the under surface of the plate, as proposed by Dr.
Bing, he proceeded as follows : — The contour of the
tooth was restored in wax, after which an impres-
sion in plaster was taken, from which a model was
made, and from this a die and matrix. With these
plates were swaged, covering the defective parts of
the teeth to be treated or filled, and on the inner
surface of these plates loops of gold, or platina wire,
were soldered. Gutta-percha, or Hill's stopping, was
• now softened and carefully packed on these plates
and through the loops, and the tooth was likewise
filled with gutta-percha. The plates were now put
in the mouth over the teeth they were intended to
cover, and by means of a heated instrument the
gutta-percha in the tooth and on the plate was
softened and united, and the edges of the plate
burnished down to the remains of the tooth. When
finished the operation presented the appearance of a
well-executed and laborious gold filling. Dr. Essig
THE PERMANENT TEETH. 31
stated that the material, Hill's stopping, was well
known as most excellent for the preservation of the
teeth, cases having been brought to his attention
where it had effectually done this for fifteen years,
in localities not subjected to the attrition of masti-
cation. The object of these gold caps was to over-
come this liability to wear in the material. The
plates were of pure gold (made from scraps of gold
foil), which was milled down to number 29 of the
standard gauge. Dr. Essig laid no claim to
originality in this matter, according the idea
entirely to Dr. Bing. The only point of difference
in what he now proposed was the attempt at
restoration of contour, which Dr. Bing did not
resort to, so far as he was informed. For the better
understanding of the two methods, Dr. Essig illus-
trated both plans on the blackboard. Dr. Bing's
plan was to dress down the crown of the tooth ; the
entire cavity of decay was now filled with Hill's
stopping, and a pure gold plate, to which two loops
of gold or platina were soldered (thus r\ r\ ),
was warmed, and while warm was pressed into the
gutta-percha already inserted into the tooth, after
the cooling of which the edges of the gold could
be neatly burnished down to the edges of the
tooth. By this plan onhj simple crown cavities were
attempted. Dr. Bing kept on hand, ready made
for these cases, thin plates of different sizes, and
applied them in size to suit each case. Dr. Essig
had acted on the suggestion, but proposed to
extend the field of its usefulness in cases where
32
DENTAL PRACTICE.
proximate, buccal, or palatal walls were consumed
by decay. He proposed to restore the tooth in
shape as well as usefulness as follows : — cutting
down the tooth wherever a comparatively firm
border could be obtained, he restored the contour
in wax, and, by having the patient close the jaws,
obtained from the antagonizing tooth a complete
and proper occlusion. By this plan teeth in almost
any stage of decay might be made serviceable for a
considerable time. The idea will be better under-
stood by the following diagrams. (Figs. 9 and 10.)
,t0I\ul^.
Figure 9.
Fi.'uie 10.
The case illustrated a was now restored in wax as in
h ; when, as stated, an impression in plaster would
be taken, plaster model made, and die and counter-
die obtained ; a gold cap could now be swaged, and
loops soldered to it, as represented in Fig. 10. The
body of this gold cap is filled with softened Hill's
stopping, as well as the remains of the tooth. The
cap is placed in position, and with a heated instru-
ment the temperature is conveyed through the gold
THE PEEMANENT TEETH. 33
cap to the gutta-percha in both tooth and cap. The
jaws may now be closed while the gutta-percha is
soft, and when cooled off, the excess of Hill's stop-
ping removed, and the edges of the gold burnished
down to the tooth. To a cursory glance the whole
operation presents the appearance of an artistically
executed contour gold filling. These dies and plates
may all be made by assistants in the laboratory,
, and the entire operation may not call for more
than fifteen to thirty minutes of the operator's time.
Dr. Essig gave the preference to Hill's stopping
over oxy-chloride of zinc in these frail teeth, as he
said he had found that, when large masses of this
were used, it had sufficient expansive force to some-
times break a weak wall of enamel."
