the mesial surface. The illustrations, Figs. 25, 26
and 27, will give a good idea of the two systems of
treatment. Figs. 26 and 27 are from casts taken
from the mouth of a young lady of sixteen, the
molars having been extracted when she was twelve
• I have seen thifi case again, six months after the extractions, and
the lower canine is now clear of the upper lateral, and will come quite into
the arch.
E
66 DENTAL PEACTICE.
years old. It will be seen that the wisdom teeth are
already in position, and that they are well-developed
Figure 25. — Another illustration from the work of Dr. Arthur, showing
only twelve teeth in the upper jaw, but giving a good idea of his method.
teeth. This is by no means an exceptional case.
I could in time make a collection of a large number
of similar results from the extractions of the molars,
but one is sufficient to show what is possible.
There is, in truth, no reason why wisdom teeth
should not be quite as serviceable as any others
in the mouth, although this is not usually the case
with wisdom teeth, because when all the others are
in the mouth, or when one has been extracted here
and there without a specific plan, and the gaps
remain, there is no room for the teeth that are
latest in formation, and thus their development is
interfered with, or their eruption is retarded. In
the one case, therefore, they will be malformed or
misplaced, and in the other they will be decayed
before they even come into a position to be of any
service, or to be treated to prevent decay. There
EXTRACTION AS A MEANS OF PREVENTING DECAY. 67
can be no doubt that civilisation has so fined
down the human face, that the maxillary bones of
Europeans and Americans are much smaller than
Figure 26.
Figure 27.
FigureB 26 and 27. — Showing the condition of the upper and lower teeth in
the mouth of a young lady at sixteen years of age, the six year molars
having been extracted about four years.
those of the savage races that still inhabit the
earth; and, if there is anything in the theory of
evolution, this is easily accounted for. The heavy
68 DENTAL PEACTICE.
animal character which is given to the face by a
large development of the maxillary bones is not a
type of beauty that is much admired in civilised
life, consequently it becomes fined down by the
process of natural selection. Again, civilisation
leads to good cookery, and this to diminished
labour for the bones and muscles that are called
into action in mastication ; and the theory of evolu-
tion is, that the organs which are called into greater
activity by new conditions of life receive increased
development, while those which are of diminished
importance become dwarfed and rudimentary. Thus
it is easily seen that, after centuries of civilisation
and good cookery, the organs of mastication are
not likely to be so well developed as those of the
savage, who does not hang his meat until it
becomes tender, and is satisfied with rude cookery,
or none at all. The maxillary bones have become
smaller in these days of luxury and good living,
and the wisdom teeth suffer from want of room,
so that we often find them misshapen, or so much
smaller than other teeth, that they might be said
to be rudimentary ; or else we find them coming
slowly and painfully into position, protruding one
cusp through the gum, and making little or no more
progress for months, and often for years, because
there is no room for them to advance.
It is unnecessary to explain to the dental student
that the soft tissues do not adhere to the enamel of
a tooth, and that if one cusp has found its way
through the gum, the soft tissues must form an
EXTRACTION AS A MEANS OF PREVENTING DECAY. 69
open pouch around the remainder of the crown of
that tooth. Therefore, if this condition of things
exists for any considerable period, the secretions
and particles of food which find their way into the
mouth of the pouch must have an injurious effect
upon the tooth, and when it finally emerges from
the gum, it is likely to be with a softened and
chalky condition of enamel, at least, if not with its
dentine also affected. Thus wisdom teeth have got
a reputation for coming late, giving much pain in
the process, and going early; but if they have
a fair chance given them in time to benefit by
it, there is no reason why they should not be
as good as any other teeth, and quite make up for
the loss of the first molars, if that can be called a
loss which we have shown to be a gain to every
part of the dental arch.
The period when isolation is so essential to the
preservation of the anterior teeth being past, the
wisdom teeth serve another important use, for they
press the second molars forward and gradually close
up the spaces, until the mouth presents the appear-
ance seen in the last illustration, of a remarkably
good and regular set of teeth.
Some of our best men tell us that extraction
should never be resorted to until we have^^done
everything in our power to preserve all the teeth.
