ordinary lower root forceps 7hawk's-bill pattern71 the blades being placed on the mesial and distal surfaces of the root1 and movement applied in a direction to and away from the median line of the mouth4 ,when the crowding is not so extreme as shown in fig4 #dd1 forceps of the hawk's-bill pattern with a strong but narrow inner blade should be used 7fig4 #de71 and the principal extractive movement made in an outward direction4 ,for an incisor placed as shown in fig4 #dg1 the narrow blade should be the outer one 7fig4 #df71 and the principal force should be applied in an inward direction4 7f7 ,lower ,bicuspids placed as in fig4 #dh are ,illustration3 ,,fig4 #de4 ,illustration3 ,,fig4 #df4 most difficult teeth to remove4 ,one of the most useful instruments for their extraction is a pair of upper root forceps 7,read's pattern1 fig4 #bb71 which should be held so that the curve of the blades is downwards4 ,the blades should grasp the root on its anterior and posterior surfaces4 ,slight rotary movement may first be attempted1 followed by lateral motion4 ,these movements may be persevered with until the tooth is found to yield4 ,too much haste may lead to a fracture1 which would be extremely difficult to deal with4 ,illustration3 ,,fig4 #dg4 ,illustration3 ,,fig4 #dh4 ,in cases where the crowding is not so great1 and the tooth is more in the normal line of the arch1 a forceps with a narrow outer blade will suffice 7fig4 #df74 ,extractive force should be used principally towards the median line of the mouth1 and this may be combined with slight rotary movement4 ,illustration3 ,,fig4 #di4 7g7 ,impacted ,lower ,third ,molars are amongst the most difficult teeth to extract4 ,where the tooth is deep-seated1 the gum should be pushed aside by careful packing1 and as clear a view of the tooth as is possible obtained4 ,for removing these teeth it is difficult to give any rules1 as each case must be treated on its own merits4 ,as useful an instrument as any for their removal is a curved elevator 7fig4 #di71 the blade of which can often be inserted under the crown1 and assuming that good leverage is thus obtained1 the tooth can be prised up4 ,sometimes the tooth is firmly embedded in the bone4 ,in such cases a clear view of the tooth may be obtained by gradually packing the soft tissues apart1 the periosteum covering the alveolus should then be raised1 and the bone surrounding the tooth cut away with suitable instruments4 ,the tooth1 when freely exposed1 should be removed with an elevator or forceps4 ,the wound resulting must be carefully packed and treated as described on page #he4 ,,chapter ,,iv4 ,the ,use of ,ansthetics during ,extraction of the ,teeth4 ,the ansthetics used during the extraction of teeth may be divided into two classes1 viz43--general and local4 ,it is not proposed to make any allusion to the methods of administering general ansthetics1 as they hardly fall within the scope of this volume4 ,there are1 however1 a few points which the operator should bear in mind when employing them and which may with advantage be briefly dwelt upon1 but before considering these1 a word or two may not be out of place with regard to the choice of the ansthetic4 ,in dental practice three agents are generally used1 nitrous oxide alone or in combination with air or oxygen1 ether and chloroform4 ,in the very large majority of dental operations nitrous oxide is to be preferred to ether and chloroform1 and possesses the great advantage over them of being practically safe4 ,in addition1 the administration of nitrous oxide occupies a shorter period1 and the recovery is rapid and complete4 ,within the last few years1 combinations of nitrous oxide with oxygen and with air have been introduced by ,dr4 ,hewitt and ,mr4 ,rowell respectively1 and both combinations possess advantages over nitrous oxide used alone4 ,the advantages of nitrous oxide and oxygen over nitrous oxide alone are3-- 7#a7 ,the ansthesia is quieter4 7#b7 ,the mucous membranes of the mouth do not swell to the same extent1 and the operator therefore gains a clearer view of the tooth4 7#c7 ,the period of ansthesia is lengthened1 perhaps by only a few seconds1 but the quieter condition of the patient assists indirectly in prolonging the period for operating4 ,the advantages of nitrous oxide with air over nitrous oxide alone are somewhat similar to those of nitrous oxide and oxygen1 though less marked4 ,for operations requiring a long ansthesia1 such as the extraction of a difficult third molar1 ether should be used1 the administration being commenced with nitrous oxide4 ,in such cases many operators prefer to use chloroform1 but the regular employment of this agent in dental surgery is to be severely condemned1 and the cases are rare indeed in which its use is called for4 ,a most careful inquiry into this important subject has been made by ,dr4 ,hewitt1 and the results of his work were communicated in an exhaustive paper published in the ,journal of the ,british ,dental ,association for ,november1 #ahie1 which is well worthy the perusal of all those who are in the habit of administering chloroform4 ,whenever a general ansthetic is given for the removal of teeth1 two people should always be present1 one to confine his attention solely to the administration of the ansthetic1 the other to the removal of the tooth1 as it is impossible for one person to operate and at the same time to observe the condition of the patient during the ansthetic period4 ,this rule should be strictly adhered to4 ,for extraction under nitrous oxide1 and also to a great extent under ether1 the positions of the patients should differ but little if at all from those already advocated1 with this exception1 it is advisable not to have the head too far back4 ,before the administration of the ansthetic is commenced1 any removable artificial teeth that may be in the mouth should be taken out2 the operator should decide exactly what he intends to do2 at the same time it is well not to attempt too much and to avoid pricking the gum during the examination of any roots that it may be necessary to extract4 ,the prop should be placed on sound firm teeth in such a position that the operator can work without being hindered by it1 and a final view of the mouth should be taken4 ,where several teeth have to be extracted at one sitting1 their order of removal should be decided upon before the operation is commenced1 and if any particular tooth is causing pain1 it should be extracted first4 ,the order of removal should also as far as possible be arranged so that changes of instruments are reduced to a minimum4 ,as a rule1 lower teeth should be extracted before upper teeth1 because if the latter are removed first1 the blood may pass down and so obscure the lower ones4 ,roots should be removed before whole teeth for the same reason4 ,each tooth or root must be cleared from the mouth before any attempt is made to remove another except in cases where the gum is thoroughly adherent2 under this condition the tooth or root may be left and freed from the gum when the patient has recovered4 ,with teeth which have a liability to slip out from between the blades of the forceps1 it is well as a precaution to keep a finger of the left hand behind the blades to prevent the tooth passing backwards should it slip out4 ,,local ,,an,,sthetics4 7a7 ,cocaine4--,the most efficacious of the local ansthetics in use is cocaine4 ,it is an alkaloid obtained from the dry leaves of ,erythroxylon ,coca1 and in practice the hydrochlorate form is generally used4 ,for the removal of teeth it is necessary to inject a solution of the drug into the tissues1 a simple application to the gum being of little use4 ,cocaine has the reputation of not being thoroughly reliable in its action1 but this in a great measure often arises from want of care in injecting it4 ,not more than half a grain should be injected for the removal of a tooth1 and even then with people