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Minimum Essentials for Tooth Removal Operations
Clark and Clark— M in im u m Essentials for T o o th R em ova l O perations
mined by another m eans; viz., observa tions o f the minimum cure at various curing temperatures which will assure maximum tensile strength. From this study, the relationship was found to b e : ti l o g ------- = Í2
X2 10.27 l o g -------Tl
(The dotted line, Figure 12, is the curve o f this equation.) Since the constants are nearly alike, it is not entirely improbable that the correction which should be applied to constant 14.5 would reduce the two re lationships to the same equation within experimental error.
571
B IB LIO G R A PH Y 1. S k in n e r , E. W .: Science of Dental M a terials. Philadelphia: W. B. Saunders Co., 1936, p. 96. 2. P e r k s :
/.
Soc.
Chem.
Ind., 4 5 : i 4 2 T ,
1926 . 3. B. S. Res. Paper No. 162. 4.
Ind. Eng. Chem .,
2 7 : 1 4 1 - 1 4 6 , 19 3 5 .
5 . K i m b a l l , H . D ., and P e y t o n , F . A .: Temperature Conditions Induced During Process of Vulcanization. J.A .D .A ., 24 :179 31798, November 1937. 6. T a y l o r , D . B .; H o v o r k a , F r a n k , and M o h l e r , J. B .: Relationship Between Time and Temperature o f Vulcanization of Dental Rubber. J.A .D .A ., 2 4 :113 2 , July 1937. 2165 Adelbert Road.
MINIMUM ESSENTIALS FOR TOOTH REMOVAL OPERATIONS By H e n r y B. C l a r k , J r ., M .D ., D .D .S., and H e n r y B. C l a r k , D.D.S., St. Paul, Minn. N E o f the most vicious expressions in the field of dentistry is the term “ simple extraction.” I t im plies that one can tell by examining the crown of a tooth whether the operation will be done with ease or difficulty. In asmuch as the removal o f a tooth is an operation, and since any operation is attended with some degree o f risk and the opportunity for accidents to occur, it should not be undertaken until every thing possible has been done to insure the safe, speedy and sure completion of the procedure. The preparations necessary to this end are not simple, yet if one takes the re sponsibility seriously and establishes the same thorough routine for each case, accidents will seldom happen, and the surgical phase of dentistry will become a
O
Read before the Section on Oral Surgery, Exodontia and Anesthesia at the Eighty-First Annual Session of the American Dental Asso ciation, Milwaukee, Wis., July 20, 1939.
Jour. A .D .A., V ol. 27, April 1940
source o f much pleasure and satisfaction. Let us then first consider the prepara tions that we w ould make in advance for a known difficult extraction. I f we can then be convinced that every tooth re moval is potentially a difficult one, it will become apparent that the only cor rect procedure is to conduct each case with the same degree of thoroughness. M IN IM U M ESSEN TIALS
T h e minimum essentials for each case are : 1. A clear, recent x-ray picture of the tooth and surrounding tissues. 2. A suitable anesthetic agent. 3. A good suction apparatus. 4. Brilliant illumination. 5. A competent assistant. 6. Suitable forceps and elevators. 7. A tray of instruments for perform ing flap procedures. It m ay seem at first glance that these requirements are too exacting, and that
572
T h e Journal o f the Am erican D en ta l Association
all will not apply to each case. This is, 2. A Suitable Anesthetic Agent.— T h e of course, true. The abdominal surgeon use o f gas should be avoided for impacted of the present day m ay use in a given or devitalized teeth or for operations operation no more equipment and facili requiring trimming and suturing, unless ties than the “ horse and buggy doctor” a trained surgical team is at hand. Local employed in his kitchen table operations, anesthesia affords a universally applicable yet he needs the assurance of additional service, and is to be preferred except in aids when an emergency arises. None of the presence o f acute infection. Even us can rationally hold that “ horse and in seemingly simple operations, there are buggy” exodontia is justifiable today. always things that can be done, such U nfortunately, even the best is none too as trimming or suturing, which will be good at times. left undone under general anesthesia, L et us now consider the requirements but will be undertaken if the anesthesia in greater detail. is local. T h e most important factor of i. A Clear, Recent X -R ay Picture of all in the use o f local anesthetics in den the Tooth and Surrounding Tissues.— tistry is that the syringe and needle be Every one w ill doubtless agree that this boiled prior to use. This warning cannot aid is desirable in all cases. T h e old be stressed too strongly. Most cases of motto “ought means must” could well be serious infection following extractions can applied to preoperative pictures. I t is be traced to cold “ sterilization” of the impossible to compromise on this point, injection needle. as the very case in which a roentgen 3. A Good Suction Apparatus.