This is a well-sounding theory, but practically timid,
and working harm instead of good ; for when we
have tried it, and have found our efforts ineffectual,
as we surely shall find them, if the conditions of
70 DENTAL PRACTICE.
weakness of structure and excessive acidity exist in
conjunction J it will be too late to try back, for the
period when the greatest benefit could be gained
from extractions will have passed, and permanent
gaps will remain in the mouth to remind us con-
stantly of our timidity and failure.
The extraction of the molars is always a difficult
and painful operation, even when they are com-
paratively strong, and we may reasonably hope to
get all the roots at once ; but when they are
seriously decayed and broken down, the difficulty
is greatly increased, and both patient and operator
must needs have plenty of nerve to contemplate
the operation without the aid of anaesthesia. The
certainty that there will be no suffering from the
operation, except the soreness that must imme-
diately follow, helps the patient wonderfully in
making up the mind to submit to what often seems,
to a child, a piece of wilful cruelty on the part of the
dentist, for the child cannot be expected to see the
necessity which is so apparent to the professional
eye. And the same certainty helps the operator
too ; for although he may have to struggle with
rigidity of muscle, and obscurity of view from the
flow of blood, it is a help to him to know that he
is not inflicting pain, and he is not discouraged if
his first effort to remove an obstinate fang results
in failure. Once undertaken, the work must be
thorough. All fragments of roots must be removed,
even though it be necessary to cut through gum
and alveolus to accomplish it ; indeed, if it will
EXTRACTION AS A MEANS OF PREVENTING DECAY. 71
facilitate the extraction of a troublesome root, one
should never shrink from cutting through the
alveolus, for it only takes away what would be
removed afterwards by the natural process • of
absorption.
A.S I have observed, it is most important that
all roots and fragments of roots should be removed,
and although there may be nothing new in my
suggestions, it may not be out of place to give
some general instructions for this operation. If
the teeth are strong, no instrument can be better
Figure 28. — Lower molar forcep.
Figure 29.— Upper molar forcep. (a) Right side. (6) Left side.
adapted for their extraction than the ordinary forms
of molar forceps of English make — Fig. 28 for
lower molar of either side, and Fig. 29 for right
72
DENTAL PEACTICE.
and left upper molars. But when the teeth are
much broken down, I prefer the stump forceps of
American make. The strong beaks of the right-
angle instrument, Fig. 30, for the right side, and
Fig. 31, for the left side, lower jaw, are most
useful, giving one the power, if necessary, to cut
Figure 30. — Lower stump forceps. Eight side.
Figure 31. — Lower stump forceps. Left side.
Figure 32. — Elevator.
through the alveolus and remove the posterior root,
and then with the elevator, Fig. 32, to push back
the anterior root, so that it may be grasped by the
EXTRACTION AS A MEANS OF PREVENTING DECAY. 73
mesial and distal surfaces with the thin flat beaked
instrument, Fig. 33, made from my own design ;
and the bayonet- shape, Fig. 34, for upper stumps.
Figure 33. — Thin flat beaked forcep, for grasping a loose root by mesial and
distal surfaces.
Figure 34. — Upper stump forcep.
These instruments enable one to remove stumps
with more certainty, and actually with less lacera-
tion of surrounding tissues, than the ordinary
stump forceps of English make, which are not
strong enough in the beak for the purpose, and
always bend or break in my hands.
If it is decided to make use of an anaesthetic,
the assistance of a surgeon should be considered
74 DENTAL PEACTICE.
indispensable. No dentist should ever attempt to
give any of the preparations used for this purpose
without such assistance. A man cannot do two
things at the same moment, and do both of them
well, and although a dentist may understand how
to administer an anaesthetic quite as well as a
surgeon, and how to watch its effects, he cannot do
this if his whole attention is directed to his opera-
tion, as it should be, to make success a certainty.
The selection of the anaesthetic to be used would,
therefore, rest with the surgeon, and it is unneces-
sary for me to do more than allude to the various
preparations employed for this purpose, which I
shall do from the purely practical point of view of
a busy dentist.