of feeble health1 untoward symptoms may supervene4 ,mode of ,employment4--,a fresh solution of the drug should be made each time its use is called for1 by dissolving a tabloid weighing half a grain in #e minims of distilled water4 ,half of the solution should be injected into the gum on each side of the alveolus4 ,the gum being such a dense tissue1 the solution should be injected slowly1 otherwise the bulk of it will escape by the side of the needle into the mouth4 ,as there is always a tendency for this to happen even when the solution is slowly injected1 it is well to keep a finger of the left hand pressed on the gum where the needle is inserted4 ,speaking personally1 ,i usually occupy about eight minutes over the injection1 and wait for four or five minutes after its completion before operating4 ,as a local ansthetic ,i have generally found cocaine satisfactory1 so far as its ansthetic properties are concerned1 but the occasional appearance of toxic symptoms1 especially in those of feeble health1 should not be lost sight of4 ,tropacocaine has been recommended as possessing the ansthetic properties of cocaine without giving rise to toxic effects1 but in practice ,i have not found these statements fully borne out4 ,toxic ,effects4--,the administration of cocaine1 especially if given in large doses1 may be followed by well-marked toxic effects of which the following are cited by ,dr4 ,hewitt4#d 8,headache2 vertigo2 pallor2 a cold1 moist skin2 a feeble1 slow1 or rapid pulse1 becoming imperceptible in grave cases2 incoherence of speech2 nausea2 vomiting2 unconsciousness2 trismus and other muscular spasms2 epileptiform attacks2 dilated or unequal pupils2 and disturbances of respiration1 culminating in dyspna and asphyxia40 ,the treatment of cocaine poisoning should be directed first to restoring the circulation by the administration of a rapidly acting stimulant1 such as sal-volatile1 brandy1 or the hypodermic injection of ether4 ,the patient should be placed in the horizontal position1 and the respiration watched for2 should this tend to fail1 artificial respiration must be immediately resorted to4 7b7 ,freezing ,agents4--,this group includes such preparations as chloride of ethyl1 coryl 7a mixture of chloride of ethyl and chloride of methyl in such proportions that the mixture boils at #j ,c47 and anestile4 ,generally speaking1 the ansthesia produced is by no means satisfactory1 and to use them to the greatest advantage1 attention must be given to the following points3-- 7#a7 ,the gums must be well dried1 and as far as possible all neighbouring regions1 such as the cheeks or tongue1 protected by napkins or other suitable material4 7#b7 ,the gums must be thoroughly frozen before commencing to operate4 7#c7 ,the extraction must be carried out as quickly as is consistent with thoroughness4 7#d7 ,if possible the spray should be continued during the operation4 7#e7 ,too great a jet should not be used4 ,freezing agents can be employed much better for front than for back teeth1 in fact it is found at times difficult to freeze the gums at all satisfactorily at the back of the mouth4 ,,chapter ,v4 ,difficulties1 ,complications and ,sequel of ,extraction of the ,teeth4 ,like all other surgical operations1 the extraction of teeth is at times attended with certain difficulties1 complications and sequel which for the sake of description will be considered under the following headings3 7#a7 ,difficulties1 complications and sequel connected with the teeth themselves4 7#b7 ,difficulties1 complications and sequel connected with the jaws4 7#c7 ,difficulties1 complications and sequel connected with the soft parts4 7#d7 ,difficulties1 complications and sequel arising during extraction under ansthetics4 7#e7 ,miscellaneous complications1 difficulties and sequel4 7#a7 ,,difficulties1 ,,complications ,,and ,,sequel ,,connected ,,with ,,the ,,teeth ,,themselves4 7a7 ,undue ,resistance of the tooth and alveolus4--,considerable resistance to our efforts to remove a tooth at times occurs4 ,this is naturally most often1 though by no means always1 met with in those of strong physique4 ,teeth isolated are always firmer than those in series2 this is accounted for by a consolidation of the bone around them4 ,experience will act as a guide1 and it is to a certain extent possible1 after a little observation1 to gather from the general appearance of a tooth if it will give more than normal trouble in removal4 ,should undue resistance be met with1 steady attempts to move the tooth slightly in different directions should be made and persevered with2 if this precaution is not taken and too much force is used in any one direction1 fracture of the tooth or alveolus is sure to result4 ,it may1 perhaps1 be found impossible to remove the tooth2 when this is the case it is best to dismiss the patient and to make a fresh attempt two or three days later2 the tooth will then probably be loose1 as a result of the inflammation which has been set up by the previous attempt at extraction1 and can be easily removed4 ,the causes of undue resistance are3-- 7i47 ,abnormal density of the alveolar process4 7ii47 ,divergent and twisted roots4 7iii47 ,alteration in the shapes of the roots brought about by periodontal inflammation 7exostosis74 7b7 ,fracture of the tooth4--,the principal causes of this accident are3-- 7i47 ,the use of badly fitting forceps4 7ii47 ,the use of unnecessary or wrongly applied force in attempting to loosen the tooth in its socket4 ,a tooth having been fractured1 the patient should be made to rinse the mouth until the bleeding has ceased1 the socket should be dried with cotton-wool1 and the position and edge of the root defined with a probe before attempting to remove the fractured portion4 ,it is neglect of these steps that so often leads to failure to remove the remaining portion of a fractured root4 ,too many attempts to remove a fractured root should not be made2 if a second endeavour proves fruitless1 the patient should be dismissed and a fresh attempt1 if necessary1 made after a period of one or two days1 as the tooth will probably then be looser from inflammatory trouble1 moreover1 the hmorrhage having ceased1 it will be possible to obtain a clearer view of the root4 ,before1 however1 dismissing the patient1 an anodyne mouth wash should be prescribed1 and the pulp if exposed touched with carbolic or nitric acid4 ,the lower third of a root may generally be left without fear of unpleasant consequences2 but it is always well to inform the patient when any portion of a tooth is allowed to remain in the jaw1 as such knowledge may be of assistance should any trouble arise at a subsequent date4 7c7 ,crowded and irregular teeth4--,the removal of these has already been referred to in ,chapter ,,iii4 7d7 ,the ,removal of the wrong tooth4--,the removal of the wrong tooth may occur and is naturally due to carelessness on the part of the operator4 ,should this accident arise1 the tooth must be immediately replaced and if necessary secured with a ligature4 ,if the pulp subsequently shows signs of degeneration or inflammation it should be removed and the canal treated and filled4 7e7 ,removal of a neighbouring tooth4--,this may occur and is generally due to a crowded arrangement of the teeth4 ,the accident seems to occur most frequently with the removal of the first permanent lower molar1 the neighbouring tooth usually involved being the second bicuspid which is simultaneously dislocated from its socket4 ,this accident can be avoided by placing the thumb on the tooth which shows a tendency to move1 and exerting only as much force in the removal of the tooth which is being extracted as can be controlled by the thumb4 ,if a neighbouring tooth is removed it must be replaced and treated in the same manner as described above4 7f7 ,removal of an unerupted bicuspid4--,this may be an avoidable or an unavoidable accident4 ,at times the developing bicuspid