Page:EB1911 - Volume 08.djvu/67

 a hammer was released automatically by a spring condensed by pressure of the operator’s hand. Then followed mallets operated by pneumatic pressure, by the dental engine, and finally by the electro-magnet, as utilized in 1867 by Bonwill. These devices greatly facilitated the operation, and made possible a partial or entire restoration of the tooth-crown in conformity with anatomical lines.

The dental engine in its several forms is the outgrowth of the simple drill worked by the hand of the operator. It is used in removing decayed structure and for shaping the cavity for inserting the filling. From time to time its usefulness has been extended, so that it is now used for finishing fillings and polishing them, for polishing the teeth, removing deposits from them and changing their shapes. Its latest development, the dento-surgical engine, is of heavier construction and is adapted to operations upon all of the bones, a recent addition to its equipment being the spiral osteotome of Cryer, by which, with a minimum shock to the patient, fenestrae of any size or shape in the brain-case may be made, from a simple trepanning operation to the more extensive openings required in intra-cranial operations. The rotary power may be supplied by the foot of the operator, or by hydraulic or electric motors. The rubber dam invented by S. C. Barnum of New York (1864) provided a means for protecting the field of operations from the oral fluids, and extended the scope of operations even to the entire restoration of tooth-crowns with cohesive gold foil. Its value has been found to be even greater than was at first anticipated. In all operations involving the exposed dental pulp or the pulp-chamber and root-canals, it is the only efficient method of mechanically protecting the field of operation from invasion by disease-producing bacteria.

The difficulty and annoyance attending the insertion of gold, its high thermal conductivity, and its objectionable colour have led to an increasing use of amalgam, guttapercha, and cements of zinc oxide mixed with zinc chloride or phosphoric acid. Recently much attention has been devoted to restorations with porcelain. A piece of platinum foil of .001 inch thickness is burnished and pressed into the cavity, so that a matrix is produced exactly fitting the cavity. Into this matrix is placed a mixture of powdered porcelain and water or alcohol, of the colour to match the tooth. The mass is carefully dried and then fused until homogeneous. Shrinkage is counteracted by additions of porcelain powder, which are repeatedly fused until the whole exactly fills the matrix. After cooling, the matrix is stripped away and the porcelain is cemented into the cavity. When the cement has hardened, the surface of the porcelain is ground and polished to proper contour. If successfully made, porcelain fillings are scarcely noticeable. Their durability remains to be tested.

Until recent times the exposure of the dental pulp inevitably led to its death and disintegration, and, by invasion of bacteria via the pulp canal, set up an inflammatory process which eventually caused the loss of the entire tooth. A rational system of therapeutics, in conjunction with proper antiseptic measures, has made possible both the conservative treatment of the dental pulp when exposed, and the successful treatment of pulp-canals when the pulp has been devitalized either by design or disease. The conservation of the exposed pulp is affected by the operation of capping. In capping a pulp, irritation is allayed by antiseptic and sedative treatment, and a metallic cap, lined with a non-irritant sedative paste, is applied under aseptic conditions immediately over the point of pulp exposure. A filling of cement is superimposed, and this, after it has hardened, is covered with a metallic or other suitable filling. The utility of arsenious acid for devitalizing the dental pulp was discovered by J. R. Spooner of Montreal, and first published in 1836 by his brother Shearjashub in his Guide to Sound Teeth. The painful action of arsenic upon the pulp was avoided by the addition of various sedative drugs,—morphia, atropia, iodoform, &c.,—and its use soon became universal. Of late years it is being gradually supplanted by immediate surgical extirpation under the benumbing effect of cocaine salts. By the use of cocaine also the pain incident to excavating and shaping of cavities in tooth structure may be controlled, especially when the cocaine is driven into the dentine by means of an electric current. To fill the pulp-chamber and canals of teeth after loss of the pulp, all organic remains of pulp tissue should be removed by sterilization, and then, in order to prevent the entrance of bacteria, and consequent infection, the canals should be perfectly filled. Upon the exclusion of infection depends the future integrity and comfort of the tooth. Numberless methods have been invented for the operation. Pulpless teeth are thus preserved through long periods of usefulness, and even those remains of teeth in which the crowns have been lost are rendered comfortable and useful as supports for artificial crowns, and as abutments for assemblages of crowns, known as bridge-work.

The discoloration of the pulpless tooth through putrefactive changes in its organic matter were first overcome by bleaching it with chlorine. Small quantities of calcium hypochlorite are packed into the pulp-chamber and moistened with dilute acetic acid; the decomposition of the calcium salt liberates chlorine in situ, which restores the tooth to normal colour in a short time. The cavity is afterwards washed out, carefully dried, lined with a light-coloured cement and filled. More efficient bleaching agents of recent introduction are hydrogen dioxide in a 25% solution or a saturated solution of sodium peroxide; they are less irritating and much more convenient in application. Unlike chlorine, these do not form soluble metallic salts which may subsequently discolour the tooth. Hydrogen dioxide may be carried into the tooth structure by the electric current. In which case a current of not less than forty volts controlled by a suitable graduated resistance is applied with the patient in circuit, the anode being a platinum-pointed electrode in contact with the dioxide solution in the tooth cavity, and the cathode a sponge or plate electrode in contact with the hand or arm of the patient. The current is gradually turned on until two or three milliamperes are indicated by a suitable ammeter. The operation requires usually twenty to thirty minutes.

Malposed teeth are not only unsightly but prone to disease, and may be the cause of disease in other teeth, or of the associated tissues. The impairment of function which their abnormal position causes has been found to be the primary cause of disturbances of the general bodily health; for example, enlarged tonsils, chronic pharyngitis and nasal catarrh, indigestion and malnutrition. By the use of springs, screws, vulcanized caoutchouc bands, elastic ligatures, &c., as the case may require, practically all forms of dental irregularity may be corrected, even such protrusions and retrusions of the front teeth as cause great disfigurement of the facial contour.

The extraction of teeth, an operation which until quite recent times was one of the crudest procedures in minor surgery, has been reduced to exactitude by improved instruments, designed with reference to the anatomical relations of the teeth and their alveoli, and therefore adapted to the several classes of teeth. The operation has been rendered painless by the use of anaesthetics. The anaesthetic generally employed is nitrous oxide, or laughing-gas, the use of which was discovered in 1844 by Horace Wells, a dentist of Hartford, Conn., U.S.A. Chloroform and ether, as well as other general anaesthetics, have been employed in extensive operations because of their more prolonged effect; but chloroform, especially, is dangerous, owing to its effect upon the heart, which in many instances has suddenly failed during the operation. Ether, while less manageable than nitrous oxide, has been found to be practically devoid of danger. The local injection of solutions of cocaine and allied anaesthetics into the gum-tissue is extensively practised; but is attended with danger, from the toxic effects of an overdose upon the heart, and the local poisonous effect upon the tissues, which lead in numerous cases to necrosis and extensive sloughing.

Dental Prosthesis.—The fastening of natural teeth or carved substitutes to adjoining sound teeth by means of thread or wire preceded their attachment to base-plates of carved wood, bone or ivory, which latter method was practised until the introduction of swaged metallic plates. Where the crown only of a tooth or those of several teeth were lost, the