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of any

sues. In the first place, the amount of dead necrotic material upon the root surface, while considerable in area, is very shallow in depth and when instruments

character, planes, files, or scalers are thrust into these pockets, the operator should have in mind the structure of the tissue upon which he operates for the simple reason that if in removing the dead necrotic root surface, the operator carelessly cuts down a sufficient depth to open the lacunae of the cementum, that tho his initial result may point toward health in the improved appearance of the gums and surrounding tissues yet in the end these root surfaces re-infect because the

into the cementum will always hold bacteria. The writer believes this fact explains why certain operators who handle the teeth they treat roughly have many recurrences of infection while others who have greater skill and patience have comparatively few recurrences of infection. The moment the dead root surface has been carefully removed, the inpour of new leucocytes is exceedingly rapid because the blood vessels which supplied the bone and peridental membrane have not been entirely destroyed, tho their ends have been blocked by an obliterating endarteritis, which is the specific lesion of pyorrhoeal infection. The operative interference necessary to clear the root surface breaks down these endarterial structures and permits of a great outpour of blood into the pyorrhea pocket itself. This bleeding is an excellent thing as it tends to carry out of the pocket infinite numbers of bacteria and also introduces into the pocket fresh arterial blood, which is nature's provisional filler of every wound and a better antiseptic for such wounds than any drug which we could place in them. To briefly describe the character of this type of surgery may be of some interest

Fig. 13 B.

contact with the uneven bony surface of the root itself. This produces a sensation entirely different than that produced by the touching of the dead peridental membrane and cannot be well described in words. If, however, the root has upon it serumal calculus, the sensation conveyed to the operator by the plane bit thru the medium of the handle of his instrument and the plane bit, might be comparable to the application of a steel edge to a concrete or stony surface. Upon removal of this stony, gritty material in the one case, or the removal of the velvety dead remains of the peridental membrane in the other, the plane bit rapidly renders the surface smooth and conveys to the operator a sensation comparable to that evoked by rubbing a steel burnisher over polished ivory. In contrast to the sensation evoked by touching dead peridental membrane or calcific deposit, the sensation is so markedly different that after it has once been experienced, the operator can definitely know that he has removed all that should be removed from the root şur. face. If now the operator, heedless of the fact that he has reached the hard layer, continued to cut with sharp instruments for a few seconds on this smooth ivory-like surface, which he has been able to produce by the removal of dead peridental membrane or calculus, the operator will soon find that the instrument will chatter and the sensation will be as vitally different to him as the sensation evoked by bringing a sharp curette over the bony plate of the alveolar process as compared to the sensation evoked by the same curette when used in the spongiosum of the loose areolar bone inside of the bony plate. It naturally follows that the fewer lacunae opened, the less subsequent re-infection. As the operator approaches the bottom of the pocket he will encounter granulation tissue. This granulation tissue is a mass of leucocytes which interposes between the bottom of the pocket and

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in this connection. It is most easily accomplished with the planes of self-limiting cutting depth. The operator should begin at the neck of the tooth and with short strokes remove the dead material, each stroke going a trifle farther into the pocket until he finally has planed off all the objectionable material to be removed. As the surface cannot be seen the operator must depend on his sense of touch. On root surfaces where there is no deposit, the sharp plane encounters first the dead peridental membrane which evokes a sensation which the author might liken to touching silk velvet, a sort of fleshy feeling. A few strokes with the sharp plane removes this velvety material and brings the plane in

living tissue beyond and serves to protect the living tissue beyond from further incursions of bacteria and also surrounds the obliterated ends of the vessels which fed the tissue. It is an advantage to press the plane bit into this mass of leucocytes in order that every bit of diseased root surface may be removed and also to break up the granulating wall and open the obliterated ends of the vessels in this locality. The action of the plane bit will naturally withdraw from the pocket most of the planed

experiments in this direction must ever be remembered. He was able to remove portions of long bones in dogs and interposed between the cut ends of these bones small glass tubes which glass tubes filled up with new bone in from four to six weeks, the outpour coming from the cancellus bone cells of the ends of long bone and not from the periosteum. Accepting the fact that new bone (Figures 15 A and 15 B) comes from preexisting bone cells, can we do (Fig. 16) anything which will tend to repair the

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off material. If the operator is in doubt as to whether the pocket is free from loose material, it is wise to syringe the pocket with Ringer's solution or normal salt solution.