When a child is brought to us with toothache in
one of these teeth, as will, unfortunately, often be
the case — for all parents will not remember our
teaching, or take the care which we have told them
would be necessary to prevent pain — we must first
ascertain whether it is primary or secondary tooth-
ache, as in the case of the temporary teeth, page 10,
and then proceed to devitalize the pulp, or to open
the pulp cavity and give vent to the gases or pus, as
the case may require. But as this is a permanent
tooth, we must try to preserve it, at least until the
jaw is sufficiently grown to make room for the
eruption of the twelve-year molar.
If devitalization is necessary — and we must be
quite sure that it is necessary, from satisfaction of
our own judgment, more than from the patient's
c
34 DENTAL PRACTICE.
convictions or statements — it will be best to remove
the arsenical dressing within a week, and then,
after cleansing the cavity, and making a sufficient
opening into the pulp cavity to permit the free
escape of gases, a simple dressing of cotton and
stiff sandarac varnish may be placed in the tooth,
to remain about a month, or until the pulp has
separated, by sloughing, from its connections at the
apical foramen. Then, after carefully removing all
the decomposing matter with fine barbed instru-
ments, and syringing with a five per cent, solution
of carbolic acid— or any other antiseptic that can be
used in sufficiently weak dilution to retain its anti-
septic qualities, without so much of the escharotic
nature as to be unpleasant in the mouth — the roots
may be filled. There are many ways of doing this, —
some dentists insisting that gold is the only safe
material for filling roots ; some would have this
used in the form of wire and screwed in, while
others can only be satisfied with soft foil, malleted
in ; some prefer tin, some gutta-percha, others oxy-
chloride, and others again prefer amalgam. Most
operators enlarge the pulp canal very much in
order to facilitate the process of filling, and, per-
haps naturally enough, every operator thinks his
own method the best, if not the only method of
performing the operation ; but all that is really
wanted is to occupy the space, so as to exclude
everything that is liable to decomposition. A root-
filling is not exposed to the action of the oral
fluids, nor to attrition ; therefore it cannot be neces-
THE PERMANENT TEETH. 35
sary to exi^end so much labour as will be required
to pack gold, or tin, into a long narrow root canal.
Oxy- chloride of zinc does very well indeed, but to
ensure success with it, a few fibres of cotton must
be used to carry the cement to the apex of the root.
The same may be said of a solution of gutta-percha ;
but it is a question whether cotton alone, properly
packed into a dry root, will not be as effective as
anything else for this purpose, and, if the fibre
carries with it a little sandarac varnish, I am quite
sure it wiU make as perfect and durable a filling as
can be necessary. The root may be dried with a
thin twist of bibulous paper ; then, as one can never
be quite sure that no particle of the nerve is left, or
that there is no leakage of lymph, or blood, into the
end of the root before it is possible to pack a filling
to occupy the space, it is best to moisten a few
fibres of cotton with carbolic acid, and pack these
carefully to the apex of the root, taking up any
suri)lus acid with another twist of paper ; then a
few more fibres of clean cotton, and more and more
until tlie root is filled. I think in the eases of
very young patients it is best to use cotton alone,
because it is desirable to be as expeditious as pos-
sible, and because, a little later, it is likely enough
that it may be advisable to extract the four first
molars to give more space to the rest of the teeth.
If this is not found desirable, we shall want to use
a filling in the crown cavity of a more permanent
nature than we should insert now, and it may be
just as well that the root-filling should be re-
36 DENTAL PRACTICE.
movable. After treating all the roots in this way,
the crown cavity may be filled with gutta-percha,
with or without a gold or porcelain cap, as may
seem desirable ; or with amalgam ; but if the latter
material is used, it is best to half fill the cavity with
gutta-percha and cover it with amalgam. In the
majority of cases the tooth will be comfortable and
useful ; but it must be borne in mind that no one
can be sure of permanent comfort in a dead tooth,
because, with every precaution, a failure is always
possible, and especially is this the case with these
teeth while the jaw is still growing to make room
for the twelve-year molars. It may be that the
more active vascularity necessary for growth is less
tolerant of the half-dead substance of dentine than
is the case later, when growth has ceased ; but it is
certain that, from some cause, failures are more
frequent in the treatment of these, than of dead
teeth in the adult mouth.
