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ESSENTIALS OF
OPERATIVE DENTISTRY

ESSENTIALS OF

OPERATIVE DENTISTRY

BY

W. CLYDE\I)AVIS,

M.D., D.D.S.

DEAN AND PROFESSOE OF OPERATIVE DENTISTRY AND TECHNIO, LINCOLN DENTAL

COLLEGE, LINCOLN, NEBRASKA.

SECOND REVISED EDITION

LONDON

HENRY KIMPTON
263

HIGH HOLBORN^W.
1917

Copyright, 1916, by C. V. Mosby

Company

Press of
C.

V.

Mosby Company
St.

Louis

\aJU

300

PREFACE TO SECOND EDITION.

In presenting the second edition of this work,

it

is

the aim

of the author to follow the plan of the first edition, in that

it

be

and yet cover a wide field in operative dentistry.

The book has been thoroughly rewritten and extensively illustrated.
Four new chapters have been added, several have been
materially enlarged, and others eliminated entirely in this edition.
There is a complete rearrangement of the chapters which it is
believed will more nearly coincide Avith the progress of the student through his technical work and the operatory.
concise

W.

C.

D.

PREFACE TO FIRST EDITION.

it has been the author's
meet a demand in dental college Avork for a treatise on
operative dentistry which is sufficiently condensed to enable the
student to master its contents in the comparatively short college

In the preparation of this text-book

aim

to

terms at his disposal.

The subject matter selected is that which is generally taught

by the instructors styled as "Professor of Operative Dentistry."

From

a study of these teachers' courses of instruction

it

Avould

seem that the definition of Operative Dentistry as commonly used

today would be "That branch of dentistry which treats of the
mechanical procedures performed within the oral cavity looking
to the salvage of the teeth."

However,

it

has seemed wise in several instances to go beyond

the exact limitations of this definition to get a better correlation

of subjects.

The arrangement
usually found, but

of the subject matter

is

is

different

from that

in accordance with the usual line of progress

of dental students.

The author claims little originality in the essentials presented,

having gleaned the facts from the writings, teachings and utterances of our greatest educators.
The "quiz-explanation" method of teaching is the one most in
vogue in the leading universities as productive of the most work
on the part of the classes taught, and at the same time giving
the tutor more freedom for the expression of opinions to

give

individuality to his course of instruction.

An

effort

has been made to so publish the "Essentials of Operit Avould serve as a foundation for this quiz

ative Dentistry" that

course as well as be suggestive to the teacher for a more full

explanation, and, at the same time, encourage the student to ex-

tend his studies to more voluminous reference books, Avhen time

Mould permit, for an explanation in greater detail.
The author is much indebted to his co-laborer, partner and wife,
]\r.
Davis, D.^M.D., for valuable assistance in connection
with the publication of this volume.

]Mattic

W.

C.

D.

CONTENTS
PART

I.

CHAPTER

Page

I.

Instrument Nomenclature

17

CHAPTER

II.

Cavity Nomenclature

21

CHAPTER
Cavity Preparation.

III.

(General Considerations.)

CHAPTER

29

IV.

Gaining Access

31

CHAPTER

V.

Outline Form

34

CHAPTER

VI.

Resistance Form

38

CHAPTER

VII.

Retention Form

40

CHAPTER

VIII.

Convenience Form

42

CHAPTER
Removal of Remaining Carious Dentine.
Toilet of the Cavity

Cavities.

CHAPTER
Management of Pit and Fissure

Cavities.

CHAPTER
Management of Proximal

Enamel Walls.

44

CHAPTER
Management of Pit and Fissure

IX.

Finishing

X.
(Class One.)

......

XI.

(Class One, Concluded.)

Two.)

(Class
.

58

XIII.

Large Proximal Cavities Endangering the Pulp.

tinued.)

52

XII.

Cavities in Bicuspids and Molars.

CHAPTER

48

(Class T-wo, Con65

CONTENTS

10

CHAPTER
Management of Proximal
ing THE Angle.

XIV.

Page

Cavities in Incisoes and Cuspids

Not Involv-

(Class Three.)

72

CHAPTER XV.
Management of Proximal

Cavities in Incisors Involving the Angle.

(Class Four.)

78

CHAPTER

XVI.

Management

of Cavities in the Gingival Third.

Management

op Abraded Surfaces.

....

93

(Class Six.)

96

(Class Five.)

CHAPTER

XVII.
Occlusal and Incisal.

CHAPTER

XVIII.

Cavity Preparation for Gold Inlays

98

PART

II.

CHAPTER XIX.
The Making and Setting of a Gold Inlay

112

CHAPTER XX.
Manipulation of Cohesive Gold in the Making of a Filling

CHAPTER

XXI.

Manipulation of Cohesive Gold in the Making of Fillings by Classes

CHAPTER

123

129

XXII.

Finishing Gold Fillings

137

CHAPTER XXIII.
Manipulation of Amalgam in the Making of a Filling

139

CHAPTER XXIV.
The Use of Cements

in Filling

Teeth

146

CHAPTER XXV.
Manipulation of Silicate in the Making of a Filling

148

CHAPTER XXVI.
The Use

of Gutta-Percha in Filling Teeth

164

CHAPTER XXVII.
Tin as a Filling Material

166

CHAPTER
Combination Fillings

XXVIII.
169

CONTENTS

PART

11

III.

CHAPTER XXIX.
Examination of the Mouth Looking to Dental Services

Page
174

CHAPTER XXX.
The Alleviation of Dental Pains

177

CHAPTER XXXI.
Prophylactic Treatment of the Mouth

180

CHAPTER XXXII.
Exclusion of Moisture

187

CHAPTER XXXIII.
Treatment of Hypersensitive Dentine

195

CHAPTER XXXIV.
Protection of the Vital Pulp

204

CHAPTER XXXV.
Pulp Devitalization and Removal

211

CHAPTER XXXVI.
Management of Putrescent Pulp Canals

219

CHAPTER XXXVII.
The Filling

of

Management

of Children's Teeth

Pulp Canals

225

CHAPTER XXXVIII.
229

CHAPTER XXXIX.
Extraction of Permanent Teeth

CHAPTER

233

XL.

Extraction of Temporary Teeth

CHAPTER

269

XLI.

Local and Regional Anesthesia

CHAPTER
The Use

275

XLII.

of Fused Porcelain in Filling Teeth

CHAPTER XLIII.
Preparation of Cavities for Porcelain Inlays

293

296

CHAPTER XLIV.
The Construction and Placing

of a Porcelain Inlay

306

ILLUSTRATIONS
PAGE

FIG.

4.

Defects in enamel
Defects in enamel
Smooth surface decay
Smooth surface decay

5.

Class

6.

Class Two cavity filled

Class Three cavity filled

1.

2.
3.

7.

One

cavities filled

Class Four cavity filled

Class Five cavity filled
10. Bisected molar in which a mesial Class Two cavity has been cut and line
angles indicated
11. Bisected molar in which a mesial Class Two cavity has been cut and point
8.
9.

20.

angles indicated
tooth, giving angles and surfaces
Technic group illustrating outline form
Another view of cavities illustrated in Fig. 13
Fillings in place in cavities shown in Figs. 13 and 14
Another view of fillings shown in Fig. 15
Complex Class One cavity prepared
Class One filled. Cavity shown in Fig. 17
Large Class One cavities prepared
Class One filled.
Cavities sho^^^l in Fig. 19

21.

Lingual pit cavities

12.
13.
14.

15.
16.
17.
18.

19.

One filled.
One of the few

35
36
36
50
51
53
54
55
56

shown in Fig. 21

Cavities

23.

cases in which the step

may be

omitted in Class

Two
60

cavities
24. Class

Two

cavities in

molar and bicuspid suitable for cohesive gold or

amalgam
25. Class

Two

filled.

Cavities

shown

in Fig.

24

shown in Fig. 25 contacted, illustrating the marble contact

Large Class Two cavities in non-vital teeth restoring part of the occlusal
surface for the protection of weakened walls
Class Two filled. Cavities shown in Fig. 27
Mesio-occluso-distal cavities in molar and bicuspid, vital teeth
Mesio-occluso-distal fillings.
Cavities shown in Fig. 29
(A) First superior molar, non-vital, restoring the lingual cusps. (B)
Second superior bicuspid, non-vital, restoring the entire occlusal

26. Fillings
27.

28.
29.
30.
31.

....

surface
32. Class

Two

33. Class

Three cavities

34.

Drawing

filled.

Cavities showTi in Fig. 31

filled

cavity

Three cavities prepared for cohesive gold

36. Class Three filled.
Cavities shown in Fig. 35

Drawings
Drawings

39.

Drawing

67
67
68
68

69
69
73
75
76
76

to illustrate the principle of the lever in the dislodgement of

fillings

38.

61
62
63

to illustrate the retention at the incisal angle of Class Three

35. Class

37.

26
26
27
35

Diagram of

22. Class

21
22
23
23
24
24
25
25
25

of the Fourth Class, plan one

79

to illustrate the principle of the lever in the dislodgement of

of the Fourth Class, plans one and two

difference in the directions the point angle
fillings take in tipping to exit with various fillings
fillings

80

to illustrate the

12

82

ILLUSTRATIONS

13
PAGE

FIG.

40.
41.
42.
43.
44.
45.

46.
47.

48.
49.
50.
51.
52.

Drawings

importance which should be given to the proper

placing of the incisal point angle in fillings of Class Four, plan two
A study in the proper placing and depth of the gingival angles
A study of the planes in which the gingival angles should be laid
Cavity of Class Four, plan one, for cohesive gold
Class Four, plan one, cavity filled
Shows incisal outline in Class Four, plan one, fillings with direct occlusion
Cavity of Class Four, plan two, for cohesive gold
Class Four, plan two, filled
Cavity of Class Four, plan three, for cohesive gold
Class Four, plan three, filled
Cavity of Class Four, plan four, for cohesive gold
Class Four, plan four, filled
Cavity of Class Four, modified plan three, for cohesive gold in the distal
to illustrate the

...
.

of the superior cuspid

53. Class Four, modified plan three, filled

54. Cavities Class Five for cohesive gold or

amalgam

Five filled
56. Cavities of Class One for gold inlays
57. Class One inlay in position showing gold wire cast in the filling
58. Cavities of Class Two for gold inlays
59. Cavity of Class Three for gold inlay, lingual approach
60. Inlay shown in Fig. 59 partly in place
61. Cavity of Class Four, plan one, for gold inlay
62. Class Four, plan one, inlay in position
63. Cavity of Class Four, plan two, for gold inlay
64. Class Four, plan two, gold inlay in position
65. Cavity of Class Four, plan three, for gold inlay
66. Class Four, plan three, inlay in position
67. Cavity of Class Four, plan four, for gold inlay
68. Class Four, plan four, showing cavity side of pattern with pins
69. Class Four, plan four, inlay in position before removing wire loop
.
70. Class Five cavity and inlay
71. Shows the necessary amount of metal for adequate protection of abraded
surfaces, when opening the bite
55. Class

72.
73.

Large restoration in non-vital case

Some of the methods by which inlays may be given retentive form
large decays and non-vital cases

75. Starting cohesive gold,

76. Starting

92
92
93
94
101
102
103
105
105
106
106
107
107
108
108
109
109
109
110

110
113
1]5
130
131
132
133
134
149

Class One cavity on the labial of a central incisor properly prepared

for a silicate filling
81. Extensive Class Three cavity properly prepared for a silicate filling
.
.
82.
Class Five and a Class Three cavity suitable for the use of silicate
80.

91

in

74. Starting cohesive gold, first plan

second plan
cohesive gold, third plan
77. Burnishing back excess gold foil in covering the gingival margin
78. Covering the gingivo-lingual angle with cohesive gold
79. Suitable cavities for the use of silicate fillings

83
84
84
85
85
86
88
88
89
89
91

149
150

84.

A
A

as a filling
Class Five cavity properly prepared for a silicate filling
Class Three cavity, lingual approach, properly prepared for a silicate

85.

small Class Three cavity, labial approach, properly prepared for a

83.

filling

silicate

filling

.'

150
151
151

152

ILLUSTRATIONS

14
FIG.

PAGE

86.

small Class Three cavity, lingual approach, properly prepared for a

87.

large Class Three cavity, labial approach, properly prepared for a

88.

large Class Three cavity, lingual approach, properly prepared for a

silicate

silicate

silicate

filling

152

filling

152

filling

large Class Three cavity properly prepared for a silicate filling

90. Two extensive Class Three cavities properly prepared for a silicate
89.

'

filling

91.

92.
93.

94.
95.
96.
97.

98.
99.

100.

101.
102.

103.
104.
105.

106.
107.
108.
109.

110.
111.

112.
113.

114.

115.
116.
117.

118.
119.

120.
121.
122.

123.
124.
125.
126.
127.

A
A

small set of instruments for manipulating silicate

suitable slab and spatula for working silicate
Proper position of the spatula on the slab when manipulating silicate
Proper placing of the materials when manipulating silicate
Mixing the silicate filling
Mixing the silicate filling
Circular motion used in mixing the silicate filling
Scraping the material from the slab
The entire mix on the spatula
Method of removing the mix from the spatula to the slab
Proper consistency of silicate
Shows mix of silicate too thin
A homemade mallet and point
Three cavities suitable for silicate fillings
Shows the results obtained after filling with silicate the cavities shown
in Fig. 104
Combination gold inlay and silicate
Amalgam in position ready to receive a partial facing of silicate
Amalgam filling shown in Fig. 107 with the silicate facing built in
An improper position with the operator doing his work at arm 's length
Types of superior central incisors
Types of superior lateral incisors
Position for extracting superior incisors
Types of inferior central and lateral incisors
Position for extracting lower incisors
Types of superior cuspids
Position for extracting right superior cuspids
Position for extracting left superior cu.spids
Mesial and distal application of forceps to a superior right cuspid
when both adjacent teeth have been extracted
Types of inferior cuspids
Position for extracting inferior cuspids
Types of superior first and second bicuspids
Position for extracting right superior bicuspids
Position for extracting left superior bicuspids
Types of inferior first and second bicuspids
Position for extracting right inferior bicuspids
Position for extracting left inferior bicuspids

....

130.
131.
132.
133.

........

and second molars

and second right superior molars
Position for extracting first and second left superior molars
Types of inferior first and second molars
Position for extracting first and second right inferior molars
Position for extracting first and second left inferior molars
Types of superior third molars
Types of superior

first

128. Position for extracting

129.

first

....

152
153

153
154
155
156
156
157
157
158
159
160
160
161
161
162
163
163
171
172
172
235
236
237
238
239
240
241
242
243

244
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260

ILLUSTRATIONS

15

FIG.

134.
135.
136.

137.
138.
139.

PAQE

Types of abnormal superior third molars

One of the many abnormal conditions found when extracting upper
second and third molars
Position for extracting right upper third molars
Position for extracting upper left third molars
Types of inferior third molars
Elevator beaked forceps for extracting third molars

140. Position for extracting right inferioi third molars

141. Position for extracting left inferior third molar
142-.

Complete

set of

deciduous teeth witli the

143. Irregularity resulting

144. Horizontal

injection

145. Perpendicular
146.

first permanent molar added

from premature extraction of first deciduous molar

injection

Drawing representing the

positions of needles in local anesthesia

mandibular injection
Second position in the mandibular injection
Third position for the mandibular injection
Fourth and last position for the mandibular injection
A very clear and easy case with the needle in the best position for the
mandibular injection
A difficult case where the lingula is almost entirely wanting
Same mandible as shown in Fig. 153 with the needle passed to position
sufficiently high to be above the lingula
A mandible which belongs to a class on which it is very hard to give
a mandibular injection
First and ideal position for giving the mental injection
Second position for giving the mental injection

147. First position in the

148.
149.
150.
151.

152.
153.
154.
155.

156.

....

157. Position of needle in giving the infra-orbital injection

158. Final position of the needle in giving the zygomatic injection
159. Cavity preparation for a Class
160.
161.

162.
163.

164.

Two

porcelain inlay
Class Three cavity labial approach for porcelain inlay
Class Three cavity labial approach for porcelain inlay
Class Three cavity lingual approach for porcelain inlay
Class Four cavity incisal approach for porcelain inlay

A
A
A
A
A Class Four, plan one, inciso-proximal approach for
A Class Four, plan two, with double step for porcelain
A Class Four, plan three, for porcelain inlay

porcelain inlay
inlay

....

cavity for porcelain inlay

Class Six cavity using pin anchorage for porcelain inlay
170. Chisels for securing outline form

....

165.

166.

167. Class

Five cavities for porcelain inlay

168. Incisal

169.

171. Spoons
172.

for

removing softened

Enamel hatchets for completing

dentine
outline

and sharpening base line angles

Hatchets and hoes for cutting ascending line angles and completing
retention form
Gingival marginal trimmers
Gold building pluggers
Dr. Rathbun's dontech with teeth in position ready for practice work
A student who has kept his appointment with his patient, "Mr. Dentech"
Forceps made after the patterns of the author

173. Instruments for cutting point angles

175.
176.

177.
178.
179.

180. Foi-fops

made

26U
263
264
265
266
266
267
270
271
275
276
277
278
279
280
281
282
283
284
285
286
287
289
291
297
298
298
299
300
300
301
302
303
304
305
314
315

form and flattening dentine

walls
174.

261

after the patterns of the author

316
317
318
319
320
321
322
323
324

OPERATIVE DENTISTRY
PART

07

CHAPTER

o ^

I.

INSTRUMENT NOMENCLATURE.

i^
p-\

dental instrument

is

an appliance, or

a dentist performs dental operations.

learn the
to

names and uses

tool,

by means of which

It is quite essential that

we

we

are

of the instruments most in use

if

understand the teachng of operative procedures.

Instruments are named according to the purpose for which they

are intended, where and

how

used,

by describing

their

working

points and the shape of their shank.

An

order

name

describes that for Avhich an instrument

is

used,

as for example, excavator, clamps, mallet, pluggers, burnishers, etc.

name

sub-order

describes where or

used and

made by

how an instrument

given order

is

der name.

Examples are hand pluggers, push or

class

name

is

of a

inserting a prefix before the orpull scalers, etc.

describes the Avorking point of an instrument.

amples are serrated plugger, ball burnisher,

Ex-

chisel, hatchet, etc.

A sub-class name describes the shape of the shank, and is made

by prefixing this description to the class or order name or to both
combined. Examples are bayonet plugger, bin-angle chisel, monangle hatchet excavator,

etc.

Rights and lefts are made as further divisions of manj^ of the

sub-classes of instruments and this division is especially advantageous in the spoons, bin-angle, contra-angle hatchets and marginal trimmers, as

it

enables the user to do the

ment of the instrument from right

work by

a move-

to left, or left to right, respec-

tively.

An

excavator

is

that order of

hand instrument used in the reto the making of a filling.

moval of tooth substance preparatory

chisel

is

that class of excavator

placed at right angles to the shaft,

17

which has the cutting edge

sharpened by grinding on

is

OPERATIVE DENTISTrV

J8
'':

(_
;;^

one side only and

is

used by a pushing force applied in the diree-

lion of the long axis of the shaft.

The chisel edge is made with a bevel at an angle calculated to

plane and cleave a substance possessed of a grain, and is so tempered as to retain an edge Avhen working on hard substances.
The use of the chis,el is, therefore, the cleaving and planing of
The planing of dentine may be done M'ith a chisel or with

enamel.

other instruments of a similar edge.

CJhisels are divided into sub-classes
Z)

^
in

according to the shapes of

their shanks, as straight, bin-angle, contra-angle, etc.

hoe

is

that class of excavator with the cutting edge at a right

angle Avith the shaft, sharpened on the distal side only and

is

used

by a pulling force applied parallel Avith the long axis of the shaft.
Hoes are divided into sub-classes according to the shape of their
shanks, as, mon-angle, bin-angle, contra-angle and triple-angle contra-angle. The hoe is used mostly for cutting dentine.

A hatchet is that class of excavator Avith the line of the cutting

edge laid in the plane parallel Avith the long axis of the shaft.
Hatchets are divided into sub-classes the same as the hoes, acas, mon-angle, bin-angle and

cording to the shape of their shank,

triple-angle contra-angle.

construction of
of lines

A
A

flat Avails

The hatchet form is indispensable for the

and internal surfaces, the straightening

and the sharpening of angles.

gingival marginal trimmer

spoon

is

is

a modified hatchet.

that class of excavator AA^hich resembles in most re-

This is sharpened
convex side of the boAvl
name. The cutting edge is

spects the hatchet, other than the cutting edge.

on one side only Avhich

is

rounded

like the

from Avhich it derives its

rounded and sharpened to a thin edge. Spoons are alAA^ays made
rights and lefts.
The use of a spoon is to remove foreign matter and softened
dentine from the tooth caAnty.
of a spoon

The angles betAveen the shank and the Avorking part are designated as mon-angle, bin-angles, and triple-angles, according to the
number of angles used being one, tAvo or three, respectively.
The contra-angle is the placing of such angles in the shank of
the instrument as to bring the cutting edge near the central line
of the shaft Avhich removes the tendency to tip or turn in the

during

hand

iise.

Bin-angles and triple-angles are properly

tra-angled, provided the cutting edge

from the central

line of the shaft.

is

made only Avhen

con-

more than three millimeters

Instrument NOMENcLATUitE

Formula Names.
on the handle

The

first is

second
is

is

19

Sonic instriuuents have the formula stamped

There are generally three numbers given.

in figures.

The
The third

the Avidth of the blade in tenths of a millimeter.

the length of the blade given in millimeters.

the angle of the blade with

its

handle given in the hundredths

is

given, as with gingival marginal

of a circle.

When

a four-number formula

trimmers, the second number in the

name

designates the angle of

the cutting edge of the blade with shaft or handle.

given in the hundredths of a

This

is

also

circle.

an order of instrument for the packing of material

Those for gold are serrated on the working point in such shape as to result in a surface made up of prisms.
These prisms should be of exactly the same size on all the points
used in any individual filling when packing cohesive gold, as the
interchange of points of different-sized serrations causes bridging.
(See manipulation of cohesive gold, Chapter XX.)
plugger

in the

is

making

of a filling.

The dental engine

is

is

almost indispensable and

when properly used

How-

a blessing to our patients and a time-saver to the dentist.

ever,

it is all

too frequently used, especially

by students and young

do things which can properly be done only with

the hand instruments. The misuse of the dental engine has caused
practitioners, to

the public to regard

it

asthe climax of all pain-producing instru-

ments in the dental office, v.hen in reality, if that which should be

done with the engine is properly done, only a few seconds of pain is
induced in the preparation of a very severe cavity.

The engine bur is the working point of the engine and is made
many shapes and sizes. However, those which are round and inverted cones, whose diameter is smaller than one millimeter, are
most frequently indicated. The tendency of the beginner is to use
ill

Burs are primarily intended to cut dentine in outand for undermining enamel to facilitate the
use of hand instruments and they should rarely come in contact
with the enamel.
too large burs.

lining cavity walls,

The most indispensable use

of the engine

is

for the polishing

grinding necessary to the successful termination of

operations, both in and out of the mouth.

many

and

varied

The sharpening of instruments is of the utmost importance and

No better can a dentist
is by no means accomplished without skill.
whose tools must be
tradesman
execute finished work than can a
keen of edge if he is to produce that which is worthy of his craft.
Again, dull instruments cause an undue amount of pain at each at-

OPERATIVE DENTISTRY

20

tempt to

pain

cut, -whereas Avhen sharp, the

is less

and the

effort

in cutting is materially lessened, resulting in a saving of pain to

the patient and time and energy to the dentist. A hard, smooth
Arkansas stone is the only suitable abrasive and should be well
oiled and wiped Avith a cloth after each use.
Care of Instruments. As the instruments are shipped to the dentist they are usually made and sharpened especially for the use intended and care should be exercised in sharpening that the degree
of the angle of the beveled edge is not changed.
Tests for Sharpness.

An

by placing the edge with

attempting to move
edge.

If

it

it

instrument

is

tested for sharpness best

light pressure against the finger nail

and

across the surface at right angles to the

catches or clings to the nail

it

is

ready for use.

chaptp:r

11.

CAVITY NOMENCLATURE.

A cavity nomenclature is necessary that we may understand one

another in conversing about the formation of cavities, the descripand the methods

tion of their several parts

preparation of cavities for

of procedure in the

fillings.

names from the surfaces of the teeth in

Thus occlusal cavity, buccal cavity, labial cavare cavities occurring in the surfaces named.

Cavities derive their

which they occur.

ity, etc.,

Fig.

Defects

1.

in

enamel.

Proximal cavities are those occurring in the proximal surfaces

and are divided into tAvo classes, namely, mesial and distal.
A simple cavity is one which involves but one surface.
A complex cavity is one which, either from decay or extension
in preparation, involves more than one surface.
Complex cavities are named by combining the names of the surfaces of the tooth involved, as mesio-occlusal, disto-occlusal, mesiodisto-occlusal, etc.

An

axial surface cavity

is

one which occurs in an axial surface.

Cavities are divided as to their origin into

First.

two groups.

Pit and fissure cavities, which are those originating in

(See Figs. 1 and

the minute faults in the enamel.

21

2.)

OPERATIVE DENTISTRY

22

Smooth surface

Second.

cavities,

which are those occurring on sur-

faces without defects in the enamel, but are habitually unclean.

(See Figs. 3 and

4.)

Cavities are divided according to similarity in line of treatment

into six divisions.

Class One.

and

Those cavities beginning in structural defects.

(Pits

fissures.)

Class Two.

Those cavities in the proximal surfaces of bicuspids

and molars.
Those cavities in the proximal surfaces of incisors

Class Three.

and cuspids not involving the

Fig.

2.

incisal angle.

Defects

in enamel.

Class Four. Those cavities in the proximal surfaces of incisors

and cuspids which require the restoration of the incisal angle.
Those cavities in the gingival third of the labial,
Class Five.
buccal and lingual surfaces not originating in faults in enamel.

Class Six.

Abraded

The outside walls

surfaces.

of a cavity are those walls placed toAvard the

outside surfaces of a tooth

and take the names

of the surfaces of

the tooth toward which they are placed, as in an occlusal cavity

the outside walls are buccal, distal, mesial and lingual, while the
fifth or internal

wall

The pulpal wall

pulp and

is

is

is

the pulpal.

that inside wall of a cavity which covers the

in a plane at right angles to the long axis of the tooth.

CAVITY NOMENCLATURE

hi case the pulp

pulpal wall,

The

ill

removed the

is

piilpal

23
Avail

becomes the sub-

multi-rooted teeth.

axial wall

is

the inside wall of an axial surface cavity which

covers the pulp and

in a plane parallel to the long axis of the

is

tooth.

Fig.

3.

Fig.

In case the pulp

is

Smooth

surface decay.

Smooth

surface decay.

4.

removed

in

an axial surface cavity the axial

wall becomes an outside wall and takes the

the tooth toward which

The gingival

it

is

name

of the surface of

placed.

w^all is the inside

wall of an axial surface cavity

OPERATIVE DENTISTRY

24

placed toAvard, and running in the same plane

as,

the gingivae.

Both gingival and sub-pulpal walls may be present in cases of

palp removal in mesio-occlusal, disto-occlusal, and mesio-disto-oc-

Fig.

5."

Fig.

clusal cavities

of each wall

The

is

when each

Class One

6.

is

cavities filled.

Class Two

cavity

filled.

on a different level and the individuality

retained.

inside walls of a cavity are those placed

root of a tooth.

toward the pulp or

CAVITY NOMENCLATURE

The base

of a cavity, or seat of a filling,

is

25
that portion of a cav-

ity situated at right angles to the lines of force to

Generally speaking, this

likely to be subjected.

is

which

it is

most

the gingival or

pulpal wall, or both, where these walls are present, as in a step

cavity.

Fig.

7.

Class

Three cavity

Fig. 9.

line angle

a line

and

is

is

Fig.

filled.

Class

Five cavity

formed where two

named by

8.

Class

Four cavity

filled.

filled.

Avails of

a cavity meet along

joining the name's of the walls so meeting.

There is hut one exception to this rule. That is where the labial
and lingual walls of a proximal cavity in the incisors and cuspids
meet along a line. By applying the rule this would be called the

OPERATIVE DENTISTRY

26

labio-lingual aiigie, but for convenience this

is

named

the "incisal-

line angle."

point angle

formed Avhere three walls of a cavity meet

is

liisccted

at

Two

cavity has been cut and line angles

indicated.
The line angles are: a, Gin.2;ivo-buccal b, Gingivo-lingual; c, Gingivo-axial; d,
A.xio-bucca!
e, Axio-lingnal
/. Axio-pulpal; g, Pulpo-buccal; h, Pulpo-lingual; i, Pulpo distal;
/, Disto-buccal; k, Disto-lingual.
l"ig.

10.

molar

in

which a mesial Class

Fig. 11.
Bisected molar in which a mesial Class Two cavity has been cut and point angles
indicated.
The point angles are: a, Gingivo-axio-buccal b, Gingivo-axio-lingual; d, Pulpo-distolingual; e, Pulpo-disto-buccal.
;

a point

There

and
is

is

named by

joining the

hut one exception to

tliis

names
rule.

of the Avails so meeting.

The point of junction of


CAVITY NOMENCLATURE

27

the axial, labial and lingual walls in proximal cavities in the six
anterior teeth

is,

for convenience,

named

the "incisal angle."

simple cavity has two sets of line angles.

line angles

surrounding the internal

in axial surface cavities,

The second

Avail,

First, the internal

which

and the pulpal wall

set of external line angles is

is

the axial wall

in occlusal cavities.

formed by the junc-

tion of the outside walls with each other.

The enamel margin is that point on the surface of the tooth

where the cavity begins in enamel.

;\\vsjc5^^^^v;^i,:^

A, Kxternal enamel surface; B, Cavo-surface angle; C, Marginal bevel; D, Revel

H, Base line angles.
angle; B, ICnaniel wall; F, Dento-enamel junction; G, Dentinal wall;
I'"ig.

12.

The external enamel

its

line

is

the entire outline of the cavity at

enamel margin.

The cavo-surface angle

is

the angle formed by the junction of

the wall of the cavity with the external surface of the tooth.

The base of the cavo-surface angle is the external enamel surface.

The marginal bevel of a cavity is the deflection of a cavity wall
from its established plane, near the external enamel line.
It is necessary that beveling be resorted to, in order to manage

OPERATIVE DENTISTRY

28

the enamel margins, direct the external enamel line and control

the degree of the cavo-surface angle, withont disturbing the gen-

form of the cavitj-.

The bevel angle is the angle formed by the junction

eral retentive

of the mar-

ginal bevel with the remaining portion of the wall of Avhich

it is

part.

The base

of the bevel angle

is

the remaining portion of the cavity

wall.

The bevel angle

is

covered when the

filling is in position.

Its

distance from the enamel margin depends

upon the filling material

used, and the location in the cavity outline. To illustrate: With
porcelain inlays and amalgam the bevel angle must be deeply burWith cast gold
ied, resulting in a thicker edge of filling material.
inlays and platinum combination fillings the bevel angle should be
near the surface, resulting in a short marginal bevel. The distance
of the bevel angle from the cavo-surface angle must not affect the
degree of the latter angle but determines only the length of the
bevel and the thickness of the filling at its margin.

The planes

of a tooth are three in

and
The horizontal plane

distal plane

number

horizontal plane, mesio-

bucco-lingual plane.
is

at right angles to the long axis of the

tooth.

The mesio-distal plane passes through the tooth from mesial

to

with the long axis.

The bucco-lingual plane passes through the tooth from buccal to
lingual parallel with the long axis of the tooth. In the six anterior
distal parallel

teeth this plane

would be

labio-lingual.

CHAPTER

III.

CAVITY PREPARATION. (GENERAL CONSIDERATIONS.)

Definition of Cavity Preparation.

Cavity preparation

is

that term

applied to those mechanical procedures upon a tooth, looking to

the

making

of a filling, as well as those changes

and extensions

necessary to resist stress and prevent a recurrence of decay.

is dentine which has been acted upon by the
advance of the micro-organisms of caries.
Infected Dentine is dentine which has been penetrated by micro-

Affected Dentine

lactic acid in

organisms.

Objects in Filling Teeth.

There are four general objects in view

in the filling of teeth

To arrest the of tooth substance.

To prevent recurrence of
Third. To restore
tooth contour.
Fourth. To improve the primary conditions

First.

loss

Second.

caries.

full

ance of function and esthetic

as to the perform-

effects.

Completed Cavity should be a combination of

flat

walls com-

ing together at definite angles, surrounded by an external line

made

up of the largest curves permissible.

The Line Angles within a cavity, Avhich are a necessary part of
resistance and retention forms, should never be pej-mitted to end
in the external

enamel

line.

Order of Procedure. To simplify the preparation of all cavities

and to insure the observance of certain fundamental principles it
is

well to follow a definite order of procedure.

This will greatly

and lead to the establishthe practitioner which will stand for thorough

facilitate the operations of the student

ment of habits bj^

methods of execution.

The following would seem

to be the natural order:

Gain
Outline form.
Third. Resistance form.
Fourth. Retention form.
Fifth. Convenience form.
Sixth. Removal of remaining decay.
Seventh. Finishing of enamel
Eighth. Toilet of the cavity.

First.

access.

Second.

walls.

29

OPERATIVE DENTISTRY

30
Modification of

Form

is

necessary in cavity preparation to meet

the various properties of the different filling materials used.

is

particularly true

when

This

considering the difference in edge strength

and flow 'of metals and alloys.

The character of the oral fluids, the evident care bestowed upon
the teeth, condition of patient's health, age of patient and the life
expectancy of the patient and of the individual teeth, will frequently require a modification of cavity formation to best resist
the recurrence of decay and the dislodgement of the filling through
stress.

CHAPTER

IV.

GAINING ACCESS.
Gaining access

Definition.

make

ures necessary to
of the

the term applied to those proced-

is

sufficient

room

for the proper introduction

filling.

we may have

Sufficient Access is Important, that

of space to properly handle the instruments

we may be able to intromay be complete contour

desired contact relation may

in the procedures of

making a

duce the

the cavity, that there

filling into

filling,

the advantage

and appliances used

that

restoration of tooth form and that the

be established to the adjacent tooth.

Access to the Tooth

the opening of the

is

mouth

the

first

consideration and will involve

degree to permit of the

proximal
spaces used for the
The

to a sufficient

free use of the usual appliances.

adjustment of the dam should be examined to make sure that the

rubber and ligatures will pass to the gingival line without injury.
A sufficient number of teeth should be isolated, say four or five,
to give a clear and unobstructive view of the cavity and surrounding teeth.

The operator must be able

to bring the cavity into full view.

Cases where there has been considerable decaj^ sub-gingivally, and

tumefaction of the gum septa has taken place, proper access Avill
involve the packing of the cavity with a

tampon

of cotton

which

has been dipped in chlora-percha, or a packing of gutta-percha,

for a period of twenty-four or forty-eight hours, to crowd the encroaching gum tissue from the cavity. A neglect of this consideration of access will often make proper management of the gingival
wall and margin most difficult or impossible.

may

Surgical Access
all

be practiced on the cavity margins,

when

tooth structure thus removed will subsequently be replaced with

filling material.

It

may

be practiced on the

gum

septa

when

there

has been excessive tumefaction in the proximal space.

Formerly

method Avas practiced with Class Five cavities

was to a marked extent subgingival, and it was
make a cohesive gold filling. However, much of this
this

Avhere the decay

desired to

questionable practice
inlay,

made from

the

may now

be avoided

wax model,

bj^

the use of the gold

as the presence of the overlying

gum

is no considornl)le hindrance.
Access as Related to Restoration of Proximal Space.

31

As tooth

OPERATIVE DENTISTRY

32

substance

is

through decay in proximal

lost

cavities, there is in

movement

most cases a
of the teeth to the proximal, encroaching
on the normal space, robbing the gum of sufficient room for full
festoon. It is wholly impossible in such cases for the operator in
making a filling to restore tooth contour, or leave a normal amount
of room for the rehabitation of the gum septa, without resorting
The surfaces of a tooth which are covered with
to separation.
healthy gum tissue are practically immune from both prim.ary and
secondary caries, and it is greatly to the advantage of a filling, the
outline of which in the proximal gingival third, to be so protected.
Good access should be gained by preliminary separation, so that
when the completed filling with its full tooth-form restoration is
in place, there is restored the normal proximal space for the habitation of the

gum

septa.

failure to regard this fact

Avill

result in

a strangulated, diseased and dwarfed septa, inviting an accumulation of the

enemy

of tooth structure

through secondary

and an early

loss of the filling

caries.

Restoration of Tooth
the masticating organs

Form is essential that the full function

may be established and maintained. It

also desirable for esthetic reasons, as the

more nearly a

of
is

dentist

approaches complete tooth contour restoration, with all its details,

the more pleasing is the appearance and the more artistic the
result.

Proper Contact Point is often impossible unless sufficient achas been secured through separation.
This contact should
l^e a point of contact, the embrasures widening therefrom in every
direction.
It should be in no sense a line of contact or a surface,
no matter how small. It is advisable many times, in this respect,
to improve on nature by slightly varying the surface of the filling
from the original shape of the tooth, as often the predisposing cause
of the primary decay has been defective contact.
cess

The Saving of Tooth Substance is materially effected by access

through preliminary separation, particularly in the placing of inlays, as the more thoroughly this first step in procedure has been
accomplished the less cutting will be required for convenience form,
a point of no small importance.
Methods of Separation.

There are two classifications of separawhich is also slow separation, and

rapid, both of which are a part of gaining ac-

tion to gain access, preliminary,

immediate, which

is

cess.

The preliminary

is

a part of the

first

consideration, while im-

GAINING ACCESS

mediate separation

is

33

brought to our attention during the introduc-

tion of the filling.

Preliminary Separation
in bicuspids

is

best accomplished in proximal cavities

and molars (Class Two) by packing

into the partially

excavated cavity an excess of gutta-percha base plate. A few days,

or in some instances a few weeks, will suffice to accomplish the
desired result, particularly

mouth

if

the patient uses that location in the

for daily mastication of solid food.

In the proximal space in the six anteriors preliminary separais best accomplished by the use of cotton tampons tightly

tion

packed in the cavity and ligatured securely to position.

Immediate Separation is best accomplished with the mechanical
separator, and should be used to gain additional access, not already
secured by preliminary separation, or may be used primarily when
only a small amount of additional space is desired. This instrument should be adjusted as soon as convenient after securing outline form, and removed only when the filling is finished.
Avoid Gum Injuries in the use of elastic rubber. In the use of
the methods given care should be used not to croAvd the gum tissue
as permanent injury may result.

There are other materials used in slow separation, as linen tape,

"^vooden wedges, etc., each with its merit

and indicated

use.

Soreness Resulting from Tooth Separation should be treated as

any case of acute pericementitis, by giving the tooth physiological
rest,

and the use

tooth's root.

of stimulating applications on the

gum

over the

CHAPTER

V.

OUTLINE FORM.
Definition. Outline form is that part of cavity preparation which
determines the area of the tooth surface to be included within the

external enamel

Rule

1.

line.

Extend to Sound Enamel.

be extended until

all

All cavity margins should

indications of surface decay have been in-

cluded.

Rule

2.

Obtain Full Length Rods.

If necessary, further

extend

the outline until full-length enamel rods, supported by sound dentine,

have been reached.

Rule
til

3.

Self-Cleansing Margins.

Extend the cavity outline un-

the surface of the filling can be so formed that the enamel mar-

gin not protected by the

gum

will be mechanically cleansed

by the

excursions of food in mastication.

In Relation to Developmental Grooves. A cavity outline should not follow a developmental groove, or parallel it so
closely as to leave a small strip of intervening enamel. The outline
should cross the grooves as squarely as possible.

Rule

4.

Rule

5.

Fissures

and Sulcate Grooves.

All

fissures,

sulcate

grooves and angular developmental grooves encountered should be

included Avithin the cavity outline. This comes in for the greatest
consideration Avhen part of the outline

is

laid on

an occlusal sur-

face.

Rule 6. Enamel Eminences. The outline should avoid extreme

eminences of enamel and centers of primary development. Such
locations are subject to the extremes of stress during mastication.

When

is the seat of primary calcification

found to be less perfect in formation than the portion
midway from that point to the grooves.
Rule 7. Avoid Angles in Outline. The outline should be made
np of the greatest curves possible, avoiding all angles. Nearly flat
axial surfaces should show nearly straight lines or the segments
of very large circles, while on occlusal surfaces, which are made up
of a succession of depressions and eminences, the outline should
be a combination of smaller curves.
Rule 8. Outline in the Embrasures. The outlines in the labial,
buccal and lingual embrasures should be parallel to each other and
it

the eminence in question

will be

34

OUTLINE FORM

35

at right angles to the seat of the cavity, and pass under the free
margin of the gum at a point in full view of the operator.
Rule 9. Enamel Margins. The enamel margins should be planed
smooth to a full cleavage of the enamel rods and then slightly

beveled that the rods at the cavo-surface angle

Fig.

Fig. 14.

rods, supported

13.

Technic

Another

may

be full-length

group illustrating outline form.

view of cavities illustrated in

Fig. 13.

by shortened enamel rods which are protected by

the overlying filling material.

Rule

10.

Extension for Prevention.

When

possible, carry the

cavity outline upon smooth, unclean surfaces, from an area of great

an area of lesser liability to caries.

This has reference to caries of enamel only and will come into

liability to caries to

OPERATIVE DENTISTRY

36

consideration in cavity outline Avhen the rules previously given

have not carried the outline to comparatively safe and immune

localities.

I"ijj.

15.

Fillings

Fig. 16.

in

place in cavities

Another view

shown

of fillings

in

shown

Figs.

in Fig.

13

and

14.

15.

Extension for prevention does not mean tJie consideration of

sistance to stress. It bears no reference to decay of the dentine.
has no relation to the management of frail walls.

re-

It

OUTLINE FORM
Its

37

maximum

application is found in the management of small

where the ravages of decay have not yet carried the outof the cavity to areas not subject to primary enamel dissolu-

cavities
line
tion.

The abuses of extension for prevention result in much unnecesits sane and legitimate use is one
of the most important factors in tooth salvage.
Dangers of Increased Cavity Outline. The danger of secondary
caries increases in each mouth proportionately as the aggregate

sary loss of tooth substance, while

length of cavity outline

To

Illustrate.

is

increased.

If the total length of cavity outline of all fillings

doubled by the increase in number of fillings the

liability to secondary caries is doubled, all else being equal.
For
that reason each individual cavity should have its outline as short
in a

mouth

is

as permissible.

The laying of cavity outline in locations not susceptible to primary caries will materially decrease the liability to recurrent decay, even though the aggregate cavity outline in the mouth is
thereby greatly lengthened.
feet

is

An

aggregate cavity outline of two

preferable to a total of one foot, provided the additional

length has been caused to extend to locations not liable to caries.

CHAPTER

VI.

RESISTANCE FORM.

Definition.
Extension for resistance is a term applied to that
procedure Avhich has for its sole object the carrying of the cavity
outline from localities subjected to great stress, to localities not
frequently subjected to the crushing strain. This is often mistaken
for extension for prevention, whereas it has reference only to re-

sistance to stress.

A proper application of this procedure Avill involve a careful

study of occlusion and articulation in each individual case.
Resistance form involves a consideration of the management of
weakened enamel walls and a study of the flow and edge strength
of the filling material used with a view of so shaping the cavity
as to minimize the effects of the crushing strain.
Its

importance

is

in direct proportion to the

exposure of the

fill-

ing in occlusion and articulation, and the strength of the closure

of the jaws.

in

The force to provide for is from one to two hundred pounds and
some cases even more, particularly in mid-jaw locations.
Weakened enamel walls are those which through decay, or un-

necessary cutting, have been robbed of

dentine.

chisel, particularly if

sideration

much

of their supporting

All such unsupported enamel should be cut

Avill

away with

by any chance the wall of enamel under con-

receive

much

stress in the process of mastication,

or the introduction of the filling.

Stress from within should be avoided by not allowing such weakened walls to remain and form any part of the retention of the
filling.

Weakened walls are sometimes allowed to remain, or a portion

when they can be so protected by a layer of rigid filling
material as to prevent all stress, but this is permissible only when
their presence will screen unsightly metal fillings and when the
of them,

kind of filling used can be introduced without injury to the walls.

Before applying the rubber dam each case should be inspected
for the surface contact in occlusion and articulation and then the
margin so laid as to occupy the least exposed position. Many times
all stress cannot be avoided, but the amount of stress a margin is
liable to receive should

have due consideration and good judgment

exercised in the placing of the margin.

38

RESISTANCE FORM
Resistance

Form

39

as Applied to Filling Material.

We

to consider the properties of the filling material to be

individual cavity.

In preparing the cavity

ing power of the enamel margin

we

we

are forced

used in each

consider the resist-

are able to obtain.

We

also

take into account the resistance of the filling material used, to the
crushing strain, as this property varies greatly. Amalgam, even

under the most favorable manipulation, is subject to flow and more

or less spheroiding, which often results in a slight exposure of
the cavo-surface angle.
Again, amalgam is not ductal, hence these
edges of this filling are easily fractured at the margins under
stress.
This liability to fracture at the margin is also true of our
cement and silicate fillings and great care should be exercised in
placing the margins of these fillings.
Cohesive gold, especially
Avhen alloyed with platinum, is our best filling material to resist
the crushing strain at the margins, and when the edges are not too
thin, the repeated blows from the opposing teeth only tend to drive
this material in closer adaptation to the margins.

gold inlay,

it is

When

using the

quite necessary to exercise great care at the mar-

gins to resist the crushing strain, not of the gold, but of the en-

amel margin and the intervening cement, for unless the gold inlay fits better than the average gold inlay, there is a line of cement which is subsequently dissolved. This leaves the last rods at
the cavo-surface angle unprotected, and very liable to injury.
It therefore folloAvs that the amount of marginal extension for
resistance form is less for cohesive gold and gold inlays than other

The greater the edge strength of the filling material, the

more protection it gives the cavity margins. Yet resistance form
fillings.

should receive careful consideration with

strength.

fillings of

maximum

edge

CHAPTER

VII.

RETENTION FORM.
Retention form is that part of the procedure in cavpreparation which deals with the provisions for preventing the

Definition.
ity

from being displaced by the tipping strain. Force which

from the cavity, is one of the
greatest enemies to permanency in tooth filling, second only to re-

filing

results in tipping the filling bodily

current caries.
Partially Provided

For

Retention form

Form.

in Resistance

is

partially provided for in the previous step of resistance form, but

it is

made

to resist the force of

filling as

a whole from being

further necessary that provision be

mastication in order to prevent the

moved from

Maximum

its seat.

