Teeth, moreover, show at times excessive development or marked displacement or defects of development. Thus they erupt in abnormal positions, or fail completely in eruption, or they project in abnormal directions or are sometimes amalgamated. The art and science of the dentist permit of wonderful control of abnormal development of those teeth which once appear upon the surface. Children whose teeth are irregularly placed, or which are abnormal in any respect, should be placed under the care of a competent specialist. The most serious tumors of the teeth are those connected with cyst formation, which may assume considerable size. A dentigerous cyst is proper material for the surgeon rather than for the dentist, inasmuch as while the operation can be usually done through the mouth it may require external incision and removal of a considerable shell of bone, perhaps with plastic restoration of tissues.
THE EXTRACTION OF TEETH.
The general practitioner has often to remove diseased teeth as well as the surgeon. The theory of tooth extraction is simple. Its performance, especially when the tooth is diseased, may be exceedingly difficult, for such teeth may be crumbled in consequence of the force needed for their removal.
Forceps of different shapes are required for the various teeth. At least half a dozen different patterns are requisite. A form of elevator is also of use in elevating stumps which may lie beneath the alveolar border.
The tooth to be removed should be seized along the fang and beyond the crown. The blades of the forceps should be pressed firmly down and along the tooth, in order to separate from it the softer tissues of the gum and the firmer tissue of the alveolar socket. This is thinner upon its outer aspect than its inner, save in the location of the wisdom tooth, and it is the outer border which is more easily broken away by force applied toward the cheek rather than toward the interior of the mouth. Using first one blade of the forceps and then the other to split the socket and separate the osteofibrous tissues, the tooth being then firmly grasped between them, the operator makes a series of rocking movements, by which it is itself loosened and its further attachments torn, until by a lifting effort it can be extracted from the socket. In this minor operation the head must be firmly held with the disengaged hand, or better between the forearm and the operator’s body, while with that hand he supports and manipulates the lower jaw, if it be a lower tooth which is to be removed.
The operation is painful for the moment. With timid patients local anesthesia may be produced with cocaine or one of its substitutes, the solutions being sterile, and either locally applied around the socket or injected into the surrounding tissues with the ordinary hypodermic syringe needle. Such attempts are not without their own danger, for I have seen serious infection follow the introduction of unsterile solutions by dentists not familiar with aseptic technique. Again, nitrous oxide gas may be administered, it being usually necessary to employ a mouth-gag. Recovery from anesthesia is prompt and muscle spasm may not be entirely abolished; therefore, the gag should be inserted before the gas is administered. It may be sufficient for the purpose to employ a good-sized piece of cork, to which a cord should be attached in order that it may not disappear down the patient’s throat during a violent effort at inspiration. The horizontal position is the safer for this purpose.
It is especially the removal of fangs or roots which gives the greatest trouble in these cases. For this purpose special forceps are devised, but for their use it is necessary to clear away the gum and periosteum and to cut away a portion of the alveolar process. Such broken fragments of teeth allowed to remain give rise to curious reflexes, such as convulsions, neuralgia, etc., all of which makes it apparent that the extraction of a tooth being undertaken it should be thoroughly performed. After its removal the patient should rinse his mouth with water as hot as can be borne, to check hemorrhage. The removal of the tooth having left an open pathway for infection, antiseptic mouth-washes should be frequently used and the socket packed with antiseptic gauze. Except in rare instances granulation tissue fills the cavity and the process of repair is rapid.
Among the accidents which may follow extraction of teeth are hemorrhage, which may be checked by plugging and the use of adrenalin. Adjoining teeth are occasionally injured in clumsy efforts at extraction, while not infrequently a patient who has not sufficiently described his symptoms has indicated to the dentist the wrong tooth, whose consequent extraction has, therefore, not relieved him of his difficulty. Some teeth have such spreading roots as to make their removal extremely difficult, and even careful operators have occasionally inflicted fractures, especially of the lower jaw. The treatment of such an accidental fracture will not be different from that of fractures otherwise produced. Such an accident as forcing a tooth upward into the antrum of Highmore should be followed by its removal, even at the expense of further operation, while excessive tearing of the alveolar border, or especially of the gum, may be treated by suitable packing or by suturing. The accident of aspiration into the larynx of part or all of a tooth just removed has been known to be followed by suffocation. The operator, therefore, should not release the tooth from the grasp of the forceps until the latter are entirely out of the mouth.
By accident or from indifference it may happen that a healthy tooth has been removed instead of one diseased. Should this happen the tooth may often be re-implanted after being cleansed, and will usually resume its previous position and function. So feasible is such re-implantation of teeth that they have been frequently removed or transplanted from one mouth to another, for a compensation, a new socket being made for the reception of the healthy tooth just removed from the mouth of the individual willing to part with it.