The term dead tooth is in common use, but it
conveys a wrong impression ; for if a tooth were
absolutely dead, it could not be tolerated in the
mouth ; but when the pulp has been extirpated,
the tooth receives the necessary sustenance through
the peri-dental membrane, and is thus kept in a
tolerably comfortable condition. This membrane,
however, sometimes resents the increased labour
that is thus thrown upon its vessels, and a slight
soreness is common enough in such teeth, when,
from any cause, the strength of the patient is below
par, as from a cold, or over -work, mental or
THE PERMANENT TEETH. 37
physical. Soreness of this nature almost invariably
follows the extirpation of the nerve within a few
weeks, but is usually quite controllable by the appli-
cation of a counter-irritant to the external surface
of the gum. Tincture of pellitory (Pyrethrwn ana-
cyclus) is peculiarly valuable in these cases, used on
the finger for rubbing the gum, or, in more urgent
cases, on a piece of lint laid upon the gum.
If the toothache is caused by the presence of a
putrescent pulp in the tooth, it is best to simply
open the pulp cavity, syringe with warm water, and
tell the patient to come .again in three or four days,
by which time we can probably open the tooth into
the roots, remove all the putrid matter, and give the
roots an antiseptic dressing. This treatment will
have to be renewed several times, with thorough
syringing, until the roots are quite clean and free
from any fetid smell, when they may be filled. But
if the pulp dies before the child is nine years old,
there may be a difficulty in treating the roots, be-
cause the foramina are larger than the canals, as
described in the chapter on temporary teeth ; but
in this case it will be owing to incomplete forma-
tion. (Fig 11.) The age is not, however, a
Figure 11. — Showing roots of bicuspid and molar teeth not fully developed,
the foramina being very large.
reliable criterion. We must test with a probe, and
38 DENTAL PEACTICE,
if we find the canal widening towards the apex, we
may as well treat it as described in the case of the
temporary tooth (page 15), and try to keep the
roots, at least until the twelve-year molars appear,
for there will be no further development of roots
after the death of the pulp, and if incomplete then,
they will remain so.
As soon as the first permanent molars are fairly
through the gum, we may begin to look for the
lower central incisors. We often see them sooner,
sometimes before any of the molars appear, but it
is not in regular order. These teeth are a great
source of anxiety to parents, because they are so
often, apparently, out of place. I say apparently,
because it really seems so to one who is not ac-
customed to watch the progress of second dentition ;
but it is only in appearance, for the teeth may be
far inside the dental arch without any real cause
for anxiety about them, and without any need of
professional aid, other than the extracting of the
two temporary centrals, if they have not already
come out with a little home assistance.
It is a matter of almost daily occurrence for
children to be brought to us with these teeth making
their appearance more or less inside the arch, or
slightly turned in a diagonal position, and probably
the cutting edges serrated. The parents are anxious
that we should do something at once to remedy
these deformities, as they consider them ; usually,
however, the dentist's assurance that the teeth will
move forward to their proper place as soon as the
THE PERMANENT TEETH. 39
jaw has grown sufficiently to make room for two
teeth that are half as large again as the two which
have occupied that position, and that the serrations
are perfectly normal, and will wear away as soon
as the teeth come into use, will satisfy them. But
whether they are satisfied or not, nothing will
justify the dentist in yielding to the desire to have
something done at once, and extract four teeth to
make, room for two, or a central and a lateral to
make room for a central. We should never extract
more than the precise number we wish to make
room for, and leave the rest until the appear-
ance of more new teeth shows the necessity for
further extraction. If the new central is very far
inside the arch, we may find that there has been
very little absorption of the root of the temporary
central, but it must be removed nevertheless, and it
will be enough to do this. Nothing more will be
needed, although the tooth may seem much wider
than the space it has to occupy. I have seen
several cases where the permanent central appeared
almost directly behind the temporary lateral ; but
it may be taken for granted that it is a central out
of place, and extraction of the temporary central
will almost certainly make it right. There is always
an appearance of justification for the operator, who
thinks it right to get these teeth quickly into place
by extracting more than the proper number, for a
satisfactory result is quickly visible to the parent.