— T h e ogram is omitted m ay be that in which inclusion o f this point m ay amuse m any an accident or serious error occurs. I f men who feel that sponging with gauze one wishes to lim it extractions to uncom or cotton is adequate for the removal of plicated cases, the roentgenogram is the blood and other fluids from the mouth, only means a t hand that will be really but it is our belief that the suction prin helpful in selecting his cases. I f a tooth ciple in exodontia constitutes the greatest is loose, there m ay be a cyst or tumor single advance in recent times. Several present. E ven if the need for extraction outstanding advantages commend it to is obvious, the evidence recorded on the our use : a. W hen the suction tip touches the film m ay be o f great help should the op erator later be accused of having removed floor of the mouth or is inserted in the the wrong tooth. Frequently, an adjacent socket, a bloodless field is instantly tooth m ay be as badly diseased as the created. b. T h e operator is not only relieved one that brought the patient to the den tist. T he issue is much the same as in of the delay occasioned by the spong the breaking o f a bad h a b it: there can ing, but is able to achieve a degree of be no exceptions to the newly formed, dryness and vision otherwise impossible. correct habit. As in any superior dental This makes easy the removal o f root tips, service, the element of cost is not to be etc., which might otherwise be almost emphasized. T h e cost o f the film is best impossible. included in the fee quoted for the oper c. T he fact that bacteria and other ation, and, in the case o f worthy patients débris are constantly being removed from who object to a roentgenographic exam the socket contributes to the sterility of ination on the grounds o f expense, the the wound and reduces the incidence of service m ay be furnished gratis. It is the “ dry socket.” In the gauze or cotton dentist him self who suffers when he at sponging technic, foreign matter is con tempts to work under an inadequate stantly being introduced into the socket, diagnosis. where the sharp bony points will catch
Clark and Clark— M in im u m Essentials for T o o th R em oval O perations
573
and hold the minute cotton fibers. Since exolevers that should be at hand. Three the entire mouth can be kept dry, there upper and two lower forceps do nicely, is no need for the patient to rinse the and four crossbar elevators (two pair) mouth or expectorate, and saliva does will fill most needs. It is essential that not enter the wound. elevator points which are designed to d. T he initial cost is the only one. The engage or bite into cementum or dentin saving in time and expense over the be kept perfectly sharp by frequent ap sponge technic will soon pay for the plications of the stone. 7. A Tray of Instruments for Flap apparatus. T h e added speed in extrac tion operations also constitutes a most Procedures.-— T h e required instruments important factor to patient and dentist are as follows : (a) a small sharp scalpel; (b) a periosteal elevator; (c) a small alike. A detailed description of the suction ribbon retractor or tongue blade; (d) a apparatus will not be given, as many three-sixteenths-inch straight sharp chisel; (e) m allet; (f) needle, needle holder supply houses are now prepared to fur nish and install it at very reasonable cost. and suture m aterial; (g) scissors; (h) a A resourceful dentist can construct his straight, stiff explorer, and (i) a rongeur. own with the aid o f a good machinist These instruments must be boiled and kept sterile, in readiness at all times on a or plumber. 4. Brilliant Illumination.— Good light small enamel ware tray covered with a is imperative. T h e preferred source is sterile or perfectly clean towel. O nly if one which does not have to be held in they are always at hand will one resort the hand, namely, a head light or mir to their use promptly, as he should, when ror. I f this is not practical, an efficient the need arises. T h e small expense required to procure shadowless spotlight will serve. 5. A Competent Assistant.