Retention

Form

is

required in cavities in the proximal

surfaces as the missing proximal wall renders these fillings particularly exposed to injury

by the tipping

force,

during the movements

of the mandible.

Flat seats for fillings are imperative in retention form.

Seats
should be cut in a plane at right angles to the stress of nlastica-

which
The Step

tion,

is

usually at right angles to the long axis of the tooth.

as a Part of Retention

Form.

The addition

of the step

Two and Class Four is for the purpose of giving

form. By this procedure in proximal cavities in

in cavities of Class

added retention
bicuspids and molars, the
the cavity proper

is

upon buccal and lingual walls of

transferred to those portions of the same walls

which are a part of the

stress

step, a location

much

better situated to

In cavities of Class Four, the addi-

withstand the tipping strain.

tion of the step on the incisal or lingual, or both, will give added
retention form, avoiding heavy cutting at the angle, Avhich weakens
the remaining tooth substance at the angle, to say nothing of the
dangers of crossing the retractive tract of the pulp in this location.
Maximum Retention Form is not required when making simple
cavities, as they are protected from the dangers of lateral strain
by the presence of surrounding external walls. This will be found
to be the case in cavities of Classes One, Three and Five when occlusion

is

normal.

While

Two, Four and Six,

sometimes necessary to give ample re-

in cavities of Classes

nuieli additional cutting is

tention form.

Acute Angles Required.

IMuch of the retention form required

40

RETENTION FORM
is

41

gained by laying the external surrounding walls at definite angles

to the seat of the filling.

Little Retention in

Enamel.

It

should be remembered in this

step of cavity preparation that there

is

very

little

resistance to

form is provided for in enamel

walls.
The enamel should be removed to a depth sufficient to get
anchorage in angles laid in dentine. A good idea of the amount
of retention form possessed by any completed cavity may be gained
if one will for the time being imagine that all enamel has been removed from the tooth. The remaining cavity will still have nearly
tlie original amount of retention form.
We rely upon the presence
for
resistance
recurrent caries and upon
liable
to
in
areas
of enamel
form.
sound dentine for retention
force in a filling Avherein retention

CHAPTER

VIII.

CONVENIENCE FORM.
Convenience form

Definition.

wherein

is

made

placing of a

is

that part of cavity preparation

those additional changes necessary for the proper

filling.

Sparingly Used.

accompanying

As

and

these additional cavity changes

loss of tooth substance

are

made

their

entirely for the

convenience of the operator they should be resorted to only in cases

of necessity.

Maximum

Convenience Form.

venience form reaches the

The cutting necessary for con-

maximum

the previously prepared filling

is

first,

moved

with inlay

fillings,

as

to position en masse; sec-

making of a cohesive gold filling, as it is of A'alue to

apply force as near as possible at a right angle to the anchorage
of the first portion of gold, and at an angle of 45 degrees to the
wall against which the gold is being condensed; third, in cavities
in the posterior teeth, and in distal cavities as compared with mesial
ond, in the

fourth,

more

is

required for proximal

fillings

not previously sepa-

rated.

Minimum Convenience Form

fillings; second,

first,

in using plastic

in anterior oral locations; third,

where the teeth

required;

is

have had ample separation before the making of a proximal

The Abuse of Convenience Form

reached

its

excessive cutting for convenience

of an inlay,

is

harm

of

to the teeth

height in a desire to inlay every case possible.

it

form

is

filling.

and has

When

necessary to the making

would often be better to avoid the unnecessary

by changing the character of the filling.

loss

of tooth substance

Suitable Instruments for various locations in the mouth, particularly Avith the posterior distal cavities, will

do much

to

minimize

convenience form.

Previous Separation
the

amount

is

the most potent factor of all in lessening

of cutting for convenience form, the

same having been

considered fully in access form, and should be resorted to in cavities of Classes Two and Three if for no other reason.
Starting Points for the making of a cohesive gold filling are a
jjart of convenience form and are made by making one of the
point angles more acute than

This

is

made

is

required for general retention.

in the point angle farthest

42

from the hand when the

CONVENIENCE FORM

43

same

is in position with the plugger point resting in the cavity.

This will be found to be the point angle farthest from vision and

most
filled.

difficult to

fill,

and from the

latter fact should be the first

CHAPTER

IX.

REMOVAL OF REMAINING CARIOUS DENTINE.FINISHING

ENAMEL WALLS.TOILET OF THE CAVITY.
Removal

This order

Definition.

ity preparation Avill

little

to the

is

secondary consideration of

the

af-

In the smaller cavities the previous steps in cav-

fected dentine.

has

of Remaining: Carious Dentine.

have removed
However,

consequence.

mind even

all

affected dentine

it is

and

this step

well to have this step come

in these cases so that the

minute corners and ob-

scure localities are not allowed to pass imperfectly prepared.

In Large Decays the pulp

is

been softened to a near approach to the pulp.

moved

The dentine has

often in question.

be re-

If all of this

early in the procedure, the pulp will be exposed to the

dam-

aging effects of air drafts from the chip blower, or possibly low
temperatures in the operating room.

Pulps thus exposed not

in-

frequently take on the initial stages of destructive diseases from

which they never recover, resulting in much pain to the patient

and chagrin to the operator. The foregoing is particularly true
when one is making a filling for each of two large proximal cavities.

Two Large Proximal

Cavities.

both cavities at the same

sitting,

It is often desirable to

particularly

when

prepare

filling

Avith

amalgam.

With

the cavity

first

prepared, there might be a long exposure

of the pulp to a lower than l)ody temperature, if the overlying de-

cayed dentine

is

removed

at

the time the major portion

is

ex-

cavated.

Technic. The remaining decay in this step of procedure should

be removed Avith broad spoon excavators, when working on axial
or pulpal walls. In small cavities Avhere there is no danger of pulp
exposure the instruments should be small hatchets, with which the

dento-enamel junction should be examined around the entire cavity.

In case a softened area is found and removed the overlying
enamel should be chiseled away, thus restoring the correct outline.

Where Exposed Pulp

the decay

is

removed

is

expected or pulp treatment

just folloAving outline form.

44

is

intended,

TOILET OF THE CAVITY

45

Finishing Enamel Walls.

The

done in the preparation of a cavity

This should always be done with
the rubber dam in place or at least sufficient means taken to prevent the margins from again becoming moist.
No Moisture should be Permitted to come in contact with any
portion of the cavity surface, after final instrumentation, and if
by accident any portion should become wet that portion should be
thoroughly dried and freshened by cutting away the surface, and
the filling immediately placed.
The Cavo-surface Angle of the cavity in every part of the cavity
Definition.

is

last cutting

the finishing of enamel

Avails.

outline should receive special attention at this step in cavity preparation.

The Plane

Enamel

a\ all should be so laid with reference

enamel that these will be cut more from the
outer than the inner ends of the rods, resulting in the last rod at
the cavo-surface angle being a full length rod, supported by shortened rods. The shortened enamel rods are covered with the filling material when the completed filling is in position.
This is accomplished by a slight planing motion parallel to the
external enamel line, using a keen-edged chisel or enamel hatchet.
The gingival margin trimmers are especially adapted for this purpose when finishing the margins in the gingival third.
The Marginal Bevel should be laid in a plane at an angle of from
six to ten centrigrade degrees from the plane of the enamel cleav-

of the

to the cleavage of the

age.

The Depth of the Marginal Bevel should generally not include

more than one-fourth of the enamel wall, but Avhen making a filling of inferior edge strength, as amalgam, porcelain, cement, etc.,
it becomes necessary to bury the bevel angle more deeply.
Locations subject to great stress also require the placing of the
it beyond the enamel and

bevel angle more deeply, even carrying

laying

it

in the dentine.

Toilet of the Cavity.

Definition.

The

prep-

toilet of the cavity is the final step in the

aration of the cavity and consists of freeing the cavity of

particles of tooth substance

all

which are not firmly attached

loose

to the

cavity walls.

This

is

best accomplished by a blast of air

from the chip blower,

followed by a thorough sweeping and brushing of

all

surfaces with

OPERATIVE DENTISTRY

46

cotton or spunk held in the pliers, and again using the chip blower
to

remove

dust.

White Enamel Margins indicate the presence of loosened enamel

If the SAveeping does not remove this, the margins should be
again chiseled, using a keen-edged instrument and a light hand,

rods.

then again be swept with cotton.

If the
Avith

whitened margin

an extra

still persists,

it

fine cuttle-fish disk or strip

will be carried away.

should be brushed over

when

the loosened rods

The margin should be planed again

Avith

the chisel.

Care in the Use of Disk or Strip.

that Avhen a disk or strip

is

It

should be fully understood

used for this purpose, the grit mus't

is no considerable cutting done, as there is

danger of changing the relation of the bevel to the enamel cleav-

be so fine that there

age.

All Fluids Should be Used Previous to Cavity Toilet.

The habit

of SAvabbing out cavities with alcohol or other substances after cavity toilet is useless,

and may do harm by introducing substances

Avith the liquid not easily remoA^ed.

Disinfection and Pulp Protection should have consideration folloAving the removal of remaining decay

and

as a preliminary step

in toilet of the caA'ity.

If a fixed oil, or an essential oil A\hich may contain impurities
has been used, free SAvabbing and scrubbing of the walls with alcohol, or sulphuric ether, is advised for cleansing purposes, to get

rid of the oil

and other

residue.

HoAvever, simply Aviping the

caA^-

must be thoroughly rubbed with an alcohol or ether-moistened cotton ball, folloAved by reasonable desiccation from the chip bloAver, and then every part of the Avails and
margins gone oA-er and freshly cut. This is the only means of obity out Avill not suffice.

It

taining a clean surface.

Leaks in Rubber Dam, particularly near the gingival outline,

must positively be detected. The portion which has become wet
should be dried Avith an absorbent and the air blast. Then all parts
which haA^e been moistened must be gone over and freshly cut.
Simply drying such portions is not adequate, as there is left salts
and albuminoids from the saliA'a and blood serum Avhich can only
be removed by the cutting instruments. The placing of a filling
over this

gummy

residue invites secondary caries.

Avill subsequently dissolve out, resulting in a leak.

These deposits
may be small

It

TOILET OF THE CAVITY

47

but the acid of tooth decay will easily exchange places with such
films.

If the cleaning has been fairly well done,

what

it

may

result only in

termed "blue margin."

When time intervenes between cavity preparation and the making of the filling, as from one sitting to another, the walls and margins should be retrimmed to give fresh cut surfaces to fill against.
This is not possible in the making of inlays as to retrim the margins destroys the fit. The fact that many times we cannot place
the inlays against surfaces which have been freshly cut constitutes
is

the greatest
It is the

sitting

enemy

to their permanence.

one great argument that inlays should be made at one

and under dry conditions.

Oonclusion.

All fillings should be

made

against clean, freshly

cut walls.

r\?

CHAPTER
MANAGEMENT OF

PIT

X.

AND FISSURE

CAVITIES.

(CLASS ONE.)
Location.
Class One cavities occur in the occlusal surfaces of
molars and bicuspids; in the middle and occlusal thirds of the buccal and lingual surfaces of molars and in the lingual surfaces of
nicisors, more frequently in the laterals.
(See Figs. 1 and 2.)

The Predisposing Cause of decay

in these localities

is

a fault in

the enamel due to imperfect closure of the enamel plates, affording

a convenient point for the lodgment of food particles and the active principles of fermentation

which

is

the exciting cause of

all

tooth decay.
is Seldom Necessary in this class of
from the fact that the surface of the enamel in the immediIt is
ate neighborhood is exposed to the friction of mastication.
only necessary to cut away the enamel walls sufficiently to uncover
the area of affected dentine, and to include in the cavity outline
all sharp grooves connected with -seat of primary decay to a location that will permit a smooth finish to the surface of the filling
and an outline void of angles.
Tendency to Extensive Dentinal Decay must be remembered in
dealing with this class of cavities as the merest opening through
the enamel will frequently, upon excavation, show an extensive loss

Extension for Prevention

cavities

'

,^.

of dentine.

Incipient Decays in Occlusal Defects.

'

r ,,

Upon examination

Description.

I,

'M

sharp exiDlorer

Avill

it

is

found that the tine of a

pass betAveen the non-united plates of enamel

depth of the entire thickness of enamel in one or more points.

more careful examination may show the surface of the dentine

to the

to be softened to a greater or less extent

immediately pulp-wise

Such cases demand immediate attention.

To open such cavities there is placed in the engine a discarded No. i/o or 1 round bur which has been made into
This drill is made to
a spade drill by flattening on two sides.
travel between the plates of the enamel through a major portion
of the defect, whicU results in Avidening the fissure. This preliminary step will result in much saving of burs, as a bur which has
been once used on an enamel wall is unfitted to cut dentine. The

from the enamel

Outline Form.

fault.

48

PIT

AND PISSUKE

practice of using dentate fissure burs for this

eoiniiioii

sidered as brutal to the patient and

time.

No.

or 1 round bur

plied to the dentine.

dentine

49

CAVITIES

is

cut

is

work

is

con-

a thief of the operator's

noAv used in the engine and ap-

By swaying

away from beneath

is

the

hand

and fro the

The bur should

piece to

the enamel walls.

be frequently removed to allow of cooling as heat readily develops

and is a great and frequent source of pain to the patient.

.The Use of the Chisel is next advised for the removal of the
overhanging enamel wall; first, because this is the easiest and
speediest means of its accomplishment, and second, because this is
the only means of securing the cleavage of the enamel, giving the
operator the opportunity to judge the amount of resistance to
stress in the several localities,

Many

enamel rods.

and

to learn of the direction of the

times a chisel-edged hatchet will be most ad-

vantageous, one Avhich has a chisel edge upon the sides of the
blade as well as the cutting edge.

The

size

should be governed by

the size of the opening secured, but in every case as large an in-

strument as the orifice will admit should be used. This process

should be repeated with bur for cutting dentine and chisel or
hatchet for cleaving enamel until the desired cavity outline is obtained.

Resistance Form.
sulcate grooves.

angle as possible.
the outline as

The operator should include all fissure and

all grooves and ridges at as near a right
Avoid eminences of primary calcification. Lay

Cross

much

as possible along the sloping sides of the tri-

angles and ridges, as these are the most favored localities for a
cavity margin, for on these sloping surfaces we find the greatest
amount of friction during the process of mastication, due to the

excursions of food, and they are the least exposed to direct stress,
as the blows are of glancing nature.

Retention Form.
Class One.

When

Here

is

a good rule to follow in cavities of

the depth of the cavity

is

equal to or greater

than the width, parallel walls are suflficient. But Avhen the width
exceeds the depth the external walls should meet the internal wall
at a slightly acute angle. These angles are best made acute by the
use of a chisel-edged hatchet or hoe, having corners that are slight"With a planing motion they should be made to travel
ly acute.
This will, at the same time,
parallel with the base line angles.
The extreme ends of long arms in
flatten the seat or pulpal wall.
a filling, such as results from following a slender fissure, must be

made

retentive.

OPERATIVE DENTISTRY

50

Convenience Form.

No

convenience form

is

usually necessary

it may be of
angles
to facilitate
point
of
distant
sharpen
one
the
advantage to

in small cavities Class One, except in rare instances

the starting of a cohesive gold

may

tion of gold

be used

pulpal wall, in which case

filling.

But usually the

first

por-

of sufficient size to entirely cover the

can be securely locked to position be-

it

tAveen the surrounding walls.

Removal

of

Remaining Decay.

Fig.

By

17. Complex Class One

have been removed.

excavated with suitable spoons.
will usually

this time the carious dentine

cavity prepared.

Should any remain

it

should be

At this point there should be a thorough inspection of the dentoenamel junction for small areas of softened dentine which may
have escaped notice.
The Walls should all be flat, particularly the pulpal. In cases
where decay has progressed so deeply into the dentine that to flatten the pulpal wall would cause the involvement of the recessional
tracts of the horns of the pulp, the base-line angle should be made
intermittent, omitting the squaring of the angles in the regions of
the recessional tracts.
Disinfection.

The cavity should be flooded with alcohol carry-

ing a small per cent of formaldehyde, say one or one-half per cent,

and evaporated
Finish of

to dryness.

Enamel Walls.

The enamel wall should be planed for

PIT

AND FISSURE

CAVITIES

51

the entire outline of the cavity with a sharp chisel using a light
hand; the desired cavo-surface angle secured, and the bevel angle
buried to the desired depth. The movement of the chisel should
parallel the travel of the external enamel line.
Toilet of the Cavity. The cavity should be swept with a tightly
rolled cotton ball or piece of spunk in the pliers and the dust finally
removed with a blast of air from the chip-blower, and the filling
immediately placed.

Fig. 18.

Class

One

filled.

Cavity shown in Fig.

17.

to be occupied by an inlay, retention

form may have been omitted and applied to the cavity just before setting the filling, in which case the toilet of the cavity should
be repeated. If the cavity has already been given retention form
the same should be temporarily removed while making the model
by wiping into the retaining angles wax, temporary stopping, or
cement to be removed before final placing of the filling.

Inlays.

If the cavity

is

CHAPTER XL
MANAGEMENT OF

PIT

AND FISSURE

CAVITIES.

(CLASS

ONE CONCLUDED.)
Large Cavities in Central Fossa of Molars.
Description.

Such

cavities are usually the result of

neglect on the part of the patient.

enamel

is

knowing

HoAvever, in cases where the

strong and of a good resistant quality, or the teeth are

have received little stress, the patient may be in

ignorance of the great havoc which has been done, due to the
major portion of the enamel remaining intact. There may exist in
so occluded as to

such cases only the slightest aperture through a defective fissure

or fault in the enamel.
Outline Form.

This division of Class One should be opened with

a straight or bin-angle chisel of rather large size to prevent easy

chisel of from two to

The securing of adequate
finger rest on adjacent tissues is important.
The chisel should be
applied so as to throw the chips into the cavity, and the malle't
substituted for heavy hand pressure. It is best to begin on margins most mesial and nearest the operator's eyes, as this increases

passage to the sensitive pulpal wall.

three millimeters in width

is

advised.

the range of vision to the deeper portions of the cavity at an

This chipping away of the enamel

early stage in the procedure.
should be continued until enamel supported by sound dentine is
reached and until the margins have been carried to desired regions
as set forth in general in the chapter on outline form.

When

Pulp Exposure

is

Feared.

In this case the sixth step in

we have for considera-

cavity preparation will come in third and

tion the removal of remaining decay.

Up

to this point only the

most superficial examination of the

in-

ternal surfaces has been made.

Rubber Dam at this point is expedient as dryness is

The decay is now removed Avith large spoon excavaThese spoons
tors, whose blades are at least two millimeters Avide.
which should be keen of edge are carefully Avorked under the edges
of the masses of softened dentine and by a prying, SAveeping movement this lifted en masse from the Avails. The blade of the exPlacing- the

imperative.

cavator should be prevented from scraping, or sliding over the regions of suspected exposure.
52

PIT

AND FISSURE CAVITIES

53

When

the Pulp is Exposed or nearly so the operator will propulp

treatment, of either devitalization or conservation,
ceed to
This step completed outline form is again
as the case demands.
taken up and fissures and sulcate grooves included in the cavity
outline.

Resistance and Retention Forms.

As

to resistance,

we have only

by the

to consider the probable stress to be sustained

a whole and of the margins in their various localities.

filling

as

This will

ihvolve a study of each case in hand, as to occlusion and articulation, as well as to habits of the patient in mastication.

lem of concave pulpal wall

is

here met in

Many

times

The prob-

most exasperating

Fig.

form.

its

19.

if

Large

Class

One

cavities prepared.

the operator were to take the lower levels

to flatten and carry this wall latmeet surrounding walls at different

angles, the recessional tracts of the pulp would be crossed and exposure of that organ result.
The Flattening of the Pulpal Walls Avoided.
(See Fig. 19.)
This lateral cutting to flatten pulpal walls may be avoided in two

of the pulpal wall

erally until

it

and attempt

could be

made

to

ways
First.

The operator may

estnblish a level higher

up on the

lat-

eral Avails for the creation of the base line angles, resulting in
steps.

These steps should be established in places most remote

OPERATIVE DENTISTRY

54

from recessional tracts, Avhich -will generally be found in the neighborhood of developmental grooves. There should be at least three
of the steps or small supplemental seats. Four point suspension is
As the seats are small and Avill probably be required to
better.
carry relatively heavy loads their angles should be most definite.
Second. To avoid the flattening of these pulpal walls in large
cavities of this class the operator should build the metal portion

of the filling immediately into cement

the pulpal wall.

seat

and

which has been applied to

This renders the base of the

nullifies the

tendency of the

adhesive to

filling

filling to slip

its

or revolve under

load.
It

might be said here that the principle of the inlay

is

marginal
'^M

l^-ffS

A
Fig.

20.

Class

One

ridge introduced into a built-in

many

Cavities

filled.

filling,

shown

in Fig.

19.

much valued

feature by

operators.

Convenience Form.
this class of cavities

There

is

no convenience form required in

when making

a plastic

filling.

In the making

of a cohesive gold filling in this division of cavities care

must be

taken that the mesial wall can be reached by direct force from the
plugger point. In some cases it will be required to move the mesial
margin well upon the mesial marginal ridge to accomplish the desired result.

Convenience Point for the beginning of the first pieces of gold

should be obtained through the use of a small quantity of thin cement applied to the deepest portions of the cavity.
Finish of Enamel Walls and Toilet. The cavity should be phenol-

PIT

AND FISSURE

CAVITIES

55

and the same evaporated to dryness. The entire cavity outline

should be freshly planed, the margins slightly beveled and a positively determined cavo-surface angle established.
The depth the
bevel angle is to be buried should be determined.
ized

The cavity should be thoroughly swept with cotton, the dust dissipated with a blast from the chip blower and the filling immediately placed.
Pit Cavities in Buccal

and Lingual Surfaces of Molars.

Description.
These cavities have their origin in defects in the
enamel on the buccal surface of lower molars and the lingual surface of upper molars.
Instrumentation is the same for the same class and size of cav-

Fig. 21.

Lingual

pit cavities.

described on the occlusal surface, excepting perhaps it

necessary to use the engine burs in the contra-angle hand

ities just

may be

seldom met with on the occlusal surfaces.

The outline should be carried well out of the
pit or groove and sufficiently extended to meet the general rules
given in the chapter on this subject.
piece, a necessity

Outline Form.

Resistance

Form

will

come up for consideration only when the

outline approaches the occlusal marginal ridge.

the occlusal wall

is

not

made up

In such cases

if

of a sufficient bulk of dentine to

withstand the stress of mastication, the outline should be carried

over the marginal ridge to the occlusal surface, in which case rules
for the outline of this portion of the cavity will be the same as previously given and applicable to all cavities invading occlusal surfaces.

OPERATIVE DENTISTRY

5G

Extension for Prevention will come in for consideration Avhen

the outline has for other causes been brought near to the free
margin of the gum. A full application of the rule ''Extension for
prevention" would demand that the gingival outline be carried
under the free margin of the gum when the gum has already been
approached to within one millimeter. A failure to extend the outline is permissible in mouths kept scrupulously clean.
Retention Form. This step is very simple when the cavity does
not involve the occlusal surface and is fully obtained when the inHowever, when the
ternal line angles have been well squared.
is

subjected to the

strain in mastication.

These will then

cavity reaches the occlusal surface, the filling

greatest

amount of tipping

A
Fig. 22.

demand

flat

Class

One

filled.

Cavities

shown

in Fig. 21.

gingival wall, and in some cases of a vital tooth, a

pulpal wall placed parallel to the gingival wall, and the line
angles surrounding these walls well defined. The four point angles
flat

should be slightly acute.

Finish of Enamel Walls.

In the management of these axial sur-

face pit and fissure cavities the varying slant of the enamel rods

should not be lost sight of.

the cavity with the chisel.

This should be noted Avhen outlining

The rods will generally be found to

incline towards the pit, from every direction close to the defect,
Avhile a little way out they will be found at right angles to the
surface.

Going farther toward both the occlusal surface and gingival

line.

PIT

AND FISSURE

57

CAVITIES

the outer ends of the rods will be found to incline more

and more

aAvay from the seat of decay.

These facts should be borne in mind and a

full

cleavage ob-

tained.

There now remains only the usual marginal bevel and cavity
toilet.

Pit Cavities in Lingual Surfaces of

Should Receive Early Attention.

Upper

Incisors.

These cavities should be de-

tected in their early stages as their near location to the pulp ren-

ders pulp complications an early sequence.

It is the best of practice to

where

faults in

permanently

fill

all

cases presented

enamel are diagnosed.

Instrumentation.

Their location renders excavation hazardous.

superficial opening only, the

The engine bur should be used for

most of the preparation being done w'ith hand instruments.

Outline Form. The general rules in outline form should be observed. Particular note should be made of the extreme incisal inclination of the outer ends of the enamel rods along the margin
of the incisal wall.

Inciso-Axial Line Angle.

It is

generally advisable to alloAV the

meet the axial at quite an obtuse angle, in some

cases almost to the obliteration of this line angle, as the squaring
of this angle will greatly endanger the pulp.
incisal wall to

CHAPTER

XII.

MANAGEMENT OF PROXIMAL CAVITIES IN BICUSPIDS AND

MOLARS.
Location.

Class

Two

(CLASS TWO.)

cavities are those

which originate on the

proximal surfaces of molars and bicuspids at a point slightly

gival

from the point of contact.

The predisposing cause

Predisposing Cause.

is

gin-

the fact of the

presence of the adjoining tooth Avhich establishes and maintains

the sheltered position for the accumulation of substances Avhich un-

dergo fermentative decomposition.

Early Detection of These Cavities is Essential. It is of the utmost importance that Class Two cavities be discovered early. More
pulps are lost to the teeth from the neglect of these cavities than

from

an.y other cause.

Their early detection

is

by no means an

easy matter to the inexperienced operator, as often their presence

IS shown only by a change in the color of the overlying enamel.

There are yet other cases where the teeth must be separated for
an examination of the suspected surfaces.
It requires

education in the use of the explorer to detect the dif-

ference in the ''feel" of the explorer tine in the proximal space

and the entry

of the point into a cavity of slight depth.

When!

the decay has extended along the dento-enamel junction the case

becomes much easier and should never escape the detection of the
operator.

Small Proximal Cavities (Class Two).

By examination there is found to be established
an area of decay upon the enamel surface between contact point
and the free margin of the gum, or one or both teeth which go
The dentine may or may not be
to form the space in question.
involved. The marginal ridge is yet intact and firm. The enamel
shows no signs of injury in either the buccal or lingual embrasures.
Description.

(Molar, Fig.

3.)

Gaining Access.

Opening the cavity

is

often the most difficult

step in the procedure.

There are three plans of procedure open to the operator.

The First Method. The one most common and often the best
is to place the angle of a sharp, straight chisel, say one millimeter in width, on the proximal slope of the marginal ridge and
tap it lightly with a mallet turn the other angle so that the chisel
;

58

PROXIMAL CAVITIES IN BICUSPIDS AND MOLARS

59

edge rests at forty-five degrees to the position of first impact and

again apply the mallet. Repeat several times and this will generally break away the enamel rods in a small V-shaped space. This
may be continued until the cavity is completelj^ uncovered. In
comparatively resistant cases the bi-bevel drill may be applied to
break in the enamel.

The Second Method

of procedure

is

to use the bi-bevel drill in

hand piece that slant Avhich

will cause the drill to enter the area of decay, when sufficient depth
has been reached. The chisel is then applied and the occlusal surface enamel cleaved away either by hand pressure or the mallet.
This method is more liable to cause pain than the first given and
the mesial or distal

pit,

giving the

should be used with caution.

The Third Method

is

to adjust the mechanical separator

and

at-

tack the enamel with a small chisel from the buccal direction, gradually shifting more and more to the occlusal surface until finally
the enamel ridge gives

way

to the force of the chisel.

Preliminary Separation should in most cases be resorted to for

proper access for the many reasons set forth in Chapter IV.
This

is

Best Accomplished by packing the cavity at this stage

with gutta-percha for a few days or weeks.

should be ready to consider outline form.
Outline form in Class

Outline Form.

When

Two

case returns

we

involves the outlin-

ing of the cavity proper, as well as the outlining of the occlusal

step which

is

generally necessary because of the more secure seat-

ing and rigidity

it gives a filling in all proximo-occlusal cavities in

molars and bicuspids when the marginal ridge has been broken.

Step May be Omitted. First: In cases which are to remain

permanently disarticulated, as when opposing tooth has been lost.
Second: When the proximating tooth is to be absent permanently
thus obviating

much

cutting buccally and lingually in extension

for prevention, as the remaining walls are sometimes strong

to give sufficient resistance

Third:
cessive

form without the added

enough

step.

In proximal decays in the gingival third following ex-

gum

recession (so-called senile decay).

Fourth: When for any reason the patient should be shielded from
long operations, or the life expectancy of either the patient or the
individual tooth

Fifth:

is

short.

In that form of lower bicuspids with a well defined and

perfect transverse ridge.

(Fig. 23.)

Outline of Cavity Proper.

The

outline should be carried into

OPERATIVE DENTISTRY

60

both buccal and lingual embrasures until the excursions of food

through these embrasures will sweep the margins of the completed
This extension will result in carrying

filling for its entire length.

the outline out sufficiently that

can be seen to pass under the

gum

to cut sufficiently that a chisel

one

it

in full view.

Good Rule

to Follow

is

millimeter in width will pass easily from the embrasures to the

open cavity when dragging the cutting edge lightly over the free
margin of the gum. This is stated as a general rule only, there
being circumstances which would permit falling short of this amount
of space and yet there are cases which demand a greater amount
of cutting to fully meet the requirements of extension for prevention, due to oral conditions and dental irregularities.

A
-One

l"ig.

of the

few cases

in

Extensions Gingivally.

which the step may be omitted

in Class

Two

cavities.

The cavity outline should be carried sub-

gingivally in extension for prevention w^hen from other reasons

that part of the outline approaches to within one millimeter of the

gum

The application

line.

outline to go beneath the

normal

of this rule

gum

If there

to

gum

invariably cause the

gum

is

in or

resumes

its

position.
is

reason to believe that

it

position this fact should be considered.

cession

Avill

in case the

it is

will return to its

normal

In cases of permanent re-

better to stop the cavity outline

midway from

contact

line.

Care at Axio-Gingival Angles.

Tlie buccal

and lingual portions

and be made

of the outline should be carried directly gingivally

PROXIMAL CAVITIES IN BICUSPIDS AND MOLARS

to join the gingival portion of the outline

ment of a small

common

circle.

The

by the use of a

use of a large circle

Investigation of fillings will shoAV

error.

61

here

is

many

seg-

a most
failures

Avherein a large circle has been used allowing the external outline
to disappear in the

proximal space before

it

has disappeared be-

neath the gum.

The Gingival Outline should be

gum

defined and high

a straight outline except in well

festoons, Avhen

it

may

be made convex to the

occlusal surface.

Forming the

Step.

Place a small round bur or spade drill against

the axial Avail at the dento-enamel junction, immediately beloAV

the central fissure and undermine the enamel the desired distance
in the direction of the central axial line of the tooth.
all

of the rules

and methods

^^^^^^^^^^^^^^^^^^^^^^^^^B^'

A
Fig. 24.

Class

Two

Here apply

of procedure given in the formation

^^^^^^^^^^^^^^^^^^^^

B
cavities in

molar and bicuspid suitable for cohesive gold or amalgam.

of a simple occlusal cavity. Also remember to apply the rules as

given in outline form, particularly as to resistance form.
Area Included. In addition to the above it is a safe rule to state

that the step portion should involve the central third of the occlusal surface bucco-lingually.

Avoid

Angles in outline. Care should be taken -\Ahen usits union Avith the cavity proper does not shoAv
Also Avhen not usin the outline by an angle at their junction.
ing the step, as in the few eases cited, care should be given not to
alloAV the axio-buccal and axio-lingual line angles to meet the exThese line angles should be stopped before
ternal enamel line.
they approach the enamel wall.
all

ing the step that

OPERATIVE DENTISTRY

62

Resistance and Retention Forms.

these forms

it

is

To reach the maximum of

flat and laid
of mastication. The gingival

necessary that the gingival wall be

in a plane at right angles to the stress

should meet the axial wall at an angle slightly acute.

The grooving of the gingival Avail is condemned.
The Buccal and Lingual Walls should be flat, parallel, meet the
gingival Avail at least at right angles, and meet the axial Avail at
definite and acute angles.
The Axial Wall should be convex to the proximal and meet the
pulpal Avail in a rounded pulpo-axial line angle.
The Pulpal Wall should be laid parallel to the same plane as
the gingival Avail and slightly broader at the portion most disThis gives a pulpo-distal or pulpotant from the cavity proper.
Avail

A
Fig.

25.

Class

mesial line angle of a

Two

little

filled.

Cavities

shown

in

Fig.

24.

greater length than that of the pulpo-

axial line angle, resulting in a doA'etailed effect that

is

most

ef-

ficient.

The line angles should be squared out and made

by the use of small hatchets and hoes of suitable shapes

Line Angles.
definite

to reach the desired localities.

The gingivo-buccal and gingivo-lingual line angles should extend from their corresponding point angles to the dento-enamel
The axio-buccal and axio-lingual line angles AA^hich arise
same point angles should travel occlusally one-third to onehalf the height of the axial Avail. In some rare cases AA^here the
pulpal Avail is Ioav from decay these line angles may meet the axio-

junction.
in the

PROXIMAL CAVITIES IN BICUSPIDS AND MOLARS

pulpal line angle.

63

failure to observe this rule endangers the

pulp through a liability of crossing

its

recessional tracts.

Convenience Form. In the making of a cohesive gold filling a

convenience point for the retention of the first piece of gold is
This is best accomplished by employing a small indesirable.
verted cone bur, say

The

number

thirty-three

and

one-half.

placed on the gingival wall and

first sunk to onedepth then drawn for a short distance occlusally along
the axial line angle, taking dentine slightly at the expense of both

flat

face

is

third

its

axial

and external

walls.

A
Fig. 20.

With

the

Fillings shown

in Fig. 25 contacted, illustrating the marble contact.

making of a
form in

for convenience
Inlays.

When

no need of cutting

plastic filling there is

this cavity.

using an inlay proper convenience form

is

ob-

tained by thorough separation and causing the external walls of

both step and cavity proper to meet the gingival and pulpal wall
at slightly obtuse angles.
This Avill give draw to the occlusal.
Finish of Enamel Walls.

The enamel walls are planed

cleavage and the margins arc slightly beveled.

margins

may

be done with the

chisel.

Special instruments are re-

quired to bevel the gingival cavo-surface angle,

marginal trimmers.
cavities,

known

These are made rights and

and rights and

to full

All but the gingival

lefts for distal cavities

as gingival

lefts for mesial

and should be on

OPERATIVE DENTISTRY

64

hand in two sizes,

good working set.
in

"vvhicli

would

In planing the gingival enamel wall the operator should have

mind the gingival inclination of the enamel rods in this locality.
Toilet of the Cavity should

ately placed.

S'

result in eight instruments in a

now

be made and the

filling

immedi-

CHAPTER

XIII.

LARGE PROXIMAL CAVITIES ENDANGERING THE PULP.

(CLASS TWO, CONTINUED.)
when presented shoAV extenproximal Avail. The marginal ridge may
be standing or it may have been broken through stress of mastication.
In some cases there may be an occlusal decay in the central
This class of cavities

Description.

sive loss of dentine in the

fossa.

Danger of Pulp Exposure. There is ahvays great danger of pulp

exposure in these cases and this fact must be continually borne in
mind, during the procedure of preparation.
The liability is increased -when the patient is young or the cusps of the tooth are
high, particularly -when there exists a deep pit cavity -in the oc-

low pulpal wall. With young paand the horns of the pulp generally ex-

clusal surface necessitating a

tients the pulps are large

tend well toward the cusps.

Teeth

Avith high,

prominent cusps us-

ually have long pulp horns, Avhich should be considered in

resistance, retention

making

and convenience forms.

The first cuts in this class of cavities should be

using hand pressure, being sure that adequate hand
and finger guard has been obtained. This precaution is essential
as the chisel must be prcA^ented from reaching the sensiti\'e softOutline Form.

Avith the chisel,

Place the chisel so as to throAv

ened dentine Avithin the cavity.

The
only a small portion of enamel

the chips into the cavity.

made to engage
Should the enamel
be resorted to, still main-

chisel should be

at each cut.

prove resistant the aid of the mallet

may

taining a firm finger rest.

Extension for Prevention

is

frequently not necessary as the ex-

tension necessary for proper resistance form

Avill carrj'

the caA'ity

the required distance into both buccal and lingual embrasures.

However, in many cases the decay Avill be found to have progressed

more toAvard one embrasure than the other Avhich necessitates additional cutting for prevention, in the direction of the embrasure
least approached by decay. This should be done to the fulfillment
of the rule for ''extension for prevention."

The gingival outline in these cases Avill genmargin of the gum. At this stage it should
erally be under
hatchets until the overhanging enamel
enamel
be planed Avith the
Gingival Outline.

the free

65

OPERATIVE DENTISTRY

G6

broken away to give access form for the free passage of the dam
ligature, which should now be placed and the cavity super-

is

and

ficially sterilized.

When

Occlusal Outline.

the cavity has been rendered dry the

occlusal outline should be proceeded with.

This

is

carried out as

previously given in the forming of the step portion, and the full
satisfaction of the rules given in Outline

Removal of Remaining Decay.

This

Form, Chapter V.
is

an instance where the

and should now

sixth step in cavity preparation comes in third

be cautiously proceeded with.

Large spoons should be used. The softened and discolored dentine should be lifted from its position with as little pressure pulp-wise as possible. If exposure exists upon its removal, pulp
treatment for devitalization and removal is the immediate procedure.
If exposure does not exist and the operator has reason
to believe that that organ is healthy the pulpal and axial walls
should be lightly scraped with large spoon excavators, the walls
disinfected with the favorite drug, then dried, phenolized and dried
again, the latter precaution to prevent thermal shock to the pulp
during the remaining portion of cavity preparation, the imperative necessity for which is shown when pain is induced by a blast
of air from the chip blower.
Technic.

Resistance and Retention Forms.

the decay

is

fovuid to be deep

and axial walls should be

"When the central portion of

and no exposure exists, the pulpal

left in their central portions

much

as de-

cay has left them, no attempt being made to flatten these walls on
a plane of their greatest depth as pulp exposure may result. The
line angles surrounding these two Avails should be established on
higher levels.

is

The Gingival Wall should be made flat in every direction. This

accomplished by lowering the point angles root-wise to the level

of the central portion.

Convenience Form.
ined to see that

it

is

Every part of the cavity should be examaccessible to direct force in the packing of

the filling and a convenience point cut in each of the gingivo-axiolingual

and gingivo-axio-buccal point

angles.

The cavity should be flooded with an efficient

and again dried. If
danger it should be protected as described in Chap-

Pulp Protection.

non-irritating disinfectant, dried, phenolized

the pulp
ter

is

in

XXXIV.

LARGE PROXIMAL CAVITIES ENDANGERING PULP

67

Finish of Enamel Walls.

The enamel

Avails

Fig. 27.

Large

should

now

be inspected, corrected for com-

and the proper cavo-surface angle

plete cleavage

Class

Two

cavities in non-vital teeth restoring part of the occlusal surface for

the protection of weakened walls.

A
Fig. 28.

established, us-

Class

Two

filled.

Cavities

shown

in Fig. i7.

ing for this a keen-edged chisel and a light hand Avith a planing
motion parallel with the external enamel line.

For Toilet

of the Cavity use a

few blasts of

air

from the chip

OPERATIVE DENTISTRY

G8

bloAver, followed Avith a

and more

thorough brushing

The

air blasts.

filling

Avith a ball of cotton

should be immediately placed.

Large Proximal Cavities in Non- Vital Teeth.

In the

management

of this class of cavities, cutting for resistance

Fig. 29.
Mesio-occluso-distal (M.O.D.) cavities in molar and bicuspid, vital teeth.
Note
It is not necessary
that the occlusal portion of the cavities does not show any retentive form.
to undercut these walls as there is ample retention in other parts of the cavity.

A
Fig. 30.

Mesio-occluso-distal

to stress reaches the

fillings.

maximum and

Cavities

outline

is

shown

in

many

Fig.

29.

times materially

extended for this purpose alone.

Outline Form, With Molars. All decay and softened dentine is
Often this will leave standing an entire cusp of unremoved.


LARGE PROXIMAL CAVITIES ENDANGERING PULP

69

supported enamel and possibly both proximal cusps are thus unsupported. In such cases a thin-edged carborundum wheel is placed
on the occlusal and this surface ground away for one or tAvo millimeters, extending as far toward the central axial line to just be-

Fig. 31.

(A) First superior molar, non-vital, restoring the lingual cusps.

(S) Second superior

bicuspid, non-vital, restoring the entire occlusal surface.

A
Fig. 32.

Class

B
Two

filled.

Cavities

shown

in Fig.

31.

yond the buccal or lingual groove, or both when both cusps are
be removed.

This grinding process

is

in the region of the groove, resulting in a step

ing

nil

occlusal surface seating.

to

carried to a greater depth

which gives the

fill-

OPERATIVE DENTISTRY

70

With Bicuspids

this buccal or lingual outline is carried past the

crest of the cusp involved

and partially down the opposite

slope.

This procedure results in disarticulating the frail enamel wall and

so placing the metal that

it Avill

receive the force of mastication.

In Mesio-Disto-Occlusal Cavities in both bicuspids and molars,

which are vital, and when using cohesive gold as a filling, the occlusal
outline should include all of the middle third bucco-lingually.
It
should be made sufficiently deep to remove all of the enamel in the
central fissure.

For cohesive gold the buccal and lingual Avails should be parallel
and Avithout retention as the retentive form should all be placed low
in the gingival angles of both mesial and distal cavities.
In the use of amalgam the outline should be farther extended bucco-lingually, to include about one-half of each of the buccal

be

form

lin-

Thus two-thirds of the occlusal surface bucco-lingually

gual thirds.
Avill

and

This occlusal portion should be Avithout retentive

filling.

and lingual

Avith the buccal

angles slightly obtuse.

for favorable

This

is

Avails

the

meeting the pulpal

minimum amount

Avail at

of extension

A'ital cases.

In Cases of Extreme Frailty the entire occlusal surface of molars

and bicuspids sliould be replaced Avith filling of at least one milli-

meter in thickness. AVith upper molars and bicuspids, A\'hen nonAdtal and very frail mcsio-occluso-distal cavities, the lingual cusps
should be removed for one or two millimeters and replaced Avitli
filling material.

Retention
sub-pulpal

Form

Avail,

is Completed by squaring up the side Avails and

making a box shape of the pulp chamber, Avith

fairly definite point angles.

Convenience Form.

No convenience form

is

necessary in this

class of cavities, except for inlay fillings, Avhich AAdll be considered

later.

Neglected Access Form.

In cases AA-here large proximal cavities

much tipping to the proximal of one or both teeth, preliminary separation for good access
Without this preliminary step complete contour resis essential.
toration and proper contact is impossible. This is particularly true
are of long standing and there has been

Avhen the cavity

is

in the mesial of the first molar.

seem to

Many

times

been engulfed Avithin the

molar cavity. In cases AA'here preliminary separation for obA^ious
reasons is impossible, the evil may be partly overcome by the free
cutting aAvay of both buccal and lingual Avails until the filling may
the second bicuspid

Avill

haA^e

LARGE PROXIMAL CAVITIES ENDANGERING PULP

71

ill Avith a proximal surface slightly convex to the proxHowever, this is but a makeshift of a filling and the resulting proximal space Avill always be defective.

be built
imal.

Toilet of the Cavity. In large decays, particularly if the pulp

has been removed, there is more or less danger in leaving coatings
Care should be taken
of various materials clinging to the walls.

that the walls are scrupulouslj^ clean.

It is

an advantage

if

cavity be scrubbed Avith solvents for the suspected coatings.

the

The

cavity should then be dried, the enamel Avails planed and the cavity freed of all debris.

Over-desiccation.

Particular care should be had not to use ex-

cess desiccation in pulpless teeth as this Avill render

and easy

of fracture Avhen put to use.

them

brittle

CHAPTER

XIV.

MANAGEMENT OF PROXIMAL CAVITIES

IN INCISORS
(CLASS

AND

CUSPIDS NOT INVOLVING THE ANGLE.

THREE.)
Definition.

Class Three cavities are those in the proximal of

and cuspids where it is not necessary to restore the incisal

angle.
The angle may be allowed to remain when the enamel at
the angle is supported by sound dentine to an extent which will
give it sufficient resistance to prevent fracture under stress of

incisors

mastication.

General

Form

Cavities in incisor proximal sur-

of Class Three.

faces differ from all others in that they are in the surface of teeth
of a triangular form and the cavities of necessity must be of this
form, rather than the typical box shape in the other classes of
cavities.

Location of Primary Decay. The location of primary decay, as

with all contact decay, is just gingivally from contact point. This
will result, as a rule, in the seat of initial decay being about mid-

way from

the incisal edge to the gingival outline.

of enamel, l)oth labial

removed from
loss of

and

lingual, are quite

As the

plates

heavy and usually

direct stress, there will generally be considerable

dentine while the enamel walls are yet intact.

The decay

may

be apparently small, yet reflected light by the use of mouth

mirror will shoAv a discoloration of a well defined area.
The

curved tine of an explorer

may

or

may

not enter from either the

labial or lingual embrasure.

Opening the Cavity. Bathe the surfaces of all the anterior teeth
jaw Avith water to free them of micro-organisms and gummy
material, particularly the gingival border, and apply the mechan-

in that

ical separator.

Gaining Access. With a small straight chisel of about one millimeter in width cut away the enamel edge, throwing the chips into
the cavity. Adequate finger rest must be secured before applying
the chisel and only small portions of enamel engaged at each application, as a failure in either respect may result in checking the
enamel to a greater extent than desired. When sufficient entrance
has been made to the cavity to admit the instrument, the remaining enamel margins may be planed from this direction until a liga72

PROXIMAL CAVITIES IN INCISORS AND CUSPIDS

73

Where time
permit the case should be packed for preliminary separation
as described in Chapter IV. If immediate separation and filling is
to be practiced the rubber dam should be adjusted and the mechanical separator placed and tightened to a snug pressure. The
separator should be tightened from time to time until the required
lure will pass from the incisal to the gingival line.

Avill

separation

is

obtained.

The approximate space required

is

from

one-half to one millimeter M'here only one cavity exists in the proximal,

and a

full millimeter in cases Avhere

two

cavities exist.

As these cavities are located in the most exposed

portion of the mouth esthetic reasons demand as little cutting as
possible consistent -with the demands for permanency.
HoAvever,
Outline Form.

