Frank Colyer

“ Whenever a general anæsthetic is given for the removal of teeth, two people should always be present, one to confine his attention solely to the administration of the anæsthetic, the other to the removal of the tooth, as it is impossible for one person to operate and at the same time to observe the condition of the patient during the anæsthetic period. ”

“ In removing the third molars it is advisable not to have the patient’s mouth opened to the fullest extent, as the tension of the tissues of the cheek will thereby be lessened and a clearer view of the outer side of the tooth thus gained. The application of the forceps is of the utmost importance, as one is liable, unless care is taken, to include some of the soft tissue between the blades{26} and the tooth and so cause a painful laceration. Force applied inwards and then outwards is generally sufficient to loosen these teeth, their removal being carried out by a downward and outward movement. ”

“ Wounding the tongue.—This is most likely to occur under nitrous oxide, as the tongue during anæsthesia is generally swollen, and is, moreover, not under the control of the patient. Wounding the tongue is nearly always due to carelessness, and arises generally in using the elevator. When the tongue is much lacerated, the overhanging portions should be trimmed off with scissors and the surface kept clean with antiseptic mouth washes. If the tongue is punctured and the wound does not involve a large branch of the lingual artery, but yet bleeds freely, the tongue should be drawn forward ”

“ It is advisable to inform the patient of the possibility of pain following the extraction of a tooth, especially after periodontitis, and in all cases where a large number of teeth have been extracted a mouth-wash [20] should be prescribed; for, even if there is no pain, it will prevent the discharge from the sockets of the teeth undergoing putrefactive changes.
In pain due to necrosis of the socket deodorant antiseptic injections must be used, while in extensive laceration of the soft and hard parts an anodyne mouth-wash [21] may be tried. ”

“ Extractive force should be applied principally in the outward direction, and if this is not sufficient, slight rotary movement should be tried. In cases where there is less room between the approximal teeth, the projecting tooth may be removed with a pair of straight forceps (fig. 17) , the blades being applied to the mesial and distal aspects of the root. The blades should not be driven very far up, and the loosening of the tooth should be accomplished by slight rotary motion, in using which care should be taken to avoid loosening the approximal teeth. ”

“ From the wound caused by the removal of a lower tooth such is not the case, and should suppuration take place the socket must be frequently syringed with some antiseptic solution, and if necessary, packed.
The Extraction of the Temporary Teeth.—Although the actual details of the extraction of the temporary teeth do not differ from those of the permanent teeth, there are, nevertheless, one or two points to which attention may with advantage be directed. First and foremost, a child should not be deceived, and if it is necessary to extract a tooth, the child should be told and not taken unawares. ”

“ In cases where the resistance presented by the roots is very great and an unsuccessful attempt has been made with ordinary root forceps, an instrument with a buccal blade similar to that shown in fig. 24 may be used. The inner blade is first applied, the outer one being brought so as to come,{30} if possible, into the space between the buccal roots. A firm hold of the roots having been gained, an attempt to extract should be made by force applied in an inward and outward direction; this failing, sufficient pressure should be put upon the handles to split the roots asunder. ”

“ 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 tissues. “A vertical fracture extended from the side of the canine up to the root of the nose, then nearly horizontally across to the opposite side, being connected there with another vertical fracture. The lesion passed completely through the jaw from before backwards, and there{69} was a wound in the palate three quarters of an inch from the alveolar border, through which was considerable hæmorrhage.” ”

“ The roots of lower bicuspids are to be removed in a manner similar to that required for the extraction of a whole tooth. 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 forceps; in such cases, if an attempt with forceps has failed, the straight elevator may be employed. ”

“ The internal and external surfaces of the root are for all practical purposes of equal curvature.
The second bicuspid has usually only one root, which is not so flattened in the antero-posterior diameter as the first. There is also not the same tendency to grooving or bifurcation of the root as there is in the first bicuspid.
The blades of forceps for the bicuspids should be equal segments of the same circle; they should also be bent at an angle with the handles, so that the latter may clear the lower lip. The forceps shown in fig. 18 is a useful pattern. ”

“ The advantages of nitrous oxide with air over nitrous oxide alone are somewhat similar to those of nitrous oxide and oxygen, though less marked.
For operations requiring a long anæsthesia, such as the extraction of a difficult third molar, ether should be used, the administration being commenced with nitrous oxide. In such cases many operators prefer to use chloroform, but the regular employment of this agent in dental surgery is to be severely condemned, and the cases are rare indeed in which its use is called for. ”