Chloroform is the most powerful agent for pro-
ducing insensibility to pain. It is not disagreeable
to the patient, and causes only a moderate amount
of excitement during inhalation. If I were pre-
paring the mouth of a strong man for artificial
teeth, or if such a patient required anaesthesia for
even a much shorter operation than that, I should
consider that nothing else would do so well, and
that nothing could be better. If I were taking an
anaesthetic myself, I should prefer chloroform to
anything else.
Ether is probably more reliable as a safe agent
for producing anaesthesia for very prolonged opera-
tions. Women take it very quietly as a rule, but it
is very troublesome in the case of a strong man, as
it is pungent and disagreeable to inhale, causing a
EXTRACTION AS A MEANS OF PREVENTING DECAY. 75
feeling of suffocation, and generally a good deal of
excitement and struggle to resist the approach of
insensibility, so that it is followed by exhaustion
and depression on the part of the patient, and
certainly by a very considerable amount of fatigue
on the part of all who have been engaged in the
operation.
Chloroform and ether are sometimes combined
with a certain proportion of alcohol, and adminis-
tered in that form ; but I have not had any experi-
ence of this combination. Chloroform is also
frequently given as a preparation for ether. In
such a case the former is inhaled until after the
stage of excitement is passed, and then ether is
substituted for completing and maintaining insensi-
bility. This method avoids the disagreeable effects
of ether, and the supposed danger of chloroform,
and is certainly preferable to ether alone, inasmuch
as it saves the patient the exhaustion which so
frequently follows the use of that agent by itself;
but it does not appear to be very generally used,
although I am unaware of any objection to it. Why
women take ether so much more quietly than men,
I cannot attempt to explain ; but every one who has
had experience with anassthetics is well aware of the
fact. Both cloroform and ether may be used for
children with almost perfect safety, as, whatever
may be the danger to adults from either of these
agents, it is certain that there is very little to
children. One of the disagreeable after-results from
anaesthesia is sickness, which almost always follows,
76 DENTAL PRACTICE.
if there is any undigested food in the stomach. It
is therefore always best to make the appointment
for these operations early in the morning, when the
stomach is absolutely empty.
Several other preparations have been recom-
mended since the discovery of chloroform, but none
of them has come into general use. I have, how-
ever, had a good deal of experience, in the last two
years, with ethidene dichloride, and I am so far
greatly pleased with it, for children especially. It
is not so potent as either chloroform or ether, but it
is quite sufficient to make any child absolutely
insensible to pain long enough for the extraction
of the four molars, and that is the most serious
operation the dentist will have to perform for a
child. It is not more disagreeable to inhale than
chloroform ; is administered in precisely the same
way as the latter ; and is said to be quite as safe as
ether.
Nitrous oxide, or what is commonly called
" gas," is the anaesthetic most frequently asked for,
and when it is in constant, daily and hourly use, it
is undoubtedly the best agent for producing insensi-
bility for dental operations. But as the chief
business of the dentist is the preservation of the
teeth, it cannot be expected that he will be con-
stantly engaged in extracting them. Yet, as the
apparatus required for the gas, even in its
compressed form, is too bulky for the surgeon to
carry about with him, the dentist is expected to be
provided with it, and it must often happen that it
EXTRACTION AS A MEANS OF PREVENTING DECAY. 77
will not be in daily, or even weekly, requisition ;
and certainly it is not improved by disuse. The
insensibility produced by " gas " is very transient,
and, if there is any difficulty or delay in the opera-
tion, the patient will recover consciousness, and feel
the pain as though no attempt had been made to
avoid it, for, unlike other anaesthetics, the return of
consciousness is not gradual, but sudden. It is not,
therefore, and never will be, a favourite anaesthetic
with those dentists who are cautious enough to
have always the assistance of a surgeon when
anaesthesia is required ; but used as it is in some of
the larger towns in the United States, nothing can
be better. A well-qualified man, with such assist-
ants as may be necessary, makes a specialty of
extracting teeth, and does nothing else. He does
not even call himself a dentist, and will not examine
a mouth for the cause of pain, or give advice, but
simply extracts the tooth that he is asked to
extract ; thus making a previous consultation of a
practical dentist necessary to any one who is in any
degree doubtful of the operation required. He
gives tbe "gas" in every case, and it is made on
the premises, fresh every day. Thus the apparatus,
and all the appliances, are always in order, until
they are worn out ; and new fittings are always in
readiness to replace those which are found defec-
tive or useless. He becomes wonderfully expert,
even to the extent of making a complete clearance
of a mouth — when the preparation of the mouth for
artificial teeth makes such an operation necessary —
78 DENTAL PEACTICE.
without renewing the administration of the gas.