ABC

Fig. 33. Class Three cavities filled so that the entire cavity outline, excepting that portion covered by gum tissue, is in full view of the operator.
The gingival portion of {B) has
been cut sufficiently low to be covered by gum tissue.

it

all

is

a good rule, in outlining cavities of Class Three, to extend in

directions until

when

outline not covered with

(Fig. 33.)

As

the filling

gum

is

completed, the entire cavity

tissue, is in full

view of the operator.

stated before, excessive cutting to obtain this con-

may be obviated by proper separation.

The Gingival Outline should be carried midway between contact and gum line, and farther extended to go under the gum when
it approaches to Avithin one millimeter of the gum.
Great care
should be exercised to square out both labial and lingual axiogingival angles, carrying them sufficiently into these embrasures
dition

OPERATIVE DENTISTRY

74
that the cavity margins

may

be in full view as they pass under the

gum.
The Incisal Outline should be carried incisally until the margin
of the filling will be permanently in view, with a space sufficient
This
to admit of the free use of the tooth brush on the margin.
Avould, in many instances, carry the margin beyond the incisal
edge and make a Class Four cavity and is only avoided by separation and filling of the cavity to a slightly excess contour.
The Labial Outline should be carried into the labial embrasure
The enamel should be split
until the margins are in full view.

away until full length rods are obtained. On account of the exposed location of these cavities the esthetic reasons demand as little

As

cutting labially as possible.

moved from

the stress of occlusion

this

it is

margin

be supported by dentine in every instance.

However, care should

be taken that the rods are full length and that

moved where

there has been a

practically re-

is

not essential that the enamel

backward decay

all

rods are re-

as

shown by a

whitened powder-like condition at their dentinal ends.

Additional Extension for esthetic reasons is sometimes required
This is more often true in the mesial caviill the labial embrasure.
ties Avherein the teeth are angular in form and present surfaces
that are quite flat, resulting in a very square or prominent mesiolabial angle. In such cases the outline should be carried over the
angle and into the labial surface, that the metal may be brought
into the light, otherwise the completed filling will have the appearance of a decay or dark spot on the tooth.
The Lingual Outline must be carried into the lingual embrasure
sufficiently to be brought into full view in all cases.
In the case of teeth of rounded form this will not alwaj'^s include the proximal marginal ridge.
In teeth of a squared form
and prominent lingual ridges the marginal ridges should be included and the outline carried along the axial slope of the ridge.

The

fact that

many

cases

show

a lingual articulation

and occlusion

on the lingual marginal ridges of upper incisors, will bring demands for including within the cavity the major portion of these
ridges, unless supported by a good bulk of sound dentine.
The
failure to recognize this fact on the part of

many

operators

sponsible for the loss of a large per cent of this class of

Resistance Form.
just given

is

No

special resistance

is re-

fillings.

form other than that

required in this class of cavities.

When this order in the preparation has been

Retention Form.
reached attention should be directed to the incisal angle, particu-

PROXIMAL CAVITIES IN INCISORS AND CUSPIDS

met

larly in the larger cavities, as eases Avill be

75

in Avhich

it

will

be found necessary to remove the incisal angle to secure proper

**

retention form."

This looking to the incisal

first

Avill

decide

this point early in the procedure.

The

Incisal Line

a right angle.

Angle should meet the axial wall at

In cases where this line angle

is

least at

short, as^found in

shallow cavities, the incisal line angle should meet the axial wall
It is not necessary to make a convenience

at a slightly acute angle.

atigle at the incisal point angle.

(Fig. 34.)

The bevel angle on the gingival wall becomes the fulcrum. It

is only necessary that the distance from this point to the incisal
point angle be greater than that from the same point on the gin-

Fig.

34.

Drawing

to

illustrate

Three cavity.
at b should be acute.
c, the incisal point
the illustration shown

the retention at the incisal angle of Class

In shallow cavities with a short incisal line angle as d b, the angle

In deeper cavities and longer incisal line angles as the one shown at
angle is efficient if it is a right angle and may even be obtuse.
In
the filling would pivot to exit at a.
Dotted lines a fc and a c are

the same length hence

the point angles of the two fillings would describe an arc of the same circle in tipping to exit.

gival wall to the most external portion of the incisal line angle.

The more shallow the cavity

in Class

Three the more acute must

be the incisal point angle.

Other Point Angles.

The

axio-lingual point angles are

gingivo-axio-labial

now

and the gingivo-

carried into the dentine at the

expense of both axial and external Avails, care being given not to
groove the gingival Avail.
Line Angles. Line angles are made Avith small hatchets and hoes
of suitable sizes, say, one-third to one-half millimeter in Avidth, Avith

edges that are keen and Avhose corners are

Avell defined,

been rounded through careless sharpening or

Avear.

not having

OPERATIVE DENTISTRY

76

The Axio-Labial Line Angle is chased and sharpened for its

making it particularly definite as it approaches each

length,

entire

of the

point angles.
in

The Axio-Lingnal Line Angle is made definite for one millimeter

each direction from its two point angles, omitting the central por-

While the cavity in the cuspid

l""ig. 35.
Class Three cavities prepared for cohesive gold.
(A) restores the mesial angle the shape of these cavities and the rules governing their management places them in Class Three.

ABC

Fig. 36.

tion, as this

Class

Three

filled.

Cavities

shown

in Fig. 35.

precaution will give added resistance form to the lingual

The sharpening

of these line angles is best accomplished by

engaging the instrument in the dentine the desired distance from
the point angle and cutting to the angle.
The Gingivo-Axial Line Angle should be Avell defined to make the
wall.

PROXIMAL CAVITIES IN INCISORS AND CUSPIDS

77

gingival Mall meet the axial at a definite angle, but should in no Avay

be a ditch or groove.

The Gingivo-Labial and Gingivo-Ling-ual Line Angles should be

away from their point angles out to and end at the dento-enamel
junction. As the general form of the cavity is that of a triangle
cut

these angles

Avill

always be acute.

Gingival Wall.

The gingival wall should be

flat in

every direc-

tion.

Axial Wall.

The

axial wall should be left as decay has left

the central portion and all additional cutting should tend to

it

make

in
it

take on the form, in miniature, of the surface of the tooth in which

the decay has originated.

the pulp, Avhereas

if

disregard of this rule will endanger

the axial wall

is left

as convex as possible the

pulp has all possible protection.

Labial and Lingual Walls. These walls should be, as far as possible, of

the same thickness for their entire length, which

sult in their inner surfaces

^Vill re-

being of the same contour as the ex-

ternal surface of the tooth.

Convenience Form.

Two

convenience points are advisable in this

class of cavities, cut in each of the gingivo-axio-labial

givo-axio-lingual angles.

The

filling

and the

gin-

should be begun in the latter

angle.

Removal of Remaining Decay. At this point inspect the dentoenamel junction for softened dentine. Also the entire axial wall
should be scraped with large spoons for the removal of the last of
the softened dentine, the cavity disinfected, dried, phenolized and
again dried. Pulp protector should be applied Avhen indicated.
Finish of Enamel Walls. The enamel Avails should be planed to
full cleavage, with suitable instruments of chisel edges, not forgetting the incisal and gingival inclination of the rods of these locations.
Bevel the cavo-surface angle, give the cavity its toilet and
immediately place the filling.
In Non-Vital Cases. When the axial wall has been lost by reason
of pulp removal the entire pulp chamber should be filled with cement of a very light yellow color or even a white cement may be
used. In extremely frail teeth this may be only partially filled and
the remaining portion used for retention.

CHAPTER

XV.

MANAGEMENT OF PROXIMAL CAVITIES

VOLVING THE ANGLE.

IN INCISORS IN(CLASS FOUR.)

which the incisal

The deciTo cut the
sion as to its restoration is of most vital importance.
angle from nearly every incisor which has a proximal decay is little
short of malpractice, while at the same time to attempt to save those
not wholly and adequately supported by dentine is to invite many
Definition.

Cavities of Class

Four are those

in

angle has either been lost or can not be safely retained.

disastrous failures.

Conditions
contact

is

involve

all

Second.

Demanding Frequent Angle

in the incisal third.

of the dentine

Restoration.

First.

When

In such eases a verj^ small decay will

toward the

incisal angle.

Incisors which have long flat proximal surfaces.

Such

decay extending gingivo-incisally and may

entirely weaken the incisal angle before the pulp is in danger.
Third.
The pulp may be involved and its removal materially
lessens the resistance of supporting dentine at the angle.

teeth will

Fourth.

show a

line of

The angle under consideration may be

so located that

it

frequently requii'ed to stand great stress in service. This is a

point Avhich must not be overlooked as an angle Avhich stands well
is

exposed must bear much greater and more often repeated force than
an angle which does not occlude or can not be brought into articulation.

Difference Betw^een Mesial and Distal Surfaces.

The above four

met with in mesial surfaces,

hence the mesial angles are in greater danger and more often reconditions will be more frequently
quire restoration.

Plans of Angle Restoration.

There are four general plans of

storing the incisal angle Avhich are worthy of consideration.

re-

Many

plans have been advanced from time to time, but the four given

below seem to have remained in favor.

Retention Form in Class Four Fillings.

With each of the plans

is made to remove or

presented and generally practiced the effort

nullify the principle of the lever.

With proximal

fillings wherein the force of mastication is brought

with the filling the principles of the lever must be
reckoned with. The force of mastication is the power, the filling the
lever, the anchorage in the point angles the load and the point on

in direct contact

78

PROXIMAL CAVITIES IN INCISORS INVOLVING ANGLE

79

which the fillmg would most likely pivot to exit the fulcniui. By a
study of the case we find we must deal with the force of levers of
both the first and second class.
In Fig. 37 Ave have an illustration of a Class Four, plan one filling
wherein the principles of a lever of the second class are fully operaThe heavy long lines a-h represent the full length of the
tive.
The short heavy lines a-c represent that part of the lever
lever.
which is the working arm, as the load is at c. That we may study
tiie amount of anchorage to be provided for at the incisal angle, (c),
we will ignore the assistance of the two gingival point angles and
for that reason they have not been shown in the drawing. We here

Fig. 37.

Drawings

to illustrate the principle of the lever in the

fourth class, plan one.

have a lever of the second

c

and the force

In order that

at

class

dislodgement of

with the fulcrum at

a,

fillings of

the

the load at

J).

we may not inject into the problem at

we w'ill consider that by the

principle of the bent lever

this time the

lateral

move-

ment of the mandible the force is applied at right angles to the

"lever-arm." In diagram A, Fig. 37, the working arm is one-half
is of the second class.
We then have the following W'ith X representing the load, or unknoAvn quantity:

of the lever Avhich

100 lbs.

It

= 4002x = 200

would therefore follow that an

lbs.

x.

incisal point angle placed mid-

OPERATIVE DENTISTRY

80

Avay between the gingival Avail and the incisal surface of the filling
"would be required to stand a strain just double the force at the in-

In diagram B, Fig. 37, the incisal point

placed three-fourths of the way from the gingival to the in-

cisal,

or place of impact.

angle

is

cisal

and we then have

400
100

lbs.

z=:

3^

= 1331^

lbs.

x.

This shows a strain on the incisal point angle of one hundred and
It will therefore be seen that the incisal point

thirty-three pounds.

rig. 38.

Drawings

to illustrate the principle of the lever in the

fourth class, plans one and two.

dislodgmcnt of

fillings of the

angle should be laid as close to the incisal edge of the tooth as the
strength of the dentine protecting that angle will permit as
lows that: "TJic fartJier

flie

cation the greater will he

tins

incisal angle

tlie

is

from

tJie

strain on hotJi dentine

it fol-

force of masti-

and

filling at

angle."

With

Fig. 38

plicated form.

we

will consider the principles in a little

Let a represent the fulcrum, h and

the point of the application of the force.

The

more comand d

c the loads

radii of the arcs of

the circles represent a few of the directions from which force

be received by the

filling.

With

may

the light lines the force Avould be

PROXIMAL CAVITIES IN INCISORS INVOLVING ANGLE

81

Avails of the cavity. Force from the direction of the

would put into operation the principles of the lever.
In diagram A, Fig 38, the filling would operate as a lever of the
second class upon the load at c, as described in Fig. 37. With the
gingival point angles at h the filling would operate as a lever of the
first class over the same fulcrum (a), provided the gingival outline
or fulcrum has been laid higher than the point angle and therefore

absorbed by the

dark

lines

nearer the point of the application of the force.

In case the gingival margin has been laid loAver than the point
angle or farther from the point of impact than the fulcrum we have
'

a lever of the second class which Avhen figured out

mense load as shown

Avill

draw an im-

in the explanation of Fig. 37.

In case the gingival point angles are cut more root-wise than the
gingival margin and Ave

a lever of the

liaA'e

sider the principles of the bent lever.

force (or of the resistance)

lever

on

is

must con-

the direction of the

not at right angles to the arm or the

"lever-arm"

AA^hich it acts, the

first class Ave

When
is

the length of the per-

pendicular from the fulcrum to the line of the direction of the force
(or the resistance).

We

must therefore conclude

First, that gingiA-al point angles

should be placed so as to extend more root-Avise than the height of

the gingival line at the proximal (that part of the gingival Avail
which is nearest the incisal is regarded as the highest point).
Second, the farther the gingival Avail Avith all its parts is from the
incisal the greater Avill be the length of the poAver arm Avith each
individual bloAv. Third, the nearer the gingival Avail is to the incisal
the less the
Avhich

Avill

number of directions from

act upon the filling as a

In order that

Ave

may

38.

may

be received

lever.

eliminate the principles of the levers, the

step cavity, in classes tAvo

diagram B, Fig.

Avhich force

and

It Avill

four, has been devised as shoAA^n in

be seen by the radii of the three arcs

draAvn that the increase of the surface of the filling exposed to

force does not increase the dangers of the lever as the area of the

been increased Avhich Avill absorb the force

beneath the increased surface. Again, so long as the incisal angle
in the step (at c) holds and the filling material remains rigid the
IcA^er principle has been eliminated as regards all other anchorage

seat of the filling has also

of the filling.

Direction of the Incisal Angle.

Fig. 39

is

a draAving to illustrate

the difference in the directions the point angles take in tipping to

Let the perpendicular shaft represent the

varying length of Class Four fillings and the horizontal bars the

exit Avith various filling.

OPERATIVE DENTISTRY

82

The dotted
which the point
pivoting on the gingival

varying lengths of the step in plan two of this

class.

lines are the radii of the various circles the arcs of

angles would describe in moving to exit,

margin.

The length

of the step portion relative to the height of

the filling determines the direction the incisal point angle must take
to exit.

With

a short proximal portion and a comparatively long

step portion, the

pendicular.

Tig. 39.

Sec

Drawing

first

movement

fillings in Fig.

of the point angle

39

is

almost per-

{a, x, li; also g, f, n).

to iilustratc the difference in the directions the point angle fillings take in

tipping to exit with various

fillings.

Note the difference in the direction the pohit angle would take
with an increased length of filling inciso-gingivally. Also
see 7i, X, a, and then 7i, x, h, and on down until it is li, x, g. It will
1)0 seen that there is a gradation toward the horizontal movement
Again note the change of direcof the incisal point angle to exit.
tion to exit of the incisal point angles in g, a, i, and then g, h, j, then
to exit

and on down to g, f, n. We see in this series that there is a

gradation toward the perpendicular movement of the incisal point

g, c, k,

PROXIMAL CAVITIKS IX IXCISORS INVOLVING ANGLE

angle to exit.

In the

fii-st

instance

ing the same length of step.

the axial wall, us-

In the second instance

we shortened

same time lengthened the step and the

seem then that the direction to be
given the incisal point angle is determined by the degree of the
circle in Avhich lays a line draw'n from the deepest portion of the
incisal point angle to the fulcrum.
(See dotted lines Fig. 39.) The
the axial wall

change

is

more

and

we lengthened

83

at the

rapid.

It W'Ould

nearer this line in a given case approaches the perpendicular to the

axial part of the filling the more essential is it that the point angle
be cut in the same plane as the axial wall.

Also the nearer this

approaches ninety degrees from the perpendicular the more essential is it that the incisal point angle be cut at forty-five degrees
to the perpendicular of the axial Avail.
Bv a studv of Fig. 40 it will be seen that the incisal angle of
line

Fig. 40.
Drawinsts to illustrate the importance which should be given to the proper placing of the incisal point angle in fillings of Class Four, plan two, with particular reference to
c should be cut.
the plane in which wall b

would be

effective while

a filling pivoting at

a.

By

B would

offer

no resistance to exit with

materially shortening the axial walls of

becomes effective and that of A ineffective.

As shown in the drawings in A the dentine included in h, c, d is
the retention produced by having dotted line a, h longer than line
a, c.
In B these lines are the same length, hence no retention. The
filling becomes a lever to lift the gingival point angles.
The Gingival Angles. In the study of the gingival angle retention, we will eliminate the incisal angle and consider that it has been
improperly laid or has been Aveakened and the lever force has been
transmitted to the gingival angles.
both, the point angle of

OPERATIVE DENTISTRY

84

111 Fig. 41, a is the fulcrum and h the extreme point of the angle.
Dotted lines a-h are the radii of the circles the arcs of Avhich the
point angle fillings Avould describe in going to exit.
The two

gingival point angles should be of different depths so that they will

describe the arcs of different circles in being

drawn

to exit.

It is

most convenient to make the gingivo-axio-lingual the deeper.

A
I'ig.

4l.

study in the jiropcr placing and depth of the gingival angles.

-J

Fig. 42.

study of the planes in which the gingival angles should be

It is also essential that the

laid.

two gingival point angles be

so laid

that the circles, the arcs of which the point angle fillings describe in

passing to exit, stand in different planes as illustrated in Fig. 42.

Failure to observe the last two principles given removes retention

form as regards the gingival angles.

PROXIMAL CAVITIES IN INCISORS INVOLVING ANGLE

First Plan of

The
edge.

first

Angle Restoration.

plan of anchorage

This plan

is

is

85

(Class Four.)

made by undercutting

the incisal

indicated in teeth of rather thick incisal edge

that are rather short and stocky as they have a greater body of dentine near the angles

upon which

to depend.

Fig.

Fig.

As

44.

-13.

Cavity

of Class Four, plan one, for cohesive gold.

filled.
Labial and lingual views.
Cavity shown in Fig. 43.

-Class Four, plan one, cavity

a rule the horns of the pulp in such teeth are Avell retracted, at

adult mouths, and there is less danger of pulp exposure as

compared with the teeth of thin edges and angular outline. If this
lea.st in

plan has been decided upon, the cavity should be cut well to the

OPERATIVE DENTISTRY

86

gingival, particularly at the gingival angles, in

tent that the gingival Avail

made convex

is

some cases

to the ex-

to the incisal.

The Gingival Point Angles should be deep and well defined at

and axial walls. This is particularly

the expense of both gingival

true of the gingivo-lingual angles, to protect agahist the torsion

strain.

To

To resist the tipping strain both the

and lingual Avails should be slightly grooved along the axioand axio-lingual line angles much in the same Avay as Avith

Assist the Incisal Angle.

labial

labial

large Class Three cavities.

The Labial Outline should

so proceed that the completed filling

be of about equal Avidth for its entire length except that as it
approaches the incisal edge it should be slightly curved to the axial.
Avill

Fig. 45.

Shows

incisal outline in Class Four, plan one, fillings with direct occlusion.

Rule for Labial Outlines.

All cavity outlines in incisal angle

restorations should curA'e to the axial as they approach the incisal

edge.

The nearer

this outline

approaches the central axial line of

the tooth the greater should be the curve.

line is

reached by a

cavitj' outline, the

When

the central axial

same should then be extended

There are exceptions to the aboA^e

is only thereby obtained.
The Necessity for Curving to the Axial. When approaching the
incisal edge curve to the axial that the last rods at the cavo-surface
angle may be adequately supported. A large per cent of fillings
AA'here this precaution has been neglected fail, shoAving a primary
fault due to the breaking aAvay of the enamel at this point.

to involve the opposite angle.

rule but

maximum

resistance to stress

PROXIMAL CAVITIES IN INCISORS INVOLVING ANGLE

The

Incisal Outline as

should have in

its

it

87

crosses the iiicisal edge of thick teeth

center a curve toward the axial caused by a slight

groove in the center of the dentine.

This groove which ends at this

point in the cavity outline should originate at the external end of

the incisal line angle.
erally

Avill

tion, this

If there

is

sufficient dentine,

and there gen-

be in the class of cases calling for this plan of restora-

groove

is

of best service

if it

be a flattened groove and

made Avith a small hoe or hatchet. (Fig. 45.)

The Lingual Outline should be the same as for large Class Three
except in the incisal third when it should curve to the axial even
more rapidl}^ than the labial outline and for a longer distance, resulting in cutting away more enamel from the lingual than is removed by the labial outline. This is made necessary from the fact
'

that

all stress is

With Lower

from the

lingual.

is true and it is necessary to rpmore of the labial enamel in angle restoration, a fact
which materially mars these teeth from an esthetic point of view.
Fortunately we have comparatively few angles to restore on lower
incisors, but when they are presented the fact must be borne in
mind that they receive the major portion of stress from the ineiso-

Incisors the reverse

iiiove slightly

labial direction.

Second Plan of Angle Restoration.

The second plan

medium

of restoration

thickness, particularly

if

(Class Four.)

is indicated in teeth that are of

they are of angular build or have

a direct contact on the incisal edge either in occlusion or articula-

and consists in the additon to plan one of Avhat is termed the

The cavity proper is prepared the same as has been
outlined in plan one up to the forming of the step.
The Incisal Edge is cut aAvay Avith a narrow-edged carborundum
tion,

incisal step.

stone, the cutting being

extended toward the opposite angle a

tance equal to the width of the cavity proper.

The

dis-

incisal outline

should avoid both the centers of primary calcification and the point
of coalescence,

ting should be

by one-half

two weak places in enamel construction. The cutmore at the expense of the lingual side of the tooth

to one millimeter.

The Depth

of This Step, inciso-gingivally,

Avill

depend upon

thickness of the cutting edge, and the probable stress

it

t)ie

will receive.

The thinner the edge and the greater the probal)le stress, the deeper must be the step. The majority of cases Avill show not to exceed
one millimeter of gold on the labial in the step portion.
Technic of Cutting. A small round bur is then used to cut a

OPERATIVE DENTISTRY

88

groove in this newly formed pulpal wall, near the dento-enamel

The lingual enamel is
then removed with a chisel thus carrying that portion of the pulpal
wall to a lower level. This process is continued until it is at least

junction next to the lingual plate of enamel.

Fig. 46.

Fig. 47.

Class

Cavity

Four, plan two,

of Class Four, plan two, for cohesive gold.

Labial and lingual views.

Cavity shown in Fig. 46.

filled.

very popular method.

one-half millimeter to one millimeter lower than the labial portion

This leaves the major portion of the dentine supporting the labial plate of enamel.

of the pulpal wall.

The Point Angle

in the Step Portion should be

deepened and made

PROXIMAL CAVITIES IN INCISORS INVOLVING ANGLE

acute largely at the expense of the pulpal wall.
just the right position to resist stress

This will place

89
it

in

from the probable source and

prevent tipping.
(See Fig. 37.)
This Second Plan is Particularly Indicated in cases of nuich wear

I'ig.

48.

Cavity

of Class Four, plan three, for cohesive gold.

A
Fig. 49.

Class

on the

Four, plan three,

ineisal,

filled.

Labial and lingual views.

Cavity shown in Fig. 48.

due to what is called "end-to-end" bite. However,

exposed dentine on the ineisal edge should
the step and it is not necessary to remove much of

in such cases all of the

be included in

^ither of the labial or lingual plates of enamel.

In such cases the

Ot*ERATIVE DENTISTRY

90

step jjortion should be retentive throughout as

it

is

liable to be

worn aAvay by subsequent wear, growing thinner from year to year,

hence the necessity of retentive form from cavo-surface angle to the
base line angles.

Third Plan of Angle Restoration.

This plan

is

(Class Four.)

the addition to plan one of the lingual step.

It is

particularly indicated in eases of long incisors which are quite thin

and subjected to a long sweep of the lower incisors

movements of articulation, or what is spoken of as the "scis-

labio-lingually
in the

sors bite."

Also Indicated in cases where the axial wall extends out to the
enamel edge on the lingual thus removing the lingual wall.
The Labial Outline is the same as with the first plan of restoration. The step is formed on the lingual by cutting away the enamel
from the lingual surface of the tooth toward the central axial line
for a distance of from one to two millimeters at the incisal edge.
As the gingival is approached the cutting is narrowed to a point
Avhere the marginal ridge may be crossed at right angles to meet
the gingival portion of the outline. This will form a V-shaped axial
Avail of dentine facing the lingual.
There should be cut a flatfloored groove in this dentine parallel Avith the remaining enamel
wall ending in the gingivo-axio-lingual angle which should be an
acute convenience angle. The plan gives great resistance to stress
from lingual pressure.

Fourth Plan of Angle Restoration.

This plan consists of resorting to

all

(Class Four.)

of the features of resistance

and retention embodied in plans two and three by combining both

the lingual and incisal steps.
Each of these has been fully described and the method of cutting both steps to the same should not
prove hard to accomplish.
By this plan the maximum resistance and retention forms are secured with the minimum loss of dentine. It must be remembered
that resistance to stress is good in proportion to the amount of seit should be sparingly cut away.
removal
of enamel to lay bare dentine Avherein to lay anchorThe
age is only harmful from the esthetic standpoint and is of little loss
when taken away from a surface not in view, as is the case when we

curing dentine retained, hence

cut aAvay a portion of the lingual plate.

Cavities in the Distal of Superior Cuspids.

On

account of the

peculiar articulation of the lingual surface of superior cuspids this

PROXIMAL CAVITIES IN INCISORS INVOLVING ANGLE

cavity has been left for separate consideration.

91

The plan given

is

a modification of plan three, using a lingual step not unlike the occlusal step in a class

50.

l'*ig.

with a

Cavity

minimum

two

cavity.

of Class Four, plan four, for cohesive gold showing maximum anchorage
The use of this plan is advised when the lingual stress is

loss of dentine.

great.

A
Fig.

51.

Class

Access

is

Four, plan four,

B
tilled.

Labial and lingual views.

an easy matter as the decay

I)art of the distal

cess to the cavity.

surface and a

little

is

Cavity shown in Fig. SO.

in the

most prominent

M'ork with the chisel gives

a<

OPERATIVE DENTISTRY

92

Outline Form.

In outlining the cavity proper most of that which

has been said about plan one should be followed here.

As to the lingual outline and that of the step particular attention

must be paid to so placing the margins as to remove them as much
as possible from the stress of articulation.
The Step. The lingual step is added to this cavity as it materially assists in retention, resistance and convenience forms.
In the laying of the walls of the step portion the particulars
much as though the lingual surface of the cuspid

are carried out

were an occlusal surface, as next

to

an occlusal surface

it

receives

the greatest stress in articulation.

Axial Walls.

It will

Fig.

Cavity

be seen that this cavity has two axial walls.

Fig.

52.

53.

Four, modified plan three, for cohesive gold in the distal of

This plan is sometimes used to advantage in the incisors when the
the superior cuspid.
In such cases the lingual step is made to include the lingual pit.
tooth is short and stocky.
Fig.

52.

Fig. S3.

Class

of Class

Four, modified plan three,

filled.

Cavity shown in Fig.

The one

52.

in cavity proper is the axial, while that in the .step is

termed the lingual axial Avail.
The Lingual Axial Wall should be placed on a plane parallel Avith
the lingual surface of the tooth. Its surrounding line angles should
be laid just below the dento-enamel junction.
Convenience Form in this cavity is pretty well secured by the addition of this lingual step, as the filling is then easily built in from
the lingual direction.
Both gingival point angles in the cavity
proper should be made convenience angles as well as the axio-

gingivo-mesial point angle in the step portion.

CHAPTER

XVI.

MANAGEMENT OF CAVITIES

IN THE GINGIVAL THIRD.

(CLASS FIVE.)

Gingival Third Cavities Differ from

ill

all

other cavities in the teeth

that they originate on perfectly smooth surfaces generally with-

out flaw in enamel formation and without covering of any kind, or

more

no predisposing cause.
an easy matter, as the accumulation of sordes
which is the sole exciting cause, is unprotected and of easy access to
the brush so that patients Avith this class of decay are paying the
to state it

concisely, there seems to be

Their Prevention

is

A
Fig.

54.

Cavities

B
Class Five for cohesive gold or amalgam.

penalty for the careless neglect of the simplest forms of oral cleanliness. With these facts before us it becomes the duty of every practitioner to fully advise the patients of the neglect of their

mouths

in

an effort to check farther destruction.

Spread in the Enamel is a characteristic of this
class of cavities.
They usually originate near the center of the
buccal surface near the free margin of the gum and seldom stop
until they have extended both mesially and distally nearly to the
angles.
The fact that the encroachment seldom reaches the angle
in the external enamel decay, is a point to be considered in the

this particular locality, in

The Tendency

to

93

94

Ot^ERATlVlS

DENTISTRY

study of extension for prevention in this class of cavities. It apwhen the outline is carried quite to the angle that

pears that

secondary caries rarely occurs.

The Gingival Outline should be laid below the gum line for its
entire length until the angles are reached when it should emerge
from beneath the gum at a right angle to the free margin of the
gum.

The Occlusal or

Incisal Outline should be carried to a region

sound enamel. Where this extension does not carry this outline
farther than one millimeter from the free margin of the gum farther extension should be made. AVith teeth surrounded by a heavy
gum, particularly if there seems to be a condition of hypertrophy
of

A
Fig.

55.

Class

Five

Cavities shov/n in Fig. 54.

filled.

two millimeters
from the border of the gum.
Retention Form. Retention is secured by squaring out the four
point angles. The axial wall should generally be left as decay has
present, the occlusal outline should be laid at least

left it in

Any

the central portion.

of such a nature as

would tend

to

subsequent cutting should be

it convex to the external,

make

or so to speak, the miniature of the tooth's surface in

being cut.

An

which

it is

effort to cut a flat axial Avail mesio-distally Avill

often endanger the pulp and

is

unnecessary as these cavities need

no resistance form.
In Large Buccal Decay often- the

gum

has so grown into and

CAVITIES IN
filled

the cavity that the

is difficult

much

THE GIXGIVAL THIRD

acljustiiieiit

of the

95

clamp and rubber dam

In such cases if the pulp is not involved

secured by packing the cavity full ot gutta-

or impossible.

assistance

is

percha base plate allowing it to crowd well down upon the gum.
In a few dajs the gum will have receded or have been absorbed
sufficiently to permit convenient access.
If the Pulp is Involved and requires extirpation make the application of the devitalizing agent, covering this with amalgam which
should fill the cavit}^ Care should be taken that the gingival wall
has been planed to a solid condition. During this operation dryness may be obtained by the assistance of cotton rolls.

When

case returns the clamp will ride on the

amalgam

at the

may

be had through the upper

portion of the amalgam. After the pulp canals have been filled
the dam may be removed, the remainder of the amalgam excavated
and cavit}^ preparations proceeded Avith, as well as the placing of
gingival and access to the pulp

an amalgam filling, under dry conditions by the use of cotton rolls.

If Gold is to Be Used the gold inlay is clearly indicated as producing the best results with the least tax upon patient and operator.

With Labial

Cavities in the gingival third the

Hatch clamp

will

expose nearly every case presented and render access not difficult
for the introduction of a cohesive gold filling.
In cases of extensive gum recession on labial exposures the porcelain inlay is
clecirlx'

indicalcd and

is

considered

in

the chapters on that subject.

CHAPTER

XVII.

MANAGEMENT OF ABRADED SURFACES. OCCLUSAL AND

INCISAL.

(CLASS

SIX.)

Class six includes the group of cavities necessary

Definition.

for the repair of injuries to the teeth through the loss of a portion

The condition
abnormal and the extent of the destruction of tooth substance
is by no means in proportion to the amount of use to Avhich the
teeth have been subjected. However it will be noticed in mouths
Avith teeth of short cusps, and particularly if the incisors occlude
directly upon the incisal edge, that there is an abnormal amount of
lateral motion in the act of articulation, and in such mouths we
find the maximum loss of tooth substance at any given age.
of their articulating surfaces, as the result of wear.

is

Cause Not Wholly Clear. Yet, that friction is the sole cause for
can not be demonstrated, as the surfaces thus affected
do not show the exact impression of^the opposing teeth, neither is
Cases Avill be
this condition always delaj'ed till advanced years.
occasionally met Avith in the mouths of people in middle life showing the advanced stages of this trouble.
this lesion,

At the same time locations will be found on the occlusal surfaces

which at one time must have been in articulation but are
so far lost and seemingly worn aAvay that they could not be
of teeth

l)rought into occlusion.

It

would seem from a study of a great number of cases that

l)e some causes predisposing and exciting not yet un-

there must
derstood.

not improbable that the cause

It is

structure, not so

much

is

a fault in tooth

in the constituents of the tooth as in the

lack of strength in their com1)ination.

This conclusion would seem

and of the
same chemical analysis are affected to a different degree by even
slight friction. The bond of union does not seem to be so strong.
plausible

from

The Object

the fact that teeth similarly situated

in Filling or in

making a

cavitj'-

to

fill

is

to

perma-

nently check the loss of tooth substance by entirely covering the

affected surface with a substance that will resist the full force of

mastication.

Occlusal

showing the
vised.

Surfaces.
first

As soon

In

occlusal

surfaces,

particularly

molars

stages of general erosion, earlj^ interference

as a cusp

is lost

it

96

should be restored and

is

ad-

if pos-.

ABRADED SURFACES.
bible built

OCCLUSAL AND IXCISAL

high "with gold, preferably

an alloy

97
either

gold,

of

platinized foil or a cast inlay of gold alloy.

This Early Restoration of cusps to their full height

restrict the lateral

motion of the mandible

Avill

tend to

in mastication, Avhich

seems to be a factor in this dissolution.

Cavity Preparation. These cavities should be prepared as class
cue and should 1)0 retentive throughout.
If the Major Portion of the Occlusal Surface of a single molar is
affected the whole occlusal surface should be lowered about one millimeter and the same restored with a cast inlay, sometimes termed
an onlay. This is advised from the fact that the occlusal side of
the filling

may

better

may and probably

fit

Avill

the surface of the occluding teeth.

This

necessitate the devitalization of this in-

dividual tooth Avhen the pulp chamber should be utilized for anchorage.
If

Contact Points have lieen reached by this cutting, a mesio-oc-

clusio-distal cavity

When Wear

is

is

imperative.

General opening the bite to the extent of about

one millimeter is preferable to cutting away any more tooth substance than is necessary for firm foundation and a correct outline.
With Incisal Abrasion, if the wear is not excessive, the building

on of the "shoe," or covering the entire incisal end of the tooth

with platinized gold is the best practice. The gold inlay, which is
ti'eated in the chapters

When

there

is

on inlays,

excessive incisal

is

also of service.

wear opening the

])ite

to practi-

and
crown for the anterior.
The Entire Enamel Edge on the occlusal and incisal surfaces
must be covered with a protecting layer of metal as with these
teeth the bond of union seems to be A'ery weak, particularly at
the dento-enamel junction, and they will chip away if not wholly
protected from the force of mastication.
cally

normal

the porcelain

is

indicated, using gold for the posterior teeth

CHAPTER

XVIII.

CAVITY PREPARATION FOR GOLD INLAYS.

Definition.

An

inlay

is

a body placed within a previously pre-

As applied

pared excavation.

process whereby the filling

is

to the filling of teeth

it

refers to the

inserted into the cavity of a tooth in

one piece and retained there, by the assistance of cement.

The Materials
loj's

in

most common use are porcelain, pure gold,

al-

of gold, as well as alloys of base metals.

The Indications for a Gold

restorations, as there

is

Inlay.

First.

In

large

contour

a material saving of both time and energy

on the part of both patient and operator. Such cases, particularly with posterior teeth are frequently crowned with the shell gold
crown with its almost universally irritating band, when the inlay
could be of greater service.
Second.

When

it

difficult

is

maintain dry conditions for a

to

long period of time about a cavity, as with large gingival cavities

molars and bicuspids.

in

Third.
stored.

When
It is

there are extensive occluding surfaces to be re-

much

easier to cast a correct contour than to build

up with the plugger point Avhich

dam is in
Fourth. When

rubber

given short time.

is

largely guesswork

when

the

position.
it is

desired to put in a

number

In such cases the operator can

of fillings in

nmke

the

a,

wax

models, and engage the help of the laboratory in completing the

fillings

while he

Fifth.

When

is still

busy with other

fillings at

the chair.

the necessary force to properly condense a cohe-

sive gold filling is not permissible, as Avitli loosened teeth, or in-

valid patients.

Gold Inlays Are Not Indicated

ities,

unless the outline

is

in small cavities, or shalloAv cav-

extensive.

The Cavity Preparation for a gold inlay does not materially diffrom that which has already been advised in the preceding

fer

chapters.

It is possible to construct

an inlay without change for

nearly every cavity which has been correctly prepared to receive

a cohesive gold

filling.

However

ly rearranged the operation

is

if

the order of precedure

is slight-

simplified.

This Change in the Order would be to put retention form last, attending to that part of the cavity preparation after the model
has been made and just before setting the inlay.
98

CAVITY PREPARATION FOR GOLD INLAYS

99

In cases where this has not been done, or the cavity

is

naturally

retentive, the retention should be temporarily covered, as Avill later

be described, Avhile

Change
just as

making the model.

of Position of Retention Angles.

heavy retention angles

It is quite ideal to cut

in the different classes of cavities

for gold inlays, as for cohesive gold, only they should be laid in a

and cut at the expense of the base walls rather

than the surrounding \^'alls, in order to give the cavity draw.
This feature of the cavity preparation will be described as we consider the preparation of cavities by classes farther on in this

different position

chapter.

The Order

of Procedure for Inlays

1.

Gain

2.

Outline form.

3.

Resistance form.

4.

6.

Convenience form.
Removal of remaining decay,
Finishing enamel walls.

7.

Toilet of the cavity.

5.

aa

ould then be as follows

access.

Retention form, which is given as the fourth order in other

forms of fillings.
Gaining Access for inla.y filling is the same as that with other
fillings as far as surgical procedure is concerned.
No more tooth
substance should be cut aAvay on this account.
When using preliminary separation for access, there should be
in most of Classes Two or Three cavities, more room secured, as
8.

this will materially assist in getting a correct

wax

pattern as well

as aid in the process of placing the inlay.

Resistance

Form

for Inlays should receive the same careful con-

sideration as given for other fillings.

Weakened enamel

walls

should be protected not only from th-e subsequent force received

in stress but from the stress of setting the inlay. Flat seats for all
inlays are imperative.

The usual steps

in Classes

Two and Four

are called for as an important factor in retention to resist the tip-

ping strain.

Convenience Form for Inlays should not be practiced to excess.

No convenience points are required. The major portion of convenience form should be gained through separation, preferably

slow separation.

Removal of Remaining Decay. When it has been fully determined that the pulp is not to be removed, some decay may be left on
the axial wall, or in the region of the bucco-axial or the linguo-

OPERA'TlVE DENTISTRY

100

axial line angles, luntil the inlay has beeii cast

and

fitted.

It

should then be removed arid the dentine over-lying the pulp, if

hypersensitive to thermal changes, given a eoat of cavity varnish.
AUoAving this softened dentine to remain during the interim betAveen the making of the pattern and the setting of the inlay, wiW
protect the pulp against irritation and save devitalization before
setting the inlay.

The Finishing

Enamel Walls

come

in at

this point as all cutting of the external outline of the cavity

must

of the

will necessarily

be completed before proceeding to make the pattern. The only

change advisable is that the cavo-surface angle should be more obtuse, and the bevel angle should not be as deeply buried, which
results in a thinner metal edge.

This

Avill assist

in burnishing the

margins to a closer adaptation

in the final finish.

More Beveling
for tAvo reasons.

at the Cavo-surface

Angle should be resorted to

have a margin of

First, the gold inlay should

may be burnished
Second, during the process of setting

rather an acute angle in order that the material

more

closely to the margin.

the inlay and burnishing the margins, the cavo-surface angle stands
in great

The

danger of being fractured.

Toilet of the Cavity for Gold Inlays.

est Aveakness

clean after

it

in inlay methods.

No

Herein

cavity margin

lies

the great-

is

surgically

has been moistened or been in contact Avith the inlay

Avax pattern.

After the pattern has been formed and removed our methods
not permit of again planing the cavity surfaces and particularly the margins, Avhich is the only Avay to render them entirely

Avill

clean.

Hence

Ave are forced to Avash the cavity Avails just before setting

the inlay Avith solvents of the substances Avhich haA'e contaminated

them. Without going into detail, it is adAdsed that the cavity be

thoroughly scrubbed Avith chloroform, then absolute alcohol as a
second cavity toilet, and immediately the cavity be floAved Avith the
cement, introducing the inlay under dry conditions.
Line of Approach. In inlay Avork the cavities should be approached from the direction in Avhich they are to receive stress
during service.
In AvithdraAving the Avax pattern and Avhen the inlay is placed,
each should travel parallel Avith a line draAvn from the seat of the
cavity to the source of the force of mastication.

proach

is

good practice

Avith

any

filling,

but

is

This line of ap-

more

essential Avith

CAVITY PREPARATION FOR GOLD INLAYS

the gold inlay than the cohesive gold

filling,

by the use

we do not have the

retention made pos-

for

assistance of the elasticity of the dentine in

sible

101

of the Avedging pi-inciple in the manipulation of

cohesive gold.

Preparation of Cavities of Class One.

Of the

cavities of this class calling for gold inlays only the large

occlusal surface cavities in molars are of importance.

and

fissure cavities are

more quickly and

Small pit

easily filled

by other

methods.
Outline Form.

In large occlusal cavities the outline should be

A
Fi^. 56.

Cavities of

Class

One

for gold inlays.

Cavity side of inlays shown.

crest of marginal ridge.

reached on the buccal or lingual the outline should
include the marginal ridge and at least one millimeter of the axial
wall be involved.
The
All deep grooves should be included.
curves should be as generous as possible.

SO carried as to avoid eminences at the

AVhen

this is

Resistance Form.

When much

The same

rules apply as

of the supporting dentine has been

to

other

fillings.

removed through

decay or cavity preparation from either the buccal or lingual walls,

that portion within the cavity should l)e covered with a thin layer
of black wax, which prevents the wax pattern from coming in eon-

OPERATIVE DENTISTRY

102

The cast mlay will then not touch these

during the process of introduction, which will often save a
fracture of these walls, due to stress from within when driving the
tact with these walls.

Avails

inlay

home

to a seat.

Form comes in for considerabeen cast and fitted and just before cementing to place.- However, a flat seat and nearly parallel walls
The Major Portion

of Retention

tion after the inlay has

I"'ig.

into the

57.

Class

wax

One inlay in position showing gold wire cast in the filling, which was put
Cavity shown at (B) Fig. 56.
pattern to support the long buccal arm.

to this seat Avith fairly definite angles, is necessary to

guard against

the tipping strain and produce proper retention form.

Preparation of Cavities of Class Two.

Large proximal cavities in molars and biscupids are successfully

handled with this method of filling.
Access. Preliminary separation is of the greatest service here
and should be general practice as much cutting for convenience
form is avoided, and better contact secured.
Complete Preliminary Separation very materially facilitates the
removal of the wax pattern as the operator does not have to be
as careful about having his wax pattern tight against the surface
of the adjacent tooth.
In addition to the preliminary separation
before making the pattern, it is to the advantage of the operator

CAVITY PREPARATION FOR GOLD INLAYS

103

pack the case for additional separation during the interim between making the pattern and setting the inlay.
Outline Form. The outline for inlay filling is much the same as
Care should be taken that the buccal and
for other methods.
lingual walls are parallel, particularly the enamel portion of these
walls, as the wax pattern must move directly to the occlusal surface in exit. It is equally essential in inlays that angles and sharp
to

turns in outline be avoided, particularly as they will not take in

the

wax

pattern and any defect in the casting exaggerates the

misfit.

Flat gingival and pulpal walls are

Resistance Form.
in class

Weakened buccal and

two.

moved and replaced with

Fig. 58.

Cavities

of Class

been used

in the

Two

molar

demanded

lingual cusps should be re-

the filling material.

Cavity side of inlays shown. Black wax has

temporarily remove the retention produced by decay.

for gold inlays.

to

Retention Form is best secured for vital cases by making four

convenience angles in each case similar in size to those for cohesive gold.
However, these convenience angles should be laid
down in the gingival and pulpal walls and cut entirely at the expense of these walls rather than at the expense of the tooth substance
in the region of the

ascending line angles.

more accurately take a round

ber two, sink

it

bur, about

To describe the process

number one-half or num-

into the gingivo-axio-buccal

and gingivo-axio-linTo this point the

gual point angles about the depth of the bur.

procedure

is

the same as though

venience angle for cohesive gold.

we were going to make a conInstead of sinking the bur later-

ally into the ascending line angle

and drawing

it

occlusally, as

OPERATIVE DENTISTRY

104

with cohesive gold,

we

draAV

it

toward the mesio-distal plane along

the gingivo-axial line angle, alloAving

it

to fade out, after going

once or twice the width of the bur, taking the tooth substance

from the gingival

ner.

wall. Treat both lower point angles in this manIn the step portion of the cavity follow the same procedure

in the

two point

angles, cutting all tooth substances at the expense

of the pulpal wall.

occlusal

This results in giving the cavity draAv to the

and giving your inlay four

lugs, Avhicli

key the

filling to a

seating, particularly in the region of the gingivo-buccal

givo-lingual point angles.

form high

in vital cases

It also results in

and near the force

a part of a vital tooth Avhich

strain.

is

and

gin-

placing your retention

of mastication,

and

in

well suited to stand the tipping

(Fig. 58.)

In Non- Vital Cases the retention form should be placed low in

In fact the major portion of it should be below the gingival wall, and this is more frequently secured by the use of the
pin inlay. When the pin is not used, the pulp chamber is so shaped
that the Avax pattern will show a lug, which can be used for the
major portion of the retention.
the tooth.

Finishing of Enamel Walls.

This part of the cavity prepara-

tion should be attended to with all of the care

required

when making

a cohesive gold filling.

and

detail that

is

In addition there-

after the planing has been done with a chisel, particularly

on the buccal and lingual outline, these margins should be polThis facilitates the travel of
ished with a veiy fine grit disk.
A chisel finthe wax on these two surfaces when going to exit.
ish on these surfaces results in a pattern that under the microscope shows little fine projections, which have gone into the roughened surface. In drawing the pattern these little projections have
This results in an imperfect cast])een bent and point gingivally.
to,

ing along these surfaces and interferes Avith the

fit.

Whereas

if

the surfaces have been polished, a polished w'ax pattern results

nnd the completed inlay more nearly fits the margins.