Assuming always that the diagnosis has been properly made and the advisa. bility for treatment of any given case determined and that the work has gone forward to the removal of the diseased root surface, the next thought which confronts us is the possible regeneration of bony process to compensate for that which has been lost. The regeneration of bone of course precedes from living bone. This has been well proven by the work of Macewen (*1) of Glasgow, (Figures 14 A and 14 B) whose classical

loss of bone already suffered? The writer believes to a limited extent that we can, by simply following the laws of general surgery in relation to bone growth. Therefore, our need is freshly opened bone cells, absence of general infection, absence of pressure, and rest. Presuming the pyorrhea pocket and root surface to be as surgically clean as they can be gotten, our next step is to reach into the process with a fine sharp instrument and lightly stir or roughen up the process edge. This stimulates the bone cells to an outpour of callus. If the pocket be filled with sterile blood clot, the new bone cells pour out and in some instances actually pile up against the root surfaces never in great amount because the pressure of surrounding tissue limits the amount of outpour, be

*1-Macewen-“The Growth of Bone."

cause we begin to have shrinkage of the overlying soft tissue as soon as we remove the irritating debris of the root surface, which shrinkage of the gum limits the outpour of bone from the thin process

Fig. 15 A.

requirements will we be able to gain bone. Some men deny the possibility of regeneration of bone of the jaws. The author draws your attention to a lantern slide in a case first operated by Doctor R. E. Farr, of Minneapolis, wherein he removed an inch and a half of the man. dible for the removal of a malignant growth. The writer subsequently placed a splint of iridio-platinum wire connected with the left cuspid and laterals and the right second and third molars. A radiograph of this jaw some two years after the splint was put in position

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The implanted tooth in socket from

which 13 B was removed.

edge. The subsequent entrance of bacteria from the tooth's surface and saliva into the pocket also tends to limit the bony outpour. Movement of the teeth themselves also tends to limit the bony outpour. If, however, the teeth are made

Fig. 15 B.

Radiograph of Dr. Farr's case showing complete repair of mandible from whence one inch had been removed. An iridio platinum splint placed by the writer to hold the cut ends apart can be seen in the picture.

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was

shows that the bone reached across from the left to the right side and that the bony continuity of the mandible has again been restored.

The writer also wishes to show in this connection, a picture which illustrates the ability of the process to pour out new bone around and against the teeth. This particular picture

obtained from the late Doctor Fletcher with whom the writer of this article had much in common. Its origin was briefly as follows: (Figures 17 A, 17 B, 17 C).

A patient had applied to a dentist for the removal of a lower bicuspid tooth. The dentist had attempted its extraction and had broken the tooth off well below the gum level and had then left this tooth in position. The gum had healed

New bone around implanted

tooth one year later.

a

rigid by a splint, the root surface clean, the process edge lightly curetted, the pocket filled with blood and protected from infection, we can confidently expect a certain amount of bony outpour from the process edge. Just in proportion as we can maintain these sensible

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Extracted tooth with new bone in pulp chamber.

Fletcher's case.

root and subsequently had sections made, a picture of which I throw upon the screen, showing new bone deposited on the broken root end and pulp chamber of this tooth. A second picture shows an area of alveolar process photographed from the center of this chamber. While we all recognize, the fact that the alveolar process is not a favorable field for regeneration, these examples show conclusively that if we can maintain our case under proper conditions that we certainly may expect a small amount of new bone at least in many cases. That bony outpour does frequently happen in the experience of

root surfaces, and, having no elastic peridental membrane interposed between the root surface and the new bone, you have an analogy to ankylosis which occurs about implanted teeth. Presuming that this treatment of a case has been successfully carried to this point, is there anything further the operator may do to enhance regeneration ? The author believes there is, and that the next step should be to protect the sterile blood clot in the pockets from the incursion of bacteria from the saliva and the tooth's surface. The bacterial growth is constantly recurring on tooth surfaces, and its inhibition or prevention must necessitate a constant battle to the end of life. Immediately, following the surgical treatment, the application of

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