is so firmly embraced by the roots of the deciduous molar that during the extraction of the latter tooth the bicuspid is removed--such an accident cannot be avoided4 ,it is an avoidable accident when it occurs during the extraction of the roots of a temporary molar and arises from using too much force4 ,as previously pointed out it is best to leave the fractured roots of temporary molars alone unless they can be easily removed4 7g7 ,breaking one tooth in extracting another4--,in the extraction of lower teeth with hawk's-bill forceps the upper teeth may be fractured4 ,this accident is most likely to occur to the inexperienced1 and arises from the tooth leaving its socket suddenly1 due frequently to the extracting force being used in an upward rather than an outward direction4 ,it may1 however1 occur when a lower tooth has been more than normally resistant4 ,in all such cases it is well for the operator to be on guard by keeping the thumb or a finger of the left hand over the joint of the forceps4 ,also in using the elevator an adjacent tooth may be fractured4 7#b7 ,,difficulties1 ,,complications ,,and ,,sequel ,,connected ,,with ,,the ,,jaws4 7a7 ,fracture4--,the fracture and removal of a small piece of the alveolus is not an unfrequent accident which is fortunately by no means serious4 ,it is sometimes unavoidable but at other times is due to getting the blades of the forceps on the outer sides of the alveolus instead of between the bone and the root of the tooth4 ,extensive fracture is sometimes seen1 for instance in a case that came under my notice at the ,dental ,hospital of ,london an unqualified person in removing the first lower right permanent molar fractured the bone in a horizontal direction so that the second and first bicuspids with the canine were completely separated from the body of the bone4 ,mr4 ,salter#e gives an account of an extensive fracture of the jaw which occurred in a lady t4 #ce4 ,the fracture occurred in connection with the removal of the superior central incisors4 ,the right central incisor required some force for its removal1 and when it came away the whole of the front of the alveolus was firmly attached to the root4 ,in removing the left central incisor considerable force was required during the exertion of which the bone was fractured4 ,on examination of the parts the mass of bone corresponding to the intermaxillary bone was found to be merely held in place by the soft tissues4 8,a vertical fracture extended from the side of the canine up to the root of the nose1 then nearly horizontally across to the opposite side1 being connected there with another vertical fracture4 ,the lesion passed completely through the jaw from before backwards1 and there was a wound in the palate three quarters of an inch from the alveolar border1 through which was considerable hmorrhage40 ,a still more severe example of fracture during extraction of teeth is recorded by ,mr4 ,cattlin1#f where in an attempt to remove a third upper molar with an elevator the tuberosity of the maxilla1 a portion of the floor of the antrum and part of the sphenoid were fractured4 ,fracture of the maxilla tuberosity may occur during the removal of the third upper molar1 and ,mr4 ,nicol#g records such an accident during the removal of the second upper permanent molar4 ,in a case recorded by ,mr4 ,l4 ,matheson#h a transverse fracture of the maxilla occurred in a line between the first and second permanent molars during the removal of the first-named tooth4 ,direct transverse fracture of the horizontal ramus of the mandible due to extraction of the teeth has also been recorded4 ,treatment4--,in fracture of small portions of the alveolar process1 no special treatment is called for except that all loose fragments should be removed4 ,when the fracture is of a more extensive character1 the fragments must be retained in position by a suitable form of splint1 a description of which will be found in most works on dental surgery4 7b7 ,necrosis of the alveolus may result from extraction and is generally the result of undue violence or of some septic process occurring in the wound4 ,the treatment to be followed consists of the use of antiseptic and deodorant mouth washes2 the necrosed bone when quite separated from the living tissue should be removed with a pair of suitable forceps4 7c7 ,dislocation of the mandible4--,the use of too much force in extracting a lower tooth and not at the same time counteracting the force by supporting the chin1 may lead to unilateral or bilateral dislocation of the mandible4 ,this accident may also be brought about by forcing the mouth open too much with a ,mason's gag during the administration of an ansthetic4 ,it may likewise occur without the employment of undue force in those who have previously met with or are liable to dislocation4 ,reduction may be brought about by placing the thumbs1 carefully wrapped in a napkin1 on the molar teeth and the palmar surfaces of the fingers below the chin4 ,if downward pressure is then made with the thumbs1 and upward pressure with the fingers1 the condyles of the mandible will generally pass back easily into the glenoid cavity4 ,in cases where more difficulty than this is experienced1 the patient should be placed in a recumbent position1 and corks should be inserted between the back teeth4 ,upward pressure should then be applied on the under surface of the chin4 ,it is advisable1 after reduction1 for the patient to wear a four-tailed bandage for about a week4 7d7 ,forcing a root into the antrum4--,this accident occurs mostly in connection with the extraction of the second upper bicuspid root and buccal roots of the first upper permanent molar4 ,if a root has been so dislocated into the antral cavity as to still partly remain in its socket1 the best course to pursue is to leave it alone and not to attempt removal as the attempt might only result in complete dislocation of the root into the antrum4 ,the socket should be kept quite clean by the continual use of antiseptic washes4 ,as a rule the root gives rise to no subsequent trouble4 ,when a root has been forced completely into the antrum1 the latter should be enlarged and the antral cavity thoroughly syringed4 ,for this purpose it is well to use an aural syringe of five or six ounce capacity4 ,the rationale of this form of treatment is that the root may pass out with the return current from the antrum4 ,if this treatment fails1 an attempt may be made to remove the root with a little scoop of gutta-percha fixed on to a flexible wire4 ,when it cannot be removed in this manner1 the cavity should be thoroughly irrigated with an antiseptic solution and the root left alone1 as it will in all probability become encysted and not give rise to any subsequent trouble4 ,if1 however1 the patient has a history of epitheliomatous disease of the jaws further attempts should be made to remove it4 ,a case where a tooth was forced into the antrum in a patient with a family history of epithelioma of the jaw is recorded in the ,transactions of the ,odontological ,society1 vol4 ii41 page #ae1 old series4 7e7 ,forcing a tooth into an abscess cavity4--,this accident may occur2 if it does1 it requires similar treatment to the accident just described in connection with the antrum4 7f7 ,trismus4--,inability to open the mouth naturally renders extraction of the teeth more difficult than usual4 ,when1 however1 the closure is the result of inflammatory trouble in connection with the lower molars1 an ansthetic should be given and the mouth opened forcibly with a ,mason's gag4 ,if the trismus is the result of tonic contraction of the muscles closing the jaw1 ether should be used in order to overcome the resistance of the muscles1 as nitrous oxide would not have the desired effect4 7#c7 ,,difficulties1 ,,complications ,,and ,,sequel ,,in ,,connection ,,with ,,the ,,soft ,,tissues4 7a7 ,extensive laceration of the gum4--,in cases where a tooth has