When the cavity on account of decay is naturally retentive or
lias undercuts these are temporarily filled and overcome by covering the retentive portion of the cavity Avith some substance, as
temporary stopping or Avax of a different color than that used
in making the pattern.
Preparation of Cavities of Class Three.

The gold inlay

is

seldom indicated, in cavities of Class Three.

CAVITY PREPARATION FOR GOLD INLAYS

may

All exception

through decay

be

made

in those Avhich

105

are large

and have

lost their entire lingual wall.

from the lingual as Class Three

from that direction.
The Outline is the same as though a cohesive filling Avere to be
made. Care should be taken that the labial level is laid on the
same plane as the travel of the Avax pattern to exit, else this portion of the model will be distorted in removal.
The Gingival Wall Should Meet the axial Avail at an acute anAccess.

It is

of a necessity

cavities receive their stress

59.
Cavity of Class Three for
Fig.
inlay, lingual approach.
Cavity side

Fig.

60.

Inlay

shown

gold

in

Fig.

59

partly

in place.

of inlay shown.

gle

and the cavity should have a line angle Avhich might be termed
The labio-axial line angle should be slightly shorter

axio-incisal.

than the outline of the cavity Avhere the axial Avail meets the lingual surface. This Avill result in alloAving the pattern exit to the
lingual.

As

the labial

Avail,

care should be taken that

Avhich

is

the seat of the cavity,

is frail,

supported by sound dentine,

cause fracture of this Avail.

it is Avell

else the seating of the inlay Avill

Preparation of Cavities of Class Four.

The use
and

cases

of the inlay should be largely restricted to non-vital

a pin in the pulp canal used for the

major portion of

retention.
If the Inlay

is

used in Class Four plans one and three, the case

OPERATIVE DENTISTRY

106

In vital cases the inlay may be

should always be devitalized.
used to advantage in plans two and four.
In this part of cavity procedure the same
Resistance Form.
exercised
as when using the cohesive gold filling.
care should be

Fig. 61.

Cavity

Fig. 62.

This

is

of Class Four, plan one, for gold inlay.

Class

Four, plan one, inlay in position.

Cavity side of inlay shown.

Cavity shown in Fig. 61.

particularly true at the incisal edge, where the beveling to

the axial should be quite generous to protect against breaking

down

of this

margin due to the fact that

angles to the long axis of the enamel rods.

stress

comes at right

CAVITY PREPARATION FOR GOLD INLAYS

Retention Form.

107

This step in cavity procedure will vary acis used.

In plan one, which
only in non-vital cases, a pin

cording to -which plan of Class Four

as before

stated should be used

should be placed in the pulp canal and depended upon almost en-

Fig.

63. Cavity of Class Four, plan two, for gold inlay. Cavity side of inlay shown.
wax has been used to temporarily remove undercuts caused by decay.

Fig. 64.

Class

Four, plan two, gold inlay in position.

Black

Cavity shown in Fig. 63.

In plan two, largely used in vital cases,

iridio-platinuiii or tungsten should be
pin
of
a short, 20-gauge
placed in the step portion of the cavity lying parallel to the long
tirely for the retention.

axis of the tooth.

This small pin had best be from one to three

108

OPERATIVE DENTISTRY

millimeters long, owing to the possibilities of the case.

The

gin-

may

be accomplished either by using a similar pin

to that used in the incisal, placing the hole for same in about
the center of the gingival Avail, or the plan of retention used in
gival retention

the gingival wall Class

I"ig.

65.

Cavity

Fig. 66.

Two may

be used.

of Class Four, plan three, for gold inlay.

Class

Four, plan three, inlay in position.

This consists in cut-

Cavity side of inlay shown.

Cavity shown in Fig. 65.

ting the two convenience angles in the gingival

In plan

w'all.

three, non-vital, the pin in the root canal should be used.

four same retention used as in plan two as the case

ways

is

In plan

nearly

al-

in

no

vital.

The Enamel Walls should be

Avell

beveled, Avhich

Avill

CAVITY PREPARATIOX FOR GOLD INLAYS

way

hinder the removal of the model.

109

Model should make

exit

to the incisal with a slight lingual travel.

Fig.

Fig.

67.

68.

Pig. 67.
Cavity of Class Four, plan four, for gold inlay. Black wax has been spread on
the labial wall before making the pattern to prevent the gold from touching this wall when
setting the inlay for two reasons.
First:
It removes liability of fracture of this wall when
setting the inlay.
Second: This wax is replaced with cement and the color of the tooth is
preserved.
The wire loop secures the alinement of the two posts and facilitates handling the
pattern.
the wire is not entirely buried, platinized gold should be used.
When it is

When

may be used.
Four, plan four, showing cavity side of pattern with pins.

entirely buried tungsten

Fig. 68.

Fig.

69.

Class

Class

Four,

i)lan

inlay in position before removing wire loop.

pattern shown in Figs. 67 and 68.

four,

Cavity and

Preparation of Cavities of Class Five.

Of this class the large buccal cavities call for gold inlays, in
which they are the ideal filling, and should largely replace amal-

gam

so

commonly

used.

OPERATIVE DKNTISTRY

110

The Occlusal Wall.

The axio-occlusal angle should be slightly

and distal angles may be nearly a
permit the model to tip to the buccal in

obtuse, Avhile the axio-niesial

right angle.
exit,

This will

though the gingivo-axial ang]e be acute.

Preparation of Cavities of Class Six.

The restoration of abraded surfaces with the gold inlay is good

inasmuch as it is possible to effectually protect these

practice,

Fig.

l.'jg.

71.

Showing

the necessary

70.

Class

amount

Five cavity and inlay.

of metal for adequate protection of ahraded surfaces,

when opening

the bite.

surfaces from further destruction with the minimum amount of

cutting. As is the case with the other forms of filling the surface

CAVITY PREPARATION FOR GOLD INLAYS

111

covered should be generous. If only one tooth is to be treated

with this filling the amount of tooth substance cut away will be
about the same as the quantity of gold in the inlay.
However if the bite is to be raised on most or all teeth the cutting should be very slight and only enough to properly cleave
and bevel the enamel margins.
In vital cases either incisal, lingual or occlusal, the retention
should be made by the introduction of short pins, iridio-platinum
or tungsten preferred, through a matrix of pure gold, and then
casting the contour.

In Non-Vital Cases a single large pin should be used, or the

so made as to occupy a part of the pulp chamber

model may be

in lien of the pin.

n~

PART
CHAPTER

II

XIX.

THE MAKING AND SETTING OF A GOLD INLAY.

In discussing the methods of making any

filling,

particularly

must bear in mind that the best practice today

may be obsolete tomorrow. In this chapter an attempt is made
to bring out only the most popular methods at this time, as we
are fully aware that new methods are continually being devised,
which may prove of better service. In fact, since placing the first
edition of this book on the market, there have been material
changes in methods, which have resulted in much improvement
IIoAvever, it is a question in the minds of
in this class of fillings.
most of our prominent teachers, as to the comparative value of
this method Avhen considering the cohesive gold filling.
If the
the gold inlay, one

excellent results obtained in the use of cohesive gold are to be

approached in the use of the

be taken Avith every

The Object

inlay,

great care and pains must

little detail.

of the Inlay.

The object

of the inlay

the cement which covers the cavity Avails

and restore

is

to protect

lost contour.

If cement were permanent in the mouth Avhen exposed to wear

and dissolving agents, there Avould be no call for inlays, Avhich

are really only

made

to protect the cement. It is therefore of the

utmost importance that the inlay completely cover the cement by

and that it be so conmaintain this close adaptation.

In choosing the method of construction in each case the marginal adaptation should be considered and the one selected which
promises the greatest perfection.
History.
The gold inlay is one of the oldest forms of filling.
In fact, it is the oldest, as proved by excavations in the Orient.
Teeth in the skulls of m.ummies have been found wherein cavities
have been croAvded full of leaid, with the probable intent to cheek
Even in modern times the inlay has ahvays been pracdecay.
ticed more or less, and has become more popular as time goes on.
As compared Avith the making of a cohesive gold filling, it is infinitely easier, and the history of our college clinics shoAA^s that
the beginner attains a passing degree of success AA'ith the gold ina perfect adaptation at the cavity margins

structed that

it Avill

112

MAKING AND SETTING OF A GOLD INLAY

lay long before he
to bear

many

is

able to understand

and successfully bring

of the qualities of cohesive gold.

Method Using Pattern Entirely

of

113

Wax.

The cavity should be

prepared as for any other metal filling except that the retention
form should be omitted. In case decay has so left the cavity that
it is naturally retentive by having excavated undercuts these should
be filled with some substance which does not become a part of
the pattern, and which is easily removed before setting the inlay.
The substances used to temporarily remove the retentive
form, are cement, temporary stopping, modeling compound and
wax, the preference being with the Avax.

wax

This

should be of a decidedly different color than that of

is made.
(See Fig. 72.)

M'hich the pattern

TvJ

Fig. 72.
Large restoration in non-vital case.
Part of the pulp chamber has been filled
with black wax to remove undercut caused by pulp removal.
The weak buccal wall has been
covered with the same material to protect it from stress from within when setting the inlay.
It goes without saying that this wax is all removed before setting the inlay and is therefore
replaced with the cement with which the inlay is set.

The
walls,
it

Filling of the Undercuts should

and with the wax quite warm

may

be

made

to

dry cavity

to insure its adhering, that

not leave the walls to distort the pattern.

The

difference

used will cause the detection of any particles

v.'hich may adhere to the pattern and make their removal easy.
By a little study and the judicious use of the above method
much cutting for convenience form may be obviated and many
seemingly difficult cases rendered quite simple.
in the color of Avax

The Making

of the Pattern.

After the retentive form has been

water of ordinary

removed, the

cavity should be flooded with

temperature.

This will render the Avax Avithin the cavity

suffi-

Ol'ERATIVE DENTISTRY

114

hard not to yield under the force necessary to introduce

It will also prevent the portions of wax from

cieiitly

the pattern wax.

The wax

adhering.

erably in

warm

permit of molding

wax

taken that the

Wax

for the pattern should then be softened, pref-

The wax should be sufficiently plastic to

when manipulated in the fingers, care being

water.

is

not folded upon

itself as

the portions will not

and come away

The wax should be gently shaped so
that it can be introduced into the cavity in such manner as to come
in contact with the base walls or floor of the cavity first, then by
slow continued pressure for about fifteen seconds made to expand
adhere.

so folded

from the cavity

till

it

entirely

is

liable to part at the folds

in sections.

fills

the cavity, overflowing

all

margins.

any portion of the occluding surface the

dam off. The patient is
requested to close the teeth to full occlusion, slowly.
It must be
remembered that the casting wax is only semi-plastic and moves
very slowly, hence the best impression is obtained by moderate conIf the inlay is to replace

operation should be done with the rubber

tinued force, giving the sluggish

wax

when

when

quite elastic
is

removed

confined and

will spring

be too high

when

back the

time to flow.

Wax

is

really

the pressure from the bite

least bit, so that the cast inlay will

set.

To overcome this it is good practice to have the patient again close

the teeth to occlusion with one layer of rubber dam over the occlusal surface of the model,

for

some seconds.

The

requesting him to maintain the pressure

elasticity of the

the elasticity of the wax.

This will do

rubber dam will overcome

away with much grinding

The pattern should then be carved

contour restoration and correct external surface form, and

after fitting the inlay to position.

to full

the

wax thoroughly burnished around

the entire cavity outline.

The carving and burnishing of the wax is materially assisted

the surface is warmed by the use of warm water. This is best
accomplished by dipping large loosely-rolled cotton balls in water
that is almost too warm for the fingers, carrying it to the mouth
and folding about the wax, allowing it to remain for a few seconds.
Upon removing the cotton the wax will be found to have softened
if

depth to be easily manipulated. In case the wax does

not quite reach the margin, the same should be crowded over to
to a sufficient

the margins, carrying quite a body of the

wax

over before attempt-

down to the margins. If this is not done the wax

found to fit only at the cavo-surface angle, leaving a space
just below this point to which the wax is not adapted.
ing to burnish

will be

MAKING AND SETTING OF A GOLD INLAY

Ideal Conditions Are Obtained

when

115

the Avax slightly overlaps

the eavo-surface angle at all points in the outline, about one-tenth

of a millimeter.

This will give sufficient bulk for correct finishing.

pletion of the pattern
to the

it

is

After the comwell to insert the tine of an explorer

depth of about one or two millimeters in a convenient posi-

tion for removal.

The

tine should be

removed and the pattern

water, the tine reinserted into the previously

chilled with cold

made

hole, the pat-

tern gently pushed to exit and then given a cold water bath.

The Placing of the Sprue Wire. While the pattern is still carried
on the tine of the explorer, the sprue wire should be warmed and
inserted.

The sprue wire should be very fine, preferably copper, and introduced deep into the pattern. This use of a fine sprue wire is of

Fig.

7i.

Some

of the

methods by which inlays may be given retentive form

and non-vital cases.

advantage from the fact that no

in large decays

considerable body of the

wax

melts and runs back up the wire to produce a concavity, close to

where the wire

wire

is

is

introduced, which happens

when

a large sprue

used.

In selecting the position for the wire, care should be taken that
a location is chosen so that the contour of the surface of the pattern
leaves the sprue wire in all directions at an obtuse angle. A neglect
of this point will occasionally result in imperfect casts near the

The tine of the explorer should now be withdrawn

and the resulting hole sealed by touching with the Avarm end of

sprue former.

a small instrument.

good instrument for such work

is

the flattened end of a large

canal cleaner or broach, mounted on a Avooden handle.

Giving the

Wax

Pattern Retention Form.

Portions of the pat-

116

OPERATIVE DENTISTRY

tern should noAv be removed, preferably by the use of the heated

hollow needle, in such manner as to give the cement an ample grasp

upon the

and should be equal to or more than the amount

which the cavity in the tooth is capable. The pattern is then ready for investment.
Method of Using Wax Pattern, Pin Attached. This method is
of service when for any reason it is desired to have the maximum
amount of retention. In such cases the tooth Avill generally be nonvital and a portion of the pulp cavity used for the reception of
inlay,

of retention of

the pin.

Placing the Pin. The cavity should be first freed from retentive
form as described above, using either cement, temporary stopping,
modeling compound, or Avax, then the opening made in the root
canal to receive the pin which is placed in position, with a light
coat of sticky Avax on the outer end. The pin should be long enough
to reach Avell into the body of the wax pattern and should be iridioplatinum, platinized gold or tungsten. These materials Avill stand
the heat of casting the inlay without alloying or losing their rigidit3^

The use

Tungsten Pins.

of tungsten in casting gold inlays

great advantage, as this material

easily cast

is

The wire

has been previously gold-plated.

is

is

of

upon when the wire

about six times as

strong as iridio-platinum of the same gauge and three times as strong

its temper upon being heated.
very rigid pin in the completed work. As the
gold will not cast to the end of the pin, which has been cut off and
is not gold-plated, it is very essential that these exposed ends be
well buried in the Avax, which can be accomplished by seeing that
the pin does not come near the surface of the casting, or else that
the end is bent so as to throw the exposed surface uiore deeply into

This material does not lose

as steel.

It therefore gives us a

With

the Avax pattern.

the pin in position in the cavity the

wax

manipulated the same as though no pin had been

used. When the pattern is withdrawn the pin should come aAvay
with the wax. In case it does not, withdraw the pin from the tooth
for the pattern

and

seal

it

is

into the hole

it

has left in the Avax pattern and return

to position to insure alignment.

ing and

all is

Method

of

Withdraw

the pattern after chill-

ready for investment.

Using Pure Gold Matrix With Pin Soldered on,

This method is advised as most practical in

Casting the Contour.

cavities of Class

Four

(first

plan),

when

teeth are non-vital, in in-

cisal restorations vital or non-vital, in occlusal restorations, cavities

of class six particularly in vital cases,

and

in lingual restorations.

'

MAKING AND SETTING OF A GOLD INLAY

With

these lingual restorations, the

amount

117

of surface covered

is

generally quite large as compared to the thickness of the restoration

which

best termed an

is

'

'

onlay.

'

This method simplifies angle restoration in Class Four plan one

and provides ample resistance form, -without the cutting of either

In such cases the alignment of the pin

not go to proper place. The
soldering of the pin to a gold matrix gives the desired security during
the processes of removing and investment. The cavity preparation
the incisal or lingual step.

must be perfect

else the inlay will

is the same as for cohesive gold except the convenience angles.

The pin is fitted to a portion of the root canal as previously given.
A sheet of pure gold, 32 to 34 gauge is selected of sufficient size to
more than cover the cavity by about two millimeters. This is partially burnished to the cavity, enough to shoAV the cavity outline
in the gold. A hole is punched in the proper position to receive the
pin, but smaller than the pin, which should be 15 or 16 gauge. In
case the inlay is to be used as an abutment for a bridge, the pin had

better be as large as 14 gauge,

tungsten

is

used, 16 gauge

is

if

platinized gold

is

used.

When

ample.

The operator should then place the matrix

the pin through the hole to place

in position

and croAvd

then scribe the pin just external

to the gold matrix, remove and solder as nearly in correct position
as possible, without stopping to invest, using 22K solder.
;

Only a very small amount of solder

used, care being taken that

it is all

will be

needed or should be

flowed close to the pin to pre-

All should then be returned to the

vent stiffening the matrix.
cavity and the gold reburnished to a perfect fit of the entire cavity
outline.
It is

necessary to burnish the gold only partially into the deep

recesses of the cavity as the pin,

will be sufficient anchorage.

if

of iridio-platinum or tungsten,

This can be

quently relied on for an entire croAvn.

the incisal for exit and if the matrix

made

to equal that fre-

This pattern must

move

to

burnished to contact with

the axial Avail it Avill become fixed.
The matrix should be burnished to a complete fit of the gingival Avail Avhich should be flat
and Avell squared into the lal)ial and lingual angles.
is

Making the Wax Contour. The matrix and attached pin are removed, and the desired contour built up by floAving the Avax to
position Avith a spatula, trying the Avhole pattern to place in the

cavity to guide in the restoration.

chilled

and removed and

all is

When

complete, the Avax

readv for investment.

is

OPERATIVE DENTISTRY

118

To Restore Occlusal and

Incisal Surfaces

where the tooth

Avith inlays

is vital,

better than the following method.

lost

from

abrasion

nothing answers the purpose

The outline

of the surface to

Small holes are drilled to convenient

depths in safe locations of sufficient size to receive a 20 gauge
Three or four pins are required
iridio-platinum or tungsten pin.
for molars and two or three for bicuspids or incisors. A pure gold
matrix, 32 or 34 gauge, is then burnished to an approximate fit.
be covered

is

established.

The positions of the holes in the tooth will be outlined in the gold.
The matrix should be pricked at these points with a sharp pointed
instrument smaller than the ijins. One pin is inserted and should
protrude occlusally through the matrix for a short distance, and
be bent at right angles.
It is

good practice when using tungsten

to

goes to the full depth of two of the holes and

make

a loop which

along the gold

surface in the body of the loop, thus establishing the alignment of
This also places the exposed end of these
tAvo of the pins at once.
lies

tungsten pins, to which gold will not cast, entirely away from a
position which might result in shoAving the exposed ends in the

completed

case.

This pin and matrix are then removed and attached Avith solder,
applying the solder to the occlusal side of the matrix. The matrix
should be returned to the tooth and another pin placed and attached in the same Avay, repeating until all pins are in position,
Avhen the matrix should receive a final burnishing. The Avax contour

is

then added as before described, the pattern replaced and

mouth and finally trimmed to desired

The Avax should then be chilled and the entire pattern
remoA'ed and iuA'Csted.
articulation secured in the

contour.

Method

Contour. Advantages. The advanmaking an inlay still exist Avhere the

cover considerable surface and is very shalloAV. Such
generally termed "onlays."
This method is advised

of

the

SAveating-

tages of this older method of

inlay
inlays

is

to

are

from the fact that models of such nature Avill seldom maintain exact form during the process of removing and investment unless a
gold matrix

is

If the gold

used.

matrix

is used it is difficult to cast a thin layer of

gold over the entire surface of this matrix and get good margins
unless a large quantity of gold is melted to make the cast in Avhich

case the gold matrix

is

very liable to be entirely fused, AA-hich Avill

Speed is also a factor in this instance.

not give the best results.

MAKING AND SETTING OF A GOLD INLAY

Many

119

times an onlay can be flowed to the desired thickness in

much less time than that required to invest and cast.

Making the Matrix. This is done in the same way
greater bulk of gold were to be added.

as though a
Such inlays must be re-

tained by one or more pins soldered to the cavity side as previously described.
is burnished to perfect fit and the outline definitely
The matrix should be trimmed to within about onefourth millimeter of the cavity outline and reburnished and care-

The matrix

established.

fully removed.

The matrix is then given a coat of whiting on all that portion

is to come in contact with the tooth to prevent the solder
from flowing on that surface.
Avhich

The gold matrix should be then laid

upon the soldering block and Avith a brush flame from the bloAV
Sweating the Contour.

pipe

22K

plate or

22K

solder fused to the thickness desired in the

When a sufficient amount has

been fused in any portion, that part of the surface should receive a
various locations on the matrix.
coat of whiting.

Gold can then be fused to

spreading to portions where it
possible to build

exposed

still
is

surface

not wanted.

up a given portion

By

this

without

means

its
it is

of the inlay, even to the add-

ing of cusps to occlusal surfaces.

Method

of Using

Sponge Gold as a Pattern.

Take the sponge

gold as bought on the market for making a cohesive gold

fillinjr

with any casting Avax on the market. This is best

accomplished by dipping a sufficient amount of the heated gold,
while held in the pliers, into the molten Avax, and immediately re-

and saturate

moving

it

to a clean surface to cool.

Making the

Remove any

excess Avax.

AVhen this method is used any undercuts

with cement. A portion of the saturated gold large enough to a little more than fill the cavity is
grasped between the pliers and slightly Avarmed and carried to the
cavity and croAvded to position and the contour determined in
much the same Avay as amalgam is manipulated. A matrix should

in the cavity

Pattern.

should be

filled

be used in class tAvo cavities, but not sufficiently high to prevent

occluding the teeth. When the pattern has the desired contour
form, the Avhole is remoA-ed the same as described for removing a
pattern composed of Avax alone.
Investing.

sprue of Avax

is

attached to the usual place as

The pattern is then

though the casting method Avere to be used.

OPERATIVE DENTISTRY

120

submerged

in

much

backing flowed but

upon

the same

way

sufficiently

as a tooth

deep upon the

is

invested to have a

wax

sprue former to

removal a receptacle for the gold solder to be fused.

Saturating the Model. Heat may be applied to the invested pattern as soon as the investment has set, and the wax gradually
leave

its

burned out leaving a frame\\ork of pure gold

Then scraps

of

22K

sprue former and

which

heated to the point of fusing the

is

22K

gold

disappear through the opening and completely saturate

Avill

and

The inlay may be immediately

This method has to

finished.

manipulation, and
it

the mold.

gold plate are placed in the hole left by the

all is

the pure gold Avithin the mold.

chilled

filling

is

recommend

it,

speed of

indicated in large contour restorations, where

desired to use a solid inlay.

Making

Generally considered

the Cast.

we have

three forces

used in placing the gold in the mold; suction, pressure, and centrifugal.

Centrifugal force

is

the only one wherein all atoms or

molecules of the material are acted upon, and greater accuracy

is

obtained by this method.

Place of Heating- the Gold.

time the gold strikes

fore, the place

it,

The temperature

in casting,

where the gold

is

is

of the

mold

of great importance.

at the

There-

melted should not be on the body

by that method we are not

able to vary the temperature of the mold at the time of casting.
The gold should be melted on a separate tray and the mold should
of the investment over the mold, for

be heated to the desired temperature independently of the material

being

east.

Temperature of the Mold.

a])le
first,

to

By

little

experimenting we will be

demonstrate that a body of molten gold contracts toward,

that part which

is

chilled

first,

second toward the greatest

body of gold; that is, when the gold consists of two parts connected by a small isthmus, or in other words, pedunculated, there
is a tendency for the smaller body of gold to shrink toward the
larger one.
The first part of the gold which we desire to set
through the process of chilling is that part of the inlay which is
most essential to a perfect fit, namely the margin or that which
covers the marginal bevel and second all of the cavity walls.
Therefore, it is important when the gold is thrown into the mold
that the investment which forms the mold be of a temperature to
chill the gold at first impact, bearing in mind that it should be
Avarm enough to permit of the gold to enter the sharpest recesses.

MAKING AND SETTING OF A GOLD INLAY

121

When

Using- Pin or Pure Gold Matrix. When casting an inlay

mold Avhich contains a pin or a pure gold matrix, the temperature of the mold should be considerably higher. Particularly
is this true Avhen the pin is large or the amount of gold to cover
to a

the matrix

is

thin as

it

may

be close to the margins.

When

Quantity of Gold Used in the Cast.

pressure machines
as

when

{IS

much

it is

using the suction or

quite necessary to have a large sprue

left,

amount of gold is near the size of the inlay, failure is

liable to result owing to the philosophy of the force used in casting.
However, with the centrifugal machine, it is not absolutely
essential that there be any considerable sprue left. Yet if Ave try
to guess too closely, many failures will result from having too little material.
Owing to the law of the shrinkage of the metal towards the larger body, the sprue Avhich is left should never Aveigh
there

is

the

as the inlay cast.

large sprue left

a tendency to hold the Avhole

body

is

of advantage, as

of gold at a tempera-

its Avay through the sprue

advantage Avhere there is a large
pin or matrix present, as the high temperature is maintained longer.

ture sufficient to give

hole into the mold.

The large sprue

it

is

particularly at a disadvantage Avhen casting

the base to pin croAvns.

There

is

also

time to thread

It is also of

The

more danger

Ioav fusing pin is liable to

be melted.

of checking the porcelain.

The size of the hole leading to the mold is

of importance for a number of reasons. As a general rule the
larger the inlay, and the loAver temperature of both the hole and
the material at AV'hich you cast, the larger should be the hole; it
Size of the Opening.

necessarily folloAvs that the hole should be smaller Avith the reverse
conditions.

A small hole lengthens the

time required for the stream of molten

Hence, if the mold is cold and the material is not extra Avarm in casting a large body, the material is liaHoAvever,
ble to become chilled and the mold not entirely filled.
if Ave are casting a small inlay, in a rather Avarm mold Avith the
gold to pass to position.

gold extra hot, the small hole is preferable as there is less liability
of a backAvard shrinkage of the gold to the sprue, Avhen cooling.
Better results are obtained Avhen the Avax pattern

is

immediately

burned out and casting completed Avithout alloAving the

mold, either Avith the pattern in position or burned out, to lay over
night. If it must lay over night, it is best to burn out the Avax and
thoroughly heat the mold, as less change takes place thereafter in
the investment. In this connection your attention is called to the
invested,

OPERATIVE DENTISTRY

122

findings of Prothero in the expansion

and contraction of plaster

paris in the various periods following

mixture with water.

Finishing' the Inlay.

With any

its

of the processes of

inlay there are liable to be some imperfections which

making an

Avill

be seen

upon removing from the investment. If these are on the cavity

side of the inlay and are of any considerable size it will probably
be necessary to make a new^ pattern. If they are only slight and
are in the form of little pedunculated masses they can generally be
removed without injury to the filling. If the contour shows that
the mold did not entirely fill the necessary amount to complete
contour, and the margin is not involved it may be sweat on using
Another
a gold of lower fusing point than that of the inlay.
inethod is to make a gold amalgam and build to the desired contour.
Then the inlay should be subjected to heat gradually raised
ta nearly red heat when the mercury will be volatilized leaving the
pure gold fused to the position desired. This gold amalgam is
made by adding mercury to cohesive gold foil, pellets or fiber
which have been annealed, mixing thoroughly in the palm of the
liand and applying immediately to place. All exposed surfaces of
gold inlays should receive a high polish before setting, omitting
a line about one-fourth of a millimeter next to the entire margin.

Setting the Inlay.

The inlay should be Mashed with

Avater

and

then dipped in chloroform to remove any oil that may have

adhered from the hands. The cavity should be freed from all for-

dried

eign substance, given complete retentive form, bathed with chloro-

form and alcohol

in the order

named and

the surface of the cavity

entirely covered with cement.

The inlay is given a coat of cement on its cavitj'- side from the
same mix and gently but firmly moved to position using hand presThe inlay should be
sure assisted by light blows from the mallet.
of the cavity for
directed
toward
tlie
seat
pressure
subjected to
v.ill
measure
overcome
the tendency tominutes
which
in
a
some
ward displacement caused by the expansion of the cement. An inlay may be finished at its margins Avithin thirty minutes from setting,

time.

but

it

is

better

if this

step

is

attended to at a subsequent

CHAPTER XX.
]\rA\lPULAT10X OF COHESIVE GOLD IN THE
A FILLING.
Physical Properties.
.tilling

MAKING OF

The physical properties most desired

in n

are fonnd in cohesive gold to a greater degree than in any

other filling material, which places

at the

it

head of the

list

as a

means of restoring
cay.

It is

lost contour and preventing recurrence of denot affected by the fluids of the mouth; it may be very

perfectly adapted to the walls of the cavity; the shrinkage

pansion range in varying temperature

and

ex-

very slight; the cavity

can be filled immediately upon freshly cut surfaces before they
have been contaminated, an advantage over the fused inlay; and
when sufficiently condensed it possesses a greater specific gravity,
hence density, than a fused inlay of pure gold. Hammered gold
will flow under sufficient stress and always in proportion to the
is

when it ceases to flow, unless the load is increased

marked distinction between it and amalgam. This quality of gold
makes it possible to build a filling which will at once sustain the

load,

force of mastication provided

it

has received sufficient aggregate

Aveight during the process of introduction.

erty of gold

when

is

also of service in that

it

This physical prop-

does not farther compress

wedged between the Avails of living dentine which are

elastic and retain a certain amount of residual elasticity Avhich
permanently grasps the unyielding gold. The expansion and confirmly

traction of gold under the varying oral temperatures is fully compensated for by this residual elasticity of the dentine so that the
closely adapted cohesive gold filling is at all times in perfect

adaptation.

The Objectionable

Qualities of Gold.

Gold

is

a good conductor

of thermal changes, hence endangers the health of vital pulps.

color

is

The

an objection in anterior positions, and the process of build-

ing a filling

is

comparatively slow and

taxing

on patient and

operator.

Welding of Gold.

Gold welds cold when properly prepared,

is

absolutely pure, and the contacting surfaces are clean. Any alloy
in its substance (excepting platinum) or foreign substance upon

such substances
again returns.
cold
welding
are removed, when the property of

its

surface totally destroys

this

123

quality, until

OPERATIVE DENTISTRY

124

// tlie Surface of Foil Becomes contaminated with a non-evaporable substance the injury is permanent.

Place in the drawer where the

tlie Surface of Gold.
kept a small pledget of cotton or spunk saturated with am-

To Protect
gold

is

monia.

Ammonium

salts Avill

form on the surface of the

gold,

which are

by heat, leaving the gold clean.

Before annealAvill
ing such gold
be found thoroughly non-cohesive. This method of treating the gold to the fumes of ammonia will obviate the
necessity of keeping more than one kind of gold on hand, as all
will be non-cohesive till annealed and can be used in either form.
easily volatilized

Annealing' Gold

is

for the sole purpose of cleaning the surface

by volatilizing any film that may have collected.

The Degree of Heat is about 1100F., or just below red heat.
In the daylight this color is not apparent, but on a dark day
the dull red color should show. The gold is not materially injured
if carried to the full red of 1200 or 1300 degrees, but in no case
of the gold

should the melting point be reached, as it destroys the possibility

of adaptation to the walls of the cavity, or the surface of the gold
already in place.

Methods of Annealing.
satisfactory means, as

The
is

it

electric annealer is

by far the most

same de-

possible to always obtain the

gree of heat for a continued period.

The Next Best Means

is

to place the gold

on a tray above a flame,

thus separating the flame from the gold, preventing contamination

of the gold with carbon,

and various gases which are frequently met

with in combustion.

Gold SJiould Not Be Annealed hy Passing It TlirougJi tlie Open

of either gas or alcohol, holding the gold either on a plug-

Flame

ger point or the

foil carriers.

This

is

quite a

common

practice,

which should be discontinued. In the first place, heating the gold

with the open flame frequently contaminates its surface, to the
injury of its welding properties.
Also that portion of the gold next to the carrier
and remains non-cohesive, a fact which

ly heated

subsequent pitting of the surface of the

filling

is

not sufficient-

shown by the
during service by
is

the flecking off of these non-cohesive particles.

Specific Gravity.

The

specific gravity of the cast gold inlay

is

varying the fraction of a point.

It is possible to condense a cohesive gold filling when confined
between the walls of elastic dentine so as to obtain a slightly
greater specific gravity than the cast inlay. However, this degree
about

19,

COHESIVE GOLD IN THE MAKING OF A FILLING

of solidity

is

125

not possible of attainment unless the gold

and the wedging principle is

Cohesion of Gold. The surfaces

fined

clean readily cohere.

is

eon-

advantage of.
of pure gold when absolutely
This cohesion is brought about by the frictakeji

tion of the surfaces of the gold M^hen in absolute adaptation.

The

degree of cohesion is in proportion to the friction. The friction

is in proportion to the load, the extent of the surfaces in opposi-

and the speed of the travel of the surfaces one upon the other.
Hence, the greater the load, the smaller the surface, and the more
rapid the movement of one surface upon the other the greater
the cohesion. Polished surfaces of gold must be brought into coadaptation in order to get cohesion. The smaller the surfaces and
the thinner the sheets, the less load and speed will be required.
The Serrated Plugger Points are used in condensing cohesive
tion

gold for the folloAving reasons: That these polished surfaces

be kept small and uniform; that great pressure (load)

may be

may
eas-

exerted on the polished planes previously left in the surface

ily

of the gold

by the wedge-shaped

serrations.

The mallet

is

applied

to give the additional factor in friction (speed) as the fresh gold

is

moved over

these small polished surfaces.

The above conditions

are obtained with the least exertion on the part of the operator

and annoyance
is

made

by the serrated plugger point, which

pyramids which act as so many Avedges

to the patient

of a collection of

and exert great

lateral force

(load)

upon the polished

sides of

That gold coheres to polished surfaces

can be easily demonstrated by taking any cohesive gold filling
and burnishing its surface to a glossy finish. Pellets of gold from
the annealer will readily cohere and the filling may be continued
to full contour by applying a steel burnisher with heavy pressure

their previous impression.

drawn over the surface of the fresh gold. This process proves that
burnished gold coheres, but it is slow and laborious and objectionable to the patient, hence the serrated plugger point which accomplishes the same result, the friction of polished surfaces of
gold under pressure, causing their Avelding.
Bridging is the term applied to that faulty manipulation which
body of the filling, caused by the
gold failing to reach the bottom of the indentations of the serrated
plugger point.

results in air spaces within the

The Cause may be

insufficient pressure

being given the plugger

point, the gold thereby stopping short of the

bottom of the serra-

be caused by too much light malleting, going over

the gold surface repeatedly thereby bending down the crests of

tions, or

it

may

OPERATIVE DENTISTRY

126

pyramids thus choking them to the entrance of the gold.

it may be caused by changing to a plugger "with a less number of serrations to the millimeter, or one Avherein the serrations
are not as deeply cut, resulting in a collection of pyramids that do
not reach the bottom of the indentations made by the previous
the

Again,

plugger.

Plugger Points Should Have the Same Sized Serrations.

Each

operator should have a set of gold plugger points same denomination as to the cuttings on the

When

ing.

working point to use in the same

surface of the filling should be gone entirely over with the

ger to be used, before adding additional gold.

new

accommodate the gold added with the new

(See Figs. 176A and 176B.)

little

plug-

This will create a

set of facets to

ment.

fill-

forced to change to one of different sized serrations the

new

instru-

care in this respect will greatly increase the specific grav-

ity of the cohesive gold filling.

Rotating the Plugger in the Fingers Should Be Avoided. The

ser-

and unless the point is rotated oneeach time the pyramids will ride the crests of the

rations are cut on the square

fourth of a circle

indentations, whereas

if

the shaft

is

held in one position as described,

the leverage produced by the plane on the surface of the plugger

point coming in contact with the plane on the surface of the

filling,

plugger point to position with each blow of the mallet.

All this will prove plain to the vision if the field of operation is

will twist the

viewed under a high power lens while operating with a serrated

plugger on the surface of gold in a technic block.
The Size of the Plugger Point. This depends entirely upon the
it can be used.
It would seem from all the facts
hand that a point with the surface of one square millimeter should
be regarded as the maximum. The force required to properly con-

force with which

at

dense gold with a point of greater surface,

in

many

is

either not permissible

cases or often not possible with the operator.

point of

one square millimeter should receive a load of 15 pounds pressure at

each contacting of the point.
the same time points of much less than one-half millimeter
chop the surface by disturbing the gold close to the point with
each impact hence we are limited to a narrow range as to size of

At

will

points.

The gold foil may be used from the

comes from the dealer, and shaped as desired by the opermay be purchased as cylinders, squares, ropes and various

Preparation of the Foil.

book as

it

ator, or it

other forms.

COHESIVE GOLD IN THE MAKING OF A FILLING

The shaping should be done

contact with the fingers, and

Avithout bringing the gold in direct

all

done previous to annealing.

The Application of the Foil.
shaped,

127

manipulation and cutting should be

In whichever form the

foil

has been

should be so placed upon the surface of condensed gold

it

that the leaves lay

of gold are

If the pellets are placed so that the leaves

flat.

crumpled in packing

not be as great in the finished

to place the specific gravity will

Neither will the cohesion be

filling.

as perfect.

Sheet gold has left in

it

a certain amount of spring even after an-

nealing that has to be overcome

sheets in folds

when packing

if

folded.

The

handling of the

less

the better the result.

The gold should

be grasped by the carriers with as small a bite as possible to prevent

precondensation and carried to the position desired and condensed,

with no attempt to shift

its

position by pushing or poking

it

around

over the surface.

If the pellet
lies fully

condensed.
ing.

is

placed near a wall,

against that wall that

it

it

may

should be placed so that

it

be crowded for room when

Short of this will hinder the wedging principle in pack-

new pellet is to come out to contour it should reach

beyond contour and be burnished back to contour with a

If the

slightly

flat-faced steel burnisher.

The Forces Used

in Condensing Cohesive Gold.

principal forces used in condensing cohesive gold,

blows from the mallet.

These

may

There are two

hand pressure and

be either alone or one following

named is the most popular, the

on patient and operator and produces as great specific
gravity in less time. However, the best results are obtained by using each method at given times in the process of building most fillings.
To Illustrate. Hand pressure alone should be used in the filling
Also when on account of position the force
of convenience angles.
must be applied at nearly a right angle to the wall against which
the gold is being condensed, as in starting a filling and when covering the seat of the cavity with the first one-half millimeter of gold.
With the plugger point pointing directly at a dentinal wall, with
the other or in combination; the last
least taxing

a thin layer of gold between, the elasticity of the dentine causes the
gold to rebound

when

struck a blow Avith the mallet.

In such posi-

by hand pressure alone which

should be applied with a rocking motion secured by swaying the
outer end of the plugger from side to side for a distance of, say one
tions the closest adaptation is secured

change of position.
Pressure Alone is also of most service Avhen packing gold

inch, at each

Hand

OPERATIVE DENTISTRY

128

Again

against thin walls.

in cases

where the condensing force should

be applied at an angle to the long axis of the shaft of the plugger

point as sometimes met with in distal cavities in posterior teeth with

Hand

a distal inclination.

pressure alone

is

required

when

it

be-

comes necessary to use force at an angle which would tend to unseat

the

filling.

filling

should never receive a blow through the plugging instru-

ment when that instrument does not point quite

directly toward

one of the inner walls of the cavity, preferably the seat.

Mallet Force Alone is of service in adding the last poi'tions of

when adding thin layers of gold at each

hard surface.
A Good Rule is to increase the hand pressure (load) both in frequency and weight as you increase the thickness of the pellets applied, and as the angle at which the gold is driven to a dentinal wall
approaches a right angle.
gold to an occlusal surface

time, resulting in a very

The Different Plans

Hand

By

is the hand mallet

method the operator is
vary the amount of hand pressure (load) and its relation to

Mallet.

far the best mallet force

driven by an experienced assistant.

able to

of Mallet Fores.

By

this

the mallet force (velocity) at will all through the

filling,

as well as

at different points in the condensing of a single pellet of gold, a point

of no small consequence.

The Automatic Mallet.

It

has been attempted to imitate this

combination method in the automatic plugger, and

substitute for the
it

hand pressure and

must be regarded

absence of better

Power

is

today the best

assistant mallet method, but

as a substitute only

and supplies a need in the

facilities.

Mallet.

PoMer mallets

either electric

or

driven by the engine are of service in that part of each

mallet force alone
is

is

filling

indicated as previously described.

such a small proportion of each

care to bother Avith

mechanically

filling that

them and few have them

where

But

this

most operators do not

at hand.

CHAPTER

XXI.

MANIPULATION OF COHESIVE GOLD IN THE MAKING OF

FILLINGS BY CLASSES.
Class One.
,

This class of cavities

is

Pit

and Fissure.

the easiest of

all

in that they are sur-

rounded by solid walls of dentine with generally only one wall missing, which is the means of access to the cavity.
Starting the Filling.

In the case of a small pit cavity

erally well to start with a piece of gold that

is

it is

gen-

sufficiently large to

more than cover the internal wall and condense the greater portion
with a rather large plugger point using hand pressure alone on this
piece.
"With occlusal cavities the inner wall is the pulpal wall.

When

an axial surface it is the axial wall.

may be added and condensed in the same
way. The mallet force should now be used on a smaller plugger
point going entirely around the cavity close to the walls holding the
shaft of the plugger at an angle of about 12 degrees centigrade to
the wall against which the condensing is being done.
In Occlusal Cavities the condensing should be in the central portion first; then next to the distal wall; then along the buccal and
This plan of procedure
lingual walls and lastly the mesial wall.

the cavity

is

in

second pellet of gold

pertains to each separate layer of gold as

ing simple occlusal

In Buccal Cavities the order of stepping

gingival; third, distal; fourth, mesial;

When

it is

when

applied

treat-

pits.

the Cavity

is

first,

center

second,

fifth, occlusal.

Has a Long Irregular Outline caused by the

following out of one or more rather long fissures the plan

except that the most distant

arm

of the cavity

is

the same,

is filled first,

allow-

ing the gold to gradually build toward the operator's viewpoint,

covering the base wall, portion by portion, with the plugger point

always at the given angle to this base wall, which permits of the
use of mallet force after the first pieces of gold have been securely
anchored along the disto-pulpal line angle.
Class Two.

Beginning the
ing a

Proximal Cavities in Bicuspids and Molars.

Filling.

filling of cohesive

There are three distinct methods of

gold in this class of cavities.

start-

It is well if

both gingival point angles are sharpened to a convenience angle.

129

It

130

OPERATIVE DENTISTRY

will not

sufifice

to

have these made into the form of a round hole or

but they should be shaped up to the distinct wedge shape. This

shape will cause the condensed gold to crowd the elastic dentine on
slot,

driven to place and insure the stability of the

all sides as it is

piece of gold.

If this small convenience angle

is

first

not sharp at

its

deepest point, but has a flat wall or seat, the mallet force is precluded as that flat wall will not permit its use, the elasticity of which

rebound when struck a blow, whereas when

and the approaching sides leave a wedge-shaped

will cause the gold to

this point is sharp

opening the gold

is

As

when driven
make easy starting

firmly grasped

tion to this small detail will

to the Three Plans of Starting Class

Fig.

74.

Starting

cohesive gold,

to position.

Two. The

first

Atten-

of such fillings.

First Plan,

plan.

and probably the most popular, is to fill one convenience angle, the
one the farthest from the viewpoint of the operator, and while supporting this in position with a suitable instrument build along the
gingivo-axial line angle to the other point angle.

A Second Plan is to fill each point angle separately and join the
two with a third piece of gold laid along the gingivo-axial line angle.
A Third Plan is to start with a quantity of gold sufficient to fill
both point angles and cover the connecting line angle as well as a
considerable portion of the gingival wall next to the axial.

This last

one used by some experienced operators and is well to be attempted when working for speed. The beginner will do well with

plan

the

is

first

plan.

The Order

of Stepping the Plugger in Class

Two.

With each

COHESIVE GOLD IN THE MAKING OF FILLINGS BY CLASSES

131

wedging principle is made most effective

by the following order of stepping: Center of filling first; contour
second; ascending line angles third; surrounding walls fourth and
pellet of gold added, the

against ascending cavo-surface angles

fifth,

keeping the long axis

of the plugger shaft at about a twelve degree centrigrade angle to

and lingual

the axial, buccal

When

the Gold Extends

walls.

Beyond Contour

it should be burnished
back to correct position and the plugger again stepped along the
contour, holding the plugger close to a line of the long axis of the
tooth, instead of striking the gold at nearly a right angle to this line,

a practice so

unseat the

common with

filling

operators, and one that has a tendency to

and separate the layers of the filling already con-

densed.

The Progress

of the Filling should be kept on a plane parallel

Fig.

75.

Starting

cohesive gold, second plan.

to the plane of the gingival wall

completion of the

filling,

and kept

having a

in this plane to near the

strict care as to

complete contour

in the proximal, as the filling advances.

Covering the Pulpal Wall.

step portion in Class Two.

common

is

There are two plans of covering the

The first and most

Tlie First Plan.

to build the cavity portion to a level of the pulpal wall

and gradually cover the pulpal wall by allowing each

pellet of gold

to extend a little farther than the previous one out over the pulpal

wall

till

the pulpal point angles have been reached.

The Second Plan

is

to start

an independent body of gold in the

pulpal point angles, in one of the three ways outlined in starting the
cavity portion on the gingival wall and finally uniting the two portions of the filling. Whichever plan is used nothing should be done

OPERATIVE DENTISTRY

132
in the

way

of covering the pulpal wall

till

the gold in the cavity por-

tion has reached a level with the axio-pulpal line angle.

The Contact

The

Point.

when

attention

special

bviilding of contact point should receive

the proper height of the filling has been

The gold should be thoroughly condensed against the proxmuch in the same manner as it is wedged against the
and should receive extra malleting to insure extreme hard-

reached.

imating tooth
walls,
ness.

Position of Contact Point.

When

the proximating tooth

is

in-

tact, the contact

point should be in about the same position as

was previous

and should be a contacting point and not surThis should round away from this point
contact.

face or a line of

Fig.

in

much

it

to decay,

the same

76.

Starting

manner

cohesive gold, third plan.

as do the surfaces of

two marbles when

touching, and has come to be spoken of as the "marble contact."