Dr. Slocum, of the Cooper Institute, in New York,
showed me, on his register, the record of several
cases where he had extracted the remains of twenty-
five teeth without renewing the inhalation, and also
the acknowledgment of the patients, signed after
the operation, that no pain had been felt. Thus,
such a specialist becomes an invaluable assistant to
the practical dentist, who would gladly send all his
cases for extraction, or go with his patients, to a
man who will do this disagreeable work so well, so
safely, and with so little trouble. Dr. Slocum had
administered the gas in over 100,000 cases, without
an accident, when I saw him in 1879 ; therefore it
may be said that the danger from anaesthesia is
reduced to the minimum degree, when it can be
managed in this way.
When the necessity for the extraction of the
molars is admitted, there ought not to be any doubt
about the best time to do it ; but it appears that
there is, apparently, a very considerable diversity
of opinion on this point, — some dentists advising
their removal at the age of ten, and others at
fourteen. The fact is, we must not be governed by
any strict rule as to age, but rather by development,
which may range over the whole of the four years
that lie between the advocates of early and late
extraction. The object being to gain room for the
teeth to be saved, we should surely choose the time
when the gain is greatest, and if we extract before
the second molars appear we shall stop a certain
EXTRACTION AS A MEANS OF PREVENTING DECAY. 79
amonnt of growth, and therefore lose so much
space ; while, on the other hand, if we wait long
after the second molars are in position, we may
certainl}^ gain a little more space from the develop-
ment of the wisdom tooth, which would he making
rapid progress ; but we risk more than we gain, for
there is danger that decay may make serious pro-
gress on the approximate surfaces of the bicuspids,
while we are waiting for a small gain in growth,
which, after all, is not needed, because the space
gained by the extraction of the molars is usually
quite enough. It appears, therefore, that the best
time for extraction is immediately after the erup-
tion of the twelve-year molars. The chief argument
for deferring the extraction to the fourteenth year
is the supposed tendency of the second molars to
tip forward out of the perpendicular position, there-
by diminishing their usefulness as grinding teeth.
This argument, however, is based on unsubstantial
grounds, for, practically, the tipping does not take
place, and is not likely to, because, if anything is to
cause tipping, it must be the development of the
wisdom tooth ; and as we cannot suppose that the
roots of the second molar will be quite fully formed
at the time of its eruption, we should have the
pressure of the wisdom tooth, which, at this time,
would have no roots at all, in just the position we
should wish it to be to move the second molar
bodily forward. But if we wait until the roots are
fully formed, and the wisdom tooth also further
advanced in developement, we shall have the pres-
80
DENTAL PBACTICE.
sure in a position mucli more likely to cause
tipping, thus :
Figure 35.
Figure 36.
Figures 35 and 36. — Showing how the pressure of a wisdom teeth may act
upon the twelve year molars at different stages of development.
It will be wrong to suppose that extraction of
the molars will always prevent decay on the
approximal surfaces of the anterior teeth, for in
some cases it will have commenced before the time
has arrived for extraction ; and in other cases, the
wisdom teeth will have come, and all the spaces will
be closed up, before the period of excessive acidity
has passed. But even in these cases of failure to
obtain a perfectly satisfactory result, we shall have
the consolation of feeling that, without the addi-
tional space, no filling could have effectually
checked the progress of decay, and we should have
lost more teeth in the end. We must not relax our
watchfulness, and, if decay has commenced before
the extractions, we ought to discover it before it has
made serious progress, and take care to stop its
ravages. As I have stated before, the chisel and
the engine disk are to be relied on for removing
superficial decay ; but if the cavity is so deep that
the appearance of the tooth will suffer from cutting
it away, a filling is the best remedy. The only
EXTBACTION AS A MEANS OF PREVENTING DECAY. 81
question is, what material to use ; and, although
general rules are unreliable, we shall err on the
right side, if we err at all, by continuing the gutta-
percha fillings until the patient is quite sixteen
years of age.