“ The socket is first freed from clot, then syringed, then dried out with a pledget of cotton-wool, and directly afterwards one of the cone-shaped pieces of cotton-wool dipped in the styptic (the most useful being tannin) is placed in the socket and forced to the apex, with a fair amount of pressure; the hæmorrhage is arrested far more by pressure than by the styptic. More pledgets of wool are inserted until the socket is quite full; a plug of lint is then placed over all and kept in position by antagonism with the upper teeth, a four-tailed bandage being used for this purpose. ”

“ If a tooth is forced out it should if possible be immediately replaced.
(c) Passage of a foreign body through the isthmus of the fauces.—A foreign body, such as a tooth, a broken piece of forceps or a prop, passing through the isthmus of the fauces may become impacted in either the air or food passages.
In the air passages it may lodge (1) over the entrance of the larynx, (2) in the larynx, (3) in the trachea or bronchus.
In the food passages it may lodge (1) in the pharynx, (2) in the œsophagus, (3) at the pyloric opening of the stomach. ”

“ One of the most useful instruments for their extraction is a pair of upper root forceps (Read’s pattern, fig. 22) , which should be held so that the curve of the blades is downwards. The blades should grasp the root on its anterior and posterior surfaces. Slight rotary{53} movement may first be attempted, followed by lateral motion. These movements may be persevered with until the tooth is found to yield. Too much haste may lead to a fracture, which would be extremely difficult to deal with. ”

“ Mr. Salter [5] gives an account of an extensive fracture of the jaw which occurred in a lady æt. 35. The fracture occurred in connection with the removal of the superior central incisors. The right central incisor required some force for its removal, and when it came away the whole of the front of the alveolus was firmly attached to the root. In removing the left central incisor considerable force was required during the exertion of which the bone was fractured. ”

“ The movement to be employed depends upon the form of the root or roots to be removed and the resisting strength of the surrounding hard structures, and at this point it need only be remarked that rotary motion is alone admissible in the case of teeth possessing a single conical root. ”

“ In all obscure cases an application should be made to the socket of some local anodyne such as tincture of opium{88} or cocaine, and a mouth wash having similar properties should at the same time be prescribed.
(4) DIFFICULTIES, COMPLICATIONS AND SEQUELÆ ARISING DURING EXTRACTION UNDER ANÆSTHETICS.
(a) Tongue slipping back.—During extraction under anæsthetics the tongue not being under control may slip over the larynx, or may be forcibly pushed back by the fingers of the operator. Symptoms of difficult breathing or even arrest of respiration will follow this accident. ”

“ Upper Incisors.—The roots of both the upper central and lateral incisors are usually cone shaped, the anterior surface being the arc of a greater circle than that of the posterior. Forceps for the removal of these teeth ought therefore to have the blades made in a corresponding manner (see fig. 17) . The lateral incisor is smaller than the central, and has at times a root somewhat flattened. In removing upper incisors the posterior blade is applied first, care being taken to{20}
Fig. ”

“ It is not enough to watch the chest walls, as respiratory movement may continue without air entering the lungs. Treatment consists in pulling the tongue forcibly forward with a suitable instrument and forcibly extending the head on the spinal column. ”

“ When, too, a child resists having a tooth removed, the operation must not be forcibly carried out, for by a little patience and moral suasion on the part of the operator, the better side of a child’s nature can generally be{18} gained. ”

“ Hewitt. [4]
“Headache; vertigo; pallor; a cold, moist skin; a feeble, slow, or rapid pulse, becoming imperceptible in grave cases; incoherence of speech; nausea; vomiting; unconsciousness; trismus and other muscular spasms; epileptiform attacks; dilated or unequal pupils; and disturbances of respiration, culminating in dyspnœa and asphyxia.” The treatment of cocaine poisoning should be directed first to restoring the circulation by the administration of a rapidly acting stimulant, such as sal-volatile, brandy, or the hypodermic injection of ether. ”

“ The points to be specially noted in the maxilla are the thinness of the outer alveolar wall as compared with the inner, the prominence of the canine socket, and the cancellous character of the bone in the region of the third molar. In the mandible the outer alveolar border will be seen to be thinner than the inner, with the exception of that portion in the region of the{13}
Fig. ”