(See Fig. 26.)

Moving Contact Point Flush to Occlusal. The contact

when both promixating surfaces

should be moved occlusally

point
are to

be restored, one a mesial and the other a distal filling in the teeth
making up the proximal space being considered, and when there has

been considerable occlusal wear. This will result in a contact point

from which the surfaces round away in all directions except toward
the occlusal surface and is known as the "half marble contact" advised for the above condition only. In this connection attention is
called to the immunity to decay of proximating surfaces where the
"half marble contact" has been produced by occlusal wear. Many
instances are seen where caries already started in such spaces have

COHESR^ GOLD IN THE MAKING OF FILLINGS BY CLASSES

133

ceased to progress because of the cleanliness of such surfaces, due

to the lack of

the egress of food substances.

The Last Portions of Gold. After leaving contact point the last
portions of gold are added to restore normal contour or as near that
condition as occlusion and articulation will permit giving special
care to complete covering of the cavo-surface angle at
Filling Class

and

is

Two With Matrix

advised by some operators,

tional condensation

due

all points.

in Position.

This maj- be done,

who advance

the theory of addi-

to the presence of the

substitute for the

missing wall.

When

the matrix

is

used

it

should not be adjusted

gival cavo-surface angle is covered.

Fig.

n.

Burnishi!\g

at the gingival.

back excess gold

It should be

foil in

till

the gin-

thoroughly wedged

covering the gingival margin.

The matrix should be removed

just before the gold

has been built to the height of contact point.

The Use

of the Separator in Class Two.

In cases where prelim-

inary separation has not been made, a mechanical separation should

be adjusted and tightened at short intervals to the full extent of

safety.

This will permit of better and more thorough finishing of

contact point as the slight space resulting will be taken up,

upon

the removal of the separator.

Class Three.

Proximal in the Six Anterior Not Involving the Angle.

Starting the Gold, in cavities class three,

The gold

is

the same in large or

condensed into the wedge-shaped

convenience angle farthest from the viewpoint of the operator which

small cavities.

is

is

first

the gingivo-axio-lingual angle.

The gold

is

kept in this triangular

OPERATIVE DENTISTRY

134

form by covering equally rapidly the three walls forming the angle
the gingival, axial and lingual walls, keeping the shaft of the plugger pointing

When

all

the time at the point angle primarily covered.

the gold has been built out along the gingivo-lingual line

Fig.

78.

Covering

the gingivo-lingual angle with cohesive gold.

angle to the cavo-surface angle great care must be taken at this stage
of the filling that the linguo-gingival angle
built to full contour, as this

is

the only time

is

covered and the gold

it

can be correctly done

with the force directed in the right direction.

As

the gold reaches

COHESIVE GOLD IN THE MAKING OF FILLINGS BY CLASSES

135

the height of the gingivo-axio-labial angle this should be thoroughly

filled

and the

filling

continued, maintaining the same level of the

gold, restoring full contour past contact point

condensed and burnished.

Filling Incisal Angle.

which should be well

Shortly after passing contact point the

gold should be advanced along the axio-lingual angle to the incisal

angle which should then be

filled

using hand pressure alone as the

The

direction of the force will not permit of the use of the mallet.
filling

should then be completed with the plugger point

still

directed

toward the angle where gold was first condensed, the last portions
of gold being added to the labial portion of the filling at the incisal
extremity.

With Lingual Approach

The gold

versed.

The plugger point

is
is

first

in Class

Three the Avhole plan

built into the gingivo-axio-labial

is

re-

angle.

maintained in a position pointing at this angle

as the filling progresses,

till

the last additions of gold are to the

lingual surface at the incisal extremity, all the while the operator

is

working to the image reflected in the mouth mirror.

The Lingual Approach Is Advised in cases where ample preliminary separation is secured or when the lingual wall is wanting and
the axial wall meets the lingual cavo-surface angle. That said about
the use of the mechanical mallet in Class Two applies to Class
Three with equal force.
Class Four.

Proximal Cavities in Incisors and Cuspids Involving

the Angle.

The removal

of the incisal angle permits of the plugger point be-

ing used in an ideal angle to the walls and allows the force being

applied more nearly from the direction that the subsequent force of
service

is

received.

These fillings are started as has just been

described with Class Three; however, the gingival wall should be
most rapidly covered and the plan of building similar to that described for Class Two, keeping the surface of the gold parallel to
Starting the Filling.

the plane of the gingival wall, restoring lost contour as the filling

advances, and maintaining the plugger point at about 12 degrees

centigrade to the surrounding walls.

The Final Portions

of Gold should be condensed on the extreme

with the shaft of the plugger point still maintained at
an angle of 12 degrees to the plane of the axial wall.
The Layers of Gold in Class Four should receive some attention
incisal angle

and what

is

said in this connection

is

true of all contour restora-

OPERATIVE DENTISTRY

136

tions subject to great stress.

enced in the breaking of such

Not a
fillings

little trouble has been experithrough given lines of fracture.

These should be noticed and the layers of gold leaf so placed as

to cross these lines.

The

tensile strength of the sheets of gold is

greater than the usual cohesion obtained giving a filling

more strength

across the laminations than parallel with them.

Class Five Cavities in the Gingival Third.

Class Five cavities in the gingival third need no special mention
as they are built

The gold

is

under the rules already outlined in Class One.

usually started in the disto-axio-gingival angle and

carried along the gingivo-axial line angle to the other gingival point
angle.
ered.

The gingival wall will be the first wall

The mallet force should not be directed

to be completely cov-

at a right angle until

that wall has been covered with a considerable layer of gold.

Class Six.

Abraded Surfaces.

These cavities are built the same as large flat cavities in the same
which have been given.

surface, the principles of

CHAPTER

XXII.

FINISHING GOLD FILLINGS.

When

Secondary Consideration.
its full size,

a gold

filling

has been built to

the entire surface should be gone over with a plugger

point of moderate size. The point should be stepped so as to cover

every accessible part of the filling.
A light mallet with a hard surface should be used.
two ounce

steel-faced mallet is preferred.

Burnishing".

All accessible parts of the surface should then be

thoroughh^ burnished with a

nisher

is

steel burnisher.

of most universal use as

If the filling

is

it

will reach

The egg-shaped burmost

positions.

a proximal filling of Classes Two, Three or Four,

hand matrix should be forced between the filling and the

proximating tooth to burnish the contact point and to better condense and harden the filling at this place. This is done by swinging
the handle back and forth describing the part of a circle, till there
is more or less freedom of movement of the burnisher.
a thin steel

Following This Secondary Condensation the process of smoothing

the surface with abrasives begins. The first efforts should be to find
cavity outline, second, to correct contour in localities where an excess has been built and third, to polish the contact point.
This is best accomplished by the use of small carborundum stones
on occlusal surfaces, disks on buccal, lingual and labial contours,
and narrow coarse strips in the proximal, gingivally from contact
point assisted by the use of

Attention should

first

contact point which, in

file

cut burnishers.

be given to
all

proximal

parts of the filling except

all

fillings

should be the last place

to receive finish.

The Use
filling

of the

Saw

in the

proximal space in the finishing of the

In the first place no cut-

cannot be too strongly condemned.

ting instrument, or coarse abradent, as strips or disks, should be

made

to pass contact point except

where there has been ample pre-

liminary separation and the return of the teeth to position is relied

upon to close the resultant space. Again there is no excuse for building an excess of contour sufficient to engage the bite of a saw blade.

The Excess

and it, with the exaway with the files,

the edge of which should be

at the Gingival should be slight,

cess fullness in the embrasures, should be filed

or whittled off with the burnishing knife,

keen.

The

files

should be carried through the embrasures as far

137

to-

138

OPERATIVE DENTISTRY

ward the center of the filling as possible and drawn directly outward
and over the edge of the filling out to the external enamel surface.
The Finishing Knife should be engaged into the substance of the
gold and drawn from the gum and at the same time outward, takoff only a small portion of gold at each cut.
Coarse Abrasives, as carborundum stones and coarse disks and
strips, should be abandoned as soon as a near approach to the cavo-

ing

surface angle

is

reached,

and the

files,

plug-finishing burs,

and knife

edged instruments resorted to, to bring into view the exact cavity
outline, after which the finer strips and disks should be employed to
bring gold and tooth substance to an exact level at the cavo-surface
angle for the entire cavity outline.

To reduce the quantity of gold

from contact point to the gingival, a coarse finishing strip sufficiently narrow to reach from the gingival outline to near the contact
point only, is of advantage. This strip is introduced by sharpening
one end and passing through the embrasure below contact point and
then drawn back and forth till the desired surface is secured.
Fine narrow linen strips are then used in the same way to give
Finishing Strips in the Proximal.

a final finish to this place of difficult access.

When

the Entire Cavity Outline

face otherwise

made ready

Has Been Exposed and the

sur-

be tightened another degree,

for the final finish the separator should

when

it

will be

found that a broad

fine

This should be given three

linen strip will easily pass contact point.

or four sweeps with this broad strip not too tightly drawn,

when

the contact point should be considered finished.

The separator should be gradually loosened and removed, the rubdam removed and the filling tested for occlusion and articulation and properly shaped. The filling should then receive a thorough
finish, with wood points, leather wheels and tooth cleaning brushes,
ber

carrying

first

pumice, then whiting,

till

the surface of the filling

as smooth as the external enamel surface.

is

CHAPTER

XXIII.

MANIPULATION OF AMALGAM IN THE MAKING OF A

FILLING.
Definition.
Amalgam is a composition of mercury Avith one or
more other metals. It is most commonly combined with two or more
other metals which have been previously alloyed and finely divided
either as shavings or filings to facilitate union with the mercury.

History.

Amalgam

for the filling of teeth

was introduced

into

France about the year 1826 by M. Teveau, who called it "silver

paste." This was composed of silver and mercury alone, and must
have given very unsatisfactory results as compared with those secured in the use of our modern alloys.
Reception. The use of amalgam was given a most uuAvelcome
reception by the profession at large, while the converts of the "new
process" were equally emphatic in their praise of the new filling
which "would certainly cheapen dentistry, and harm the profession."
But time has proved amalgam to be a blessing to the poorer classes
in that

it

brings dentistry within the reach of

all

purses and has

thereby proved of advantage to the dental profession by broadening

its field

of usefulness.

While amalgam has many faults and should generally be avoided

when finance will permit, the fact still remains that more teeth have
been saved through its use than with any other filling material.
However the percentage of salvage is greater with gold, which

amalgam to second place.

The Properties of Amalgam which render

forces

material are:

it

of value as a filling

First, its plasticity eliminating access

preparation, making possible the building

up

form in cavity

of lost contours in inac-

mouth, where convenience and access forms are

hard to secure, sufficient for the manipulation of gold either cohesive or as an inlay; second, its property of being but slightly affected by the oral fluids, and the fact that it is fairly stable as to
bulk and shape; and last, but not least in the minds of many patients, we are sorry to say, is its cheapness, as most dentists see fit
to build fillings of amalgam for a much smaller fee than gold.
The Objections to Amalgam are: Its tendency to discolor both
as to its exposed surface and the teeth with which it has been filled
due to slight leakage with old fillings; its comparatively large expansion and contraction range; its continued flow under load; its
cessible places in the

139

OPERATIVE DENTISTRY

140
poor edge strength;

its

spheroiding during setting,

when not prop-

mixed from a perfect alloy. It is also liable to injury between

the time of introduction and complete setting through carelessness
erly

of either dentist or patient.

The Extent

of Expansion

and Contraction

of

amalgam

der the control of manipulation by the operator, but

by the composition of the

is

alloy both as to materials used

is

not un-

controlled

and

their

proportions; as well as the method of their preparation.

The Flow of Amalgam under pressure is the term applied to the

tendency of amalgams to flatten or move from under stress.
Most metals will yield or flatten under a given stress in proportion
to the load, up to a given point, and then cease unless the weight is
increased. However amalgam continues to yield as long as the pressure is continued even though it is not increased.
This peculiarity in amalgam explains the phenomenon often observed in the mouth. Amalgams differ as to the amount of force
necessary to produce flow, yet the peculiarity is exhibited by all
amalgams.

Edge Strength

in a Filling

a filling shows to stress

is

the term applied to the resistance

upon thin margins

at that portion of a

fill-

ing which covei's the marginal bevel.

Edge Strength

Amalgam. This depends first, upon the metals

entering into the alloy. The greater the proportion of silver entering into the amalgam up to seventy-five per cent, the greater the
edge strength. Above seventy-five per cent it becomes more brittle.
Second, the manner of packing. Third, the amount of actual union
in

between mercury and

alloy.

The Maximum Strength

Fourth, bulk at margin.

will be obtained Avhen the alloy contains

enough mercury so that the mass will take the impression of

the skin markings after prolonged kneading between the thumb and
Any more or less weakens the edge strength.
forefinger.
The Length of Time the Alloy Stands has an effect upon edge
strength, as amalgams made from alloys lose their edge strength progressively with time, the more rapidly the higher the average temjust

perature.

However Aged Alloys Slioiv Less Variations in Expansion, Conand Bange, and artificial aging is resorted to for this reason and is done by annealing. This annealing produces an amalgam
that shows more uniform and consistent properties.
Annealing of Amalgam is accomplished by subjecting the alloy
when freshly cut to either a dry or moist heat ranging from 110 F.
traction

AMALGAM
to 212 F. for

IN THE

MAKING OF A FILLING

some hours or days.

141

The lower temperature

for a

longer period produces the best results.

Effect of Annealing.

and the

tion, the flow,

The

artificial

aging increases the contrac-

ability to withstand the crushing strain; the

amalgam requires less mercury, and sets slower.

The Alloy Showing the Least Expansion and Contraction Avhen
unannealed

is

eight parts tin

composed of seventy-two parts silver and twentyand may be modified very slightly by adding a small

per cent of copper or other metals. When annealed the above formula of silver tin alloy should be changed to seventy-six parts silver and twenty-four parts tin, to get a stable amalgam.

Cavity Preparation for Amalgam.

use of

amalgam

Many

of the failures in the

attributed to the property of the material used are

due to laxity in cavity preparation, since many practitioners

believe that thoroughness is unnecessary in this particular.
The
preparation of a cavity for the reception of amalgam is even more
exacting than for gold, as the operator is dealing with a filling material possessed of a greater number of faults, each of which must
be given consideration, and the cavity should be prepared in such
a manner as to minimize these to the least degree.
In comparing amalgam with gold it might be said that amalgam requires
less access in awkward localities in the mouth, requires much
separation in proximal fillings, and that the outline form must receive more careful consideration as the margins must be farther
removed from positions of great liability to caries, as' well as stress.
in fact

Flat Seats for Fillings are even more imperative than Avith gold,
and the occlusal step must be broader bucco-lingually. The enamel
walls must be finished with as great care, w4th a cavo-surface angle
more acute, and a more deeply buried bevel angle. Cavities must
have more retentive form.

The Rubber

gam be

Dam

is

very essential as

it is

built against dry, freshly cut, walls

imperative that amal-

and margins.

It is as

amalgam filling as it is a good gold filling against moist Avails. The residue from the saliA^a upon the Avails
Avill shoAV leakage more quickly Avith the amalgam filling than with
impossible to

make

a good

When operators come to the full realization of this fact

and manipulate all amalgam fillings Avith as great care as gold, Avithreference to dry conditions, the frequent failures of amalgam will

the gold.

be materially lessened.

The Matrix.

All cavities filled with

uous surrounding

walls.

amalgam must have

contin-

This will necessitate the adjustment of the

OPERATIVE DENTISTRY

142

is missing and applies to all Class Two

which reach the occlusal surface.
The matrix should be thoroughly wedged at the gingival, to prevent excess contour at this point, and to secure additional space that

matrix in cases where a wall

cavities

contact point

may

be

made

as one one-thousandth of

close.

an inch.

It

should be

It should be

made of steel as thin

made to encircle the

tooth firmly either by ligating or by a retaining appliance, several

When two proximal fillings are to be

same time and in the same proximal space, two matrices

of which are on the market.

built at the

are necessary, one for each tooth involved.

to

However, better results are obtained, particularly with reference

proper contact restoration, by building up and finishing one fill-

first, and then building the other filling at a subsequent sitting.

using a specially prepared matrix band of the proper size for
the second filling, with a hole cut in the matrix to allow the metal

ing

By

to protrude at the point of contact

ideal result

may

Separation.

with the

first

made

filling,

an

be obtained.

Preliminary or immediate separation

sential in the use of

amalgam

is

just as es-

as gold.

Making the Proper Proportions

of Alloy

and Mercury.

Each

operator should test his favorite alloys and determine the exact

amount

of

mercury for a given quantity of alloy, and by the use

mix in exactly the same proBy this means the operator is able to produce the best

of a pair of balances be able to always

portions.

product ]jy having the amalgam at its best. By the uniformity he

becomes familiar with the habits of that particular alloy.
This method need not be a time-loser, if the portions of alloy and
mercury are previously put up in separate capsules ready for immediate use. In early practice this can be done by the dentist himself at leisure times

Making the Mix.

and

in after years

Upon

by the

assistant.

the thorough incorporation of the mer-

cury with the alloy prior to placing in the cavity depends much of
amalgam filling. Poorly mixed alloys have

the good qualities of an

Amalgamation in an amalgam filling is never entirely

and while this process is going on, there is a certain
amount of molecular action, which tends to change the form of the

little

strength.

complete,

a whole. A very great per cent of this union may be induced before placing the filling by a thorough preliminary mixing
and kneading of the mass.
To this end the alloy and mercury should be put into a wedgewood mortar and thoroughly groun^ together till the contents seem
It should then be removed to the palm
to have become one mass.
filling as

AMALGAM

IN THE MAKING OF A FILLING

143

hand and made into a pellet and then transferred to the thumb
and rolled between the fingers with sufficient force to
produce a decided squeaking noise, sometimes spoken of as the "cry
of tin,"
Either too little or too much mercury will destroy this
sound which should be sought. This kneading should be continued
till the maximum plasticitj^ has been secured, and the tendency to
of the

finger grasp

stiffen

has just appeared.

Wringing Out Excess Mercury. All surplus mercury should be

expressed as soon as detected. With small masses this is thoroughly
and quickly done by grasping the mass between the ball of the thumb
and the tip of the first or second finger. The flesh of the fingers
should entirely cover the mass from view. Then by a rocking motion in which the mass is kept entirely covered the mercury will
appear from between the fingers and not carry with it any appreciable amount of the alloy.
If the

mass

is

too large to keep entirely covered during the proc-

may

be placed in a chamois skin and wrung to dryness, or divided into piefees sufficiently small to be manipulated with the fingers.
As soon as the excess mercury has been expressed the whole mass
ess, it

should be again kneaded, as

and

it

should not be allowed to stand in this

The mass should be

compressed condition.

rolled between the

finger into a loose rope, broken into pieces,

tion convenient to carry to the mouth.

gam should never

and

thumb

laid in a posi-

The rope or

ball of amal-

be cut with instruments, as that part close to the

compressed and rapid setting facilitated.

The packing instruments should be as large
in
the
cavity, that the whole mass may receive
as can be well used
The face of the plugger
the force of compression at each effort.
instrument

is

Amalgam

Pluggers.

should be serrated to prevent slipping.

not be used in packing amalgam, but

is

ball burnisher should

intended for finishing after

amalgam has set.

Making the Filling. The cavity should be in complete readiness
The
to receive the amalgam immediately after it has been prepared.
size of the portions will depend upon the orifice of the cavity, and
the

should be as large as can be easily crowded into the opening.

This

should be immediately compressed upon the seat of the cavity with

as large a plugger as possible, with a rocking motion and as much
weight as the circumstances wall permit. When using a point that
is much smaller than the cavity, the same wedging principle used in
packing gold should be employed; that is, compress the central portion of the

not be used

mass
;

first

and against the walls

last.

burnisher should

neither should the burnishing nor wiping motion be used,

OPERATIVE DENTISTRY

144
but

all

compressing force should be directed at a right angle to the

base wall.

Quite a body of excess should then be added to the occlusal porand a plugger point applied with mallet force which should be

tion

augmented with hard hand pressure. The hand pressure and mallet
force combined will produce a more dense filling than by any other
method and at the same time crowd the yet movable particles of amalgam and alloy into closer adaptation to every portion of the cavity walls.

Trimming Amalgam

After packing

Fillings.

the

amalgam it
when

should be allowed to set undisturbed for one or two minutes,

the excess
2

may

be cut

and the discoid and

away with
cleoid

Gum

suitable knives.

lancet No.

from the ''University set" are

service-

spoon excavators.
Removal of Matrix. The matrix should then be removed in proximal cavities by drawing to the buccal while pressing the ball of the
finger gently on the occlusal surface. A loosely rolled, rather large,
able, as are also the large

ball of cotton should be laid

tip, in

on the amalgam

filling

under the finger

order to prevent the matrix from traveling occlusally in the

process of removal.

The rubber dam should then be removed and the patient instructed
to slowly close the teeth, stopping the instant

of the filling between the teeth,

has been
patient

l)uilt.

is

With

the teeth

which
still

he feels the presence

will occur if excess contour

held in this same position, the

requested to give the jaws a gentle side movement.

This

burnishing the spots of contact, after which the excess

should be whittled away with knife-edged instruments.
Amalgam Should Be Cut From the Margins to the filling, which
will result in

is

just the reverse

from the travel

If the cutting instrument

fillings.

surfaee angle with

amalgam

that

of the instrument in cutting gold

moves from the

is

filling to the cavo-

only partially

to sink too deeply into the substance of the filling

margin

as

it

it

is

liable

and expose the

crosses over.

Passing Contact Point.

of

set,

In proximal

fillings of

any description should ever be allowed

amalgam nothing

to pass the contact point

amalgam has completed the process of setting, as one such

attempt forever destroys proper contact and a filling so treated becomes at once a makeshift. All overhanging amalgam should be cut
away, around the entire cavity outline, but the region of contact

until the

point should be entirely neglected at this time, and

shaping during the process of polishing. Finally the
be gently wiped with spunk or cotton.

left for final

filling

should

AMALGAM
Polishing.

All

IN THE MAKING OF A FILLING

amalgam

careful ])olishing as gold.

ting.

In proximal

fillings

should receive as thorough and

This must be done at a subsequent

fillings the

145

sit-

separator should be adjusted and the

contact point properly formed and polished.

For

this Avork abradents of onlj- the finest

ployed.

nature should be em-

Burs, carborundum stones, coarse strips and disks only do

harm and prolong

Fine strips, disks, wood points

pumice then whiting, and lastly the

the operation.

and leather wheels, using

first

tooth polishing rubber cups should be used.

CHAPTER XXIV.
THE USE OF CEMENTS IN FILLING TEETH.
Varieties.

There are

use in the operation of

five

main

varieties of

filling teeth

silicate,

of zinc, oxychloride of zinc, sulphate of zinc,

cement available for

cement, oxyphosphate

and oxyphosphate

of

copper.

Cavity Preparation for cement when the entire

cement

is

not unlike that for any other

surface angle

is left

filling,

filling is to

be of

except that the eavo-

the same as that produced by the cleavage of

the enamel, omitting the marginal bevel.

The cavity should be given

the usual retention form, and the matrix must be employed in cavities to supply the missing wall that the cement may be introduced
with pressure to condense and create close adaptation to walls.
The rules given for dryness in the manipulation of gold and amal-

gam

are also to be observed in cement

The

filling.

cements have been evolved in an

effort to produce a
would
more
nearly
harmonize
with
the color of the
cement that
withstand
action
oral
teeth to better
the
of the
fluids and the abrading effects of mastication. Berylite is a prominent illustration of a
silicate

cement. Some of the silicates are now used as independent

and are not suitable for use as a cement. This material as
a silicate filling is given full consideration in Chapter XXV.
Oxyphosphate of Zinc has many uses in the cavities of teeth as
a partial filling and in some instances for the complete filling. Being a poor conductor, it makes an excellent agent as an intermediate
between metal fillings and closely approached pulps.
Its adhesive quality gives it great value as a means of adding resilicate
fillings

all kinds of metal fillings.

This quality together with its
harmonious color with tooth substance makes it invaluable for lining weakened enamel walls which have lost much of their support-

tention to

ing dentine.
Its Chief Fault is its tendency to dissolve in the fluids of the
mouth, which renders it comparatively temporary. However there
is a considerable variation in its behavior in different mouths; in

some instances it wears for years.

Oxychloride of Zinc is indicated in pulpless teeth to fill the pulp
chamber, after the canals have been previously filled with guttapercha, and for the lining of cavities for the preservation of color
where adhesiveness is not of importance. It is not indicated in
146

THE USE OF CEMENTS IN FILLING TEETH

147

teeth with closely approached vital pulp, or as a root filling, on ac-

count of

its

irritating properties.

Sulphate of Zinc, Avhen pure,

and

is

is

the least irritating of

one of the best materials for pulp protection.

cements
pulp cap-

all

ping of this material

is of most universal application.

Oxyphosphate of Copper is especially indicated in remote cavities on the necks of teeth occasioned by gum recession.
Cavities
which are so ill-defined that the use of amalgam or gutta-percha is

may be successfully filled with this preparation of copper.

can be made to adhere very tenaciously to the walls of a cavity,
thus obviating much cutting.
Oxyphosphate of copper is also indicated in the small cavities in the deciduous teeth.
It is claimed that this material exerts a therapeutic influence upon the tooth substance, thus preventing further decay.
Manipulation of Oxyphosphate of Zinc Cement. The method of
difficult,

It

mixing

this

are essential.

cement

The

is

not in the least

slab,

difficult,

yet certain details

preferably of smooth glass, should be clean.

The spatula should be flat with the side slightly convex.

Agate is the best material as it is not acted upon by the liquid.
The liquid and powder should be placed upon the slab separately, the
drop of liquid being carried there by the use of a small glass rod.
The spatula should never be immersed in the bottle to obtain more
fluid as this would destroy the efficiency of the liquid.
Crystallized
portions should be carefully wiped off the mouth of the bottle as
soon as detected.

Plan of Spatulating. The powder should be added to the liquid

a time and each portion thoroughly rubbed by a swinging
circular movement of the spatula upon the slab. This rubbing should
not be rapid or vigorous. For lining cavities, where thin layers are
desired which are very adhesive, the cement will prove correctly
mixed when it shows slight stringiness and when the first stickiness
appears, as shown by the slight resistance offered the spatula in its
a

little at

movement over the slab. Where the entire filling is to be of cement,

more powder should be added and the spatulation continued till the
cement materially resists spatulation and the mass is the consistency

made putty. When cement is of the consistency desired

no time should be lost in placing it in position, and it should be
allowed to harden undisturbed. If the cement is to form the entire filling and permanency is desired, it should be crowded to place
with some force and rapidly shaped up. As soon as crystallization
begins it should not be disturbed by manipulation till it has fully
hardened, when it should be polished with fine strips and disks.
of freshly

CHAPTER XXV.
MANIPULATION OF SILICATE IN THE MAKING OF A
FILLING.
Definition.
Materials for Silicate Fillings are marketed under
trade names which no doubt suit the purposes of the various manu-

and there can be no just

facturers,

point of the tradesman.

members

criticism offered

However some confusion

from the stand-

exists

among

the

term to use which

is broad enough to cover all of this class of fillings and not designate any special make. We will therefore consider some definitions
from Webster's "Unabridged Dictionary."
Silicate (a noun) *'is a salt composed of silicic acid and a l)ase."
Silicate from which we make fillings is made by silicatization.
Silicatization (a noun) "is tlie process of combining Avith silica,
so as to change to a silicate," which is, chemically speaking, a synthetic process,
"the uniting of elements to form a compound."
Porcelain (a noun). "A fine translucent kind of earthenware,"
named after the shell "Poreellana" "either on account of its smoothness and whiteness, or because it was believed to be made from it."
Cement (a noun) wlien used as a noun is, "Any substance used
for making ])odies adhere to each other, as mortar, glue, etc."
of the dental profession as to the correct

Cement

(a transitive verb).

"To

unite by the application of a

substance which causes bodies to adhere together."

Cement (an

intransitive A'erb).

"To

unite or become solid; to

unite and cohere."

Cementation (a noun). "The act of uniting by a suitable subChemical definition: "A process which consists in surrounding a solid body with the powder of other substances, and heating the whole to a degree not sufficient to cause fusion, the physical
properties of the body being changed by chemical combination with
the powder; thus iron becomes steel by cementation with charcoal
and green glass porcelain, by cementation with sand."
Enamel (a noun). "A substance of the nature of glass, but more
with a variety of colors; also other mafusible and nearly opaque,
highly
polished ornamental surface." Anafor
giving
a
terials used
"The
smooth,
hard substance which covers the
tomical definition:
tooth,
overlying
crown or visible part of a
the dentine."
From the foregoing references to Webster it would seem that the
term "silicate filling" is correct when used to name this kind of
stance."

148

SILICATE IN
filliiig

THE MAKING OF A FILLING

material as a class and

when used

149

to restore lost tooth sub-

stance.

The use
noun,

is

of the

word "cement"

as a part of the name, hence a

incorrect unless the substance

is

used to

"make

bodies ad-

here together" and should be eliminated from the names of the

silicates and other compounds intended for a filling per
when adhesive properties are taken advantage of.
The term "synthetic" is correctly used when applied

the plastics

now

se,

to

except

any of

in use in dentistry, with a possible exception in

amalgam, as chemists are divided in their opinions as to exactly what

takes place in amalgamation. The use of the word "Porcelain" as
a part of the name, its being correct or incorrect, depends entirely

Fig. 79.
Fig.

79.

Fig.

Suitable cavities for the

A Class One cavity on

Fig. 80.
silicate filling.

The decays

are

use of silicate

80.

fillings.

the labial of a central incisor properly prepared for a

shown

in Fig.

79.

upon our understanding of the degree of heat necessary to bring

about cementation.
This is accomplished at com(See definition.)
paratively low and ordinary temperatures with most of the makes.
All are assisted in the process by temperatures slightly above that

maker advising the melted paraffine bath durThe use of the term "Enamel" is correct provided it is a "substance of the nature of glass, more fusible,
nearly opaque, used for giving a polished ornamental surface," and
of the bod3% with one

ing the period of setting.

"a

the prefix of "Artificial" provided

it is

ural covering of a tooth's crown.

It w^ould

are

all synthetic,

that they

all

substitute" for the nat-

seem that the

silicates

partake of the nature of porcelain.

OPERATIVE DENTISTRY

150

that they are a trade enamel, that they are artificial

ing

the

lost

when used

enamel

of

human

teeth,

when

replaee-

are

cement

they

that

when

to hold a filling of other material in the tooth or

the material itself adheres to the tooth, and that they are not cement
(a noun)

when used

as a filling per se.

The author therefore takes the position that the filling material
under consideration is ''silicate" as the correct manipulation of most
makes eliminates adhesion to the cavity. Those which adhere to the
cavity or will retain fillings of other materials in the cavity are for
that reason a silicate cement.
of silicate there

Fig.

this time

Trey's

with the use

in cavity preparation.

Fig.

81.

Fig. 81.
Extensive
shown in Fig. 79.

Fig. 82.

It therefore follows that

must be retentive form

Class Three cavity properly prepared

82.

for

a silicate

Decay

filling.

Class Five and a Class Three cavity suitable for the use of silicate as a

we

find the best illustrations of this class of silicate in

Synthetic

Porcelain" and Ascher's

At

''Artificial

filling.

" De

Enamel,"

neither of which should be used as a cement.

Cavity Preparation

is

quite similar to that for an

amalgam

filling

and
here considered in the order of cavity procedure.
Gaining Access. The access required for the silicate filling is the
same as that for any other plastic filling, as far as its introduction
is considered and the conditions sought at the time the filling is comContact point in Classes Two, Three and Four is just as
pleted.
essential, but is harder to maintain due to interproximal wear.
It
is


SILICATE IN

THE MAKING OF A FILLING

151

would therefore follow that the primary contact should be greater

and broader. In other words, if we are to use the marble contact
it should be the contacting of larger marbles than in the
more durable metal fillings.
To put it in other words, the convexity of the
filling's surface should be the segment of a larger circle
than the
metal filling. Proper separation is essential.
Outline Form. In the consideration of outline form, the same
rules should apply as
tend cavity

other filling materials,

We

when using any other

margins until

filling.
should exsurface decay has been included. With

all

we sometimes falter in this because of the unwhen the color has been properly

sightly results, but with silicate,

chosen, there should be no hesitancy, as large fillings are generally

Fig. 83.

Fig. 83.
in Fig. 82.
Fig. 84.

The decay

A
is

Fig. 84.
is

shown

Class Three cavity, lingual approach, properly prepared for a silicate

filling.

Class Five cavity properly prepared for a silicate

shown

filling.

The decay

in Fig. 82.

as little observed as small ones, especially on flat labial

surfaces.

When

fissures

and

should always be included in the outline, as a leaky

sult at the triangular space

the

and buccal

sulcate grooves are encountered, they

filling will re-

formed where the sulcate grooves meet

filling.

Resistance Form.

In dealing with resistance to the crushing

we have a greater problem to solve than in the use of almost

any other material. The edge of the filling is more easily broken,
and after some months or years of wear there is great danger of exstrain,

posure of the cavo-surface angle.

It is therefore necessary to lay

OPERATIVE DENTISTRY

152

Fig.
Fig. 85.
Fig.

Fig.

85.

A small Class Three cavity,

A small Class Three cavity,

labial aiiproach,

86.

lingual

86.

properly prepared for a silicate

filling.

approach, properly prepared for a silicate

filling.

Fig. 87.

Fig. 88.

A large

Class Three cavity, labial approach, properly prepared for a silicate filling.
Note the irregular outline on the labial. This is not objectionable, for many times an irhides
a slight deviation from the proper color.
regular outline
Fig. 87.

Fig.
filling.

88.

large Class Three cavity, lingual approach, properly prepared for a silicate
This is a good form of preparation
fact that this cavity has two axial walls.

Note the

in vital cases.

SILICATE IN

THE MAKING OP A FILLING

the cavity outline in areas subject to as

little

stress

153
as possible.

In locations subject to great liability to stress, it is necessary to extend the outline until full-length enamel rods, supported by sound
dentine, have been reached and then beyond that to a location not
subject to the travel of the cusps of opposing teeth in the process
of articulation. It is not necessary to pay much attention to devel-

opmental grooves, for when these grooves are normally formed they
It is most important
that all enamel eminences be avoided, as the material is quite friable
and offers very little support to the cavo-surface angle.
are fully as strong as the material in hand.

Retention Form.

same as for other

Provision against the tipping strain

fillings

and

is

more

like that for

small

89.

the

This

Fig. 90.

Fig. 89.
Fig.

is

amalgam.

amount

remain when

Note the
large Class Three cavity properly prepared for a silicate filling.
of dentine yet remaining near the incisal angle.
While this angle can properly
using a silicate filling, it would be entirely out of the question when using co-

hesive gold.

Fig. 90.
Two extensive Class Three cavities properly prepared for silicate fillings. In both
of these cavities the dentine has been practically all repioved at the incisal angles.
Cases like
these may be filled with silicate but should be regarded as temporary in a large majority of the
cases.
The retention of these angles after filling will depend entirely upon the amount of
force to which they were subjected.
They would be comparatively permanent in cases of irlegularity when that condition placed these angles in a position removed from stress in occlusion and articulation.

material only reaches

its

maximum

the crushing strain

when

lost practically

of

all

its

it

strength to resist dissolution and

has been so thickly mixed that

adhesive qualities.

it

has

Therefore, the rules

which apply to cavity preparation in reference to retention form

would be the same as in the use of amalgam. "We must have flat
walls excepting the axial, flat seats of generous proportions and definite angles.

OPERATIVE DENTISTRY

154

Convenience Form. This step in cavity preparation for the

with other plastics, comes in for only a minimum
consideration, as it is seldom necessary in the use of this material
to make any changes to facilitate the making of the filling, for when
other rules have been followed we find ample convenience for its insilicate filling, as

troduction.

Removal
all

of

Remaining Decay.

There

is

one major reason

why

softened dentine should be removed from the cavity walls.

acid of tooth decay,

^lactic

The

always saturated with the

Experience has proved that the

decalcified portion of tooth substance

acid.

is

crystallizing silicate will absorb this acid, resulting in a filling of

would therefore follow that no softened dentine

be allowed to remain in the cavity.
Finishing of Enamel Walls. With other fillings it has been found

weak

structure.

It

-^B

^^,~.,.

"3

m^M

i?-5

mmmmmmmi
4L
^^^^^^
^^^^^^^^
""P
^-.-,,

.\i^-^,,Mm

imr;*W,w^wa^if^fef^tffibsii

aa

i.MMIMI.IIl

'^

"

'"f.

riiiniin'^'

^1

^^K 1^

^^

~.

^^^K^g?t^^^^u^t^m^i^fM

H
1

-'"'

M ttfek
iwrJl'HBI^i

^^MMmm^"
"

9
1

Fig. 91.

small set of instruments for mani[)ulating silicate.

advisable to bevel the enamel margins from 6 to 10 degrees centi-

With

beveling seems to make an adand should be avoided as it will cause the filling
to break at the margin, even though the procedure results in an imperfect cavity, from a scientific standpoint.
We should determine
that Ave have full-length rods and that we have found their direction by complete cleavage and then omit the beveling.
grade.

all silicate fillings, this

ditional weakness

Toilet of the Cavity.

To the ordinary

toilet

given for other

fill-

ings should be added the varnishing of the dentine walls, as a pre-

caution against the material absorbing either acid or moisture from

the walls or the absorption by drying dentinal walls of the fluid

part of the

filling,

Rubber Dam.
equally as

due to excessively desiccated dentine.

of the rubber dam, or other means
should have taken place following partial outline

The application

efficient,

SILICATE IN

form.

THE MAKING OF A FILLING

155

Prior to adjusting the rubber dam, the color or combination

of colors should have been selected, as the opinion formed after the

dam has been in place for a short time is worthless as a guide

proper shade to be used. During the early experience with
this material, with each operator, the shade guide should be frequently used as an educator, but in a few months, the operator should
begin to be so familiar with the resulting colors that no shade guide
rubber
to the

is

necessary.

Making the

Filling.

^Yhen cavity preparation

is

proper material and instruments for making the

Fig.

92.

suitable slab

and spatula for working

heavy in order that when chilled

it

will

remain

at a

completed, the

filling

should be

The slab should be thick and

low temperature during the mixing of

silicate.

the silicate.

placed in a handy position.

Absolute cleanliness

is

imperative, par-

ticularly during the process of mixing, as otherwise the filling

when

completed will not be chemically pure. The mixing slab should always be kept scrupulously clean, should not have a scratched surface and should be without color.
This last point is to avoid any
effect color could have on the judgment as to the shade desired.
A

good slab is produced by taking a large-mouthed bottle and filling

it with cold water, or even ice water, in order that during manipulation the material may be held at a low temperature. Before using a
thick glass slab (Fig. 92) chill to a temperature of 60 degrees or a
little below.
The temperature feature in this manipulation is of
importance. With nearly all of the processes in the filling of teeth

wherein the dentist depends upon subsequent chemical action for

OPERATIVE DENTISTRY

156

a final result, chemical action should be either retarded or held in

check during the entire process of manipulation, which is easily

accomplished by a low temperature mix. ''The process of set-

Fig.

93.

Proper

Fig. 94.

ting" as

it is

position

Proper

called

of the spatula

on the slab

placing of the materials

is

when manipulating

when manipulating

silicate.

held in check until the material

place and further disturbance unnecessary.

has been placed in the tooth, the

warmth

As soon
of the

silicate.

is

finally in

as the filling

body

is sufficient

SILICATE IN

THE MAKING OP A FILLING

157

to hasten the chemical action

and better results -will be secured.

body temperature is sufwith others the best result can only be obtained by keeping

With most
ficient

Fig.

95.

Taking

of the silicate fillings, the

the

first

Fig. 96.

portion of the powder which should be about half of the entire

amount needed.

Incorporating

the

first

portion of the powder.

the filling for a short time bathed in melted parafiine. The mixing slab should be at as low a temperature as possible and should not

produce discomfiture to the patient.

temperature of 60 degrees

OPERATIVE DENTISTRY

158

seems to be as low as can be borne by the patient when placing a

filling in

a vital tooth.

bottle slab wherein the

It

is

therefore quite practical to use a

thermometer reaches 55

to 60 degrees, as

no

about 68 Avhen placed in the

tooth. It is quite possible to use a bottle that contains iced water
when the filling is to be placed in a non-vital tooth. At such times
when the atmosphere is close to the dew point, as is evidenced by

doubt the temperature of the

filling is

the condensation on the fountain cuspidor, there

Avill

be trouble

about the formation of moisture on the cold bottle. When this is

only slight, it does not seem to damage the filling. However, when
is sufficient to be noticed, or is excessive, the denhas to either content himself with manipulation at a higher
temperature or postpone the operation to a time when the atmos-

the condensation
tist

is above the dew point. The spatula must be of some mawhich will give off: none of its substance during the process
of mixing. For this reason the agate is the best and most popular.

phere
terial

motion which should be given the spatula in mixing a

should be moved first in one direction and then in the
Also that the spatula describes segments of small circles
other as indicated by the arrows.
and that the material is not spread over any considerable surface of the slab.
Fig. 97.
Illustrating the circular
silicate filling.
Note that the spatula

Begin the mixing only when the cavity is prepared and dried, and
and ready for immediate use.
While there is no great haste as long as the material lays oq the
cold slab, there are left but a few seconds to make the filling after
the material has been removed from the slab, on account of the
rising temperature hastening chemical action.
the filling instruments are laid out

Preparing Materials.
the right, the

amount

First pour out near the end of the slab to

of

powder the mix

is

liable to require,

and

then place stopper in the bottle.

With the dropper place the
proper quantity of liquid near and to the left of the poAvder. Immediately return the dropper to the bottle and secure the cap to
prevent evaporation. The best results are obtained when no less

than three drops of liquid are used for the mix. Do not shake the
Make the mix promptly, for if there is any considerable delay, the chemical formula of the liquid may be changed, due

liquid bottle.

SILICATE IN
to
in

THE MAKING OP A FILLING

159

an evaporation in a dry atmosphere or the addition of water

taking up the condensation from the cold slab at low barometer.
Making- the Mix, Begin with sufficient liquid on the slab and do

not add any more at that stage.

Mix by drawing

into the liquid

about one-half of the total amount of powder required to make the

completed filling. Begin the mix by spatulating with a light rotating movement; hold the spatula fiat on the slab, describing the
arc of a small circle with a diameter of say one-fourth of an inch.
As soon as the powder has been all incorporated and the mass rendered uniform, scrape all of the mass off the slab with about three

Take one-third of the mix each time. This assists in securing uniformity of the mass. Then put it back on the slab this

strokes.

Fig. 98.

time getting

The

last stroke of

scraping the material from the slab.

Do

not scrape the spatula on the

on the slab, holding it firmly
a turn in the hand, which will practically clean it.

all off

the spatula.

edge, of the slab, but place

it

flat

and giving it
Here more powder is added, a small portion at a time, and incorporated in the mass already mixed, by the method of crowding,
which is done by rolling the spatula first against one side of the
mass on the slab and then against the other. The addition of the
powder by this crowding process is continued until the mass becomes of a consistency of putty, losing practically all of its adhesion and giving only slight evidence of a tendency to follow the
spatula from the slab.
The Proper Consistency is reached when the mass has been mixed

OPERATIVE DENTISTRY

160

when being crowded by a

show a glossy surface when patted

SO stiff that the material just loses its gloss

rotating spatula, yet can be

made

to

three or four blows with the spatula.

In ease the material looks very

wet and glossy the mix is not yet stiff enough. If the three or four
blows do not produce gloss, the mix is too heavy and must be entirely
discarded.

Time
cate

is

of the Mix. The lower the temperature at which the

mixed the longer may be the time of manipulation;

the thinner the mix, the longer will

it

tion of the setting will be noticed.

By

mixing, the time of manipulation

I"ig.

99.

The

entire

is

sili-

also

be before the chemical acusing the cold process of

lengthened and the time of

mix on the

set-

spatula.

lZH
I'ig.

100.

Illustrating in three

successive steps the method of removing the mix from the

spatula to the slab.

ting after leaving the slab

is

materially shortened, due to the thick

mixture obtainable.

Making the Filling. It is important that all moisture be exwe cannot manipulate silicate under moist conditions.

cluded, as

Agate or ivory instruments are preferred for placing the material

Those of bone or shell Avill do. If the instruments
in the cavity.
are absolutely clean and polished so that they will give off no substance in the material,

it is

possible to place the silicate in the cav-

instruments and get no subsequent discoloration.

Fill the cavity slightly to excess with absolutely clean instruments
by taking a quantity, one-half of that required to fill the cavity,
ity

with

steel

and crowed or wipe the material against every portion

of the cavity

walls from cavo-surface angle to cavo-surface angle.

The second

time, take

up a

sufficient quantity to

more than

fill

the cavity.

SILICATE IN

THE MAKING OF A FILLING

161

Crowd this into position and hastily get a partial contour. Immediately pat or paddle the material to complete contour, continuing until the material has been crowded slightly over the margins.
This paddling force will jar the material so as to bring back the gloss,
as produced by patting on the slab. In case the gloss is not produced
by the paddling, a homogeneous mass is not secured and the fill-

Fig. 101.

Proper

consistency of silicate, for immediate introduction into the cavity.

Fig. 102.
This mix of silicate is yet too thin and there should be more powder added.
The material should show a tendency to follow the spatula when moved from the slab but it
should not follow the spatula as here shown.

ing will lack proper color, will be of poor edge strength, and will
a very weak filling. If the gloss has been produced by the

make

paddling or jarring of the material, it should be alloAved to remain

undisturbed until the process of setting has sufficiently taken place
that the body of the filling will not be
surface.

its

moved by any work upon

'

OPERATIVE DENTISTRY

162

The Use of the Matrix either upon the posterior or anterior teeth
should be the same as that for the introduction of the amalgam
With Class Three fillings, one end of the matrix is left
filling.
loose until the cavity has been filled more than full with the material.
The loose end is then brought over the tooth and tapped on
the outside of the surface as

it is

being tightened upon the

filling.