I have often seen the four central incisors occu-
pying the position of the temporary incisors and
40 DENTAL PEACTICE.
canines, and certainly they looked very nice ; and
I have no doubt that the dentist who extracted the
six teeth to make room for four, thought himself,
and was thought by the parents, to be a clever
fellow to have straightened a set of irregular teeth
so quickly. But the error will be obvious two or
three years later, when the permanent canines
appear. The first and second bicuspids may be
expected before the canine, and the distal surface
of the lateral incisor and the mesial surface of the
first bicuspid will be in close contact before the
canine appears. The latter tooth is generally de-
veloped somewhat outside the arch, but in this case
it might be a supernumerary tooth, for there is
absolutely no room for it, and the cause of this is
plainly and unmistakably the extraction of six teeth
to make room for four. The incisors, if left to work
their own way, would have been pushed forward by
the pressure of the tongue, until they made room
for themselves, with the temporary canines still in
position ; but the extractions simply stopped the
growth of the jaw, because there was no longer any
occasion for expansion, as the necessary space had
been provided by professional interference.
The upper centrals are the next in order, and
they, too, are a source of anxiety to the fond
mother, who naturally wishes her child to have
pretty and regular teeth. They are so large, or
they overlap, or they are not quite straight — would
it not be best to take out the little tooth that seems
to make the new one stand out so at that side ?
THE PERMANENT TEETH. 41
How often we hear such suggestions, and how trite,
to us, seems the reply that there is no cause for
anxiety ; that the tooth which seems so large now,
will not appear so out of proportion when the face
has grown more mature ; that having so much more
breadth than the baby teeth, they cannot stand
quite in the same position the others occupied.
This desire to have something done at once to
hasten nature's work is a temptation that is often
unconsciously held out to the young practitioner;
and how many have yielded to it, not always for the
mere fee, but to secure a patient, or from a want of
confidence in their own judgment, a wish to oblige,
or perhaps from ignorance of the right treatment.
It has been a fault of teachers in our profession,
that they have told us too little about how and
when nature should be assisted, and when left to
herself, in the management of the mouth, while
second dentition is going on. The pupil is taught
to read, and then he is at once passed on to classics
and mathematics. The text-books tell him all
about the origin and development of the teeth, and
the minute anatomy and relation of all the sur-
rounding tissues, and then go on to tell him how
the teeth should be treated at maturity. So the
young man begins a practice with the idea that he
is a dentist, when he knows how many teeth should
be in the mouth at a given age, and how to make a
gold filling. The hiatus that is left in his training
must be filled up by the teachings of his own
experience, and naturally he makes some mistakes.
42 DENTAL PRACTICE.
The same rule that applies to the lower teeth
should be the guide in relation to extracting for the
upper incisors, viz., not to extract more than the
precise number we wish to make room for. We
must let nature do her own work as far as possi-
ble, giving her only such aid as is imperatively
demanded. But if we find an upper incisor
closing inside the lower arch^ — (Fig. 12) — we may
Figure 12. — Showing a central incisor which, when the mouth is closed,
would be found to shut inside the lower arch, and a plate and spring
for moving the tooth into its proper position.
be quite sure that here is a case that can never
correct itself, and we must temporarily prevent
the contact by covering the back teeth with a plate
thick enough to prevent the front ones meeting, and
at the same time apply pressure to the lingual
surface of the tooth to move it forward. This may
be done with a vulcanite plate, having a spring of
gold wire — flattened with the hammer and not
annealed — embedded in the substance of the vul-
canite.
THE PEKMANENT TEETH. 43
With this simple apparatus the work can
be done very quickly ; in some cases that I have
treated, the tooth has moved an eighth of an
inch in a week ; but it is never advisable to under-
take these cases, unless we are sure of the hearty
co-operation of parents and child, else we may be
in many ways thwarted in our endeavours. There
is not much pain, but the tooth becomes a little
sore, and the plate is removed at once, or the child
cannot eat with such a clumsy thing in the mouth,
and it is laid aside at meal times ; the consequence
is that no progress is made, because five minutes
without the plate may undo the work of twenty-
four hours. It is the wisest course simply to point
out the fault, and show how it can be remedied, and
then, if the parents are eager to have it done, it is
easy enough to do it ; but if the dentist is the only
person who feels any interest in these matters, very
little good will result from his efforts. Good
impressions are an absolute necessity, for the plates
must fit accurately, and great care must be taken
with the plaster casts, to prevent the cusps of the
teeth, over which the plate is to fit, from being
broken off. I have found some of the preparations
of mixed gums for taking impressions to answer
admirably for this purpose.