Figure 37. — Sbowing upper teeth of boy at sixteen years of age, the molars
having been extracted at twelve.
Figr.ro 38. — Showing lower teeth of the same.
Figs. 37 and 38 show the present condition of the
mouth of a young gentleman sixteen years of age,
F
82 DENTAL PRACTICE.
inheriting delicate teeth from father and mother,
both of them having been, one may say, all their
lives in the dentist's hands, with the result that, in
the father's case, enough teeth remain to perform
their various functions with a tolerable degree of
satisfaction, though every tooth is filled in one or
more places, and many of them are restorations,
with but little of the original structure left. In the
case of the mother, the restorations have taken a
still more prosthetic form. Educational claims, and
the needed relaxations in the holiday time, have
hitherto prevented anything like an attempt to
replace, with any more permanent work, the gutta-
percha fillings, which still protect the teeth in this
mouth. The two upper second molars, standing in
the place of the first, have gold fillings in the
grinding surfaces, but all the rest are much worn,
though still serviceable gutta-percha fillings. The
teeth are nowhere more decayed now than they were
four years ago, when the first molars were ex-
tracted ; but it is easy to see that if an attempt
had been made to retain all the teeth, they would
have given endless trouble, with certain loss of
some of them before the wisdom teeth were all
erupted, and this, probably, when it would have
been too late to hope for the present symmetrical
arrangement.
To those who would argue that extracting the
molars is unjustifiable, because it is taking alarm
without reasons of established certainty ; that the
decay might not, after all, be serious, and be per-
EXTRACTION AS A MEANS OF PREVENTING DECAY. 83
fectly under control with all the teeth in the mouth;
or, if the later condition of the mouth showed that
the prognosis had been correct, that it was a mere
coincidence, and not to be regarded as of importance
in the treatment of other cases ; or, that the decay
is so surely from inherent defects in the teeth, that
if the secretions are acid, the decay will go on all
the same, whether more space is given or not ; I
would call attention to the cases which every practi-
tioner must have seen, where the molars have been
extracted on one side of the mouth, and left in posi-
tion on the other side. Such cases are common
enough. The old ideas that extraction is the only,
or at least the quickest, way to relieve pain ; that
teeth, especially the teeth of young people, are not
worth a lot of trouble and consideration; that the
cheapest way is to " get it out," or that there is no
time for anything else ; or any of the reasons, or
want of reasons, that lead to hap-hazard extraction,
are not yet quite extinct ; and it cannot but
occur in every man's practice, that he will see
a mouth where upper and lower molars have
been extracted, at something near the right age,
on one side of the mouth, and the other side
has not been similarly treated. It seems to me
that one has but to see such a case to be convinced
of the advantage of extracting some teeth to prevent
decay in all. We shall find that on the side where
space has been given at the right time, the teeth
are in much better condition than they are on the
other side. They may not have escaped decay, but
84
DENTAL PEACTICE.
they will not be so seriously decayed, and in all
respects except space, the conditions will be similar
on both sides of the mouth. The teeth are developed
in pairs, and whatever affects the structure of one is
likely to affect its twin brother on the other side of
the mouth. The secretions will be the same on
both sides, and, therefore, if there is a tendency to
decay on one side, we may look for the same thing
on the other ; and if we find that on the side where
an upper and a lower tooth have disappeared at so
nearly the same time, that the filling up of the gaps
by change of position of the other teeth is about
Figure 39. — Showing the effect of extracting the six year molars on one side
of the mouth, and neglecting to do so on the other side.
equal, there is little or no decay, while on the other
side, where nothing has been extracted, all the teeth
are more or less seriously affected by caries, we must
conclude that the additional space has been a cause
EXTKACTION AS A MEANS OF PREVENTING DECAY. 85
of the difference in the health of the two sides of
the mouth. Such a case is represented in Fig. 39,