This jarring process of bringing the matrix to position results in a

homogeneous mass beneath the matrix. Immediately after paddling the filling and the detection of the glossy surface, the filling is
to be entirely coated with cocoa butter to exclude the air during
the process of setting.
Finishing' the Filling. After the filling has been allowed to stand
undisturbed for three or four minutes (no longer), there should be
applied a very thin-edged knife or chisel and by a scraping motion

Fig. 103.
homemade mallet and point used by the author in paddling and jarring
The mallet should be of light weight and have a soft surto position in the cavity.
face.
The plugger point here shown is made of platinized gold. Tandilum would be better
It is quite necesfor this provided it had a handle attached which was of very light material.
sary in this process that both hammer and plugger point are of the least possible weight.
silicate

parallel with the cavity outline the excess

is

away

cut

to within

one-tenth of a millimeter of the cavo-surface angle, at the same

time reducing the general contour to that desired, keeping the

When the filling has been
filling submerged in the cocoa butter.
in position five or six minutes,

very

fine strips or disks

coated Avith

may

be used to produce the desired gloss. The author

prefers to leave the filling with file and knife finish and has abandoned the use of strips and discs as injurious. This completed
filling should be scrubbed with cotton balls in order to remove all

cocoa butter

of the cocoa butter possible

copal-ether varnish.

be used.

and

test

No

and the finished

filling

varnish of which alcohol

painted with a

is

a part should

Evaporate to dryness with air, remove the rubber dam

for occlusion and articulation, provided the filling in-

SILICATE IN

THE MAKING OF A FILLING

volves the occlusal or incisal surfaces.

In case the

to strike the apposing teeth, the excess should be

fine

carborundum wheels, and again varnished.

163

filling is

ground

found
with

off

It is entirely safe

carbon paper to print these fillings, the same as with gold

or amalgam and its use will not cause discoloration of the filling.
The instruments used in reducing the size of silicate fillings should
be the same as when reducing the bulk of a gold filling.
The
manufacturers of some of the silicates advise not to use any steel
to use

Fig.

Fig.

104.

Three

Fig.

104.

105.

cavities suitable for silicate fillings.

Fig. 105.
This shows the results obtained after
previous figure.

filling

with

silicate the

cavities

shown

in

instruments in the finishing of these fillings, but clinical experience has proved that any injury which can result is not due to the
instruments, but to their unclean condition.

Facing Metal Fillings with

and

is

at this time the only

silicate is

many

method Avherein

times of advantage

it is

advisable to use

connection with angle restoration in Class Four fillings.

This will be more fully discussed in Chapter XXVIII dealing with
silicate in

Combination

Fillings.

(See Figs. 106, 107 and 108.)

CHAPTER XXVI.
THE USE OF GUTTA-PERCHA IN FILLING TEETH.
Gutta-Percha has its place in various operations upon the teeth.
not acted upon by the fluids of the mouth and is quite
permanent Avhen placed in locations protected from the force of
It is

mastication.
It is a

good tooth preserver as decay does not readily take place

in cavities so filled.

Base Plate Gutta-Percha

is

the best form to be had.

the Avhite and pink colors, the last

named being

able in positions exposed to wear as

gets the harder

it

It

comes

in

the most dur-

upon

cooling.

with Gutta-Percha. This material is indicated

in subgingival cavities, both buccal and proximal, where a filling that is a very poor conductor of heat is desired, on account of
close proximity to the pulp, the pulp being not yet exposed.
Filling- Cavities

It is also

indicated for those distressing cases where there

decay started in the occlusal surface of a lower third

has erupted with its occlusal surface at an angle of
Such
five degrees to the distal of the second molar.
as a rule be properly extended to check decay in the

gam

is

molar which
about fortycases cannot
use of amal-

or gold.

The gutta-percha

filling

will

check decay and

if

renewed

at

stated periods will produce sufficient separation for correct filling

or to render extraction easy.

and

The cavity should be freed

and the cleavage of the enamel secured, omitting the
marginal bevel. The cavity should be sterilized and dried, then
The
slightly moistened with campho-phenique or eucalyptol.
gutta-percha should then be warmed and immediately crowded to

Method

of Preparation

Filling.

of all decay

position.

Care should be taken that the material

is

not overheated

as slight burning destroys the durability of rubber.

The gutta-percha should be introduced piece by piece sufficient

more than fill the cavity. The surplus must be wiped off

to a little
flush

with the cavity margins with Avarmed burnishers.

Finally

the surface should be wiped with a cotton ball carrying chloro-

form.

For Root Canal Filling's. The gutta-percha is dissolved in chloroform to the consistency of molasses, and carried to the canals by
164

GUTTA-PERCHA IN FILLING TEETH

165

dipping a smooth broach in the container. The canals should have

been previously flooded Avith oil of eucalyptol, and the chlorapercha mixed with the eucalyptol in the root canal resulting in
what may be termed euco-percha. The eucalyptol may be added
to the chlora-percha in the bottle, but the method given first is for
various reasons the better.

For Canal Points.

Gutta-percha

is

the standard material for

canal points which should be at hand in various sizes to suit

all

cases.

These may be manufactured by the dentist, but with little economy, as they are well made by machinery. Those which are flattened on the larger end are the most handy to use. Such may be
had from your dealer, or the assistant can flatten them as purchased by placing them on a glass mixing slab and pressing each
large end Avith a smooth cold steel instrument.
Slow Separation. Gutta-percha for slow separation in proximoocclusal cavities is unexcelled, the force of mastication doing the
work slowly but surely. This fact prohibits the use of gutta-

permanent filling in Class Two cavities.

Temporary Stopping, as purchased from the dealer, is guttapercha to which wax has been added to render it more plastic
when warmed. This is ideal for sealing in dressings, excepting
when arsenic has been used, in Avhich case poorly mixed amalgam
l)ercha as a

is

better.

CHAPTER
TIN AS
History.

seem

XXVII.

A FILLING MATERIAIi

The first use of tin as a material for filling teeth Avoiild

back to about 1780 and was much written about as

to date

After the introduchave been much rivalry

a tooth preserver for the century following.

tion of

amalgam

in 1826 there

seemed

to

between the two substances, amalgam gaining the favored position.

At the World's Columbian Dental Congress, in Chicago, 1893, as

be seen by the report, many dentists of national repute went
on record as classifying tin as one of our best tooth savers and deplored the fact that its value was being lost sight of.
Avill

The
to say,

late Dr. AV. C, Barrett expressed himself so emphaticall}^ as

"Tin

is

and

everything were blotted

filled, except tin, more
be putting it a little too strongly,

as cohesive as gold,

if

out of existence with which teeth could be

teeth

would be saved."

This

may

but the fact remains that more teeth would be permanently saved
if a more general use of tin was common Avith the profession today.

Therapeutic Value of a Tin

Filling;.

Of

all

our

filling

there are only two for wliich any therapeutic value

is

materials
claimed.

by exclusion
luechanically shielding the defenseless tooth substance from the

All others prevent the farther loss of tooth substance

dissolving properties of the products of fermentation.

The Therapeutic Action of Tin is probably due to the formation

of the sulfid of tin which is caused by the presence of sulfuretted
hydrogen from the decomposition of food substance. The dentinal
walls of a cavity which has. been filled with tin for some time, turn
brown or black and seem to have undergone a structural change
rendering them quite impervious to decay, and very hard to excavate with hand instruments or the engine bur.
Discoloration.
its

In some mouths tin turns black not only upon

external surface but this color

the tooth substance, a fact which

to its use

and debars

it

is

in a

measure transmitted

to

one of the greatest objections

from exposed positions in the anterior poris

In other mouths there seems to be little

coloration, the filling remaining polished and of a light color.
tion of the mouth.

dis-

The Amount of Discoloration seems to bear no relation to its

permanency as to bulk or as a tooth preserver.
Thermal Conductivity. Tin is only one-fourth as good a con166

TIN AS A FILLING MATERIAL

167

ductor of heat as gold, hence, indicated under gold

seated caries with vital pulp.
Indicated in Rapid Caries.

deep-

In caries of a light or white color

indicating the most rapid form of decay, tin

tage, particularly

fillings in

is

of peculiar advan-

removed from view and protected

in regions

from the wear of mastication.

Tin in the Teeth of Children.

There

no better material for fillof mechanical exclusion depended upon with other filling materials to prevent recurrent decay does not seem to be sufficient in the rapid form of
decay met with in both temporary and permanent teeth in the
mouths of children particularly during the age of rapid development as found before the age of fifteen or sixteen. The additional
advantage of the therapeutic influences of tin seems to be sufficient
to check this rapid progress of decay till a period is reached when
the process of tooth destruction is less apparent, due to more hying the teeth of children than

tin.

is

The principle

gienic conditions in the oral cavity.

Cavity Preparation for Tin. The cavity preparation for the use
is not unlike that given in the chapters on cavity prepara-

of tin

by

tion

classes for cohesive gold.

convenience angles are a

little

It will

more

be of advantage if the
and the general re-

distinct,

form throughout should be emphasized. The bevel angle

little more deeply buried as the edge strength is not
However the edge strength is better
as good as hammered gold.
than amalgam. Tin has no tendencj^ to spheroid like amalgam.
Its flow is similar to that of gold but greater with the same given
load and like gold it is capable of being so condensed that it will
stand repeated stress of a given load within a limited range and
show no flow.
Forms of Tin. Formerly the only form of tin to be had for this
purpose was the sheet tin. This was manipulated in much the
same way as cohesive gold except that it required no annealing.
It was then, and is yet, sometimes combined Avith gold by rolling
a sheet of pure tin with a sheet of annealed cohesive gold into
rolls, the gold on the outside and condensed in the usual manner

tentive

should be a

using a large proportion of hand pressure.

At present there is on the market a form of tin prepared in the

which appears like a mass of coarse silver-colored hair.

removed from the tube and shaped into pellets of suitable
and placed in the cavity in the manner one would place pellets

shreds,

This
size

is

of gold.

Methods

of Introduction.

The rubber dam

or

other

efficient

OPERATIVE DENTISTRY

168

When one of the surrounding

missing as in proxinio-occlusal cavities in bicuspids and

means of dryness must be used.

walls

is

molars (Class Two) the matrix must be in place. The first pellet
of tin introduced should completely cover the base of cavity and
be thoroughly condensed by good steady hand pressure, with
points at least one square millimeter in size employing the rocking motion. The points should have deep serrations and be so stepped
as to include the entire surface.

This hand pressure should be folloAved with the mallet force

medium serrations and the surface en-

using a plugger point of

tirely

gone over.

just given repeated.

should be

filled to

new

pellet

may now

be applied and the plan

If the filling is to be entirely of tin the cavity

excess and by a process of burnishing, con-

densed and rubbed to the

size desired.

This last method gives a

surface of the greatest density possible.

Tin and Gold. When the fillhig is to be completed Avith cohesive

little dependence should be put upon the gold adhering to the
With a round-pointed instrument
tin as the union is only slight.
new convenience angles should be made in the substance of the
The remainder of the cavity should be
tin near the line angles.
retentive independent of the space occupied by the tin.
Tin and Amalgam. No special care is needed when the filling is
Amalgamation takes place in that
to be completed Avith amalgam.
portion of the tin next to the amalgam proper and the union is
([uite strong, even more than tin to tin.
The amalgam should, if
possible, be more thoroughly mixed and the process of kneading
prolonged that all amalgamation possible be secured before congold

tacting Avith the tin as the tin

from the amalgam for which

amalgam
The use of

it

take up some of the mercury

has a great affinity. This is liable

Avill

mixing has been

and amalgam is not advised where the
surface of the tin is to be exposed by forming any portion of the
contour as the presence of the mercury absorbed causes the tin to
rapidly disintegrate.
Gold should be used for topping in such
to injure the

as to strength unless the

thorough.

tin

cases.

Tin in Bifurcated and Punctured Roots, When through decay

or by accident the cavity extends to the exposure of the peridental
membrane the use of tin has no substitute. The opening should
be rendered as clean as possible, sterilized and dried.
The opening should be covered with a mat of pure tin made from folded
sheets, being lightly burnished to place and covered with amalgam and the cavity finished with the desired material.

CHAPTER

XXVIII.

COMBINATION FILLINGS

Definition,

more

eoinbination filling

is

a filling composed of two or

distinct substances introduced into the cavity separately.

Objects of a Combination.

The object of combining various ma-

terials in the filling of a tooth's cavity is to secure a perfect

ing,

one possessed of

all virtues,

and no

faults.

Many

fill-

such com-

of material meet this demand in a large measure by

bringing into service the strong features of each material, and at

binations

the same time nullifying the faults of

all

material entering into the

construction.

Since dentistry has been raised to the dignity of a science there

has been a diligent search to discover a filling material which pos-

and the faults of none in present use. At

is more nearly reached by the various com-

sesses the virtues of all

the present time this

binations possible with the usual distinct materials.

the ideal filling

much

is

If perchance

ever produced, dentistry will at once become

methods of procedure.
There are only two filling
materials now in use Avhicli are used in their pure state, pure gold
and pure tin, and there are many instances where these combined
with each other or with other materials, will produce better results
than when used alone.
Gold and Tin Combination. This combination is of service in
large cavities of Class Two which are subgingival and in large
occlusal cavities in molars, where the pulpal wall is deep and
rounded. In this combination the tin should be placed in the cavity first and thoroughly condensed, and the filling completed with
simplified as to

Single Materials Used as a Filling.

cohesive gold.

In Class

Two

the tin should cover the gingival wall at least one

millimeter deep and be condensed to place with the matrix in

position.

Dentine upon which has been built a thorBenefits derived.

By comoughly condensed tin filling does not readily decay.
pleting the filling with gold the discoloration of tooth substance
is avoided and the gold will better resLst the force of mastication.
Gold and Cement. The object of this combination is to produce
a filling that is adhesive, will protect weak walls, and resist the
fluids of the

mouth and the

force of mastication.
169

OPERATIVE DENTISTRY

170

Two Methods

There are two methods of produc-

of Combining-.

One

ing this combination.

is

cement-covered cavity, which

of soft

and lay it into the

The other is
cement with which

The

essential feature of

to cast the filling

is

the inlay method.

to build cohesive gold into a thin

mix

the walls of the cavity have been coated.

both

is

it from
mouth and the

that the cement be completely covered to protect

dissolution

by external agencies, as the

fluids of the

effects of wear.

When

The inlay combination is indicated in large

The built-in method of combination is insmall cavities of more difficult access, and where cor-

Indicated.

cavities of easy access.

dicated in
rect
this

cavity formation

is

impossible

or

ill-advised.

When

using

method convenience angles may be omitted.

Gold and Platinum.

This combination adds to the

many

virtues

by
wear of mastication. The pure gold is first used as it is capal3le of more perfect adaptation to the walls, all of which should
be covered before taking up the platinized gold. The contour porThis alloy comes from the suption should be made of the alloy.
of cohesive gold fillings

increasing the resistance of the filling

to the

ply house in sheets which appear to be pure gold except that the
color is a little lighter. This foil comes in three numbers, 1, 2 and
3,

the No. 2 being preferable for most cases.

The

rules for condensation are just the

same as for pure

gold,

only the observance of each specific rule given on that subject

more emphatically demanded

here,

and when

is

strictly followed the

alloy will prove as easily handled.

Cohesive Gold and Non-Cohesive Gold Combined.

l)ination

much time

is

By this commay be in-

saved as the non-cohesive gold

troduced in greater masses than the cohesive.

Also the soft gold

more easily adapted to the walls than cohesive.

The cohesive gold is used to finish the contour as it will better
resist the torsion strain and the effects of abrasion.
Before the
introduction of cohesive gold all gold fillings were non-cohesive,
is

but since the introduction of the former the art of filling teeth
with soft gold has rapidly declined, so that the making of an
entirely non-cohesive gold filling is now the exception.

Avell

Cement and Amalgam. Results similar to what might be termed

an amalgam inlay are produced by coating the prepared cavity with
cement, and immediately burnishing into this fresh cement, a portion of the amalgam.
The enamel margins are rendered clean

COMBINATION FILLINGS

171

again by freshly cutting them with a chisel for their entire outline
and the amalgam filling immediately finished in the usual way.
The Benefits. This combination produces a filling with the virtues of an amalgam to which is added the adhesion of the cement
and the protection of cavity wall from fracture and discoloration.

When

Indicated.

This is indicated in most large cavities to be

amalgam, where the walls "are weak and thin and in
cavities where insufficient retentive form is secured.
Cement and Porcelain. Cement is combined Avith porcelain in
the filling of teeth for the purpose of making the filling adhere.
The porcelain protects the cement from dissolution.
Silicate Cement and Fused Porcelain.
Fused porcelain inlays
filled Avith

106. Combination gold

Fig.

ready to receive the

silicate.

inlay and silicate.

A represents the gold inlay in position
represents the same after the silicate has been put in place.

may

be set with some of the silicate cements to great advantage.

The

silicate filling materials Avhich are at their best

when mixed

thin enough to be adhesive are those which can be used as a ce-

In fact some operators are using these materials for setting

ment.

the gold inlay Avith seemingly good results.

Silicate

and Gold.

for esthetic reasons.

inlay,

by

Silicate

In

may

be used to face the gold

filling Class

Four

filling

cavities Avith the gold

either one of the four plans, the Avax

may

be cut out of

the pattern so as to present a labial surface almost entirely of

silicate.

After these tAvo materials are combined in this class of

cavity, care should be taken that the incisal edge

is

of gold and

OPERATIVE DENTISTRY

172

particularly that the cavo-surface angle on the incisal outline

is

protected by one-half of a millimeter to a millimeter of the cast

The

gold.

cast should be

At

zinc cement.

made and

set

with oxyphosphate of
may be built

a subsequent setting the silicate face

is produced with the bicuspids and molars, in

crown Avork. The gold crown is made in the usual way and set.
A carborundum stone is applied to the buccal surface and ground
away and a sufficient amount of cement cut out to make room for

in.

similar effect

the building in of the silicate.

best to coat the cement which

Before building in the

silicate it is

exposed within the crown with a

is

thin application of copal-ether varnish.

Silicate

Many

and Amalg-am.

large contour

the mesial surfaces of bicuspids

Fig.

Fig.
built in.

Fig.

107.

Amalgam
108. This represents
The dotted

senting the

cutting

new

on

in the

108.

the

amalgam

shown

filling

shows the outline of the

line

silicate

Fig. 107 with the silicate facing

with that portion marked x, repre-

in

silicate.

superior teeth are unsightly.

l)y

fillings

in jjosition ready to receive a partial facing of silicate.

107.

Fig.

amalgam

and molars particularly

away

or old fillings,

silicate will

very pleasing effect

is

produced

the mesio-buccal contour of amalgam, either in

and

not discolor

in the resulting cavity, build silicate.

when thus

applied to the amalgam.

The

How-

seems to require a different shade and

mix should be made before deciding on the
combination of powder to produce the desired shade.
Silicate as Applied to Prosthetic Work.
It is not within the
scope of this book to deal with prosthetic procedures. However,
ever, each individual case
to get

it is

it

right a trial

well to call attention to the fact that this material

is

used to

COMBINATION FILLINGS

173

advantage in the facing of crowns, the fitting of gingival ends of

porcelain pin crowns to the root, and its application to many
places in pieces of bridge work. It is also useful in the facing of
partial and full removable dentures in a color to imitate the
natural

gum

tissues.

There are many other combinations which are made and used
It is improbable that the perfect
to advantage in tooth salvage.
filling material will ever be produced as the demands are so varied
in different mouths, and in different localities in the same mouth.
We are more nearly able to meet all of those varying conditions
by a wise selection of the materials to be used in each case and a
judicious combination will go far to produce the perfect filling for
each individual cavity as presented.

PART

III

CHAPTER XXIX.
EXAMINATION OF THE MOUTH LOOKING TO
DENTAL SERVI(n^:S
The

First

services
to

Duty

of a dentist to one presenting himself for dental

comply with the patient's request, Avhich

to

is

is

generally

examine a special tooth or a diseased condition of which the

patient

quest

make such

If the patient does not

aware.

is

a special re-

well to ask some form of a leading question as to the

it is

all else should be ignored

been accomplished.
A Light Hand and Slow Movements are very essential for the first
few moments, especially at the first meeting of patient and dentist,

reason of the

call.

This fact elicited,

until the object of the first visit has

as first impressions are often lasting

proached
ness,

in a careless

many

manner he may

and

the stranger

if

get ideas of

is

ap-

undue rough-

times unfounded, yet, nevertheless, lasting with the

nervous patient.

The Washing' of the Hands in the patient's presence or in running water within hearing of the patient should be universally
practiced no matter if the operator knows his hands to be already
scrupulously clean, as

it

assures the patient that the operator has

a regard for at least the simpler forms of cleanliness.

The Linen Upon the Chair should be inviting and

it is Avell that the patient see that which

convenient,

unsoiled.

If

is

already on

to

remind the

the chair changed for fresh.

Few

Instruments should be in sight, as they serve

patient of former experiences not always pleasant.

After the First Requests of the patient have been complied with
it

is

well to take a rather general survey of the

swering

many

future procedures.

view," as

it

mouth before

an-

questions regarding the advice to the patient as to

The operator should note

were, the probable care that

is

in this "bird's-eye
being bestowed upon

mouth in a prophylactic way. Also the health of the

soft tissues, the number of extracted teeth, the presence of dentures and amount of dental work previously done, noting its quality and probable age, as well as the number of badly decayed teeth

the teeth and

yet unfilled.

He

should note the health of the patient, probable

174

EXAMINATION OF MOUTH LOOKING TO DENTAL SERVICES

age and habits.

175

All this can be done at a glance and in a few

the operator wuU be much better qualified to

when

second's time,

advise the .patient as to

what

is

best to do in a special case.

If the Patient Is in Pain its alleviation

should receive immediate attention. It

is

of first importance and

may

require the applica-

tion of medicinal remedies, or

some mechanical procedure or even

but, whatever it may be, it must be done
in no mood to receive sage advice about

the extraction of a tooth,

at once as the patient is

the future

when he

is

at present in pain.

Early in the Examination Sitting the patient should be advised

of the necessity of a prophylactic treatment provided the teeth
and mouth are not scrupulously clean, which is seldom the case,
unless the patient has recently visited the dentist for that purpose.

This Is Second Only to the relief of pain and

dentist's

making

duty to attend

it is

manifestly the

to prophylaxis before proceeding to the

of fillings.

Careful Examination should be suggested, following the hasty

inspection, and,

if

advised to do so by the patient, the dentist

then proceed to search

all

not forgetting the vulnerable points about

as the margins of fillings

work previously

The Instruments Needed

are, a clear,

uninjured mouth mirror, a

small balls of absorbent cotton, Avaxed floss

placed,

and about the bands of crowns.

sharp pointed instrument called an explorer

mechanical separator,

may

surfaces for the various classes of decay,

small electric

cotton pliers and

chip blower and

silk,

mouth lamp

is

also of value.

The Use of the Mouth Mirror is to see therein the image of surand locations where direct vision is imperfect or impossible
and to flood the point being examined with an abundance of light.

faces

Many

cavities existing in the proximal spaces are not noticed until

strong rays of light from a different angle than the line of vision
of the examiner have been directed against them.

The Use

of the Explorer

at suspected points

faults in enamel.

is

to note the extent of decalcification

and the inspection of

pits

and grooves for

This instrument should be in the shape of an

elongated cork screw turn, that the more inaccessible points may
be reached. A light hand in its use is imperative as the dentist
is not excused for breaking dovvii tooth substances or for causing

much pain

in

any of the processes of examination.

Absorbent Cotton in the pliers is used to take up the moisture in

and whose depth questions proximity

cavities of considerable size

176

OPERATIVE DENTISTRY

pulp; also sensitive surfaces suspected in shallow cavities,

particularly those in the gingival third.
The cotton balls should
not be too large and rather tightly rolled.
to the

Waxed

Floss Silk

is

used to examine the proximal space where

the reflection of light does not

the surfaces of debris

from the embrasure.

incipient caries,

it

of the thread; if

and food

make

diagnosis positive.

particles,

It cleans

giving a deeper insight

When

surfaces are roughened or cupped from

show by the catching or cutting of the fibers
the surfaces still retain their normal polish the
will

thread will pass uninjured.

The Chip Blower is a small hand bellows for the expulsion of air
and is used in examination of the teeth to blow away and evaporate
the moisture from points where it is held by capillary attraction,
giving, thereby, a better view and a more correct idea as to the
color present, which is a strong factor in a diagnosis of conditions.
The Mechanical Separator Avill sometimes be of service to gain
little
added space for the inspection of contacting surfaces.
a
The Use of the Electric Lamp on the lingual side of the teeth has
many advantages and is a speedy and sure way of detecting any of
the stages of caries in the proximal spaces, the vitality of a tooth's
pulp as Avell as abnormal conditions about the alveolar wall and the
presence of pus and inflammatory changes in the maxillary sinus.
When the Examination Is Completed the patient should be advised of the true condition of his mouth, including the indicated

treatment of both hard and soft tissues. If the patient indicates

a desire to have the services rendered as outlined by the dentist it
is

entirely good business,

and by no means unprofessional, to apwork as planned when

prise the patient of the probable cost of the

it

can be approximately estimated, unless the patient is a frequent

and familiar with the charges expected from the dentist con-

visitor

sulted.

CHAPTER XXX.
THE ALLEVIATION OF DENTAL
The First Duty of the Dentist

many
i's

instances this

is

to relieve sufeering,

the reason for the

most essential that the

relieving of a

is

paroxysm

relief

PAINS.

sought

is

first call

obtained.

of pain by the dentist has

and as

of the patient

Many

in
it

times the

made a

lifelong

friend and patient.

The Diagnosis is a most vital point and the battle is half won
when this is correctly made.
Pay Strict Attention to What the Patient Has to Say as he is
quite sure to give you his symptoms in the order of their prominence
and it is generally the prominent symptoms that are pathognomonic.
After the Patient Has Given the Most Aggravated Symptoms,
make an examination of the afflicted part of the mouth to verify the
statements made. If all is not clear quiz him more specifically. Do
not jump at conclusions. The patient is generally right as to symptoms but frequently wrong as to location and cause. These last are
the points the dentist must decide, as well as upon the treatment for
relief.

There Are

Two

Divisions of Dental Pains, those arising from

and those arising from degenerative changes

same
destructive processes in the pulp. They may follow the pulp troubles

lesions of the tooth pulp,

in the sub-dental tissues, which are generally the sequelse of the

or occur simultaneously with them.

Pulp Lesions. Symptoms are sensitiveness to thermal changes.

The tooth is not necessarily sore to percussion. Pain is increased
or induced when assuming a recumbent position.
The presence of
foreign substances in the tooth cavity cause pain especially

when

Pain comes in paroxysms

Avith a tendency to intermittence.
Patient may complain of "jumping toothache." These symptoms may all be present in the same
pressed against the walls of the cavity.

case or only one at a time in the series of changes that take place
in a pulp

from the

The Treatment

initial affection to its death.

Speedy Relief is varied according to the most

prominent symptoms, as these are the indications of the stage of disfor

solution.

Cold Air or Water Causes Pain of a quick, sharp, shooting nacomes on suddenly and passes off immediately upon the tooth
regaining the body temperature, the pulp is in the stages of active
If

ture,

177

OPERATIVE DENTISTRY

17S

hyperemia, which

is

the initial stage of a destructive disease, and

respond immediately to the application of anodyne and effectual

protection from air and fluids, which is accomplished by stopping
the cavity with a non-conductor, generally cotton, or temporary stopwill

ping, or an application of phenol.

If

Warm

Fluids Cause or Intensify the Pain and the application

of cold relieves the pain temporarily, the pulp will be

found

to be

well advanced in the stages of dissolution, some portion of which

has been resolved into the end products.

Gaseous substances

oc-

cupy portions of the pulp cavity, which is closed over the entire
coronal portion by a layer of dentine, a filling or a plug of foreign
substance.
These gases are expanded by the elevation of the temperature, causing increased pressure upon the remaining vital portions of the pulp and intense pain results, which is further augmented, many times, by the pulsations of the heart. The pulsating

symptom
is

in this instance indicates that quite a portion of the pulp

yet vital.

The Treatment
putrescence,
gas.

is

for Relief in This Case,

which

is

called closed

the removal of the obstruction for the escape of the

This involves opening into the pulp chamber through the route

of the least obstruction or injury to the tooth.

Necrotic portions of

the pulp should be removed, disinfectants and anodynes applied and

devitalization of the remaining vital portion effected.

Moderately

Warm

Fluids Cause Pain as

Avell as cold the pulp

hyperemia
or
congestion.
This conis in the first stages of passive
being
more paindition is generally soon followed by the symptom of
ful upon the patient's lying down and the throbbing pains setting
in, and man}" times patients will say, "I have the jumping toothache;" or, ''It began last evening about fifteen minutes after I went
to bed."
Treatment of Passive Hyperemic Pulp for relief is sterilization
of immediate surrounding tissue at the tooth's cavity and the apIf the pulp can be bled with
plication of sedatives and anodynes.

If

causing but slight pain

The Painting
if

of the

the pericementum

then proceed to devitalization.

with a revulsive is of service, especially
taking on the stages of inflammation indi-

it is

beneficial

Gum

is

cated by slight soreness to percussion.

If the Presence of a

Foreign Substance in a cavity causes pain

it

may

be an exposed pulp which is not very highly organized, or hypersensitive dentine covered with a layer of leathery decay.

The Treatment
prevention of

its

Is the

Removal of the offending object and

the

recurrence by temporary or permanent stopping.

ALLEVIATION OF DENTAL PAINS

179

Pericemental Diseases Causing Pain have for their most pathognomonic symptom the soreness to percussion, as shown by gently
tapping on the occlusal surface of the tooth with a steel instrument. Slight swelling of the pericementum causes the tooth to appear to the patient as much elongated and the patient will generally
make such remarks as these, "I have a sore tooth;" ''It hurts to
close my teeth;" ''My tooth is too long," etc.
If the pulp is entirely dead, and removed, or there is not a case
of enclosed putrescence, thermal changes will have no effect, except
in rare cases

warmth applied

to the parts will give a slight sense of

relief.

Treatment for the Relief of Pericemental Pains is the thorough

and complete removal of the cause, generally consisting of necrotic
pulp tissue, and infectious matter in the pulp chamber. This should
be thoroughly removed by mechanical means, assisted by the use of
chemicals, and the entire chamber from crown to apex rendered
aseptic as soon as possible.

Pus Has Formed at the apical space and flows freely down the
temporary relief is most certain to follow if the case is
allowed to remain open for twenty-four or forty-eight hours for
If

root canal

free drainage,

when further treatment may be proceeded

with.

Acute Alveolar Abscesses should be opened externally, as soon

as the presence of

pus can be diagnosed, this to be done external to

is least painfully done by freezing the tissues

the alveolar wall and

to be punctured.

Abscesses Are Assisted to the Surface by painting the mucous

membrane over the diseased portion with aconite and iodine. In no
case should such an abscess, no matter what its size, be lanced through
the external surface of the face as
the mouth.

all

are easily reached from within

CHAPTER XXXI.
PROPHYLACTIC TREATMENT OF THE MOUTH.
The Importance
visits to a dentist

of Prophylactic Treatment early in a series of

and

is second only
which jeopardizes the remaining tooth structures, the permanency of attempts to check the
ravages of caries and disease, as well as the reputation of the op-

at stated periods thereafter,

to the relief of pain, the neglect of

erator's skill.

Unhygienic Conditions About the Teeth are the sole, immediate

and exciting cause of primary or secondary decay of the teeth,
and many an operator of exceptional skill as to the making of
fillings has failed from a disregard of these conditions.
As much
of the success of dental operations depends upon the care of the
mouth by both dentist and patient in the way of prophylaxis, as
upon the skill of the dentist as an operator. The making of a filling is but the repair of an injury and is only a temporary check
to the progress of destruction, if the primary cause of dissolution
is to remain operative.

The Sub-Dental Tissues are

laxis to the extent,

many

also diseased

by a lack of prophj^-

times, of their entire loss, so that the

teeth, themselves, are loosened

and

lost,

through a lack of struc-

tures to support them, while the teeth so lost are

many

times yet

undecayed, and, in the present-day advancement of dentistry, experienced operators are forced to consign more teeth to the forceps from the result of diseased conditions in the tissues surroundIf this be
ing them than from decay of the teeth, themselves.
true the dentist cannot ignore the importance of combating the
agencies Avhich bring it about.
Preventive Dentistry has the same great field of usefulness as
has "preventive medicine" in the practice of medicine and the
dentist who masters this phase of the science of dentistry has gone
a long way towards success, and many defects in manipulation,
ability

and

tainment,

ideals in conditions about tooth repair impossible of at-

Avill

stand the test of time

if

only hygienic conditions

are attained and maintained.

The Kinds

of Deposits

Upon

the Teeth are generally classified

as salivary calculus, serumal calculus, green stain

The

first

two named are enemies

180

and

sordes.

to tissue about the teeth, while

PROPHYLACTIC TREATMENT OP THE MOUTH

181

the last tAvo are responsible for most of the destruction of the

hard dental tissues by

caries.

Composition of Salivary Calculus. Mixed saliva contains in

man an average of about 0.5 per cent solids. The calculus is pre-

mouth

form of a finely divided calcoupon any stationary object,

the mouth of the gland ducts. The fresh deposit is very

cipitated into the

in a

globulin, Avhich collects in masses

close to
soft

when first deposited, but within twentyharden

and increases in hardness up to the
begins to

and greasy

four hours

it

to feel

time of thirty or sixty days, Avhen it has generally attained its full
hardness and will break aAvay from the stationary object in masses

showing distinct

lines of fracture.

Calcium phosphate and magnesium

phosphate are held in solution in the saliva, made possible by the
presence of a little carbon dioxide.

Lime

Salts

Held in Solution.

Reasons for Precipitation.

the

mouth

it is

When

the saliva

is

discharged into

released from the normal blood pressure and some

which allows the calcium salts to be

precipitated.
The lactic acid Avhich is continually formed in the
mouth converts the mucus into a curd in Avhich the calcium salts
are entangled to harden into salivary calculus. This process is assisted by the presence of the oxygen taken into the mouth with the
breath, which facilitates the liberation of the carbon dioxide, in
cf the carbon dioxide escapes

the process of oxidization.

Time

of Deposits.

It

would seem from the experiments

of Dr.

Black that the deposits of salivary calculus are paroxysmal and

also that these periods of rapid deposit follow the ingestion of

heavy meals. He thinks that these periods of excessive deposits

come at a time when the blood is overcharged with food pabulum.
Kind of Food. It does not seem from his experiments that the
kind of food has very much to do with these deposits. The more
easily a food is digested, the more quickly following the meal will
these deposits appear.

Habits of Patient. It would seem that the habits of the patient

have little to do in influencing the amount of these deposits.

However those who live a life of physical exertion, Avhich favors

the using of heavy meals have a greater tendency to deposits of
tartar than those whose vocation would cause them to eat lightly.
Mouths Most Subject to the Deposit. From our present understanding of this subject it would seem that the mouths most subject to the deposit of salivary calculus are those indi^aduals,

OPERATIVE DENTISTRY

182

who from

First,

abundance

of

This condition
activity or

constitutional reasons have a tendency to an

carbon dioxide in the excretions

may

where the

forming their

secretions.

skin, kidneys or lungs, or all, are not per-

full functions.

of carbon dioxide.

and

be brought about by great physical or mental

These are the principal eliminaters

Such individuals are very

be troubled

liable to

with precipitation within the gland and ducts, through which their
secretions are expelled, resulting in cystic, glandular, biliary or

renal calculi.

Second, those individuals

who

either occasionally or habitually

engorge heavy meals, wherein the quantity of such meals

is

greater

than that needed for growth or maintenance.

TJiird, in

mouths wherein the amount of

lactic acid is

more than

normal.

Fourth, in the mouths of public speakers and mouth breathers,

whether awake or during sleep. The great amount of oxygen coming in contact with the saliva assists in the rapid liberation of the

carbon dioxide and consequent rapid precipitation of the calcium

salts.

It would seem that salivary

by stimulating the circulation;
stimulating the elimination of carbon dioxide from the body;
checking mouth breathing as much as possible, correcting overacidity of the mouth, limiting the amount of food taken into the
stomach at each meal by more nearly equalizing the three daily
meals to the needs of the body. Also by so highly polishing the
surfaces of the teeth upon which the deposit is precipitated, as to

Prevention of Salivary Deposits.

deposits can largely be prevented

facilitate the

not

mechanical removal of the fresh deposits. Last but

the mechanical features of

least, so instructing the patients in

the care of their teeth that insofar as possible all fresh deposits

removed before hardening takes place.

Serumal Calculus is a calcic precipitate from the

are

salts in solution in the

lilood.

depends materially upon the presence of a normal amount of

bon dioxide.

Serumal Calculus
there

is

Is

The

blood as well as the stability of suspension

Deposited beneath the

gum

car-

tissue Avherein

a passive hyperemic condition or congestion.

Here we

have excessive tissue waste, lessened alkalinity of the blood, a liberation of the carbon dioxide and consequent precipitation of the
inorganic

salts.

By

the recession of the

gum

after the formation

PROPHYLACTIC TREATMENT OF THE MOUTH

of the serumal form of calculus,

mixed with the mass of salivary

be exposed to view, or

calculus.

Serumal Calculus in Appearance

salivary

may

it

183

is

of a harder constituency,

of a

much darker

color than

and generally adheres

to the

surface of the tooth more tenaciously.

Serumal Calculus Is Also Found on unexposed portions of roots

which approximate inflammatory exudates, or, are bathed
in escaping blood plasma associated with chronic conditions of the
It also appears in other portions of the body as
apical space.
of teeth

about the joints subjected to chronic inflammations as well as in

the glands continually gorged with blood.

The Bulk of Serumal Calculus

its

formatioji in restricted spaces

nodules,

naiTow bands and thin

is

comparatively small, owing to

and

generally found in small

is

scales,

not always easy of detec-

tion or removal.

Stains

Upon

the Teeth are of varying degrees of shade in several

and from cosmetic reasons stand for immediate removal

when detected. HoAvever the green stain found upon teeth is so
colors

closely connected Avith the first stages of caries on surfaces so af-

fected that

it

Green Stain

deserves special consideration.

Is

Generally Confined to the labial surfaces

particularly the gingival third of the anterior teeth.

frequently found upon the teeth of children and

It is

may

and
most

be seen

upon the temporary or permanent teeth. When it persists

for a considerable time upon these surfaces of the permanent
teeth the enamel Avill be found to be etched by a dissolution of the
cemental substance evidenced by the whitened surface.
The Color Is Due to the bacteria present.
The Injury to Tooth Substance is due to the acid Avhich these
either

bacteria produce.

The Reason for Their Presence is the favorable place for lodgment aff'ordod by the persistence of the cuticula dentis.
Sordes Consists of a mixture of food, epithelial matter and
micro-organisms collected upon the teeth.
Neglect in the Removal of Sordes results in tooth caries, particii-larly

in localities habitually so unclean.

The Removal of Salivary Calculus is accomplished by two principal i)lans, the push-cut method and the draw-cut method, each
with

By

its

advantages.

the Push-Cut

blunt chisel edge,

is

the blade of the scaler, Avhich has a

forced between the calculus and enamel trav-

Method

OPERATIVE DENTISTRY

184

In

eling in the direction of the root.

is

the slipping of the instrument to the

its

use the principal danger

gum

tissue

accident should be well guarded against by

itive

By

and

hand rest.
Method the blade

sufficient

first

beyond and

this

securing a pos-

which has a hoe

passed under the free
margin of the gum, its point engaged on the ledge of the calculus
and its removal accomplished by a pulling force applied toward
the Pull-Cut

of the scaler,

point of about twenty-eight degrees,

is first

the crown of the tooth, or in a plane parallel with the long axis of

the tooth.

Care should be taken in passing the instrument under

the free margin not to lacerate the gums. Pen grasp should be
used anc a secure hand rest obtained before making an effort to

remove the deposit.

The First Teeth to Be Scaled
first

ib

is

not important, yet

if

attention

directed to the lingual surfaces of the lower incisors,

are able to create an impression

tance of the

work

in hand.

It is

upon our patients

here

we

we

of the impor-

generally find the heavi-

and allowing them to

fall in the mouth the patient is fully awakened to the need of the
service being rendered. The same impressions never seem possible
est

if

deposits and

by removing these

the removal of the larger masses

first,

is left

until the last.

The Proximal Surfaces Are Best Scaled with the pruning hook,
draw-cut scaler or the straight push-cut having a very thin blade
and about a twenty-three degree bevel.
These proximal surfaces will need such attention more from the
deposit of serumal calculus than from the salivary variety, which
is only present in the proximal surfaces after gum recession.
is much more difficult than
done under the cover of the gum.
which requires delicacy of touch and the highest degree of digital

The Removal

of Serumal Calculus

salivary, as all of the

work

is

skill.

Be Distinguished From Cementum, bone and soft

simply by the sensation of touch conveyed through contact
of the instrument with the structures in question.
The Surface of Roots, where the attachment of the periceCalculus Must

tissues,

mentum has been

moval

must be carefully examined and the reand the root or roots thorthe gum will not regain health where particles

lost,

of all calculus accomplished,

oughly polished, as
of the deposit remain. Several sittings are often necessary to accomplish satisfactory results.

Pyorrhea Alveolaris.

The

desire to keep this

book within

cer-

PROPHYLACTIC TREATMENT OF THE MOUTH

185

tain limitations prevents the consideration of pyorrhea in its treat-

ment. However the foregoing procedure will go far towards the

prevention and cure of pyorrhea alveolaris.
In fact thorough
prophylaxis

is

the prime essential in the treatment of that disease.

The Removal

of Green Stain

is

principally accomplished by the

application of some abradent, as pumice stone, with a revolving

brush in the dental engine. This also polishes the crowns of the
teeth, removing the small particles of calculus still adhering to

them after scaling.

Hydrogen dioxide

added to the powdered pumice in

removing the stains and particularly
green stain, of which it is a partial solvent. Following the use of
pumice the gums should be thoroughly syringed with water to remove any trace of the pumice, Avhich is insoluble in the mouth and
should not be left around the free margins of the gums.
place of water

(H2O2)
in

Avill assist

New

Brush Wheel should be used and a fresh mix of

the powder made for each patient as a means of preventing the
transmission of disease as well as from a standpoint of cleanliness.
As well might our patients be asked to all use the same toothbrush,
a thing not thought of, even by members of the same family.
Clean

The Removal of Sordes

a matter which must be left to the efaccumulation about favorable portions

of the teeth and mouth is but the matter of a night or a day and
upon its speedy and frequent removal depends the salvage of the
teeth from the ravages of caries.
forts of the patients.

The Toothbrush

is

the one great cleansing agent and nine-tenths

of the removal of sordes

is

accomplished purely by mechanical abof the brush over the

bristles should be not

movements of the bristles

the teeth. The movements of the

rasion through the

surface of

is

Its

only crosswise to the long axis of the teeth, but also from root to

crown and vice

versa, that the travel of the bristles

may

parallel

the gingival, enter the embrasures and traverse the grooves and
fissures.

Hydrogen Dioxide Is the Only Agent Avhich can be used in the

mouth in sufficient strength to dissolve sordes and not injure
either the hard or soft oral tissues. This may be used either upon
the brush or as a mouth wash. The dissolution of sordes is accomplished by oxidation.
The Massage

the free margins of

Gums

is advised to remove all unsolidified

and other foreign substances from beneath
the gums as this appears to be the only satis-

of the

calculus, food particles

OPERATIVE DENTISTRY

186

The massage is also

of cleansing these spaces.
most beneficial to the gums. It stimulates the circulation, retards
tissue waste and lessens the deposit of serumal calculus, and in addition forces away that AA'hich has been precipitated before it has
an opportunity to solidify.
Instructions to Patients as to the care of their teeth is an allimportant duty of the dentist, not only from the standpoint of
what is best for the patient, but much of the dentist's reputation
as an operator depends upon the subsequent care given the teeth
by the OAvner following the making of fillings, for upon their enComparatively few indivironment depends their permanency.
viduals know how to properly care for the mouth and many will
insist to their dentist that they are most careful of their oral habits when upon examination, the dentist finds surfaces which appear
They have failed to
never to have been cared for in the least.

factory method

reach these surfaces Avith their brush.

The Technic

of

Proper Brushing should be thoroughly

ex-

plained, Avith special reference to reaching the surface AA'hich they

seem to be neglecting.

gums

Avith

from root
is all

Instruct

them

as to the

massage of the

the finger tips, rubbing not only crossAvise but also

to croAvn, assuring

them that

if

the

gums bleed

easily

it

the more essential that they repeat the operation and that

finally they Avill regain their

normal health and then they

Avill

not

bleed under the treatment advised.

The Use

of Floss Silk for passing through the proximal spaces

to clean contacting surfaces

by Aviping

oft

the

embrasures

and

reaching points inaccessible to the brush, should be demonstrated

to the patient.

as

Care should be taken not to snap the thre.ad past contact points
it may lacerate the gums.
Toothpicks have no place in the care of the teeth and should be

prohibited by

laAv,

especially those of soft

found on the market and

corners and slivered ends

Avood

at public eating houses.

so

commonly

Their square

irritate the gums, causing their disease

thereby destroying the natural protection to the
most vulnerable portions of the teeth.

iMid recession

CHAPTER

XXXII.

EXCLUSION OF MOISTURE
The Exclusion

from most operations upon the teeth

most filling materials,
the sterilization of tooth structures and the prevention of infection, the cleanliness of cavity walls and margins, that a perfect
view of the cavity may be obtained, that the extent of decalcificais

of Moisture

essential to the successful manipulation of

tion may be observed, to diminish the pain of operations on living

dentine and to protect the soft tissues from injury in the use of
caustic drugs, as Avell as to save time of both patient and operator.

The Methods

of Securing' Dryness during operations are here

given.

The Rubber Dam, invented and given to the dental profession in

18G4 by Dr. Sanford C. Barnum, of New York City, is widely used.
Absorbents, as napkins, cotton rolls and pads packed about the
teeth

and near the mouths

of ducts,

by

assisted

structed clamps upon the teeth are also used.

specially con-

Dryness

is

cured by the use of the saliva ejector whereby the mouth

tinually drained of the secretions.

also seis

con-

Use of the Rubber Dam are entirely on

and can generally be traced to awkward
and unskilled handling on the part of the operator. Every operator should become dextrous with each method, that he may em-

The Objections

to the

the part of the patient

ploy the one most expedient in every case, using the one least
objectionable to the patient.

The Neglect

of Dryness in dental operations

is

to invite disaster

in root canal treatment, as Avell as short life to all fillings so placed,

and the operator who makes

it

a practice to neglect this essential,

obtains only a partial success in that which he attempts.

So Important

Is

Dryness that a patient should be warned that

a certain operation, where moisture has been allowed to flood the

short-lived at best and is liable to failure from this cause.
Such conditions seldom arise but are occasionally' met with, due
to location and extent of decaj' and also from the fact that there
are some patients who are nauseated by the presence of the dam
or absorbents about all but the most anterior teeth.
All Filling Materials are better manipulated under dry conditions at some stage of the operation, porcelain being the only one
demanding moist conditions at any stage of the process. This
field, is

187

OPERATIVE DENTISTRY

188
moisture in porcelain

filling is

only required to preserve the sliade

of the tooth substance to be imitated in the fused

filling.