— No extrac this emergency outfit is soon forgotten tion should be attempted under gas with in the additional enjoyment from per out a surgical assistant in addition to the forming oral operations properly. It is anesthetist and operator. Procaine should an established fact that a flap operation not be used unless a nurse is able to give well done is always good surgical proce uninterrupted assistance with the oper dure, and should be resorted to without ation. It is not fair to the patient to delay as soon as root fracture occurs, or unduly prolong unpleasant procedures when a tooth fails to move after repeated which could be carried out better and applications o f the forceps. A t the risk in less time if a second pair of hands o f repetition, we shall submit the technic were available. T h e practice of attempt for one form of flap operation for the ing extraction alone is thus to be con removal of fractured roots or teeth that demned. I f we put ourselves in the place cannot be delivered b y the forceps. o f the patient, or if he could be endowed F L A P OPERATION with our knowledge of the situation, the issue would be more clear. I f the prac 1. A bold, vertical incision is made tice does not warrant an assistant for from the free gum margin rootward for full time, one m ay be engaged for half one-half to three-quarters inch, at the days, and all extractions be performed middle of the tooth immediately ahead while she is in the office. T w o nurses or o f the fractured one. T h e incision is office attendants are desirable; one is made two or three times to make sure all strands of soft tissue, including peri essential. , osteum, are severed. 6. Suitable Forceps and Elevators.— 2. W ith the periosteal elevator, the W e shall not attempt to name or de scribe the actual exodontia forceps and entire flap is carefully raised backward
574
T h e Journal o f the Am erican D en ta l Association
and rootward, tearing being avoided, un til the bone is bare and exposed to view over the entire buccal aspect of the root. 3. W ith the retractor in the left hand, the flap is held back, being left in this position until completion of the operation, since repeated manipulation will unduly traumatize it. W ith the m al let and chisel, all the buccal bone is shaved away, care being observed to prevent injury to the adjacent teeth, but to make sure that the buccal surfaces o f the root tips, if present, are denuded over half their circumference. This step must be carried out fully. It will then be possible, with any thin-bladed ele vator, to gently pry the root from its socket, or narrow beaked forceps m ay be easily applied. In the case of the lingual root of an upper molar, exactly the same method should be followed, with removal o f all bone which prevents a view from the buccal aspect. 4. T h e wound is then inspected and cleaned of all chips of bone. Granulomata m ay be carefully peeled out with a small curet. 5. T h e edges o f the socket are then slightly beveled with the chisel or ron geur, and any sharp bony processes found on finger tip palpation are conserva tively trimmed. 6. O ne or two simple sutures are then placed across the line of incision and tied snugly, but not tightly. T h e healed incision will show only as a fine white scar. T h e purpose in having placed the incision at the midline o f the next tooth ahead is to provide a definite plateau o f undisturbed bone on which the free
edge o f the flap can rest, and it is essen tial i f curling in of this edge o f the flap is to be avoided. A n y one who would attempt the re m oval of teeth must be prepared to carry out this technic promptly. It is the answer to the question, “H ow do you take out broken roots?” CO N CLUSIO N
L et us all face the issue squarely. There are too m any patients who can tell of two or three hour sessions with a tooth extraction. There are too m any who are carrying root fragments in their jaws today. T o o m any average extractions have taken three or four times as long as was necessary. Osteomyelitis, pterygoid abscess, cervical cellulitis, fracture o f the jaw , dry socket and a jagged condition of the ridges are still following opera tion for the removal of teeth. It is time that each of us establish a code of “ minimum essentials” for tooth removal operations. SU M M A RY
1. Every operation for the removal of a tooth should be preceded by an x-ray examination. 2. Every extraction operation should be prepared for as if it were going to be very difficult. 3. This routine should be observed in every case, without exception, for the purpose of avoiding the common acci dents and complications associated with tooth removal. n 32 Low ry M edical Arts Building.
mined by another m eans; viz., observa tions o f the minimum cure at various curing temperatures which will assure maximum tensile strength. From this study, the relationship was found to b e : ti l o g ------- = Í2
X2 10.27 l o g -------Tl
(The dotted line, Figure 12, is the curve o f this equation.) Since the constants are nearly alike, it is not entirely improbable that the correction which should be applied to constant 14.5 would reduce the two re lationships to the same equation within experimental error.