given rise to much trouble in removal1 the soft tissues naturally suffer1 but apart from this they may be severely lacerated when the gum is more than usually adherent to a tooth4 ,this is most frequently seen in the removal of the lower third molar1 but it is also sometimes met with in the removal of loose teeth4 ,when the gum is found more than usually adherent the tooth should be left in the socket until the gum attachment has been divided with a pair of scissors or a lancet4 ,continued attempts to remove the tooth with the forceps before the gum has been divided will only lead to undue laceration4 ,in all cases where the gums have been badly lacerated1 an anodyne mouth wash should be prescribed4 7b7 ,wounding the tongue4--,this is most likely to occur under nitrous oxide1 as the tongue during ansthesia is generally swollen1 and is1 moreover1 not under the control of the patient4 ,wounding the tongue is nearly always due to carelessness1 and arises generally in using the elevator4 ,when the tongue is much lacerated1 the overhanging portions should be trimmed off with scissors and the surface kept clean with antiseptic mouth washes4 ,if the tongue is punctured and the wound does not involve a large branch of the lingual artery1 but yet bleeds freely1 the tongue should be drawn forward2 if this does not prove successful the insertion of a stitch will generally cause the hmorrhage to cease4 ,if the tongue is punctured and a large branch of the lingual artery is involved1 the finger should be placed on the back of the tongue and the organ drawn forward2 this compresses the lingual artery against the hyoid bone4 ,the bleeding point must then be sought for and1 if found1 an attempt made to twist the wounded vessel4 ,if this fails cauterisation may be tried1 and as a last resource1 if cauterisation does not stop the bleeding1 the lingual artery must be tied4 7c7 ,bruising the lower lips4--,this may occur in the removal of upper bicuspids and molars1 and is due to having the mouth insufficiently opened1 and using forceps of too straight a pattern4 7d7 ,injury of the mandibular nerve4--,the mandibular nerve may be injured during the removal of the lower molars and bicuspids4 ,loss of sensation over the parts supplied by the nerve1 with dribbling of saliva1 generally follows the accident4 ,sensation is1 however1 usually restored1 and in cases of laceration the nerve generally unites4 ,mr4 ,sewill records a case in which 8the roots of a lower wisdom tooth contained a groove and a foramen1 through which the inferior dental nerve had evidently passed40 7e7 ,hmorrhage following tooth extraction is a most important complication1 and one which needs prompt treatment4 ,hmorrhage is predisposed to by a diathesis known as hmophylia4 ,of its pathology but little seems to be definitely known4 ,the blood in this condition is said by ,walsham to be deficient in fibrin4 ,hmorrhage may occur in people not predisposed to the above-named diathesis2 in some instances it is probably due to pathological changes in the artery supplying the tooth1 these changes being frequently induced by inflammation around the apex of the root1 and the vessel becoming adherent to its bony surrounding1 and thus prevented from contracting4 ,another condition1 which may or may not have any practical bearing1 is the occurrence of hmorrhage during the menstrual period4 ,i have1 on two occasions1 had under notice patients for whom teeth have been extracted during this period1 and in whom hmorrhage followed1 but ceased at the termination of the period4 ,teeth had been extracted for both these patients on previous occasions1 without undue hmorrhage following4 ,hmorrhage is generally divided into three stages1 viz43--primary1 intermediate and secondary4 ,in the mouth we often find the primary running into the intermediate4 ,the treatment of primary hmorrhage1 or that occurring at the time of the operation1 is not of serious import4 ,if it is at all sharp a useful plan is to give the patient some tincture of hamamelis in the water used for rinsing the mouth4 ,at the same time about fifteen grains of gallic acid#i should be given1 and the patient should be ordered to take a similar quantity every two or three hours until the hmorrhage ceases4 ,the socket should also be loosely plugged with cotton-wool dipped in some styptic1 such as gallic acid4 ,intermediate and secondary hmorrhage is of a more serious nature1 and generally sets in at night4 ,when a case of intermediate hmorrhage is first seen1 these two important points should be ascertained before treating it3--first1 whether the bleeding is coming from the gums or the socket of the tooth2 secondly1 whether the blood shows a tendency to coagulation4 ,the latter point will act as a guide in the choice of drugs for internal administration4 ,in hmorrhage from the gum search should be made for any small vessels that may be the cause of it1 and if found they should be twisted or compressed4 ,if the vessel is only partially divided it should be completely severed1 as this will probably allow contraction to take place4 ,if the bleeding is capillary in character1 a pad of gutta-percha lined with lint dipped in some styptic and applied with firm pressure is usually sufficient to stop it4#aj ,when the bleeding proceeds from the socket the following mode of procedure is adopted3 some small cone-shaped pieces of non-absorbent cotton-wool are prepared 7each about to inch long and inch broad at the base71 also a pad of lint and a four-tailed bandage2 a syringe1 a pair of conveying forceps1 some cold water and the chosen styptic are likewise placed ready for use4 ,the socket is first freed from clot1 then syringed1 then dried out with a pledget of cotton-wool1 and directly afterwards one of the cone-shaped pieces of cotton-wool dipped in the styptic 7the most useful being tannin7 is placed in the socket and forced to the apex1 with a fair amount of pressure2 the hmorrhage is arrested far more by pressure than by the styptic4 ,more pledgets of wool are inserted until the socket is quite full2 a plug of lint is then placed over all and kept in position by antagonism with the upper teeth1 a four-tailed bandage being used for this purpose4 ,an excellent method of keeping the plug in the socket if the approximal teeth are standing is to wedge a piece of wood between them4 ,excellent as this plan is1 however1 if the hmorrhage is at all sharp it is better to use the four-tailed bandage to make more certain of retaining the plug in position4 ,the number of pledgets of wool inserted in the socket should be counted4 ,the general directions to be given to the patient1 though apparently trivial1 are most important and should never be forgotten4 ,he or she should be advised to go home very quietly1 to avoid all forms of excitement1 to assume the sitting position usual during the day1 and to use a high pillow at night4 ,the patient should be fed through a bent tube1 and all fluids should be given cold4 ,in addition to plugging the socket1 hmostatics should be administered internally4 ,in cases where there is a thin watery blood and no tendency to coagulation it may be fairly assumed that the cause of the hmorrhage lies in the blood1 and such drugs as gallic acid#aa and perchloride of iron#ab are indicated1 but when the blood shows a marked tendency to coagulate in the mouth1 as often happens1 and the bleeding still continues1 such drugs as ergot#ac are indicated2 in this latter condition it may be assumed that the cause of the hmorrhage lies in some want of contractility of the vessel wall1 and ergot causes contraction of unstriped muscular tissue4 ,at the time of plugging the socket a dose of gallic acid1 perchloride of iron or ergot should be given1 and its administration continued at intervals until the bleeding ceases4 ,mr4 ,morton ,smale prefers a hypodermic injection of ergotine4#ad ,the patient should be seen within twenty-four