Those to Which Dryness Is Most Essential are silicate, cohesive

gold, cement amalgam and gutta-percha, named in the order of the
importance of the demands. It is true that all of these excepting
silicate may be successfully manipulated under moist conditions,
but the effort is greater and the certainty of success is materially
decreased.

The Exclusion of Moisture for

of infection
as

Sterilization

and the prevention

imperative in the last stages of cavity preparation,

physically impossible to properly perform the toilet of the

it is

cavit}^

is

and properly

sterilize the

same when flooded or even under

moist Conditions.

The Proper Treatment of Pulp Canals cannot be accomplished

flooded by the oral fluids to say nothing of the introduction
of a permanent root filling. The saliva is at all times impregnated
with various forms of bacteria. Its presence invites failure by preventing sterilization of canals already septic and permitting the

when

re-infection of those already sterile.

Cavity Walls, and particularly the beveled margins, must

be

and planed after being moistened before the introducis the only means of having an absolutely
clean surface. We may resort to absorbing and evaporating the
moisture from the walls and margins of a cavity, but there will
invariably be left a residue or film upon the surface which is soluble in the oral fluids.
No amount of pressure in introducing the
freshly cut

tion of a filling, as this

be it rubber, amalgam or cohesive gold, will displace the

moisture absorbed by the cavity surfaces, hence we have this layer
This
cf moisture or sediment intervening the filling and cavity.
filling,

of time for that upon the outside

and the products of fermentation or lacBacteria, which are the
tic acid and secondary caries is the result.
active agents of caries, will go where moisture will not, and the
lactic acid which they secrete will go where the space is too small
will be

exchanged

carrying with

it

in course

bacteria

be readily seen that a moist surof an evaporated mixture,'

whether medicine or saliva, intervening between a filling and a
for the bacteria.

It will therefore

face or one coated with a residue

cavity

Avail,

becomes a large passage way for the greatest enemy

to tooth substance

A
lines

Better

View

lactic acid.

of the Cavity Is Obtained

become more

distinct

and

its

size

When

Dry, as

and shape better

its

out-

defined.

EXCLUSION OF MOISTURE

189

No mechanic ever thinks of trying to accomplish his best work

with the object submerged in moistui*e.
The raj'S of light are
broken, objects are distorted and distances misjudged. The dentist
who does not effectually exclude the moisture from the immediate
neighborhood of a cavity will catch only a glimpse now and then
of portions of a cavity, this being particularly true of the gingival
wall, except in cases of

gum

recession.

The Extent of Decalcification of both dentine and enamel is diagnosed only when dryness is obtained to bring out the colors and
shades of each incident to these conditions. It is impossible to
make proper cavity extension until the cavity has been made dry
and so maintained for some time, as this is often the only means of
detecting superficial caries.
moist, materially

dried to detect

The Pain
extraction

its

Semi-decalcified tooth substance,

when

resembles the healthy structures and must be

injured condition.

of Cavity Excavation
of

moisture

the

within the dental tubules

is

tion of pain to the vital pulp.

is materially decreased by the

from the dentine. The protoplasm
the means of transmitting the sensa-

Water

is

a large constituent of pro-

toplasm and the extraction of this moisture through extreme and

continued dryness removes the media of sensitiveness. It is therefore but humane that the cutting of dentine be done with the moisture excluded.

When

Using Caustic and Concentrated Drugs the moisture

should be excluded, that the drug may not be carried away to the
injury of adjacent tissues and that the drugs may not be diluted
to detract from their efficiency in accomplishing that for which they
were used. Drugs placed in the cavities of teeth with moist margins even when placed under fillings of rubber, cement or amalgam,
will follow the moisture of these margins to join that without and
great damage to the surrounding tissues often results from no other
cause than a lack of the exclusion of moisture during the operation.
As a Time Saver the exclusion of moisture should not be overlooked.

With a dry

cavity the continued uninterrupted view per-

mits of more continuous Avork by the dentist.

He

does not have to

wait for the patient to expectorate, make a few remarks and leisurely
resume his position in the chair, not always in the position desired

The operator will also be saved much time in dryfor operating.

ing the cavity after each flooding. All this takes valuable time, much
more than

is

The Rubber

required to adjust a dam.

Dam

is

the most dependable

means of securing a dry

OPERATIVE DENTISTRY

190
field for

operating and

mastered.
the

It is

made

medium being

only one weight

The

Size

is

its

proper and speedy adjustment should be

in three thicknesses

heavy, light and medium,

the weight best adapted for all purposes where

to be kept at hand.

and Shape is of little importance so long as it commouth after it has been made to isolate the teeth
well as cover the chin and extend to either side of the

pletely covers the

desired, as

mouth

sufficient for the

proper engagement of the holder.

require a piece from five to six inches square, for

the six anterior teeth and

This will

back of
used on the

all eases

is most frequently
However, some economy of rubber dam may be practiced by cutting these squares in two triangular pieces, each of which
will do for a separate case.
These are applied with the diagonal of

the size

anterior teeth.

the quadrilateral

The Holes

(hypotenuse) uppermost.

to Receive the Teeth should be of the proper size

and

an increased liability of being torn

in adjustment.
This is best done by the use of the rubber dairi
punch to be had at dental depots. However, in the absence of this,
a very good result is obtained by drawing the rubber tightly over a
tapering round handle of an instrument and touching the sharp edge
of a knife to the rubber down the side of the handle when a perfectly round piece will be cut out.
smoothly cut, otherwise there

is

The Distance Between the Holes

between the
of the

will

vary according to the space

gum, the weight

teeth, the height of the festoon of the

dam and

the size of the teeth to be engaged.

'ing, the holes are cut

from two

Generally speak-

to four millimeters apart in

medium

dam. The lighter the dam the farther apart should be the holes.
The holes are farther spaced with extremely large gum festoons, also

when there

is

gum recession. If the holes are too close

dam may not cover the entire proximay occur, or the gum septa may be un-

a considerable

together in above condition the

mal tissues and a leakage

duly compressed and permanent injury result from strangulation.
If the holes are too far apart the rubber will wrinkle and bag at the
proximal spaces and seriously hinder operations in these localities.

The Location of the Holes in the piece of rubber dam depends

upon the location of the tooth to be operated upon and the teeth
to be isolated.

the

mouth

beginner will do well to

first

place the

dam

over

in the position desired for the outside edges, request the

patient to open the

mouth and with the

finger cause the

in contact with the occlusal surfaces of the teeth

it

is

dam

to

come

intended to

include and then punch the holes as this trial indicates.

By

this

EXCLUSION OF MOISTURE

method the operator

will soon

191

become familiar with the location in

each case.

The Number

of Teeth Isolated depends

upon the location and the

For the short treatment cases, sometimes
the placing of one or two teeth under the dam will suffice, but in
most eases where fillings are to be made and polished, from five to

operation to be performed.

eight teeth should be included that a good view of the field of operation may be had and the loose folds of dam carried farther away to
avoid them catching in the revolving points of the engine.

With Anterior Teeth the first bicuspid tooth of either side should
be included, as the cuspid from its conical shai)e is many times
unsafe for a final ligature.

With Bicuspids and Molars

tion, there

as the objective teeth in an opera-

should also be included the teeth anterior to the median

line.

The Clamp should be placed on the tooth back

of the one to be

operated upon, excepting in mesial cavities in second molars when

may be placed on the second molar, thereby avoiding the

clamping of the third molar except when absolutely necessary, as
with distal cavities in second molars.

the clamp

The Placing of the Dam requires the freedom of both hands of

and the aid of an assistant is of value. The necks of
the teeth upon which the rubber dam is to be placed should be cleansed
of all calculus and sordes and flooded with a jet of water from the
syringe. If the gums show hypersensitiveness they should be bathed
the operator,

in a solution of novocain, restricting its use to the gingival borders.

Waxed

silk

should be passed through the proximal spaces to clean

access for the rubber. If sharp margins of ca\^ties

them and prove

cut the silk these should be dulled by passing a thin ribbon saw
through the proximal space or, with the chisel, carry the margin
sufficiently into the embrasure to give access.

When

teeth are in close contact so that the silk thread

is

passed

rubber can be made

is done by placing the row of holes on the ball
of the index finger, occlusal side up, and rubbing the soaped fingers
with

difficulty, the

to pass more readily by tho

use of soap, which

hand across the holes.

The Occlusal Side of the Rubber Dam is that side Avhich is townrd the occlusal surface when the dam is in position.
The Gingival Side is the opposite side and is next to the gingival
margins when the dam has been applied to the teeth.
The Method of Applying the Dam is affected by the fact of

of the other

OPERATIVE DENTISTRY

192

whether a clamp is used or not and kind of clamp when one is used.
With the Anterior Teeth Ave do not generally use a clamp and the
rubber is placed by commencing at one side and then crowding the
rubber through each proximal space in the order they should go,
The rubber dam holder should
until the opposite side is reached.
be applied to one side before commencing the adjustment, and, as
soon as the teeth have been forced through the holes, the other side
of the holder should be attached.

With

Posterior Teeth the holder should be attached to the short

mouth, which would

side of the rubber to prevent curling into the

be the same side of the

right or

left.

dam

as the teeth are situated in the mouth,

Adjust clamp to be used as

this tooth receives first

by one pushed through.

reached, when the remaining side of

attention, while the remaining teeth are one

most anterior one is

is secured with the holder.
To Prevent Leakage Around the Teeth tlie edges of the holes
must turn toward the roots. This is accomplished by first pressing
the dam well against the gums while grasping the rubber on either
side of the tooth and drawing it tight, then releasing the rubber so
that it slackens and then gently moving it occlusally. This will genIf inversion is not
erally have the effect of inverting the edges.
complete pass a small blunt instrument, as a spatula or dull explorer, around the gingival to turn the edge under.
The Use of the Ligature is to assist in inverting the edges of the
until the

the rubber

holes in the rubber

dam and

to secure the edges about the teeth in

this position against displacement

by the movements on the part

of

the patient or the operator.

Caution in the Use of Ligatures

manent injury

is

is most important as much perdone the gingival attachments by the careless crowd-

ing of these on the dental ligaments.

where the proximal

cially

gum

This

is

particularly the case

festoons are high as in these cases, espe-

with young people, the attachment to the tooth

is

also high.

and
would thereby ride down the high proximal attachments, if the ligature is crowded to the full height both labially and lingually. Hence
either the labial or the lingual should not be crowded to the full height
tight ligature tends to encircle the tooth in a straight line

of the crown.

Ligatures Are

Made

of well-waxed floss specially prepared for

the purpose, cut into lengths of about five or six inches.

omy may

Some

econ-

be practiced where three teeth are to receive ligatures by

starting with a piece about twelve inches long.

in the center of the strand

Tie the

and w'hen the ends are cut

off

first

tooth

enough

re-

EXCLUSION OF MOISTURE

193

mains for the other two, thus getting three out of the amount usually
used for two.

The Cutting

of the Loose

Ends may be practiced

for all the teeth

two or three millimeters from the

With the lower anterior teeth, ends of two or three inches
knot.
should be left from each knot and the farther ends of all tied together, and weighted to overcome the efforts of the patient to elevate the lower lip, which endangers the security of the dam.
The Most Popular Knot for tying ligatures is the "surgeon's
knot," either full or half. This knot is made by passing the ends
around each other twice before each tie is made, for the ''full surgeon 's ,^not, " while for the "half surgeon's knot'' this is done with
except* the lower anterior, cutting

only the

first

half of the knot.

The "Wedelstaedt Tie" is even more secure than the above and
is made by using the first half of a "surgeon's knot" on the lingual
side of the tooth first and then passing contacts with the ends on
either side of the tooth, complete the operation with a

'
'

half sur-

geon 's knot" on the labial, thus circling the tooth with two strands.
The Removal of Ligatures from the tooth when the operation has
been completed should be accomplished before the rubber dam has
been disturbed, and
knife as a No. 1
side of the knot

is

gum

on the

by the use of a small sharp-pointed

The thread should be severed to one
or buccal side, and by grasping the knot

best done
lancet.
labial

with a pair of pliers, the thread

Where Amalgam

Fillings

is

pulled through from that side.

Have Just Been Completed

imal space the ligature about a tooth so

filled as

in a prox-

well as that around

the proximating tooth should be cut so that the part lying gingivally

from the fresh amalgam will be loosened and will pass out to the lingual embrasure. The ligature about a tooth in which there has just
been completed a filling in both the mesial and distal should be cut
This action will result in both ends being
Attention to this point will prevent the ligature plowing
a ditch in the amalgam and destroying the filling, in many cases, at

on the lingual portion.

loose ends.

the gingival-cavo-surface.

Good Rule

Remember with

to

mesial of the knot

with distal

mesial fillings

fillings

and where a tooth has both mesial and

is

to cut to the

cut to the distal of the knot

distal fillings cut ligature

on

the lingual.

Clamp should be made and then tried on

intended to be used upon. One should be secured

The Selection
the tooth

it

is

of the

that has jaws which

fit

the contour of the tooth at

der, that will remain in position

its

gingival bor-

and yet does not hug the tooth so

194

OPERATIVE DENTISTRY

tightly as to cause the patient pain or in

any way injure the

soft

tissues.

The Method of Applying the Clamp with the dam

is

to stretch

the rubber over the clamp, then apply the clamp forceps and carry
all to

position on the desired tooth, using the hole in the

dam

thus

intended as a means of getting a view of the tooth to be clamped,

which aids in the placing.

Some

of the older

makes of clamps require that they first be placed

and then with the first fingers of each hand

in position on the tooth

the hole
slip

is

dam

distended in the rubber

over the

bow

sufficiently to

permit

it

to

of the clamp.

In Using Cervical Clamps for cavities on the buccal and labial

surfaces in the gingival third the

dam

is first

passed to position and

then the clamp applied.

The Removal

of the

Rubber

Dam

is

accomplished by the

folloAv-

ing order of procedure:

The removal of the ligations as before described.

Pull the rubber to the buccal or
and with a sharp
pair of
cut strips passing between the
Third Disengage one side of the dam holder.
FourthWith the right hand remove the clamp which should
First

Second

labial

scissors

teeth.

be holding the rubber dam, remove

of the mouth immedikindly to any delays at this

all clear

ately, as the patient does not take

stage of the procedure.

Fifth
Sixth

Inspect the rubber to see

Inspect the teeth for any

if it

has

all

been removed.

portions of rubber dam, liga-

Now proceed to knead

same time flooding them with
a forceful stream of water from the syringe, to cleanse them and

tures or stray particles of filling material.

the

gums with the

fingers, at the

to re-establish circulation.

The Use

dam

of Absorbents

may be

resorted to in place of the rubber

and more particularly with the upper

Absorbents are to
teeth as these are the most easily managed.
be had in the market in the form of rolls and napkins at small cost
and are to be discarded after once used, which is the only hygienic
method. In their use particular attention must be paid to the
mouths of the ducts responsible for the most abundant secretions
and the absorbents so placed as to not only readily absorb the fluid
which is ejected, but also that they compress the ducts thereby refor short operations

stricting the flow.

CHAPTER

XXXIII.

TREATMENT OF HYPERSENSITIVE DENTINE.

Hypersensitive Dentine

is

dentine which

is

more than normally

responsive to mechanical or chemical irritation.

Normal Healthy Dentine

only slightly sensitive, but Avhen ex-

is

posed to abnormal conditions and irritating agents

it

may become

excruciatingly hypersensitive.

The Sensations Are Conveyed to the Pulp by means of the conwhich are prolongations of the odontoblasts.
The odontoblasts are thickly surrounded by the terminal
tents of the dental tubules

fibers of the

nerves within the pulp.

The Contents of the Tubuli is largely protoplasm and although

this has the power of transmitting sensation in response to irritation, it

has not yet been demonstrated that the nerve fibers enter
Hence it cannot be said

the tubuli or penetrate their contents.

that there

is

nerve tissue Avithin the dentine.

The Direct Cause of Sensitive Dentine is the loss of the enamel

which is the natural covering of the dentine.
The Most Common Agent in the removal of this normal covering
is caries, which exposes the dentine to mechanical injury through
contact with foreign substances and chemical irritants, particularly
the acids of fermentation.

much

do with the degree of hyperand light stages

or rapid forms of caries wherein the sensitiveness is most exalted,
while with the dark, yellow and brown varieties it is not so marked
and with the black or slow progressing form of caries the sensitiveRapidity of Caries has

sensitiveness in dentine, as

ness

is

in the white

scarcely above normal.

The Most Sensitive Part

of a Carious Tooth

the dentine with the enamel or

tubuli.

to

shown

cementum

It is therefore evident that the

is

at the junction of

at the periphery of the

second stage of caries will

show a higher degree of hypersensitive dentine than the deep-seated

stages and that the preliminary steps in cavity preparation in this
division of caries will be more painful than the deeper cuts into the
dentine, as then the more sensitive part has been passed.
Mechanical Abrasion is also an agent Avhich produces hypersensitive dentine by first wearing away the enamel and then encroaching on the dentine. However, this process may be so slow

and the

irritation so slight as to act as a stimulus to the odontoblasts

195

OPERATIVE DENTISTRY

196

and

by the deposit

result in the obliteration of the dental tubuli

matter termed ''tubular calcification."

calcific

may be absent.
Cementum through gum

When

this

is

of

the

result all sensation

Exposure of

recession

is

another excit-

ing cause of hypersensitive dentine aggravated by allowing the ac-

cumulation of sordes about the exposed cementum.

Abnormal Oral Secretions often produce hypersensitive dentine

and may be particularly looked for in the convalescent stages of
fevers, as well as in dyspepsia, neuralgia, pregnancy, pulmonary tuberculosis and acute rheumatism.
Hypersensitive Dentine

found in poorly

is

calcified dentine in-

cluding the teeth of the growing child; teeth that have not been

erupted for more than a few months; the teeth of those who follow
lives, particularly if they are under a heavy mental strain,

indoor

as well as anything

which may produce nervous

The Varying" Temperaments

of Patients

irritation or debility.

must be studied and un-

derstood to best cope with the problem of hj^persensitive dentine.

The

suffering

actual

is

upon the part of some, while there are those

who magnify every pain and seem to be able to stand nothing and
make as much fuss about a pin stick as it would be possible for them
The operator must
to make were they thrust through Avith a bayonet.

He must

separate these classes and vary the methods.

understand

the actual conditions and, by kind words of encouragement and a

positive procedure, stimulate the nervous to withstand the necessaiy

pain.
his

This can only be done

own

feelings, seeing to

it

when

the operator has full control of

that his temper

is

not ruffled, for, hav-

ing lost control of himself, he has no control over the patient.

Highly- Wrought, Nervous Temperament

is, by nature, sensitive

augmented by environment or occupation
and calls for the most skillful management of both patient and teeth.
People of this type are generally of a high order of intelligence and
when handled by a master hand prove a most desirable clientage.

to impressions, especially

Patients of This

Temperament

permit being hurt for a shoi-t

time provided something definite has been accomplished. They should
be advised at times as to the coming pain, and for what purpose it
must be inflicted, as the forming of an angle or the flattening of a
Avail,

explaining,

when

aaIII

done, that that which had been intended has

awkwardness or fumbling
but admire exactness and precision and are the class Avhich will reward the dentist most liberally for painstaking efforts and actual

been accomplished.

achievements.

Thej' will stand for no

This class make the day long but they serve to stim-

TREATMENT OF HYPERSENSITIVE DENTINE

ulatc the dentist to his best efforts

and work

to the

197

advancement of

the really progressive operator.

The Irresponsible Individuals who have no mental or physical

stamina require a strong hand to control them in any emergency in
life.
They go to the dentist only when forced there by pain or are
children brought by their parents.

While a dentist should never be

harsh with any patient, yet this class will necessitate, many times,
stern commands,

and a "why,

In cases of this

of course" method.

character where the operator has chosen to assume the role of a disciplinarian, the stern proceeding should universally be

tempered with

the kindest of tones before the patient leaves the chair, that he

depart with the impression that the dentist

been severe only for the patient's good.

is

may

kind of heart and has

The Naturally Cowardly Patient Avho is strong, healthy and rodread of any phj^sieal discomfort, is the hard-

bust, yet lives in mortal

manage. This class of patients have generally been raised

luxury and taught by example made possible by their environment, that they should not even be inconvenienced.
They seldom
work and mistake that tired feeling for sickness. To be hungry, cold
or warm, is described by them as "simply terrible."
With such,
often the best an operator can do is simply to temporize to keep the
teeth comfortable.
To attempt thorough work merely drives them
est class to

in

away to seek gas for painless extraction.

The Patient Who Simulates Pain should be early detected and
An operator should remember that a large
severely dealt with.
amount of the gesticulation, grabbing the working hand, cringing
and outcry, is simply voluntary on the part of many patients to inform the dentist that he is hurting them. Most of this can be done
away with by the following procedure:
First tell the patient that "this will not hurt you," and then proceed to make the statement true by working on enamel margins,
even to gently scratching on the external surface.
the patient that "this

may

ceed to test the dentine for

Then

its sensitive

portions.

He may

then pro-

Lastly

ceed to do the less painful parts of cavity preparation.

it

state to

hurt a little" and the operator can pro-

when

comes to cutting the angles and cutting sensitive portions the pa-

tient should be

warned that

this particular place

may

be sensitive

but that a certain amount of cutting is necessary. Advise the patient to hold still for just a second or two and then he will be allowed
Caution him against moving during this brief period as
to rest.
it

will

undo what has been accomplished, necessitating

ing the pain again.

his withstand-

Praise the patient for his bravery

when he has

OPERATIVE DENTISTRY

198

complied with the request and advise him as to the work accomplished.
All this instills confidence into the patient as to the den-

knowing what he is about and as

and time that pain may be expected.
tist

so

much

as to get the slightest

the pain he

is

inflicting or that

knowledge of the place

Nothing unnerves a patient
idea that the dentist is not aware of
he has

to his

little

care for one's sufferings

and has no definite idea as to when it will end.

The True Simulator of Pain will try to make the operator believe
he

is

causing pain when he

not suffering at

is

all,

with the idea that

This

the dentist will be frightened into extreme care in his case.

by scraping an instrument on a surface where

If the demonstrations continue it is the operator's duty to inform the patient
of the detection of the attempted deception and that such will not
be further considered, at the same time advising him to save his
demonstrations until he is hurt when they will be considered, and
class is easily detected

pain

is

impossible, as the external surface of a tooth.

made to lessen the pain.

The Agents for Relief of Sensitive Dentine are

every effort

Those

which produce a physical change in the contents of

and cold.
Second Those agents w^hich destroy or disorganize the contents
of the tubuli, as caustics and escharotics.
Third Those agents which, when applied, to the dentine, locally
or hypodermically produce a condition of analgesia or absence of
sensibility to pain, termed local anesthetics, and anodynes as phenol,
menthol, morphine, oil of cloves, cocaine and novocain.
Fourth Those agents administered with the view of reaching the
nerves of the pulp through the general system as bromide of potasFirst

the tubuli, as desiccation, heat

sium, nitrous-oxide chloroform, etc.

Fifth The mechanical condition under which the cutting of sendentine is done.

sitive

Physical Agents.
Desiccation Is a Physical Agent of great virtue in alleviating
hypersensitive dentine and accomplishes the result

moisture from the tubuli, which

is

by extracting the

a large constituent of the proto-

plasm.

This Is Best Accomplished by first flooding the cavity with abwhich has an affniity for water, and then directing into

solute alcohol

the cavity a continuous stream of

if

warm

air

which

is

more

effective

the temperature can be controlled so as to gradually raise

the highest point tolerable to the patient.

it

to

Painless cavity excava-

TREATMENT OF HYPERSENSITIVE DENTINE

tion can be accomplished to the depth of desiccation

199

which

vary

will

with different cases.

Continuous Stream of cold air will have a similar action

through its desiccating effect and is practiced where compressed air
is at hand.
The force with which the air is contacted with the cavity walls is a factor in its efficiency.
Heat and Cold When Moist will produce physical changes in the
protoplasm of the tubuli sufficient to destroy the sensation of pain.
In any locality of the body a moderate rise in the temperature,

and heightens func-

particularly moist heat, quickens vital action

This

tional activity.

true of sensitive dentine and the tempera-

is

ture must be materially raised before a stage of paralysis

The Best Means

of Applying This

Method

lrotected cavity a forceful fine stream of

is

is

reached.

to direct into the

water which can be grad-

ually raised in temperature to the point of toleration, cutting the

sensitive part of the cavity while the stream of water is

still

play-

ing on the point being operated upon.

With the Application

every nature

is

of Cold to any patt, vital

phenomena

of

retarded and entirely ceases with the lower tem-

peratures.

The Best Method

of Appl3dng this principle

is

to spray the cavity

with a highly volatile liquid as ethyl chloride, sulphuric ether, and

The rapid evaporation lowers

combinations with choloroform.

its

the temperatures, extracting the heat from that with which

it

comes

in contact.

The Primary Pain

in

Applying these agents may be lessened by

the cavity, temporarily with stopping, directing the spray

filling

first

on this and the surrounding parts and later removing the stopping,
directing the spray into the cavity without causing much pain, provided there is not a hyperemic pulp within the tooth, in which case
all

thermal changes must be avoided.

The Electric Current (Cataphoresis)

tund

as a physical agent to ob-

sensitive dentine should be mentioned.

It

has been used to

as-

sist in

carrying various drugs into the dentine, to facilitate their ac-

tivity,

but

its

use has proved so unsatisfactory, in

further description of this method

is

many

ways, that

unwarranted.

Destroying Agents.
Caution in the Use of Caustics and Escharotics to relieve sensimuch pulp complica-

tive dentine in deep-seated cavities will save

tions

and great care must be exercised in their use not only for the

safety of the pulp but also the soft tissues about the tooth must

OPERATIVE DENTISTRY

200

be effectually protected. Many caustics are not limited in their action and when once applied on the dentine continue their destruc-

Arsenic trioxide is a notable

tion to the envelopment of the pulp.
example of this.
Zinc Chloride is one of the oldest and most efficient remedies for
hypersensitive dentine. Its action is due to its affinity for water and
its coagulating properties upon albumen.
The Danger in its Use in deep-seated cavities is through the liberation of hydrochloric acid, which causes pain in case of a nearly
exposed pulp. This effect may be modified by using it in a solution
of one part chloroform and four parts alcohol. Add the zinc crystals
to the proportion of five grains to the ounce.
Clarify by adding a
drop of hydrochloric acid.
The Methods of Using Zinc Chloride are
First Saturate a pellet of cotton with the above solution, place
in the cavity and evaporate with a draft of warm air from the warm

air syringe or chip blower.

Second

Mix

a thin paste of zinc oxychloride cement.

Paint the
cement and cover with stopping or guttapercha.
After a few days or weeks, often, excavation may be accomplished with little pain.
Caustic Potassa and Carbolic Acid, equal parts (Robinson's rem-

sensitive dentine with this

edy), often relieves sensitiveness of the dentine and

is applied by
placing a pledget of cotton in the cavity, always with the rubber

dam

in position to protect soft tissues.

Silver Nitrate

may

be employed to good effect upon exposed

surfaces of dentine in the posterior parts of the mouth, such as those

on the occlusal surface of molars due to abrasions, or exposed ce-

mentum.
of silver

and by forming the albuminate

retards decay even so far, in some cases, as to render

It reduces sensitiveness
it

the surfaces to which

count of

itS'

it

has been applied

discoloring effect its use

is

immune

to caries.

On

ac-

not permissible in parts ex-

posed to view.

Formaldehyde.
great desensitizer.
to this

method

at

Formaldehyde is a protoplasmic poison and is a

The author called the attention of the profession
the World's Columbian Dental Congress in 1898

in a paper before that convention.

However,

its

irritating effects

are sometimes injurious to the pulp and great care has to be exercised in its use, particularly that there is not a near pulp exposure.
It is of

advantage

if

the material can be so combined as to cause

a slow liberation of the formaldehyde, which materially lessens danger to the pulp and pain from its application.

TREATMENT OF HYPERSENSITIVE DENTINE

201

Local Anesthetics and Anodynes.

Novocain stands

first

as a local anesthetic to desensitize dentine.

The methods of using novocain for sensitive dentine are slow absorpand injection by pressure, in the tooth and hypodermically. (See
Chapter XLII.)

tion

The Slow Absorption Method

is

best practiced

by putting

into

the cavity a one-sixth grain tablet of novocain; over this place a

pledget of cotton which has been moistened with the normal salt

and proceed

solution,

to

fill

tooth with stopping, seeing the cavity

again for excavation in twenty-four or forty-eight hours.

Pressure Anesthesia of the dentine

may

be accomplished in tAvo

The dentine should be thoroughly sterilized, the above

application of novocain in the normal salt solution made, over this
a piece of unvulcanized rubber placed, and all crowded into the
general ways.

much force as the patient will permit.

High Pressure Syringes are sometimes of service to simply

cavity with as

sensitize the dentine,

de-

but their use for this alone has never become

general practice, due to the danger of pulp infection.

Phenol (known to the laity as carbolic acid)

is

a valuable rem-

edy for hypersensitive dentine, as well as for materially lessening

the pain caused by the blast of air from the chip blower, and should

never be forgotten when the patient complains of the air causing

pain.

In addition to coagulating the albumen in the tubuli

it

possesses

analgesic properties.

The Method

of Using Phenol for sensitive dentine

and warm

is

to carefully

applying a pledget
of cotton saturated with the phenol, directing thereon a current of
warm air until the cotton is nearly or quite dry. This should be
repeated as often as the case demands.

desiccate the dentine with alcohol

Oil of Cloves
of its use

is

is

a valuable

remedy

air,

in this respect

and the method

the same as that just described for phenol.

and Phenol Combined,

as tAvo parts phenol and one

dry open cavity and evaporated
therefrom, with the current of warm air, is more effective than either
This method with these agents
the phenol or oil of cloves alone.
has to recommend it the fact of being a good means of sterilization,
it is a pulp pacifier in deep cavities, and no injury can reach the
pulp, provided the temperature of the current of warm air is not too
Oil of Cloves

part

high.

oil

of cloves, applied to the

OPERATIVE DENTISTRY

202

Through the General System.

Potassium Bromide in 5-grain doses three times a day for fortyeight hours previous to a sitting at the dentist's will do

much

to

remove the nervousness caused by the fear of the intended visit and
serve to minimize the pain to be endured.
Nitrous Oxide when properly administered is of great value and
efficiency.
It should be combined with oxygen or compressed air in
proper proportions. So combined and administered, it may be given
for a protracted period, long enough to prepare one or more sensitive cavities without pain to the patient and in most cases with no
danger to health or life.

Somnoforme when administered through a special

efficient means of rendering the patient
and practically immune from any pain of dental opera-

Somnoforme.
apparatus

one of our most

is

semi-conscious
tions.

In the administering of this as well as other anesthetics for

analgesia, all of the rules pertaining to the administration of the

same anesthetic for major operations must be observed as the same

danger to life exists.
Chloroform Slowly Administered and only to the first stage of
anesthesia is a most valuable means of dealing with severe cases.
This is particularly true of the A. C. E. mixture (alcohol, chloroform
and ether, equal parts). The primary effect is to paralyze the sensory nerves, as the ends of the fingers, the skin and mucous membrane in general and this is true in the tooth's pulp with the fibers
ending in the odontoblastic layer of cells wherein abundant sensitiveness has been developed.

The Method

of Administration

other operation except that

anesthesia.

it

is

is

quite the

same

as that for

not carried past the

first

any

stage of

All that part of the preparation of the cavity not pro-

ducing pain is carried out, after which the dental chair is tipped
back to as recumbent a position as will admit of operating. A napkin is then spread over the lower part of the face, leaving the eyes
uncovered. The chloroform, or better the A. C. E. mixture, is added,
first slowly a drop or two at a time and carried to the point where
the patient feels a tingling sensation in the finger tips or expresses
the fact that they begin to feel the effects of the drug.

The

anes-

never be crowded or confined while the patient can

smell the chloroform, but can be pushed more rapidly when the olfactory nerves have been paralyzed, so that the sense of smell is lost,
and it is not long thereafter until the dentine can be excavated painthetic should

lessly.

As soon

as the operator begins to operate the assistant should

TREATMENT OF HYPERSENSITIVE DENTINE

203

hold to the nostrils a large-mouthed bottle of the anesthetic to pro-

long the stage of anesthesia reached.

At no time should the

patient

be sufficiently under the influence of the anesthetic to be unable to

converse coherently or intelligently answer the questions put to him.

It must be remembered that any anesthetic has its dangers, particularly

mended

when

its

use

is

abused, but the above method can be recom-

as comparatively safe.

20,000 cases without

ill

effects.

One writer

reports

its

use in over

It is true that a large per cent of

the cases Avherein death has resulted from the administration of

first few breaths, as we
due to a strong mixture used at first or before the nerve
filaments of the air passages have been anesthetized.
If a few breaths administered as above, by the open method, proved
fatal, literature would be replete with long accounts of druggists,
physicians, dentists and others having met death by smelling of
opened bottles of these drugs.
Rapid Breathing as a means of producing peripheral anesthesia

chloroform or ether have occurred in the

believe

should receive consideration, not only for hypersensitiveness of the

dentine but for other minor dental operations as the use of hypo-

dermic needle, lancing of abscesses and extraction of teeth. The

is brought about by superoxidization within the tissues caused by charging the blood with an abundance of oxygen.
This Method Is Employed by instructing the patient to take

anesthetic effect

deep, long breaths as rapidly as possible and continue the same until

a sense of dizziness

is

brought on, when from thirty to sixty seconds

of the anesthetized condition will be found available for operating.

Mechanical Conditions.

The Mechanical Conditions under Avhich the cutting of dentine

done is a gi'eat factor in the amount of pain produced.
Sharp instruments which cut without pressure upon the contents
of the tubuli cause much less pain than dull ones even with hand
instruments. With rapidly revolving engine burs this is also true
to say nothing of the heat produced by the friction caused by rubbing surfaces which are worn away rather than cut, which is the
is

chief source of pain in the use of burs.

The Cutting Should Be Done

as

much

as possible at a right angle

than to follow their course with

pressure towards the pulp or in a line with their long axis.

to the long axis of the tubules rather

CHAPTER XXXIV.
PROTECTION OF THE VITAL PULP.
The Normal Pulp has no

tactile sense, neither is

it

responsive to

thermal changes even though they vary considerably from the body
temperature.

When Robbed

of Its

Normal Covering and Protection the reThe sense of touch

verse of the above conditions quickly develops.

becomes very acute and any contact with foreign substances causes
great pain. This is best illustrated when a tooth is broken through
its crown by a blow, thus exposing the pulp.
At first the pulp may
be touched with the finger or an instrument without the knowledge
of the patient but in a very few minutes the same will cause unbearable pain. Also at first the cold air does not affect the pulp, but, coiiicident with the development of the tactile sense, comes a repugnance to the cold.

The Chief Idiosyncrasy

of the Pulp

is

its

response to thermal

changes and especially to cold, when these changes are rapid or the
pulp is in any way hyperemic. A normal pulp will tolerate without response quite a range of temperature when the change is brought
about slowly. This is generally the case when the pulp is covered
with the full crown of the tooth. But when, through decay or other
causes, this covering is all or partially lost, the changes are so rapid
that the peculiar responsive features spoken of are developed.
The Recuperative Powers of the Pulp are very slight, the least
of the soft tissues of the body, as

from only the

initial

it

will regain a healthy condition

stages of disease.

a feeble effort to protect itself

up the dental tubuli with

when

calcic

It will

many

the irritation

is

times

mild by

make
filling

matter or a secondary construction

of dentine, through the activity of its odontoblastic layer of cells.

Even

this reparative process

must not be vigorously inaugurated or

the death of the pulp will result, proving that these reparative meas-

ures on the part of the pulp are pathological, rather than physiological in nature.

The Protection

of the Pulp

from

its

greatest

enemy,

sudden

thermal changes, is most essential and as most of our desirable filling materials are good conductors of heat and cold it becomes necessary to place some substance which is a poor conductor between the
filling

and the dentine,

this

operation being termed "capping the

pulp."
204

PROTECTION OF THE VITAL PULP

205

The Indications for Pulp Protection are not always

clear,

but will

involve a consideration of the age of the patient, extent of loss of

dentine, location of the cavity in the tooth, location in the mouth,

length of time the pulp has been exposed, the stage of hyperemia,

and the

the general health of the patient

possibilities of

pulp infec-

tion.

The Age

of the Patient has a bearing on the successful issue of a

conservative treatment, as the teeth of the

young are more

easily

saved from further irritation through capping than are the teeth of
those past middle age, while at the same time they

more frequently under the same

be saved

if possible until

conditions.

demand capping

Again, the pulp should

the teeth are fully formed,

and many times

and the pulp

the teeth of the younger patients are badly decayed

in great

danger before the teeth are complete, hence

be conserved and devitalization avoided,

it

is

if

the pulp can

of great good to the

patient.

In Advanced Age the apical openings become smaller and many

much contracted, barely accommodating the vessels with a
normal flow of blood so that a very slight congestion may cause death
liccome

fi'om strangulation or gangrene.

When

a Large

Amount

of Dentine

the pulp as yet seems normal,

it is

Has Been

Lost, even though

safe practice to avoid the plac-

ing of the best conductors, as gold or amalgam, in close proximity

pulp as repeated shocks to the pulp through the filling from

may bring on hyperemia of that organ. In the use
of phosphate of zinc cement in such cases, there should be an interAcning media to prevent the irritating effect of phosphoric acid.
The Location of the Cavity is a factor in the demands for pulp

to the

thermal changes

protection, as well as the probability of success in extreme cases.

The

first

portions of the pulp to show hyperemic conditions are those

nearest to the point of irritation.

These congestions are more dan-

gerous when they appear in the body of the pulp, as they do where

decay approaches the pulp in the gingival third. Hence, when a

pulp is nearly exposed in this location it demands greater protection

and is at the same time harder to save than when the horns of the
pulp are involved.
The Location of the Tooth should be considered. Anterior teeth
are subject to greater extremes of heat and cold than are the molars,

hence the demand for preventive protection with the anterior teeth
At the same time their exposed position
should be remembered.
makes pulp-capping more hazardous and it should be practiced with
great care in this location.

Again,

less risk

should be taken in the

OPERATIVE DENTISTRY

206

capping of pulps in the anterior portion of the mouth as it is better

to remove a number of questionable pulps than to have one die in
the tooth with its consequent discoloration.

The Length
ing influences

of the
is

Time the pulp has been exposed

to the irritat-

to be taken into account as the shorter the time, of

exposure, the greater the probabilities of success in capping.

The Stage

of

Hyperemia should be

a safe criterion

where there

are actual pulp complications, as there will be in almost every deepseated cavity.

In active hyperemia, from causes other than bacteria,

from future irritation and insure its

However, when the symptoms of passive hyperemia
have developed it is not safe practice to attempt to restore the pulp
to normal and expect permanency.
it

is

safe to protect the pulp

conservation.

The Symptoms of Active Hyperemia Avhen the pulp demands

may

protection and success

First

be expected are:

When the excavated cavity exposed to the

air causes a con-

tinued pain not of a throbbing nature and the condition

is

relieved

by packing the cavity with dry cotton.

Second When a blast of air from the chip blower causes a quick,
sharp, shooting pain which subsides as quickly as it came.
Third When the pulp shows the power of accommodation as evidenced by tolerating a draft of cold air when the same is gradually

applied.

Fourth

When

it is

improbable that the pulp has become infected.

Pulps Infected With Bacteria should be extirpated as too large

and capped die and thereby bring reproach upon dentistry in general and chagrin to the careful operator.
a percentage of those exposed

The time was when the profession attempted to conserve all porfound to be vital, even to amputating the coronal
portion and leaving intact the vital stumps. However, this was in
the days of imperfect root canal treatment and filling and about as
many abscesses followed one kind of treatment as the other. But

tions of the pulp

at the present time the removal of a pulp

is

attended with such uni-

versal success that the capping of exposed pulps, in general,

is unwarranted, as most pulps are infected at the time of exposure. Even

in the case of an accidental exposure in the preparation of a cavity
neither cavity nor instruments are surgically sterile.

The General Health

of the Patient

must be

considered

when

choosing between the conservative or radical treatment of the pulp.

With the same conditions presented, the pulps in the teeth of the an-

emic patient, those wherein the vital processes are at low ebb, or the

PROTECTION OF THE VITAL PULP

elimination of the vital ash
cient, protective

means

is

imperfect and

of conservation are

cell

207
metabolism

is defi-

more imperative, while

at

the same time less risk should be taken in questionable cases.

With Robust and Particularly

Plethoric Patients,

tory processes run a rapid and riotous course, and

inflamma-

all

when

the pulp

has taken on any stage of hyperemia changes towards dissolution are

of rapid succession.

In Deep-Seated Cavities

it is

the dentine covering the pulp

not unlikely that the thin layer of

is

infected

and the pulp should be

protected from the invasion by the thorough disinfection of the over-

lying dentine by medication, previous to filling as well as placing

next to the dentine in question and under the filling a permanent
dressing which will exert a mildly antiseptic influence for some time

following the operation.

The Requirements

of the

Materials

Used

in

Protective

Pro-

cedures Are:

That they
be poor conductors of heat and
That they
be non-changing in character, both
consistency and bulk.
Third That they have no action upon the pulp.
Fourth That they may be introduced into deep seated
First

shall

Second

cold.

shall

as to

cavities

without pressure.
The Materials Advocated for This Purpose Are Numerous and
is flooded with preparations of a secret nature which are
warranted to save the pulp in almost any stage of dissolution, but
the operator who pins his faith to such slipshod methods will sooner
or later find that he has been duped and his grief is measured by
the extent to which he has employed these cure-all methods.
There Are Four Distinct Classifications wherein success may be
The treatment of each
expected in methods of pulp protection.

the market

class is here given.

First Class.
tle

In the Progressive Stage of Caries wherein but

dentine has been

lost,

yet a blast of air

causes a quick, sharp pain, passing

we

off as

lit-

from the chip blower

soon as the draft of air

form demanding protective measures.

This is the class most often neglected by the operator and many
times irreparable injury is done a pulp by placing in such a cavity
a filling of high conductivity, such as gold or amalgam. The patient
often believes that ''cold water leaks in about the filling" and may
is

checked,

visit

find the simplest

another dentist thinking that he has a poor piece of dentistry,

and the patient may be lost to an otherwise good operator, all through
the neglect of what may appear to the operator as a trivial matter.

OPERATIVE DENTISTRY

208

The Treatment

of the First Class

is

the thorough disinfection

and then the application of phenol, full strength, for a few seconds,
will be found unaffected by
The change is brought about
by the superficial coagulation of the albumen in the exposed ends
of the dental tubuli which renders them non-conductive.
Second Class. If, after one or two applications of the phenol as
above, the distress from the blast of air is not relieved, or if the

Avhen the cavity should be dried and

it

the blast of air from the chip blower.

pain

is

continuous while the surface of the cavity

exposed to the

is

met with in the nearer apof eases demands a media interven-

air it is probably of the second class as

proaches to the pulp.

This class

ing the dentine and the

filling.

The Treatment in the Second Class is as follows: Moisten the

cavity with phenol and evaporate to comparative dryness.
Then
paint the entire dentinal walls with a cavity varnish composed of
copal and

gum dammar

in alcohol

and ether

aration can be had at the dental depots or

solution.

Such a prep-

can be prepared by the

druggist. This should be thin and spread evenly, applying one, two
or three coats and drying with a draft of air from the chip blower
after each coat. When the varnish is entirely hardened the filling

may

it

be placed.

Third Class.

In the deep-seated stage of caries, where large

quantities of dentine have been lost, even though the pulps

seem to be protected by secondary dentine that

it is

tine.

is

much

may

retracted,

not safe to place a metal filling directly on the overlying den-

The

lost tooth structure

a material which
dentine.

is

should in a measure be replaced with

not a better conductor of thermal changes than

This should be neutral as far as irritating properties arc

concerned, non-changing and should resist the force necessary to

properly introduce the intended

The Treatment

filling.

in the Third Class

is

as follows: Phenolize

and

Varnish with the above cavity varnish and dry. Flow over
the dentine, covering most if not all of the axial or pulpal wall, or
dry.

both, according to the class of cavity being treated, a thin layer of

oxyphosphate of zinc cement, being careful not to include thereunder

any air bubbles; also apply without pressure. Then allow this to
In the
set to complete hardness, when the filling may be completed.
three classes given above it will be noted that coagulation of the
protoplasm in the exposed ends of the tubuli was the first step. This
is good practice from the fact that this layer of coagulum is the
least irritant to the remaining protoplasm of anything of which we
have knowledge. Phenol is very limited in the extent of its action

PROTECTION OF THE VITAL PULP

and

this layer of coagulation is

class, it will

eavit.y is

very thin.

209

Again, with this third

be noted that in addition to the use of the phenol the

given a coat of varnish before applying the oxyphosphate

This procedure

of zinc cement.

is

to prevent the irritating effects

of the phosphoric acid, particularly

while the cement

is

setting.

Again, should the zinc contain any impurities their action on the
*

pulp

is

prevented.

One

of the impurities of zinc

is

arsenic

and some

cements are thought to contain traces of this devitalizing agent. The

cavity varnish given above is quite impervious to this element when
it has been thoroughly hardened, a fact which should not be overlooked when

desired to prevent the action of arsenic trioxide in

it is

a particular direction in a dental wall.

Fourth Class. In deep-seated cavities Avhere there is a slight

pulp complication from thermal shock and where the thin overljdng
layer of dentine is probably infected to some depth and more deeply
affected in the process of caries, the dentine should be subjected to

quite a continued disinfecting process

and a portion of the

lost

tine restored with a non-conducting material to shield the pulp

den-

from

sudden thermal changes.

The Treatment

in the Fourth Class of cases

is

as follows:

The

cavity should be flooded with a non-irritating antiseptic, as camphol^henique,

pure beechwood creosote or

oil

of cloves.

cavity for twenty-four hours the result will be

If sealed in the

much

better.

The

cavity should be then wiped dry with absorbent cotton and a thin

paste of a cement containing sulphate of zinc spread over the dentine overlying the pulp.
to position

This paste should be thin enough to

when coaxed with a small instrument, yet

to prevent its spreading to surfaces not needed.

floAV

thick enough

Over

this spread

a layer of oxyphosphate of zinc cement and allow this to set hard before completing the filling.

In very questionable cases, the entire cavity may be completed

with the cement and the patient dismissed for six months, at the end
of which time,

if

the pulp

is

found

to be normal, a portion of the ce-

ment may be removed and replaced with

more permanent ma-

terial.