571
B IB LIO G R A PH Y 1. S k in n e r , E. W .: Science of Dental M a terials. Philadelphia: W. B. Saunders Co., 1936, p. 96. 2. P e r k s :
/.
Soc.
Chem.
Ind., 4 5 : i 4 2 T ,
1926 . 3. B. S. Res. Paper No. 162. 4.
Ind. Eng. Chem .,
2 7 : 1 4 1 - 1 4 6 , 19 3 5 .
5 . K i m b a l l , H . D ., and P e y t o n , F . A .: Temperature Conditions Induced During Process of Vulcanization. J.A .D .A ., 24 :179 31798, November 1937. 6. T a y l o r , D . B .; H o v o r k a , F r a n k , and M o h l e r , J. B .: Relationship Between Time and Temperature o f Vulcanization of Dental Rubber. J.A .D .A ., 2 4 :113 2 , July 1937. 2165 Adelbert Road.
MINIMUM ESSENTIALS FOR TOOTH REMOVAL OPERATIONS By H e n r y B. C l a r k , J r ., M .D ., D .D .S., and H e n r y B. C l a r k , D.D.S., St. Paul, Minn. N E o f the most vicious expressions in the field of dentistry is the term “ simple extraction.” I t im plies that one can tell by examining the crown of a tooth whether the operation will be done with ease or difficulty. In asmuch as the removal o f a tooth is an operation, and since any operation is attended with some degree o f risk and the opportunity for accidents to occur, it should not be undertaken until every thing possible has been done to insure the safe, speedy and sure completion of the procedure. The preparations necessary to this end are not simple, yet if one takes the re sponsibility seriously and establishes the same thorough routine for each case, accidents will seldom happen, and the surgical phase of dentistry will become a
O
Read before the Section on Oral Surgery, Exodontia and Anesthesia at the Eighty-First Annual Session of the American Dental Asso ciation, Milwaukee, Wis., July 20, 1939.
Jour. A .D .A., V ol. 27, April 1940
source o f much pleasure and satisfaction. Let us then first consider the prepara tions that we w ould make in advance for a known difficult extraction. I f we can then be convinced that every tooth re moval is potentially a difficult one, it will become apparent that the only cor rect procedure is to conduct each case with the same degree of thoroughness. M IN IM U M ESSEN TIALS
T h e minimum essentials for each case are : 1. A clear, recent x-ray picture of the tooth and surrounding tissues. 2. A suitable anesthetic agent. 3. A good suction apparatus. 4. Brilliant illumination. 5. A competent assistant. 6. Suitable forceps and elevators. 7. A tray of instruments for perform ing flap procedures. It m ay seem at first glance that these requirements are too exacting, and that
572
T h e Journal o f the Am erican D en ta l Association
all will not apply to each case. This is, 2. A Suitable Anesthetic Agent.— T h e of course, true. The abdominal surgeon use o f gas should be avoided for impacted of the present day m ay use in a given or devitalized teeth or for operations operation no more equipment and facili requiring trimming and suturing, unless ties than the “ horse and buggy doctor” a trained surgical team is at hand. Local employed in his kitchen table operations, anesthesia affords a universally applicable yet he needs the assurance of additional service, and is to be preferred except in aids when an emergency arises. None of the presence o f acute infection. Even us can rationally hold that “ horse and in seemingly simple operations, there are buggy” exodontia is justifiable today. always things that can be done, such U nfortunately, even the best is none too as trimming or suturing, which will be good at times. left undone under general anesthesia, L et us now consider the requirements but will be undertaken if the anesthesia in greater detail. is local. T h e most important factor of i. A Clear, Recent X -R ay Picture of all in the use o f local anesthetics in den the Tooth and Surrounding Tissues.— tistry is that the syringe and needle be Every one w ill doubtless agree that this boiled prior to use. This warning cannot aid is desirable in all cases. T h e old be stressed too strongly. Most cases of motto “ought means must” could well be serious infection following extractions can applied to preoperative pictures. I t is be traced to cold “ sterilization” of the impossible to compromise on this point, injection needle. as the very case in which a roentgen 3. A Good Suction Apparatus.