hours after treatment1 and if the bleeding has ceased the plugs may be removed and an antiseptic mouth wash prescribed4 ,this course is not recommended when the hmorrhage has been severe2 under such circumstances the plugs should be allowed to work themselves out4 ,if the hmorrhage has not then ceased1 the socket should be replugged tighter than before with a plug of wood wrapped in non-absorbent cotton-wool4 ,should this prove of no avail the actual cautery may be tried2 if this fails1 and the bleeding is from the mandible1 the canal should be trephined and a plug of ivory inserted1 so as to compress the artery against the inner plate of the bone4 ,in uncontrollable hmorrhage from the maxilla digital pressure on the common carotid opposite the transverse process of the sixth cervical vertebra may be tried2 should this fail to stop the hmorrhage1 ligature of that vessel must be resorted to4 ,in one case of hmorrhage from the region of the third right lower molar ,mr4 ,boyd#ae divided the lip in the median line and reflected the cheek from the jaw4 ,the mandibular canal was then laid open by excising the outer plate of the bone1 and the bleeding was arrested by plugging the mesial and distal ends of the canal4 ,in extreme cases1 with sign of collapse1 normal saline solution#af must be infused into the median basilic vein4 ,in patients predisposed to hmorrhage extraction should be if possible avoided2 but1 if the removal of the tooth be absolutely necessary1 prophylactic treatment should be pursued for three or four days previous to the operation by the administration of one or other of the remedies previously mentioned4 ,a new styptic1 consisting of fibrin ferment #a to #aj to which #a per cent4 of calcium chloride has been added1 is said by ,walsham to act only on the blood1 not on the tissues1 and to be perfectly aseptic4 ,it was found to be effectual in arresting hmorrhage after the division of all the veins except the common jugular in a dog's neck4 ,the tooth should be extracted in the early morning1 as we then have the day before us should hmorrhage occur4 ,some hmostatic should be administered at the time of the operation and the socket plugged at once2 for it is most important to remember that in these cases it is far easier to prevent the hmorrhage occurring than to arrest it when once it has commenced4 ,the subsequent treatment will consist in the continued administration of hmostatic drugs4 7f7 ,injury of the arteries in the neighbourhood of the teeth4--,wound of the lingual artery has been referred to under the heading of injuries to the tongue4 ,laceration of the ranine1 anterior and posterior palatine arteries may also occur4 ,such accidents are usually the result of the forceps slipping and are therefore avoidable4 ,treatment consists in pressure or in twisting or tying the divided vessel4 ,in the case of the anterior or posterior palatine artery it may be found necessary to plug the foramina which give passage to these vessels4 7g7 ,pain following tooth extraction4--,the causes giving rise to pain following the extraction of a tooth are3-- 7#a7 ,incomplete extraction of the tooth1 more especially when the remaining portion contains an exposed pulp4 7#b7 ,too rapid healing of the orifice of the socket4--,it sometimes happens that the margins of the wound left after extraction unite very early1 and when this occurs the discharges which naturally come away from the granulating surface at the base of the socket1 have no exit2 the consequence is that they are retained and set up a local traumatic inflammation1 leading to swelling of the surrounding tissue4 7#c7 ,suppuration in the tooth socket4--,this may be due in the first instance to the use of dirty forceps1 and under such circumstances it may be classed as a poisoned wound4 ,an examination will reveal the presence of greenish putrid pus1 while the tissue around will be much inflamed1 and the portion immediately bordering the wound will have a tendency to slough4 ,a condition of this kind is often seen in hospital nurses and medical students and is no doubt due to infection met with in their daily duties4 ,suppuration in the socket may be due to a lowered vitality of the tissue1 produced by some such local causes as acute or chronic inflammation1 and is especially well seen in cases of extraction for the relief of periodontitis1 or where the operation has been performed in patients suffering from general debility1 syphilis1 struma or in fact any of those systemic diseases which tend to lower the vitality of the organism4 7#d7 ,extensive laceration of the hard and soft tissues in the neighbourhood of the socket2 and 7#e7 ,necrosis of the socket of the tooth are also fruitful sources of pain following tooth extraction4 7#f7 ,the presence in the wound of a foreign body4--,a curious example of this came under notice a few years ago4 ,a patient applied for the extraction of the left first permanent molar4 ,during the operation a portion of one of the cusps disappeared2 a search was made for it but1 as it was not found1 the natural supposition was that it had been removed in rinsing the mouth4 ,the patient for the next three weeks complained of slight pain in the socket for which remedies were tried but proved of little use4 ,eventually the patient discovered the cusp on the top of the granulation tissue which had filled up the socket4 ,in another case of the same character which came under notice1 the offending material was a piece of an amalgam filling4 ,a fractured blade of forceps may likewise act as the offending body4 7#g7 ,injury to the nerve4--,direct injury to the trunk of the nerve is more likely to occur during extraction of the lower third molar than with any other tooth4 ,it is more than probable that many obscure cases of pain following tooth extraction are due to exposure and irritation of the nerve at the apex of the socket4 ,an interesting case of this character was lately reported by ,mr4 ,storer ,bennett4#ag ,the patient1 a lady t4 #bc1 had had the third upper molar dislocated through the use of a ,wood's gag1 and1 as it was considered hopeless to restore the dislocated tooth1 it was extracted without difficulty4 ,the socket in spite of treatment remained painful for the next twelve days1 but in the meanwhile granulated healthily1 except at its apex1 where by the aid of a mirror and probe a spot about the size of a pin's head was noticed which caused the greatest agony on being touched4 ,incision of the nerve produced permanent relief4 ,treatment4--,the treatment naturally depends very much upon the cause4 ,a thorough examination of the socket should be made with probe and mirror4 ,when due to incomplete extraction1 another attempt1 if considered advisable1 may be made to remove the tooth4 ,this proving unsuccessful1 the socket should be swabbed with an anodyne drug and1 if there is an exposed pulp in the remaining portion of the tooth1 the pulp should be touched with fuming nitric acid or strong carbolic acid4 ,the patient should also be advised to use some poppy head fomentation4#ah ,in too rapid healing of the orifice of the socket1 the freshly healed surface must be separated1 the socket syringed out1 and a small tent of lint allowed to remain in the orifice for about twelve hours4 ,an antiseptic mouth wash should also be prescribed4 ,in those cases where the pus is putrid and there is reason to suspect infection1 the socket should be thoroughly syringed with some antiseptic such as hyd4 perchlor4 #a in #a1jjj1 carbolic acid #a in #dj2 following this the parts should be carefully dried with cotton-wool4 ,a small piece of chloride of zinc should then be introduced and allowed to dissolve in the socket1 which must be subsequently kept aseptic by constant irrigation with some antiseptic solution4 ,suppuration is most frequently seen after extraction of the lower teeth owing to the fact that drainage is less easily effected than in the