Sometimes both the upper centrals, or, if they
have erupted, the laterals also, are found shutting
inside the lower arch, forming what is called an
" underhung" jaw, although overhung would be a
more appropriate description. I'his may be treated
44
DENTAL PRACTICE.
with a similar plate, with a spring on each side,
but it will take more time, as, if the pressure is
too strong, the springs will throw the plate off.
In some cases it may be necessary to tie the
plate, or fasten it with screws through the sub-
stance of the plate, into shallow indentations in the
buccal surfaces of the temporary molars — these
indentations having been made with a drill through
the screw-hole in the plate. In these cases inquiry
should be made whether the child has not been in
the habit of sucking the fingers, and whether this
habit is not still kept up while the child is asleep.
A tooth may be so misplaced in the arch, that it
will present the mesial or distal surface to the front,
and in such a case two springs will be necessary,
one from the palatine portion of the plate, pressing
on the inner angle, and the other from the buccal
portion of the plate, pressing on the outer angle, so
as to obtain a turning force. Fig. 13 shows a good
Figure 13. — Showing a central incisor which should be turned in its socket,
and a lateral which should be pressed forward, also the form of plate and
arrangement of springs for regulating the same.
THE PERMANENT TEETH. 45
example of such an irregularity, the right central
being very much turned, and the right lateral
shutting inside the lower arch. They were easily
straightened with such a plate as I have described.
It will be found that strong pressure, often in-
creased by bending the springs, and the impossi-
bility of contact with the lower teeth, owing to the
substance of vulcanite over the grinding surfaces of
the molars, will soon correct such faults as these.
But, unlike the other cases that have been men-
tioned, in which, if the teeth are once outside the
lower arch, and shutting slightly past the cutting
edges of the lower teeth, not merely edge to edge,
they cannot easily get back to the old position, a
tooth that is turned in the socket may, and probably
will, go back to its old place if it is not held fast,
until the new alveolus is formed around it. The best
way I have found to do this is to make a vulcanite
Fignre 14. — Showing plate with clip over the cutting edge of the central
incisor, to keep it in its new position until the alveolus closes firmly
around it.
46 DENTAL PEACTICE.
plate having a strip of gold fitted to the lingual
surface of the tooth, and bent over the cutting edge,
and up the labial surface sufficiently to hold the
tooth firmly in its new position. (Fig. 14.) This
should be worn three months, or until the tooth
feels quite firm and strong in its new socket.
The lower and then the upper laterals are now to
be looked for. The latter are more frequently than
any other teeth in the mouth liable to be mis-
placed, the malposition usually being that they
are a little inside the arch, and if it is found on
closing the jaws, that either or both of them shut
inside the lower arch, a plate like those previously
described will soon put them right.
These are, I believe, all the cases in which the
use of regulating apparatus at this early age is
really necessary. The more complicated cases are
better left until the bicuspids and canines are well
established, as we can then judge better what we
must do, how to retain the apparatus in the mouth,
and, if time is required for the treatment, need not
fear that we are interfering with the eruption of
new teeth.
There is so much variation in the ages at which
children change their teeth, that no fixed period can
be stated for the appearance of any of the permanent
set ; but in the case of well-nourished and well-
cared for children, we may expect to see all the
incisors, upper and lower, before the expiration of
the ninth year ; and in a large number of cases,
of girls especially, who are generally a little more
THE PERMANENT TEETH. 47
forward than boys in this respect, it will be twelve
months earlier.
The first or anterior bicuspids are the next in
order ; but it is by no means an uncommon thing
to see the second or posterior bicuspid before the
first appears ; indeed, it is a matter of extreme un-
certainty when and in what order the bicuspids