— T h e ogram is omitted m ay be that in which inclusion o f this point m ay amuse m any an accident or serious error occurs. I f men who feel that sponging with gauze one wishes to lim it extractions to uncom or cotton is adequate for the removal of plicated cases, the roentgenogram is the blood and other fluids from the mouth, only means a t hand that will be really but it is our belief that the suction prin helpful in selecting his cases. I f a tooth ciple in exodontia constitutes the greatest is loose, there m ay be a cyst or tumor single advance in recent times. Several present. E ven if the need for extraction outstanding advantages commend it to is obvious, the evidence recorded on the our use : a. W hen the suction tip touches the film m ay be o f great help should the op erator later be accused of having removed floor of the mouth or is inserted in the the wrong tooth. Frequently, an adjacent socket, a bloodless field is instantly tooth m ay be as badly diseased as the created. b. T h e operator is not only relieved one that brought the patient to the den tist. T he issue is much the same as in of the delay occasioned by the spong the breaking o f a bad h a b it: there can ing, but is able to achieve a degree of be no exceptions to the newly formed, dryness and vision otherwise impossible. correct habit. As in any superior dental This makes easy the removal o f root tips, service, the element of cost is not to be etc., which might otherwise be almost emphasized. T h e cost o f the film is best impossible. included in the fee quoted for the oper c. T he fact that bacteria and other ation, and, in the case o f worthy patients débris are constantly being removed from who object to a roentgenographic exam the socket contributes to the sterility of ination on the grounds o f expense, the the wound and reduces the incidence of service m ay be furnished gratis. It is the “ dry socket.” In the gauze or cotton dentist him self who suffers when he at sponging technic, foreign matter is con tempts to work under an inadequate stantly being introduced into the socket, diagnosis. where the sharp bony points will catch
Clark and Clark— M in im u m Essentials for T o o th R em oval O perations
573
and hold the minute cotton fibers. Since exolevers that should be at hand. Three the entire mouth can be kept dry, there upper and two lower forceps do nicely, is no need for the patient to rinse the and four crossbar elevators (two pair) mouth or expectorate, and saliva does will fill most needs. It is essential that not enter the wound. elevator points which are designed to d. T he initial cost is the only one. The engage or bite into cementum or dentin saving in time and expense over the be kept perfectly sharp by frequent ap sponge technic will soon pay for the plications of the stone. 7. A Tray of Instruments for Flap apparatus. T h e added speed in extrac tion operations also constitutes a most Procedures.-— T h e required instruments important factor to patient and dentist are as follows : (a) a small sharp scalpel; (b) a periosteal elevator; (c) a small alike. A detailed description of the suction ribbon retractor or tongue blade; (d) a apparatus will not be given, as many three-sixteenths-inch straight sharp chisel; (e) m allet; (f) needle, needle holder supply houses are now prepared to fur nish and install it at very reasonable cost. and suture m aterial; (g) scissors; (h) a A resourceful dentist can construct his straight, stiff explorer, and (i) a rongeur. own with the aid o f a good machinist These instruments must be boiled and kept sterile, in readiness at all times on a or plumber. 4. Brilliant Illumination.— Good light small enamel ware tray covered with a is imperative. T h e preferred source is sterile or perfectly clean towel. O nly if one which does not have to be held in they are always at hand will one resort the hand, namely, a head light or mir to their use promptly, as he should, when ror. I f this is not practical, an efficient the need arises. T h e small expense required to procure shadowless spotlight will serve. 5. A Competent Assistant.