VOL. LX.

T

HE removal of impacted lower third

molars appears to be of more than passing interest to the profession generally, as evidence by the fact that such an operation is often the leading card at dental clinics, that papers upon the subject appear in our journals from time to time, and, moreover, from the fact that such cases are quite frequently met with in general practice. There appear to be two methods of removing these teeth:

(1) One in which the patient's jaw is chiseled away to such an extent that the tooth may be taken out whole, ether or novocain being used, according to the fancy of the individual operator. By whom this heroic operation was originated I am not prepared to say.

(2) The one in which the tooth itself is cut in two under novocain. The patient's jaw is handled gently, and the tissues surrounding the tooth are injured but slightly. This operation was originated by the writer and was first described before the National Dental Association in 1903.

VOL. LX.-8

No. 2

It is hardly possible to witness the removal of these teeth by the heroic malletand-chisel method, to hear the resounding blows of the mallet, and not feel compassion for the patient.

The writer has attended several clinics where clinicians of national repute removed such teeth by this mallet-andchisel method. In every case, however simple--and some of the cases were extremely simple-the patients were put "out of commission" for days, suffered for many days longer, and the wounds (for wounds really were made) were treated for several weeks thereafter. Where the operator took the operation more seriously and used ether, the patient spent one day before and several days after the operation in the hospital, making an average of from five to seven days, several of which were in bed.

Just imagine, if you can, what the total cost of such an operation would be to a patient-one day in bed before the operation and five days after; seven days' hospital charges, besides those of the chief operator, the anesthetist, and three

101

or four assistants! If a charity patient, what a burden upon those who "paid the freight"!

So much for the mallet-and-chisel method, with its mutilation of the patient and the consequent train of suffering, treatment, and expense.

Under the writer's method, the tooth itself is cut in two, as already stated, from one to two-thirds of the crown being cut away, according to the case, whereupon the released part of the crown is readily removed. The root portion is then grasped by special forceps designed for the purpose, and drawn forward into the space left vacant by the removal of the portion of the crown which has been cut away.

flammation of the throat, with discomfort and pain in that region, and in these cases the throat receives treatment; but even in these the sockets themselves have always looked well and have received no attention whatever. At other times, in very difficult cases, there is some swelling of the face, and the mouth cannot be opened freely; again these symptoms are treated, but the socket looks well and receives no attention.

TOOTH FORMS.

The writer has extracted scores and scores of lower third molars which were standing vertically, and which had all manner of roots (see Fig. 1), but he has

Once the root has been started from its socket and drawn forward, there is always ample space for its ready removal. It will be seen that by this operation little or no injury has been done to the soft tissues and surrounding or overlapping bone or process, and thus it is not surprising that little or no afterpain ensues, and no subsequent treatment is necessary.

Sometimes an elevator specially adapted to such work is used to start the root. Sometimes, in particularly difficult cases, a little of the process must be burred away in order to get the beaks of the forceps on the root.

It is not unusual for a patient to come from the country in the morning, have such a tooth removed, and leave for home the same day. The sockets are never curetted or packed; possibly that is why they require no treatment. Sometimes there is a certain amount of in

never yet met, in his own practice, any impacted teeth of such shapes. In Fig. 2 are shown typical forms of impacted teeth. Their roots are all more or less straight and are of a distinctly different class from those shown in Fig. 1.

The question naturally arises, are these simply the vagaries of his individual practice, is it coincidence, or have other operators met with the same experience? It certainly would be interesting to know, and if perchance the experience of others has been the same, then for once Providence has been somewhat kind.

INDICATION FOR THE AUTHOR'S OPERATION.

The writer's operation is only indicated where the third molar is really impacted, that is, when it lies more or less horizontally and is prevented from

erupting by its relative position to the second molar.

SPECIAL FORCEPS.

As far as the writer knows, every pair of extracting forceps now cataloged was

FIG. 2.

designed for grasping teeth standing in a perpendicular position.

In the early days of this operation, after the part of the crown of the impacted third molar was cut off, the root was removed with an elevator. The use of an elevator, however, is a harsh procedure, especially in such cases as those under consideration, and so the idea was Conceived of making a special pair of forceps with which to grasp the remain

ing portion of the tooth and draw it forward, thus materially lessening the trauma.

Fortunately, a pair of Ash's forceps was found which, with only a slight alteration, made an ideal instrument for this purpose, and undoubtedly by its use the trauma has been materially lessened in every case. Fig. 3 shows how a typical impacted third molar can be firmly grasped by these forceps. In deeply embedded molars it is necessary to bur away the process to allow the beaks to be forced into position.

In a recent number of the DENTAL COSMOS a writer upon the subject has illustrations showing how he cut off the cusps of some of these molars with disks, advancing the method as new. This shows, of course, his unfamiliarity with the literature upon the subject, as the idea of cutting off the cusp was first published in 1903, as previously stated, once or twice since, and is fully treated in the third edition of Johnson's "Text-book of Operative Dentistry," though, of course, the cutting is not done with disks, as the use of disks for the purpose is almost impossible. It is possible, of course, to cut away the cusps of well-exposed teeth by means of disks, but it never should be so done. The unerupted portion of the crown is covered upon two sides by gum tissue, and possibly some process. The disk must therefore cut gum, process, and all, lacerate the parts fearfully, and play havoc generally!

When it comes to deep-seated molars, the lower edge of the tooth which must be cut away may be fully three-quarters of an inch below the top of the second molar. In order to reach this depth the disk must be over one and a half inches in diameter. Just get a disk of that diameter, mount it, put it in the engine handpiece, and adjust it back of a second molar, and see how impossible it would be to use it!

The writer does all of the deep cutting with burs made specially for the purpose. In favorable cases he may start with a short bur, but the burs must be extra long to reach to the depths often required. (Fig. 4.)