upper1 owing to the dependent position of the socket4 ,in many cases it will be found necessary to plug the socket tightly with non-absorbent cotton-wool dipped in an antiseptic solution2 this prevents the accumulation of dbris which would act as an irritant4 ,in cases of suppuration occurring in patients of diminished vitality a tonic form of treatment should be prescribed2#ai the dressing in the socket should be removed two or three times a day and the socket syringed4 ,care must be exercised in applying escharotics to sockets to which the nerve may be in close proximity2 this is especially necessary in dealing with impacted lower third molars4 ,two cases illustrating this point have come under my notice4 ,in the first a second lower bicuspid with a long standing chronic abscess had been removed4 ,the patient complained of pain1 the socket was syringed out and a small piece of chloride of zinc inserted4 ,intense agonizing pain followed which all local anodynes failed to relieve4 ,in the second case an impacted right lower third molar had been removed4 ,the socket suppurated1 and the pain although severe was not intense4 ,treatment similar to that used in the first case was adopted with similar results4 ,since then in all cases where it is possible that the trunk of the nerve may be in close proximity to the socket1 ,i have used non-irritating antiseptic injections and plugged the socket with cotton-wool dipped in tincture of opium with much more satisfactory results4 ,it is advisable to inform the patient of the possibility of pain following the extraction of a tooth1 especially after periodontitis1 and in all cases where a large number of teeth have been extracted a mouth-wash#bj should be prescribed2 for1 even if there is no pain1 it will prevent the discharge from the sockets of the teeth undergoing putrefactive changes4 ,in pain due to necrosis of the socket deodorant antiseptic injections must be used1 while in extensive laceration of the soft and hard parts an anodyne mouth-wash#ba may be tried4 ,in all obscure cases an application should be made to the socket of some local anodyne such as tincture of opium or cocaine1 and a mouth wash having similar properties should at the same time be prescribed4 7#d7 ,,difficulties1 ,,complications ,,and ,,sequel ,,arising ,,during ,,extraction ,,under ,,an,,sthetics4 7a7 ,tongue slipping back4--,during extraction under ansthetics the tongue not being under control may slip over the larynx1 or may be forcibly pushed back by the fingers of the operator4 ,symptoms of difficult breathing or even arrest of respiration will follow this accident4 ,it is not enough to watch the chest walls1 as respiratory movement may continue without air entering the lungs4 ,treatment consists in pulling the tongue forcibly forward with a suitable instrument and forcibly extending the head on the spinal column4 7b7 ,forcing out a tooth with a prop or a ,mason's gag4--,with a prop this accident may arise from resting it upon teeth which are loose or from placing it in such a way that undue leverage is brought to bear on the teeth4 ,it is an accident most likely to occur when the prop is fixed on the front teeth and the mouth opened to its widest extent4 ,under such conditions undue leverage at right angles to the long axis of the tooth is brought to bear upon the palatal surfaces of the upper teeth and they are consequently forced outwards4 ,with a ,mason's gag the accident is due at times to clumsiness2 great care should therefore be exercised when using this very powerful instrument4 ,if a tooth is forced out it should if possible be immediately replaced4 7c7 ,passage of a foreign body through the isthmus of the fauces4--,a foreign body1 such as a tooth1 a broken piece of forceps or a prop1 passing through the isthmus of the fauces may become impacted in either the air or food passages4 ,in the air passages it may lodge 7#a7 over the entrance of the larynx1 7#b7 in the larynx1 7#c7 in the trachea or bronchus4 ,in the food passages it may lodge 7#a7 in the pharynx1 7#b7 in the sophagus1 7#c7 at the pyloric opening of the stomach4 ,in the air passages4--,should the foreign body lodge over the entrance of or in the larynx the patient will be seized with a violent fit of coughing which may expel it2 but1 should this not happen1 symptoms of asphyxia will supervene4 ,with regard to treatment2 the head should immediately be brought forward and the finger inserted along the side of the mouth into the pharynx1 and then given a forward sweeping movement2 by this means the foreign body1 if lodged at the back of the tongue1 will probably be removed4 ,this failing1 the patient must if possible be inverted and a forcible slap given on the back4 ,if the foreign body is not dislodged by this method1 laryngotomy should be immediately performed4 ,there must be no hesitation about the performance of this operation and it must be carried out promptly1 for the longer it is delayed the less becomes the chance of saving the life of the patient4 ,a foreign body in the trachea or bronchus may give rise to no immediate symptoms1 but generally a violent fit of coughing1 with signs of impending asphyxia1 takes place at the time of the accident4 ,these signs pass away1 to be followed at intervals by fresh attacks of coughing and eventually by symptoms of collapse of the lung or lungs4 ,in a case recorded by ,sir ,william ,mac,cormac1#bb during the removal of an upper bicuspid the palatine blade of the forceps snapped off close to the joint and disappeared4 ,the patient immediately suffered from great dyspna and appeared to be dying4 ,the symptoms passed away1 and for the following six weeks the patient's condition gave no great cause for anxiety1 although she suffered from a constant hacking cough accompanied by bloody expectoration4 ,seven weeks after the accident she was admitted into ,st4 ,thomas's ,hospital1 the foreign body was with difficulty removed from the right bronchus1 and the patient made an excellent recovery4 ,the diagnosis of a foreign body in one bronchus is made by an absence of signs of respiration over the whole or part of the lung on that side1 with exaggerated sounds 7puerile breathing7 over the opposite side4 ,treatment consists in performing tracheotomy and removing the foreign body4 ,in the food passages4--,a foreign body impacted in the pharynx will give rise to pain1 symptoms of dysphagia and dyspna4 ,a hacking cough is generally present4 ,should a foreign body be suspected in the pharynx1 its presence can usually be ascertained by digital exploration2 this failing1 the cavity should be examined by the aid of a laryngoscope4 ,an attempt should first be made to remove the body with the fingers1 and if this is unsuccessful pharyngeal forceps must be called into use4 ,in some cases where the impaction is very firm it may be necessary to perform pharyngotomy4 ,a foreign body in the sophagus will cause dysphagia1 and will probably give rise to constant pain2 if it is situated in the upper part it will in all probability give rise to dyspna4 ,on applying the stethoscope over the region of the sophagus1 a gurgling sound will be heard when the patient swallows fluids4 ,the presence of a foreign body may be definitely ascertained by passing a bougie2 this step will also enable the surgeon to determine the position in which the foreign body is lodged4 ,if impacted in the upper part of the sophagus1 an attempt may be made to remove the impacted body with forceps2 this failing1 sophagotomy must be performed4 ,if lodged near the cardiac end of the sophagus an attempt may be made with a bougie to push the foreign body into the stomach2 this failing1 gastrotomy should be performed4 ,if a foreign body becomes impacted at the pyloric opening of the stomach1 it will give rise to gastric dilatation4 ,under such circumstances the stomach must be emptied of its contents1 and gastrotomy then performed4 ,a