— No extrac this emergency outfit is soon forgotten tion should be attempted under gas with in the additional enjoyment from per out a surgical assistant in addition to the forming oral operations properly. It is anesthetist and operator. Procaine should an established fact that a flap operation not be used unless a nurse is able to give well done is always good surgical proce uninterrupted assistance with the oper dure, and should be resorted to without ation. It is not fair to the patient to delay as soon as root fracture occurs, or unduly prolong unpleasant procedures when a tooth fails to move after repeated which could be carried out better and applications o f the forceps. A t the risk in less time if a second pair of hands o f repetition, we shall submit the technic were available. T h e practice of attempt for one form of flap operation for the ing extraction alone is thus to be con removal of fractured roots or teeth that demned. I f we put ourselves in the place cannot be delivered b y the forceps. o f the patient, or if he could be endowed F L A P OPERATION with our knowledge of the situation, the issue would be more clear. I f the prac 1. A bold, vertical incision is made tice does not warrant an assistant for from the free gum margin rootward for full time, one m ay be engaged for half one-half to three-quarters inch, at the days, and all extractions be performed middle of the tooth immediately ahead while she is in the office. T w o nurses or o f the fractured one. T h e incision is office attendants are desirable; one is made two or three times to make sure all strands of soft tissue, including peri essential. , osteum, are severed. 6. Suitable Forceps and Elevators.— 2. W ith the periosteal elevator, the W e shall not attempt to name or de scribe the actual exodontia forceps and entire flap is carefully raised backward
574
T h e Journal o f the Am erican D en ta l Association
and rootward, tearing being avoided, un til the bone is bare and exposed to view over the entire buccal aspect of the root. 3. W ith the retractor in the left hand, the flap is held back, being left in this position until completion of the operation, since repeated manipulation will unduly traumatize it. W ith the m al let and chisel, all the buccal bone is shaved away, care being observed to prevent injury to the adjacent teeth, but to make sure that the buccal surfaces o f the root tips, if present, are denuded over half their circumference. This step must be carried out fully. It will then be possible, with any thin-bladed ele vator, to gently pry the root from its socket, or narrow beaked forceps m ay be easily applied. In the case of the lingual root of an upper molar, exactly the same method should be followed, with removal o f all bone which prevents a view from the buccal aspect. 4. T h e wound is then inspected and cleaned of all chips of bone. Granulomata m ay be carefully peeled out with a small curet. 5. T h e edges o f the socket are then slightly beveled with the chisel or ron geur, and any sharp bony processes found on finger tip palpation are conserva tively trimmed. 6. O ne or two simple sutures are then placed across the line of incision and tied snugly, but not tightly. T h e healed incision will show only as a fine white scar. T h e purpose in having placed the incision at the midline o f the next tooth ahead is to provide a definite plateau o f undisturbed bone on which the free
edge o f the flap can rest, and it is essen tial i f curling in of this edge o f the flap is to be avoided. A n y one who would attempt the re m oval of teeth must be prepared to carry out this technic promptly. It is the answer to the question, “H ow do you take out broken roots?” CO N CLUSIO N
L et us all face the issue squarely. There are too m any patients who can tell of two or three hour sessions with a tooth extraction. There are too m any who are carrying root fragments in their jaws today. T o o m any average extractions have taken three or four times as long as was necessary. Osteomyelitis, pterygoid abscess, cervical cellulitis, fracture o f the jaw , dry socket and a jagged condition of the ridges are still following opera tion for the removal of teeth. It is time that each of us establish a code of “ minimum essentials” for tooth removal operations. SU M M A RY
1. Every operation for the removal of a tooth should be preceded by an x-ray examination. 2. Every extraction operation should be prepared for as if it were going to be very difficult. 3. This routine should be observed in every case, without exception, for the purpose of avoiding the common acci dents and complications associated with tooth removal. n 32 Low ry M edical Arts Building.