foreign body going through the isthmus of the fauces will as a rule pass into the sophagus1 then into the stomach1 and will give rise to no trouble4 ,the details of such operations as gastrotomy1 sophagotomy1 c41 do not lie within the scope of this book1 and should be sought for in works dealing with general surgery4 ,the necessity of being ready for such emergencies as the above cannot be too fully emphasised1 and all who administer ansthetics should be provided with the instruments necessary to perform laryngotomy4 ,these should be kept in a little case1 and no ansthetic should be administered without the case being near at hand4 ,adherence to this rule is important4 7#e7 ,,miscellaneous ,,difficulties1 ,,complications ,,and ,,sequel4 7a7 ,uterine pain4--,a case is quoted by ,mr4 ,sercombe where extraction of a tooth was followed by paroxysmal uterine pain1 followed by the cure of an obstinate leucorrha4#bc 7b7 ,shock4--,the fact that tooth extraction is a surgical operation1 and may be followed by shock1 is often overlooked4 ,the amount of shock which follows as a rule is practically nil1 but at times1 especially in the weak1 it may be well marked4 ,this is not taken sufficiently into account when a question arises as to the number of teeth to be extracted at one sitting1 and it should be clearly borne in mind that what a strong1 able-bodied person1 can stand1 one of weaker physique cannot bear4 ,the wholesale extraction of teeth at one sitting which is carried out by some operators is not advisable1 and the amount of prostration that follows is sometimes very severe4 ,syncope at the time of the operation sometimes occurs4 ,should it supervene during the extraction of the tooth the operator should immediately desist until recovery ensues4 ,fainting is best treated by bending the head down towards the knees1 at the same time loosening anything tight about the neck and applying ordinary salts of ammonia to the nose4 ,in severe cases the patient should be removed from the chair and laid on the floor1 and the chest should be exposed and flipped with a towel dipped in cold water4 ,in more severe cases it may be necessary to inject ether or some other stimulant1 such as brandy4 ,fatal syncope following tooth extraction has occurred1 and a case which took place at ,marseilles in #ahha is mentioned by ,tomes4#bd ,the patient was a female1 and an attempt was made to remove a tooth1 but was desisted in owing to alarming syncope4 ,a second attempt was made1 or rather about to be made1 when fatal syncope ensued4 ,post-mortem examination showed nothing beyond a slight amount of cerebral congestion4 7c7 ,epilepsy4--,in those pre-disposed to epilepsy an attack often commences immediately after the extraction of a tooth4 ,in the event of a fit occurring the patient should be removed from the chair and placed on the floor1 the clothes being at the same time loosened1 and a wedge of wood or some suitable material placed between the teeth to prevent injury to the tongue4 7d7 ,hysteria4--,manifestations of this disorder at times follow tooth extraction1 but do not call for any special treatment beyond that usually adopted for this disorder4 7e7 ,septic and infective sequel4--,scattered through dental literature will be found a large number of records of septic and infective diseases which have followed the extraction of teeth4 ,in many of these cases it would be difficult to say that the infection was always the result of the operation2 in a number of them the actual cause was due to the neglected condition of the tooth which called for extraction4 ,infection can1 however1 at times undoubtedly be traced to the operation1 and once again attention cannot be too strongly drawn to the fact that antiseptic precautions should be carried out as far as possible4 ,suppuration of the socket and its appropriate treatment has already been dwelt upon 7page #hb74 ,cases of syphilis having been acquired through the use of infected forceps are recorded1 while septicmia1 saprmia1 cellulitis1 osteitis1 osteomyelitis1 periostitis1 pymia1 tetanus1 have all been known to follow the removal of a tooth1 but the treatment of these conditions hardly lies within the scope of this book4 ,,index4 ,a ,,page ,abnormality of upper molars1 #bf ,,accidents ,,under ,,an,,sthetics3-- ,forcing out a tooth with a prop or a ,mason's gag1 #hh ,passage of a foreign body through the isthmus of the fauces1 #hi ,tongue slipping back1 #hh ,alveoli of the teeth1 disposition of the1 #ab ,alveolus1 fracture of the1 during extraction1 #fg 8 8 8 8 treatment of1 #fi 8 necrosis of the1 following extraction1 #gj ,ansthetics1 the use of1 during the extraction of teeth1 #ef ,arteries1 injury to the1 in the neighbourhood of the tooth during extraction1 #ha ,b ,bicuspids1 the extraction of lower1 #cd 8 8 8 8 misplaced lower1 #ea 8 8 8 8 8 upper1 #di 8 8 8 8 upper1 #bb ,breaking one tooth in extracting another1 #fg ,bruising the lower lips during extraction1 #gd ,c ,canines1 the extraction of lower1 #cd 8 8 8 8 upper1 #ba ,central incisors1 the extraction of lower1 #cc1 #ea 8 8 8 8 8 upper1 #ai ,chloride of ethyl1 #fa ,chloroform1 the use of1 during the extraction of the teeth1 #ef1 #eg ,cocaine1 mode of employment1 #fj 8 toxic effects1 #fa ,,complications1 ,,difficulties ,,and ,,sequel ,,of ,,extraction ,,of ,,the ,,teeth3-- ,complications1 difficulties1 and sequel arising during extraction1 miscellaneous1 #id ,complications1 difficulties and sequel arising during extraction under ansthetics1 #hh ,complications1 difficulties and sequel of extraction of the teeth connected with the jaws1 #fg ,complications1 difficulties and sequel of extraction of the teeth connected with the soft tissues1 #gb ,complications1 difficulties and sequel of extraction of the teeth connected with the teeth themselves1 #fc ,coryl1 #fa ,d ,,difficulties1 ,,complications ,,and ,,sequel ,,arising ,,during ,,extraction1 ,,miscellaneous3-- ,epilepsy1 #id ,hysteria1 #id ,septic and infective sequel1 #ie ,shock1 #ic ,uterine pain1 #ic ,,difficulties1 ,,complications ,,and ,,sequel ,,arising ,,during ,,extraction ,,under ,,an,,sthetics3-- ,tongue slipping back1 #hh ,forcing a tooth out with a prop or ,mason's gag1 #hh ,passage of a foreign body through the isthmus of the fauces1 #hi ,,difficulties1 ,,complications ,,and ,,sequel ,,connected ,,with ,,the ,,jaws3-- ,dislocation of the mandible1 #gj ,forcing a root into the antrum1 #ga ,forcing a tooth into an abscess cavity1 #gb ,fracture1 #fg 8 treatment of1 #fi ,necrosis1 #gj ,trismus1 #gb ,,difficulties1 ,,complications ,,and ,,sequel ,,connected ,,with ,,the ,,teeth ,,themselves3-- ,breaking one tooth in extracting another1 #fg ,crowded and irregular teeth1 #fe ,fracture of the tooth1 #fd ,the removal of a neighbouring tooth1 #ff 8 8 an unerupted bicuspid1 #ff 8 8 the wrong tooth1 #ff ,undue resistance of the tooth and alveolus1 #fc ,,difficulties1 ,,complications ,,and ,,sequel ,,in ,,connection ,,with ,,the ,,soft ,,tissues3-- ,bruising the lower lips1 #gd ,extensive laceration of the gum1 #gb ,hmorrhage following tooth-extraction1 #gd 8 8 8 treatment of1 #gf ,injury of the arteries in the neighbourhood of the teeth1 #ha ,injury of the mandibular nerve1 #gd ,pain following tooth extraction1 #ha ,wounding the tongue1 #gc ,disposition of the alveoli of the teeth1 #ab ,e ,elevator1 #g ,epilepsy1 attack of1 following tooth extraction1 #id ,ethyl1 chloride of1 #fa ,extraction of impacted lower third molars1 #ed 8 8 individual teeth1 #ai 8 8 lower bicuspids1 #cd 8 8 8 canines1 #cd 8 8 8 incisors1 #cc 8 8 8 molars1 #ce 8 8 8 teeth1 #cj 8 8 misplaced lower bicuspids1 #ea 8 8 8 8 incisors1 #ea 8 8 8 teeth1 #df 8 8 8 upper bicuspids1 #di 8 8 8 8 canines1 #dh 8 8 8 8 central incisors1 #dg 8 8 8 8 lateral 81 #dg 8 8 temporary teeth1 #ag1 #dc ,extraction of upper bicuspids1 #bb 8 8 8 canines1 #ba 8 8 8 incisors1 #ai 8 8 8 molars1 #bc 8 8 8 teeth1 #ai 8 8 the teeth1 general principles of1 #a 8 with forceps1 #ad ,f ,forceps1 holding of1 #f ,forceps1 the1 #c ,forcing a root into the antrum during tooth extraction1 #ga 8 8 tooth into an abscess cavity during tooth extraction1 #gb 8 out a tooth with a prop or a ,mason's gag1 accidents under ansthetics1 #hh ,fracture of the alveolus during tooth extraction1 #fg 8 8 8 8 treatment of1 #fi 8 8 8 tooth during tooth extraction1 #fd ,freezing agents1 local ansthetics1 #fa ,g ,general principles of extraction of the teeth1 #a ,gum1 extensive laceration of the1 during tooth extraction1 #gb ,h ,hmorrhage following tooth extraction1 #gd 8 8 8 8 treatment of1 #gf ,hewitt1 ,dr41 on the toxic effects of cocaine1 #fa 8 8 8 8 use of chloroform in operations1 #eg ,holding of elevator1 #i 8 8 the forceps1 #f ,hysteria1 attack of1 following tooth extraction1 #id ,i ,impacted lower third molars1 the extraction of1 #ed ,incisors1 the extraction of lower1 #cc 8 8 8 8 misplaced lower1 #ea 8 8 8 8 8 upper central1 #dg 8 8 8 8 8 8 lateral1 #dg ,incisors1 the extraction of upper1 #ai ,individual teeth1 the extraction of1 #ai ,injury of the arteries in the neighbourhood of the tooth during extraction1 #ha 8 to the mandibular nerve during tooth extraction1 #gd ,instruments1 #c ,irregular and crowded teeth1 difficulties during extraction through1 #fe ,l ,laceration of the gum through tooth extraction1 extensive1 #gb ,lateral incisors1 the extraction of misplaced upper1 #dg ,lips1 bruising the lower1 during tooth extraction1 #gd ,local ansthetics1 #ei ,lower bicuspids1 misplaced1 the extraction of1 #ea 8 incisors1 misplaced1 the extraction of1 #ea 8 8 the extraction of1 #cc 8 teeth1 the extraction of1 #cj 8 third molars1 impacted1 the extraction of1 #ed ,m ,mandible1 ,dislocation of the1 during tooth extraction1 #gj ,mandibular nerve1 injury to the1 during tooth extraction1 #gd ,miscellaneous complications1 difficulties and sequel1 #ic ,misplaced lower bicuspids1 the extraction of1 #ea 8 8 incisors1 the extraction of1 #ea 8 teeth1 the extraction of1 #di 8 upper bicuspids1 the extraction of1 #di 8 8 canines 8 81 #dh 8 8 central incisors1 the extraction of1 #dg 8 8 lateral 8 81 #dg ,molars1 impacted lower third1 #ed 8 the extraction of lower1 #ce 8 8 8 upper1 #bc ,n ,necrosis of the alveolus following tooth extraction1 #gj ,nitrous oxide1 the use of1 during the extraction of the teeth1 #ef1 #eg1 #eh ,nitrous oxide with air1 the use of1 during the extraction of the teeth1 #ef1 #eg1 #eh ,o 8,oblique rooted0 molars1 #bf ,operations requiring a long ansthesia1 #eg ,order of removal of teeth1 #ei ,p ,pain following tooth extraction1 #hc ,passage of a foreign body through the isthmus of the fauces1 accidents under ansthetics1 #hi ,points in the anatomy of the teeth and jaws1 #aa ,position of the operator and patient1 #aj ,r ,removal of a neighbouring tooth during extraction1 #ff 8 8 an unerupted bicuspid 8 81 #ff 8 8 teeth1 the order of1 under ansthetics1 #ei 8 8 8 with straight elevator1 #ae 8 8 the wrong tooth during tooth extraction1 #ff ,s ,screw1 the1 #i ,septic and infective sequel following extraction1 #ie ,sequel1 difficulties and complications arising during extraction1 miscellaneous1 #ic ,sequel1 difficulties1 complications and1 arising during extraction under ansthetics1 #hh ,sequel1 difficulties1 complications and1 of extraction of the teeth connected with the jaws1 #fg ,sequel1 difficulties1 complications and1 of extraction of the teeth connected with the soft parts1 #gb ,sequel1 difficulties1 complications and1 of extraction of the teeth connected with the teeth themselves1 #fc ,shock following extraction1 #ic ,t ,teeth1 general principles of extraction of the teeth1 #a 8 which require extraction1 #a ,temporary teeth1 the extraction of1 #ag1 #dc ,tongue slipping back1 accidents under ansthetics1 #hh ,treatment of fracture of the alveolus during tooth extraction1 #fi ,treatment of hmorrhage following tooth extraction1 #gf ,trismus1 treatment of1 #gb ,u ,undue resistance of the tooth and alveolus1 #fc ,upper bicuspids1 misplaced1 the extraction of1 #di 8 canines1 misplaced1 the extraction of1 #dh 8 central incisor1 misplaced1 the extraction of1 #dg 8 lateral 8 8 8 8 81 #dg 8 teeth1 the extraction of1 #ai ,use of ansthetics during the extraction of the teeth1 #ef ,uterine pain following tooth extraction1 #ic ,w ,wounding the tongue during tooth extraction1 #gc ,wound resulting from removal of a tooth1 #af 99 99 99 99 99 ,,diseases ,,and ,,injuries ,,of ,,the ,,teeth1 ,including ,pathology and ,treatment1 ,a ,manual of ,practical ,dentistry for ,students and ,practitioners4 ,,by ,,morton ,,smale1 ,m4,r4,c4,s41 ,l4,s4,a41 ,l4,d4,s41 ,dental ,surgeon to ,st4 ,mary's ,hospital2 ,dean of the ,school1 ,dental ,hospital of ,london2 ,member of ,board of ,examiners in ,dental ,surgery1 ,royal ,college of ,surgeons of ,england4 ,,and ,j4 ,f4 ,,colyer1 ,l4,r4,c4,p41 ,m4,r4,c4,s41 ,l4,d4,s41 ,dental ,surgeon and ,lecturer on ,dental ,surgery to ,charing ,cross ,hospital and to the ,dental ,hospital of ,london4 #ccd illustrations4 #djg pp4 and ,index4 #hvo1 cloth4 ,price #aes4 ,,supplied ,,by ,,claudius ,,ash ,,sons1 ,limited1 #e1 #f1 #g1 #h1 #i1 ,,broad ,,street1 ,,golden ,,square1 ,,london1 ,w4 ,,england4 ,,footnotes3 #a ,a description of the different instruments in general use for the removal of the various teeth will be found in chapter ii4 #b ,a description of the form of each tooth1 with respect to its bearing upon the construction of forceps and its removal1 will be found in chapter ii4 #c ,the following is a useful formula3-- ,liquoris potass vi4 ,acidi carbolici glacialis ij4 ,aquam ad4 viii4 ,m4 ,one teaspoonful to be used with half a tumbler-full of warm water as a mouth wash4 #d 8,a ,system of ,surgery0 7edited by ,frederick ,treves71 vol4 i41 page #bib4 #e 8,dental ,pathology and ,surgery10 page #cdj4 #f ,transactions ,odontological ,society1 vol4 iii41 page #ach4 #g ,transactions ,odontological ,society1 vol4 xxviii41 page #c4 #h ,journal ,british ,dental ,association1 vol4 xiv41 page #gbg4 #i ,acidi gallici ij4 ,ft4 pulv4 viij4 ,one powder every two hours until the hmorrhage ceases4 #aj ,perchloride of iron should be avoided as a styptic1 it nearly always contains some free acid1 and is therefore detrimental to the teeth2 in addition to this it leads to extensive clotting in the veins1 as well as to a certain amount of sloughing of the gums4 #aa ,acidi gallici ij4 ,ft4 pulv4 viij4 ,one powder every two hours until the hmorrhage ceases4 #ab ,liq4 ferri perchloridi xxv4 ,aqu chloroformi ij4 ,aquam ad j4 ,mitte viij4 ,m4 ,two tablespoonfuls every three hours until the hmorrhage ceases4 #ac ,ext4 ergot liquidi xx4 ,acidi sulphurici diluti x4 ,aquam ros ad4 j4 ,mitte viij4 ,m4 ,two tablespoonfuls every three hours until the hmorrhage ceases4 #ad ,injectio ergotini hypodermica ,b4,p43 #a of ergotine to #b of camphor water4 ,dose #c to #aj minims1 made as required4 #ae ,dental ,record1 vol4 xi41 p4 #dbe4 #af ,common salt1 j41 water #j;j4 at #ii ,f4 #ag ,transactions of the ,odontological ,society1 vol4 xxvii41 page #abc4 #ah ,two ounces of poppy heads should be placed in one pint of boiling water1 the water being boiled down to half a pint4 #ai ,ferri et quini citratis gr4 vi4 ,aqu chloroformi ij4 ,infusum quassi ad4 i4 ,mitte viij4 ,m4 ,two tablespoonfuls three times a day after meals4 #bj ,the following will be found useful3-- ,boro-glyceride 7,barff7 ,eau de ,cologne aa4 iv4 ,tinct4 krameri ,spirit vini4 rect4 ad4 iv4 ,fiat lotio4 ,to be used with water as a mouth wash4 ,shake before using4 #ba ,zinci sulphatis gr4 viij4 ,zinci chloridi gr4 vi4 ,morphin acetatis gr4 ij4 ,aquam ad4 viij4 ,fiat lotio4 ,to be used with an equal quantity of water as a mouth-wash4 #bb ,the ,journal of the ,british ,dental ,association1 vol4 vii41 page #cb4 #bc ,british ,journal ,dental ,science1 vol4 iii41 page #bba4 #bd 8,a ,system of ,dental ,surgery10 #crd edition1 page #fbf4