Pulp Preservers and So-Called Mummifiers should be avoided.

their name is misleading and such preparations are used without permanent success in the majority of cases. Their use simply
proclaims their users as unskilled laggards who will accept an uncertainty to avoid a little honest labor in pulp extirpation and root
filling.
The entire procedure is diabolical and cannot be condemned

Even

2J0

OPEUATlVE DENTISTRY

in too severe terms as a retrogression in dentistry, unskilled in prin-

and unwarranted in practice.

Gutta-Percha as a Protecting Covering

ciple

is not a success from the

and expansion under varying
thermal changes. When enclosed under a perfectly tight and unyielding filling, as all fillings should be, the change in bulk must
have a piston-like effect upon the contents of the dental tubuli result-

fact of its great range of contraction

ing in continued irritation.

CHAPTER XXXV.
PULP DEVITALIZATION AND REMOVAL.
The Reason for Devitalization and Removal of a pulp is its preswhen its future health is in danger, on

ent unhealthy condition or

account of environment in the

There Are

way

of dental operations.

Two

General Causes of diseased pulps.

First.
That succession of tissue changes which has its origin in
active hyperemia and its end in death due to the presence of bacteria
or their products inflammation.

Second.

Reparative congestion, due to traumatic injury, abnor-

mal thermal

stimuli, lack of

normal thermal stimuli and peripheral

nerve irritation.
Bacteria and Their Products

may enter the pulp tissue either

normal covering, the dentine, as in the case of
deep-seated caries, or through the general circulation by way of the
apical foramen, as in pyorrhea alveolaris, or in other pus conditions
in close proximity to the pulp vessels. We have no means of knowing that a pulp thus invaded has recovered, while we have complete
proof of their subsequent death from this cause, hence devitalizathrough a

tion

loss of its

indicated as soon as diagnosis

is

The Removal

is

clear.

of the Cause in reparative congestion of the pulp

will generally suffice to save the

vided the intervention

is

pulp from further destruction pro-

in the stage of active hyperemia.

The Traumatic Injuries most common in the production of pulp

congestion are blows upon the teeth either through accident or excessive malleting in dental operations rapid movement by the ortho;

abnormal stress in occlusion or articulation malocclusion

and abnormal movement of the tooth in its alveolus made possible
by the loss of supporting structures.
Abnormal Thermal Stimuli is a most potent factor in producing
pulp congestion. The pulp is particularly and peculiarly susceptible
to thermal changes and this idiosyncrasy is very rapidly magnified
dontist

as the stages of congestion progress.

is

The Reason for Abnormal Thermal Changes reaching the pulp

the loss of its natural covering, the dentine and enamel, through
denuding
by a recession or loss of the sub-gingival structures.
Lack of Normal Thermal Stimuli will induce a stagnated circu-

caries, erosion, abrasion or dental operations as well as the

of the root

lation with a sequela of degenerative changes within the

211

pulp

tissues,

OPERATIVE DENTISTRY

212

many times, in the death of that organ. While the pulp

profoundly affected by abnormal exposure to heat and cold it is
eminently essential to its normal physiological existence that it receive the stimulating effects of the ranges of temperature usually
found in food and drink while covered with the entire tooth.
resulting,
is

Peripheral Nerve Irritation

may

bring about reparative conges-

tion within the pulp causing excessive tissue waste

and a

precipita-

There are two classes of these

degeneration and pulp nodules, the latter

tion of lime salts within the pulp.

deposits,

known

as calcific

being the sequela of peripheral irritation, while

is

to

the result of

little local

calcific

passive hyperemias with

its

degeneration
cause related

abnormal thermal changes.

The

Irritation

May Be

in the terminal fibers of the nerves within

the pulp where the nodules are found, or in an approximating tooth,

or in a tooth in the same lateral half of the

reported where

evident that the cause

it is

has been stated,

is

jaw or face. Cases are

even more remote than

l)eing a local expression of a general neurotic con-

it

dition.

The Requirements
First.

of a Devitalizing- Ag-ent are

That the present and future health of adjacent

tissues be

maintained.

Second.

That

it

act painlessly.

That the dentine is not discolored.

Fourth. That devitalization be accomplished promptly, resulting
in a saving of time to both the patient and operator.
The Methods of Pulp Devitalization practiced at this time are
Surgical amputation while anesthetized and poisoning by the
two
Third.

application of arsenic trioxide.

To Determine the Method

to employ in any given case requires

an understanding of the pulp presented, its immediate surroundings,
and results sought. Also the time at the disposal of patient and

operator. While each of the two methods has its advantages, either
can be so used as to meet the requirements of a satisfactory means of
devitalization.

Anesthetization of the Pulp is accomplished l)y forcing into the

pulp either a solution of cocaine hydrochloride or novocain popularly
known as "pressure anesthesia."
Anesthetization Is Indicated:
First.

Second.

When it
When

is

desired to remove a normal pulp.

slight exposure of the

pulp exists which has not

yet reached the stage of passive hyperemia.

PULP DEVITALIZATION AND REMOVAL

213

Pulps whose circulatory system is active, but whose neris either deficient in development or is in the stages of
neuroparalysis. Access to the tooth is a factor to be considered and
will I'csult in the more frequent use of this method with the anterior
teeth.
The possibility of securing a sterile field of operation must
Third.

vous system

be considered as

ftn

advantage.

The Technic of the Operation Avhere a cavity exists

Apply the rubber dam. Excavate the affected dentine.
remaining cavity.

as follows

is

Sterilize the

Place in the cavity over the pulp a small pellet

Apply over

of cotton saturated with either cocaine or novocain.

this a piece of

unvulcanized rubber which will approximately

cavity and with blunt instruments, as

the mass in the direction of the pulp.

amalgam

fill

the

packers, gently force

It is essential that the

rubber

come into contact with the cavity margins at all points, or the
fluid will not be confined and its escape renders the attempt a failure.
If the first pressure of the confined solution upon the pulp
first

causes pain the operator should stop increasing the pressure, but

hold the advantage gained by not releasing the pressure already applied, Avhen, after waiting a

minute or two, the pressure

may

be in-

creased and finally the rubber can be kneaded into the cavity with

Sometimes one application thus made will comHowever, other cases will require two
or more applications. Between such applications the dentine should
be removed from over the pulp to complete exposure where this can
be done without undue pain to the patient.
When, after two or three attempts of the above method there seems
to be no effect obtained, it is generally best for both patient and operconsiderable force.

pletely anesthetize a pulp.

ator to resort to the application of arsenic, unless the case

is

suited

to favor the use of the high pressure syringe.

The High Pressure Syringe

is of service where no exposure exand where the necessary puncture for the introduction of the
syringe point can be included in the filling, or where the crown is
to give place to an artificial one as an abutment for a bridge.
The
method has to recommend it speed, a certainty of preserving the
color and is generally accomplished with little or no pain to the paists,

tient.

The Technic

in Its Use.

To the prescription given

cavity add fifteen drops of distilled

ing that

all joints

are screwed

up

access either on the dentinal walls or

for the open

water and load the syringe, seetight.
it

may

Select a point of direct

be on the external enamel

surface, preferably in the gingival third of the tooth,

liole

directly towards the pulp one millimeter in depth

and drill a
and as much

OPERATIVE DENTISTRY

214

farther as possible without causing the patient pain.

The

should be smaller than the syringe point that a close

fit

may

be secured.

made by

used

Syringes are generally constructed so that a drill

round bur will make a proper sized hole.

flattening a No. 1-2

The syringe
its

drill

to the hole

is

then applied to the opening with some pressure and

contents forced into the dentine.

It is essential that the solution be perfectly

imprisoned as

quires high pressure to force the anesthetic through the tubuli.

ter holding the solution at high pressure in contact

for one or two minutes

the hole to test

its

it

it

re-

Af-

with the dentine

should be removed and the drill applied to

sensitiveness.

If desensitized the hole should be

carried close to the pulp but not so far as to enter the chamber.

The

syringe should be again applied and with great care, as sudden force

may

cause pain by too rapid pressure upon the pulp.

Great Care Should Be Exercised when the pulp has been thus
nearly or quite exposed not to force into the pulp any considerable

amount

of the anesthetic as it is carried or forced beyond the apical

foramen, from which no good can result and harm may, particularly
if

the contents of an infected pulp are forced through to the tissues

of the pericementum.

Pulp Extirpation by Hypodermic Injection. Pulps may be removed very quickly and Avithout pain by injecting the solution of
novocain as given for use in extracting teeth in Chapter XLI.
If Correctly Done the Pulp May Be Removed or the tooth extracted painlessly. Extreme care as to asepsis must be given. This
danger of infection makes this method unsuited for general use, but
applicable to cases where haste is imperative or where trouble is experienced in the use of pressure anesthesia or arsenic devitalization.

The Removal

of an Anesthetized Pulp

is

accomplished by gain-

ing access to the pulp chamber from a position which will admit of
direct or nearly direct approach to each of the pulp canals, and making the opening large enough to admit light enough to see either by

image in the mirror, the entire floor of the chamsmooth sterile broach is passed down each canal to the

direct vision or the

ber.

First, a

apex of the root, to test the completeness of the anesthetization. If

no sensation is found the barbed broach is then passed to the apex,
This should be twisted to the right
preferably an extra fine size.
gently drawn from the cavity,
then
turn
and
complete
about one
which should result in the amputation and removal of the entire
This accomplished, the sides of the canal should be rasped
with a barbed broach of a larger size to remove any shreds which

])ulp.

may

adhere to the sides of the canals.

'

PULP DEVITALIZATION AND REMOVAL

To Check Hemorrhage, should that

ensue,

215

wash the chamber and

canals with cold water, dry as quickly as possible, flood cavity with

a drop of adrenalin chloride and apply a plug of dental rubber,

pressing this into the cavity and holding

move

the rubber

it for a few minutes.

Reand wash again with cold water. If hemorrhage

continues repeat holding the adrenalin confined longer than before

little more force.
Care should be used in this procedure as a sore tooth will result when the method has been used
too vigorously.
Again thoroughly bathe the canals with cold water

and applying a

or alcohol and dry.

Discoloration Results from allowing any blood to remain in contact with the dentine, even

though

it

another as the iron of the hemoglobin

be only from one treatment to

is

absorbed or forced into the

tubuli resulting in permanent discoloration.

dioxide

is

The use of hydrogen

not good practice until the blood has been washed from

the dentinal walls as

oxidizes the iron of the hemoglobin

it

and

dis-

into

the

coloration will result.

Post-Extirpation Pains

may be prevented by pumping

canals phenol with a smooth broach continuing this until the nerve

stump

at the

effect of

sealing

foramen

is

bathed with this agent.

coagulating the mouths of the dental tubuli, resulting ^n

(/>

which may cause discoloration.

^^

them

to agents

r ,

erly filling the pulp canals.

Immediate Canal Filling in these cases is sometimes practiced

where lack of time demands a hurried completion of the case and
But so
is quite successfully accomplished where all is just right.
times ideal conditions for canal

filling

are not obtainable that

condemned. However, if there is to be immediate canal filling the pulp canals should be bathed with water
and dried with warm air, flooded with phenol and again dried, this
its

universal practice

is

time with the aid of absolute alcohol,

when

introduced as outlined in the chapter

Canals.

"

This also has th^

It Is the Best Practice to Dress the Canal or Canals for a few

days with a stimulating anodyne which is at least mildly antiseptic,
as the anesthetizing of the pulp has probably so much affected the
tissues in the apical space that there is nothing to guide us in prop-

many

on

the canal filling

"The

Filling

may

of

be

Pulp

'

Devitalization

With Arsenic Trioxide

is

the method in most fre-

quent use and although not always to be preferred to anesthetization, it may be used in almost any case with satisfactory results.
Arsenic Should Be Combined With Some Agent to allay the pain

^^

OPERATIVE DENTISTRY

216,

caused by

its

application as

it

is

a most powerful escharotic and

the clear arsenic applied to a pulp will often cause great pain.
of the most popular mixtures

To

is

One

here given:

Arsenic trioxide

gr. v.

Cocaine

gr. xv.

Creosote

Q. S.

ft.

stiff

paste.

added enough lamp black to make the above a

that it will have a contrasting color with that of

this should be

dark gray color so

the tooth to assist in placing

The Technic

it

in the exact location desired.

of its application

is

as follows:

The cavity should

be thoroughly protected and dried, preferably under the rubber dam.

Foreign matter should be removed from the cavity and the same
thoroughly sterilized, the softened dentine removed and the pulp apI)roached to as near exposure as possible without causing the patient

Complete exposure is not necessary. Again sterilize the cavity

and dry. Bathe cavity with phenol and again dry. With the enamel
hatchets secure a definite cavity margin, particularly if cavity is in
the gingival third. In cavities that are sub-gingival build in amalgam as high as the gum line or at least one or two millimeters high,
being sure not to let this approach the pulp exposure or the point
Ashcre the application is to be made.
Take, of the above paste on
the point of a flat excavator, a quantity equal to about one-fourth
the size of a common pin head and apply very close to, but not directly on the exposed pulp. B.y very close is meant within one-half
millimeter. Place over this a piece of spunk the size of a pin head,
or larger if cavity is large and roomy, which has been dipped in
creosote and then pinched in a napkin to dryness, putting into place
in such a manner as not to cause pressure on the pulp. The retaining filling may now be completed with amalgam, cement or temporary
pain.

stopping.

Amalgam

as a Retainer of arsenic has the advantages of

a tight filling at the margins.

Nothing

will pass

through

making
and it

it

the most easily removed if it is applied where there are frail overhanging enamel walls which a chisel will easily cleave; or if the
amalgam has been but partially mixed with not enough mercury,
resulting in a mealy filling or where a great excess of mercury has
been used, that is to say where a most poorly manipulated amalgam
has been used resulting in its being cut with a bur much more easily
than cement, an advantage in cases where a tooth becomes sore to
is

pci'cnssion.

PULP DEVITALIZATION AND REMOVAL

Cement

217

as a Retainer of arsenic has the advantage of setting

quickly, thus removing the danger, in occlusal cavities, of the patients causing themselves pain

than amalgam or stopping.

times sets so well that
ties

it is

by biting on the

With

ing pressure on the pulp.

fillings

anterior teeth

Its only

is

it

disadvantage

hard to remove and

its

is

and producmore sightly

that

it

some-

adhering proper-

maj- result in dragging or lifting the application from

its place-

ment, during the manipulation of introduction.

Temporary Stopping

as a Retainer of arsenic has to

recommend

removal with warmed instruments and especially

if its surface has been treated with a blast of warm air.
The dangers in its use lie in the difficulty in preventing pressure upon the
pulp either when applied or in mastication.
it

the ease of

as

Cotton as a Retainer of arsenic should be entirely discontinued

it has nothing to recommend it and everything to condemn it.
Caution in the Use of Arsenic about the teeth is of great impor-

its

when used it must be sealed in the dry cavity absolutely

moisture proof and particularly when any of the cavity outline is

tance and

sub-gingival as any leakage at this point will result in great destruction to the

gums and

alveolar process.

frequent and the injury thus done

is

Such accidents are

all

too

never fully repaired.

The Length of Time an Arsenical application should be

left in

most uncertain and there seems to be no set rule. Neither

the condition of the pulp nor the amount of dentine intervening can
be taken as certain in judging the time. However it is most common practice to see the case in about one week's time, as in this
time a majority of the cases will have become devitalized and the
natural process of exfoliation has taken place between the dead pulp
the tooth

is

and the living tissues at the apex of the root enabling the operator
remove the pulp without pain or hemorrhage.

to

Primary Soreness of the Tooth to percussion generally indicates

If an attempt is made to remove the pulp

the death of the pulp.

too soon great pain will result as the pulp

is

yet vital, hence

best to wait until the pulp has been fully affected.

the primary soreness and particularly during the

it

is

Again during

first

twenty-four

hours of this condition the patient cannot tolerate the instrumentaSuch cases should be left from twenty-four to
tion necessary.
forty-eight hours from the time pericemental soreness develops, having applied to the gum over the afflicted tooth aconite and iodine
when it will generally permit of treatment.

Secondary Pericementitis

is

dangerous to the sub-dental tissues

OPERATIVE DENTISTRY

218

and no arsenical application should be allowed

second attack appears, as the loss of the tooth
sibilities

is

to

remain until

this

not beyond the pos-

of such neglect.

The Treatment
cavify

is

of Arsenical Poisoning due to

its

Remove everything from

as follows:

escape from the

the tooth cavity.

Flood the cavity and destroyed tissues with a forceful stream of

tepid w^ater to remove all traces of the arsenic not yet absorbed.
With a sterile spoon excavator dissect and curet away all necrotic
Again flood the
tissue continuing until hemorrhage is produced.
parts with warm water.
Dry with a cotton ball and lightly paint
the wound with aconite and iodine, repeating the treatment every
other day until a healing is effected.
When Pulp Returns Partially Devitalized as is evidenced by sensation, particularly in the apical third of the canal, it is best to open
the pulp chamber and amputate with a sharp spoon excavator only
the coronal portion. Wash chamber with warm water and dry with
warm air. Apply absolute alcohol working same towards the apex
by the side of the pulp as far as possible without causing pain, following this with thorough desiccation with warm air. Then seal in
a dressing of phenol and dismiss for one week or even longer and
the case will usually return with devitalization complete. This treatment is particularly indicated in young teeth where the apical fora-

men

is

large.

The Removal
practically the

of the

same

the latter case there

Pulp following arsenical devitalization

is

as that following anesthetization, except that in

is

danger of going beyond the apex, while with

the arsenic devitalization method, the greater danger

is

in not ex-

tirpating the pulp entirely to the apex through mistaking a vital

pulp stump within the canal for vital tissue beyond.

Immediate Canal Filling following arsenical devitalization
quite universally practiced

and

is

generally satisfactory.

is

However,

is followed by mild or severe pericementitis,

might be averted by dressing the canals with a mildly antiseptic anodyne of a stimulating nature for a few days before filling
the pulp canals.
All Treatments Above Referred To in this chapter should be

too large a per cent

v/hich

carried out with the rubber

ter

dam

in place at each sitting.

on "The Filling of Pulp Canals.")

(See chap-

CHAPTER XXXVI.
MANAGEMENT OF PUTRESCENT PULP CANALS.
By "Putrescent Pulp Canals"

is

meant that condition

in these

spaces resulting from putrefaction.

By

"Putrefaction"

is

meant that

serial,

progressive decomposi-

tion through which albuminous substances are finally resolved into

the end-products, hydrogen sulphid

(HgS), carbon dioxide (CO2),

ammonia (NH3), water (H2O), and hydrogen phosphid (PH3).

distinguishing feature of the process

is

the evolution of malodorous

gases.

The Presence of Bacteria is necessary to the process of putrefacand all such cases must be approached with this fact in mind,
and antiseptic measures and precautions are paramount from the

tion

beginning of the case to its termination, that the pericementum

not be involved in the destructive process.

may

There Are Four Classes of Putrescent Pulp Canals, according to

manner in which they are presented, symptoms present and the
method of treatment.
First.
Those cases where the canals are open and exposed to
the fluids of the mouth known as "open putrescence" and which are
generally the result of the encroachment of caries.
Second. Those cases wherein the pulps die under a filling or a
layer of affected and infected dentine, the integrity of which will
the

not permit of the passage of fluids or gases.

"closed putrescence" and

is

This

is

known

as

the result of extrinsic infection.

Those cases wherein the crown is integral and the bachave entered the pulp tissue either before or after its death by way of the apical foramen, conveyed there
Third.

teria necessary to putrefaction

by the circulation of the blood. This class of cases, from the apparent autopathy is termed "autogenous putrescence." Such cases
are most likely to follow suppurative processes in close proximity to
the arteries leading to the pulp, yet cases are seen where no such conditions can be diagnosed, primary to the pulp symptoms, and are
generally traumatic.

Fourth.

Those cases wherein the destructive processes have been

to the pericementum, and are known as "complicated

communicated
putrescence."
its

There

may

be pericemental inflammation in any of

stages with or without soreness to percussion.

may

The

apical space

harbor pus without other communication than the putrescent

219

220

pulp canal or there

OPERATIVE DENTISTRY

may

be an abscess with a sinus passing through

the alveolar process and opening through the gum.

Treatment in General may be stated as involving the removal by

mechanical and chemical means of all products of putrefaction, thorough sterilization of all surfaces exposed, conservation of vital tissues beyond the apical foramen and the permanent closure of the
foramen to the passage of fluids and gases.
The Symptoms of Open Putrescence (Class One) are not marked
where the pulp is entirely putrescent, unless there are pericemental
complications, when the case would come under the heading of complicated putrescence. When a portion of the pulp is yet vital it is
probable that the pulp is undergoing a cellular disintegration through
surface ulceration.
This is usually a painless process and is responsive only to the encroachment of foreign substances which lacerate its tissues or produce pressure within its substance.
Such cases
call for sterilization and extirpation.
However, with simple open

putrescence the symptoms are largely objective, the operator discovering the conditions through instrumentation, and the noxious
gases encountered.

Treatment of Open Putrescence.

Excavate the cavity to comFlood with a stream of water

from the syringe. Apply the rubber dam and sterilize all teeth and
surfaces exposed.
For this purpose use a ten per cent solution of
formaldehyde to which has l)cen added a small amount of borax.
Another efficient sterilizing agent is bichloride of mercury, in the
proportion of one part to five-hundred of cinnamon water. Mechanically remove the contents of the pulp chamber and flood the open
cavity with hydrogen dioxide, repeating the dioxogen two or three
plete exposure of the i)ulp chamber.

times or until active effervescence ceases.

and evaporate to complete dryness.

With an

Apply

absolute alcohol

extra fine barbed broach

mechanically clean each root canal with hydrogen dioxide.

Care

should be taken not to force any of the putrescent matter through

the foramen. Remove the contents of the canal, portion by portion.

The canals should then be dried with

alcohol evaporation.
Follow
with a fifty per cent solution of sulphuric acid which is allowed
to remain three or four minutes when it should be thoroughly diluted
with water and the canals dried. Apply campho-phenique and desicthis

For the final dressing flood with phenol, pumping

apex of said canal with a smooth broach. To this add a
paste made by mixing iodoform with phenol sufficiently stiff to be
handled to the cavity on a large spoon excavator. If crystallization
takes place add a drop of water. Avoid glycerine or alcohol. By a
cate to dryness.
it

to the

MANAGEMENT OF PUTRESCENT PULP CANALS

pumping motion

of the broach the paste will be thinned

221

and foUoAv

the phenol already in the canal to the apex.

By

alternately adding the paste

and absorbing the excess phenol

the canal can be filled with a comparatively thick paste.

Fill the

pulp chamber with a pellet of dry cotton. Seal the cavity with temporary stopping or cement, preferably for a Aveek or ten days, when

permanent canal
pulp is encountered in the apical third
will have been devitalized by the phenol and that without pain or

the case will almost invariably return ready for

filling.
it

If a shred of vital

noticeable soreness.

The Chief Objection

Form of Treatment is the obnoxious

The deodorized preparations, however, will

to This

odor of the iodoform.

Care should be taken that the

times and finally deposited in the foun-

not accomplish the desired results.

iodoform

is

kept moist at

tain spittoon.

and the student

the above

is

all

Each teacher has a

is

different treatment for putrescence

advised to familiarize himself with

a one-sitting, successful treatment and

all.

However

its trial

is

ad-

vised particularly where other methods have resulted in pain to the

patient

and oft-repeated

visits to

the dental chair.

In Cases of Long Standing Putrescence, Avhich are generally open

cases, the dentine is thoroughly saturated with poisonous ptomaines,
These must be gotten rid of and
change these irritating
gases and poisonous liquids into non-irritating and non-poisoning
liquids and solids.
This is most successfully done through the use

amido acids and end products.

the most expedient method

is

to chemically

Formaldehyde, however, is very irritating to vital

and should not be brought into contact with them. There-

of formaldehyde.
tissues

Also
its use is contraindicated in cases of large apical foramen.
not indicated in cases where a portion of the vital pulp remains, as
many times intense pain will be induced. To modify the irritating

fore

effects there may be added to a ten per cent solution of formaldehyde an equal bulk of either phenol, creosote, or creosol, the latter
being preferable. This should be scaled in the cavity and crown ends

of the canals for twenty-four or forty-eight hours before thorough

broaching of the canals

is

attempted.

Following the removal of the

and
compounds resulting

al)ove treatment the canals should receive a bath first of water

then of alcohol to carry away

in solution the

from the chemical action of the formaldeh.yde.

Animal Fats, which consist of carbon, hydrogen and oxygen, ai-e
liable to be present in abundance in recent cases of putrescence and
should be removed from the dentinal walls as they readily undergo
fermentative decomposition.

Operative dentistry

222

Their Removal Is Best Accomplished by saponification through

This should be applied at the time of
broaching the canals, using a platinum broach. Following its use
the action of sodium dioxide.

the canals should receive a water bath.

Symptoms

of Closed Putrescence (Class Two).

cence without complications

is

Closed putres-

usually of short duration and

when

they are presented for treatment before complication there generally

remains a portion of the pulp in the apical region yet

The

chief pathognomonic

symptom

is

vital.

that heat produces paroxysms

of pain while cold applications bring relief.

The Treatment for Closed Putrescence is to apply the rubber dam

and with a small drill open directly to the pulp chamber when temporary relief will be immediate. The opening should then be enlarged and the necrotic pulp tissue removed. If no vital pulp tissue is found the case should be proceeded with as before outlined
for cases of open putrescence. When a vital portion of the pulp remains nothing will be more palliative than the phenol and iodoform
This paste will also devitalize the
remaining portion of the pulp. Pressure anesthesia is certainly not
indicated in such cases from the liability of infecting the pericementum. Neither is an arsenical application permissible within a pulp
canal, hence the phenol treatment is the best practice.
paste treatment already outlined.

Autogenous Putrescence of the Pulp (Class Three) are occasionmet with and may be of long standing without complications of
the apical tissues and only discovered when the dentine of the crown
is found to be non-vital.
Such cases are generally of traumatic
ally

origin primarily, the putrescent condition developing long after the

death of the pulp by the egress through the apical foramen of

facultative anaerobic bacteria.
Such cases are dealt with, when
treated, as any case of closed putrescence, excepting that extra
precaution as to access must be taken as the admittance of the
air to such cases seems to render the putrescent matter most viru-

and the dangers of complications are most extreme. Cases prewhich may be classed as autogenous are
generally complicated when they come to the dentist as the complication is the cause of the patient's visit, when they would be

lent

sented, of recent origin,

classed as a case of closed putrescence.

Their cause

is

the en-

trance of infection through the circulation, the bacteria having

been picked up in pus areas not far distant from the apical foramen. Strictly speaking there are no autogenous diseases or conditions, such as auto-infection as all in this life is the result of ex-

MANAGEMENT OF PUTRESCENT PULP CANALS

trinsic causes

more or

less

223

remote from the body but the classificais given, based upon

tion of autogenous putrescence of the pulp

the same theories and principles

as

those

applied

in

general

patholog.y, wherein the

immediate cause is not at all apparent.

The Symptoms of Complicated Putrescence (Class Four) vary
from slight soreness to percussion to the symptoms accompanying
most violent and acute inflammatory processes even with general
febrile disturbances.
Other cases will present themselves with an
entire absence of all the above symptoms, the only evidence of
pericemental complications being detected by observation or instrumentation.

It is generally true that the acute cases show the

more marked symptoms, and the extremes of easy and difficult
management are encountered, whereas Avith chronic complications
the symptoms are not so marked and generally yield to stereotyped methods of treatment except where great destruction of tissue has taken place, where such cases should come under the head

of surgery.

The Treatment in Complicated Putrescence

symptoms presented and the conditions found.
procedure
tion

is

as varied as the

is

The

first

order of

the removal of the cause which includes the elimina-

of the putrescent conditions within the pulp

aseptic precautions.

presence of pus

is

If

the pericementum

is

canal under

only inflamed and the

not probable, the treatment

is

the same as that

outlined for uncomplicated putrescence, adding external applications to the

gum

over the affected tooth to stimulate resolution.

Painting with aconite and iodine

is

suggested.

In Acute Complication where pus has formed and upon broachis freely evacuated down the pulp canal, it is the best of surgery to allow free drainage by this route for twenty-four or forty-

ing

eight hours before attempting further treatment.

At the end

of

this time the most active symptoms will have generally subsided

and the case can be proceeded Avith. HoAvever, there have been
some cases so deeply affected bej'ond the apex of the tooth that external pointing on the alveolar Avail is probable and only a\'oided
by immediate extraction of the tooth. In such cases the salvage of
the tooth depends upon the ability of the patient to Avithstand the
pain fb the termination. They may be assisted in this through the
general administration of sedatives.
vulsives to the

gum

Avill

Locally the application of re-

hasten the external pointing.

Evacuation

ushers in the stage of convalescence and the treatment of the pulp

canals

may

be proceeded with.

OPERATIVE DENTISTRY

224:

In Chronic Complications of Putrescence Avhere the drainage is

through the pulp canal only, the case may answer to the treatment of the pulp canal. HoAvever other cases will demand special
treatment for the sterilization of the enclosed pocket beyond tlie
foramen. The greatest danger in the treatment of this class is in
suddenly converting them into acute form. This can generally be
avoided by attempting the treatment of the sub-dental conditions
only following complete and absolute sterilization of the communicating canal. That there is a communicating canal in these cases
of so-called ''blind abscesses" is self-evident and this opening permits of treatment without the use of pulp canal drills, a method
which is not advised and a practice Avholly unwarranted, resulting, many times, in rendering the case beyond the possil)ilities of
cure.

must have additional drainage it is a case of surgiprocedure and the point of attack should be through the external alveolar wall, a method sometimes resorted to with good reIf the case

cal

sults.

Chronic Alveolar Abscess With Sinus, generally with the opening

is a complication resulting from a
closed case of i^utrescence of long standing and when not associated
with necrosis or denuded root is not, as a rule, hard to manage.
on the external alveolar wall,

The Treatment
sterilize the

of Chronic Alveolar Abscess

pulp canal, then the fistulous tract.

is

to

The

thoroughly
tract should

be established by forcing hamamelis or cassia water through the

pulp canal and out through the sinus.

Follow

this

with phenol or

aconite and iodine only sufficient to cauterize the entire surface of

the tract thus destroying the fibrous lining, improperly called the

Then proceed

"pyogenic memhrane."

as with

any other case of

putrescence, filling the pulp canal before closure of the sinus has

been effected.

Some

advise the entire treatment and canal filling

at the first sitting, but

tained

if

case

is

it is

probable that better results will be ob-

allowed a week or ten days between the

treatment and the canal

dentine walls.

filling

first

for complete sterilization of the

CHAPTER XXXVII.
THE FILLING OF PULP CANALS.
It Is

Necessary to Fill Pulp Canals following the removal of the

pulp, to prevent the exit of bacteria or their products to the

tis-

sues beyond the foramen, and to prevent the dissolution of the en-

compassing walls of dentine.

Ready

and should receive the root filling

than air and it is not desired to
again reach the pericemental tissues for treatment. To render a
canal void of all else than air is by no means universally easy, yet
it is the object sought and the conditions are not ideal until this
Pulp Canal

when

the canal

Is

is

void of

result is obtained.

for,

all else

This involves the removal of

moisture, bacteria and their products as well as

all

all

pulp

tissue,

medicines and

chemicals used in the process of treatment.

The Perfect Pulp Canal

Filling

is

one which permanently occu-

pies the entire space of the pulp canal

men
and

and

closes the apical fora-

to the exit or entrance of all substances, particularly gases

fluids.

of a Material for Filling a Pulp Canal are

be non-soluble in the fluids of the body, that it be non-irritating to soft tissues, permanent as to bulk and consistency, not
subject to putrefaction or chemical changes, capable of easy introduction, and it is an additional virtue if it can be again removed

The Requirements

that

it

from the canal after months or even years of occupancy.

The Objective Point in Pulp Canal Filling is in the region

This point must be reached, made surgically and
peutically clean, completely vacated and then permanently
foramen.

of the
therasealed

with a suitable material.

Small Pulp Canals and particularly if they are tortuous, are a
hindrance to always attaining ideal results and even, in rare cases,
thwart effort to save teeth thus afflicted.

The Means of Cleansing and Vacating small and tortuous canals

are both mechanical and chemical.
It Is
ible,

Best Accomplished mechanically by the use of small,

extent of entrance by cutting

away

the sides to increase their cal-

iber until broaches of other forms will be admitted.

is

flex-

blunt-pointed twisted reamers, which enlarge the canal to the

assisted chemically

by flooding the canal with a

225

This process
fifty

per cent

OPERATIVE DENTISTRY

226

solution of sulphuric acid, as this

tinal walls, thus facilitating the

In Cases

Where

Avill

dissolve

and soften the den-

enlargement of the canals.

the Root Is Bent on Its

Long Axis

it is

essential

that the broach should be rounded and blunt of point that

follow the canal and not cut

its

side Avail at the

it

may

bend of the canal,

produce a shoulder and hinder further progress. This

and requires preparation on
the part of the dentist of every broach used in this class of work,
fis all broaches that come from the factory have a very sharp point
entirely unfitting them for opening crooked pulp canals.
This
blunting process is best accomplished by holding the end of the
broach at an obtuse angle on the face of a fine cuttle fish disk while
revolving in a dental engine, at the same time tAvisting the broach

which
is

will

essential with the finest of broaches

from right

to left.

The Carrying of Cotton into a Pulp Canal is of assistance in the

drying process and requires the special preparation of a broach to
facilitate the application.

The Cotton-Carrying Broach is prepared by taking a perfectly

smooth fine hook broach and by grasping Avith a pair of flat-nosed
pliers, say the sixty-fourth part of an inch from the end, rocking
the pliers ])ack and forth until the end is broken off. This results
in a blunt broken surface on the end Avhich engages the fibers of
the cotton twist and prevents same from slipping up the broach
lowai'ds the handle, as

cotton to

])e

it is

introduced into the canal, alloAving the

carried to the depth that the caliber of the canal

Avill

permit.

The Cotton Is Applied to the broach by taking a fcAv fibers between the thumb and first finger, placing around the broach,
tAvisting the handle of the broach to the right, and at the same
lime moving the thumb and finger to roll the broach in the same
direction.
The use of Red Cross absorbent points is better
practice.

Intended to Leave the Cotton in the Canal as a dressing,

tightly at the point only, and Avhen introduced
to the entire depth of the canal tAvist the broach to the left part of
a turn and use a tamping motion, and the cotton Avill be disengaged and packed in the canal.
If It Is

roll

upon the broach

Intended to Remove the Cotton With the Broach, roll

entire length and Avhen the cotton is being introduced,
as Avell as during AvithdraAval, tAvist the broach to the right continuously, as this Avill cause the broach to maintain a tight hold on
If It Is

tightly

its

THE FILLING OF PULP CANALS

the cotton.

When

all

has been removed grasp the cotton between

the fingers, tAvist broach to the left and cotton

The Most Popular Root

tion of Avhich

is

Filling of today

is

is

easily disengaged.

gutta-percha, a por-

dissolved in chloroform to facilitate

HoAvever the

tion.

227

less

amount

of chloroform or

its

introduc-

any other

fluid

completed filling, the better, as these constituents are not permanent.

Methods of Use. The canal must be entirely vacant except the
air which it contains, for its entire length, not forgetting that this
includes the removal of all moisture possible.
The First Step Is to Replace This Air Avith a fluid that is a solA'ent for the gutta-percha canal filling.
A very popular substance
for this purpose is the oil of eucalyptol as this, in addition to being
a solvent for gutta-percha, is slightly antiseptic and, being an oil,
does not mix Avith any blood serum or moisture that has, perchance, escaped the operator's notice in the apical end of the
canal, or may have a tendency by capillary attraction to exude
into the mouth of the foramen, floating the same fi'om the Avails.
The Introduction of Chlora-Percha is accomplished by dipping
there

is

in the finally

a small broach into the container and carrying the broach thus
loaded, to each canal.

Carry same

ing motion the chlora-percha

is

to the

mixed

foramen and by a pumpand no

Avith the eucalyptol,

air or moisture will be imprisoned Avithin the canal.

The Introduction of the Gutta-Percha Canal Point is here accomplished b}' grasping the large end, Avhich may be flattened
with the cotton pliers or attaching same to the warmed end of a
canal plugger, then AvithdraAving the smooth broach Avhich has
been alloAved to remain part Avay up the canal and immediately
entering the small end of the canal point and shoving entirely to
place by a steady gentle pressure.
The Size of the Canal Point should be great enough to entirely
It should be a])out a millimeter longer to permit of
fill the canal.
slight

tamping

at the

mouth

of the canal.

The

previously ascertained by measurement and

size

trial,

may have been

Avhich

is

good

An

experienced operator Avill, in most

instances, 1)0 al)lc to judge as to size AA'ithout measurement.
Slight Flinching on the part of the patient or the sense of fullness is quite a trustAvorthy guide as to ha\"ing reached the apical
practice for a beginner.

end of canal in recent cases of devitalization, but such symptoms

should not be sought in devitalized teeth of long standing, particularly if there has been a loss of any of the tissue in the apical
space.

HowcA'cr, in these cases as Avith

all

others, care should be

228

OPERATIVE DENTISTRY

taken that perfect and complete filling of the apical foramen has
been accomplished, which is ideal. Yet to fill slightly beyond the
canal by a fraction of a millimeter is a less error than to not entirely fill the canal.
The opening of the canal should now be
tamped solid, which process is aided bj' Avarming the protruding
end of the canal point.
Cleanse Pulp Chamber of all traces of gutta-percha and case is
ready for final operation.
The practice of filling pulp cliamhers with gutta-percha in any
form is condemned as it is in no way suitable for the scat of a filling.
Cement, amalgam or tin is preferable.

CHAPTER

XXXVIII.

MANAGEMENT OF CHILDREN'S TEETH.

The inanagement of children's teeth presents two difficulties admanagement of the teeth of adults.
The First Difficulty and many times the most important is the
management of the child. Children are very susceptible to external influence and even when quite young believe all they hear.
The conversation of the older ones about the home pertaining to
the "horrors" of the dental office, has many times so poisoned the
mind of the child that it prejudges the dentist and his efforts to
the extent of preferring any other punishment rather than meet
the dentist, even for an examination.
The First Visit of a Child should be made one, wherein there is
an entire absence of pain, or even inconvenience on the part of the
ditional to the

child.

Such

should be repeated till absolute confidence has been

After this has been thoroughly established, the children
of a clientele will prove as easily managed as the adults, and in
after years are the most tenacious patrons, seldom changing their
dentist through life.
The Second Difficulty with the management of deciduous teeth
is the comparatively short life of the most careful operations.
The
visits

secured.

All about them is a panorama

can hope at best for only temporary results.
Parents should be given to understand this feature of the services
and not be led to misjudge the skill of an operator by the results
of operations on the teeth of children.
Early Attention is imperative and the keynote to success. All
small enamel defects should be sought out and fillings made as
soon as such are found to exist. It is hopeless to attempt the salvage of deciduous teeth after the pulps have become involved and

teeth are themselves but temporary.

of change

and

Ave

subdental disorders have been established.

Oral Hygiene With Children should be established early. The

parents should receive thorough instructions as to the use of -the
toothbrush, with or without a dentifrice, as the child prefers, and
a daily attention established by the time the full temporary denture

is

erupted.

Frequent Visits to the Dentist are essential; even more than

with adults, as the destructive process runs a rapid course when
229

230

OPERATIVE DENTISTRY

once established, a few Aveeks' neglect often resulting in irreparaThese visits should be established at regular and fre-

ble injury.

quent intervals, as the most unhygienic conditions may result from

only a few days' neglect and upon earl}' detection and eradication

depends the success of interference.

Length of Time at Each Sitting should not exceed thirty minutes for a child under twelve years of age and should not exceed
one hour until after eighteen years of age. Great care should be

exercised in causing the child anj^ considerable

amount of

pain.

Better that the filling consist of temporary stopping to last but a

few days than to cause lasting memories of dental pains inflicted

by the dentist.
The Filling Materials to Be Used are limited to those of speedy
Dianipulation, and those requiring a minimum of convenience
form. This Avill place in the list, amalgam, tin, gutta-percha and
cements.

Cavity Preparation should be limited to the removal of the maand securing the cleavage of the
enamel in cavity outline by the use of the chisel. All else should

jor portion of deca.y, sterilization

be avoided.

Extension for Prevention, Extension for Resistance, Flat Seats

and Point Angles and all else in cavity
preparation so carefully applied to filling the teeth of adults
for Fillings, Line Angles

should be ignored

when dealing with deciduous

teeth.

If

decay

has not left the cavity naturally retentive, cement should be resorted to instead of cutting.
Cavities of Class One.

amalgam

Pit

and

fissure

should

be

filled

with

or tin under as dry conditions as can be secured Avithout

the rubber dam.

The use of the rubber dam should be restricted

and when used should be very

to the six anterior superior teeth

loosely ligatured.

Two. Proximal cavities in molars should be

Mith amalgam. AVhen the retentive form is not good in the
cavity without much cutting, the amalgam should be laid in soft
Cavities of Class

filled

cemelit.

When Two
r^ot

retentive

Cavities Exist in molar proximal space

it

is

good practice to

fill

which are

the tAvo cavities as one,

counting on refilling the cavitj- in the second molar if the first

molar is lost early, or perchance Avhen this has failed, Avhich it Avill
sooner or later, the cavities Avill return Avith independent retentive
form.

MANAGEMENT OF CHILDREN'S TEETH

231

Cavities of Class Three should be lilled with cement with rubber

dam

If decay has progressed till angle is lost or pardo not build to contour but fill as a Class Three.
Classes Four, Five and Six may be ignored.
Treatment of Exposed Pulps in Deciduous Teeth. Pulp devitalization with deciduous teeth should never be attempted. Pressure
anesthesia will not prove successful. Arsenic should never be applied to deciduous teeth. The risk is too great and is condennied
in every case.
If the pulp is exposed and aching, clean out the
debris, flood with Avarm water, dry and phenolize. Apply a pledget
of cotton saturated with oil of cloves for twenty-four hours.
When case returns, dry and again phenolize and apply a paste of
phenolized iodoform over Avhich place a filling.
If the pulp has begun to suppurate, the necrosed tissue should
be cut awa.y and the space filled with a paste made of oil of cloves
and the oxide of zinc powder, over which is placed a filling of temThe pulp will usually die under this Avithout
l)orary stopping.
in position.

tially so,

further pain.

When

the case returns, Avhich should be in about two or three

and filled Avith a paste made

from campho-phenique and iodoform and cavity filled Avith a

Aveeks, the canals should be cleansed

plastic filling.

Treatment of Abscessed Deciduous Teeth.

Such teeth should be

Avill generally have

alloAved or assisted to point externally, as they

progressed almost to the stage of pointing before the dentist

is

visited.

As soon as the active stage has subsided, the case should be

given the above treatment for putrescence and filled. If abscess
persists, as Avill occasionally be the case in spite of all methods, a
small hole should be bored in the buccal surface just sub-gingivally
to the pulp

chamber, leaving the

Inter-Proximal Grinding

is

filling in place.

of service Avhen filling

is

out of the

This is practiced much after the same method it Avas

used in primitive days Avith the permanent teeth.
The proximal surfaces are cut aAvay so that they are non-reten-

question.

tive to food particles

and the

sides of the remaining surfaces thor-

oughly exposed to the excursions of food in mastication. AVith

anterior teeth the contact point is thereby moved to near the
gingival line.

With

posterior teeth the contact point

is

removed

as far to the buccal as possible by Avidening the lingual end^rasure

This method is unvt the expense of both proximating teeth.

sightly in the anterior teeth

and not altogether

Avithout its objec-

OPERATIVE DENTISTRY

232

when used on posterior teeth, but it is nevertheless good pracmany eases as it materially retards the process of decay.
The Management of Permanent Teeth in Childhood constitutes

tions

tice in

one of the greatest trials of dental practice and is at the same time
These teeth are erupted at a time of
of the utmost importance.
life when the oral conditions are the most favorable to decay.
Again these teeth are expected to give their user the longest period
of service of any of the entire set of permanent teeth.
It

Requires Extra Vigilance on the part of the dentist to prevent

first permanent molars, as the parents are

irreparable injury to the

not usually aware that permanent teeth are present at this age

and do not

assist the dentist in detecting incipient decays.

More

expected and required of the first permanent molar than any

other tooth. It must stand the onslaught of the most unhygienic
is

conditions.
It

must give

position in the

its

possessor longer years of service and that in a

mouth most often subjected

to the stress of masti-

Slight faults in enamel should be sought out early and

with amalgam to be changed for gold in more mature years.
When badly broken down they should be restored to full contour
v/ith amalgam and crowned only when the second permanent molar is fully in position. If gold is used, it should be in the form of
the inlay under about fourteen years of age as the tooth should
not receive severe and prolonged condensing force till certain of
full development, which is from ten to fourteen years with the

cation.
filled

first

permanent molar.
In treating and

Treating First Permanent Molars.

root

canals

of

these

teeth

before

fully

foramen will many times be found quite

circulation

is

so great that devitalization

large.
is

filling

the

developed, the apical

In some cases the

difficult.
In un-

most

it is well to use a medicated root canal filling that is

easy of removal and instruct patient to return in a few months or

certain cases

perhaps a year for

Good Root

final filling.

Filling for

Such Cases

is

phenolized iodoform for

the canals, topped with gutta-percha base plate for the pulp cham-

ber and covered with amalgam. When the case returns it will
generally be possible to determine the length of the root and size

when a correct root filling of chlora-percha will be

In applying arsenic for devitalization in teeth that have

of the foramen
possible.

may be expected from their age, great care

should he exercised, as there is great danger of apical arsenical
poisoning which nearly always causes the speedy loss of the tooth.

not fully developed as

CHAPTER XXXIX.
EXTRACTION OF PERMANENT TEETH
General Consideration.

Under normal conditions tooth

extrac-

However, there is no oral surgeon

even of experience who meets with universal success. There are
abnormal conditions which render unsuccessful any attempts at
removal by ordinary means; but if the patient is placed under an
anesthetic there are instruments manufactured and competent and
able surgeons to handle them, that can remove the tooth entirel>',
and if need be the entire maxillae with it. Yet there is a limit to

tion

all

is

not a

difficult operation.

operations.

There

a time to stop.

All oral surgeons have had the same exwhere the unavoidable injury to the tissues
in removing the tooth would do more harm than alloM ing a small
part of the tooth to remain. To the laity, however, the skillful extraction of a tooth seems "quite a trick." For instance, the blackis

perience, finding cases

smith or a

man

of the teeth

tooth and

fail.

who has not made a careful study

may attempt to extract the
made the subject a study, although

of great strength,

and

their environment,

One who has

possessed of far less strength, removes the same tooth skillfully

and seemingly without the exertion of much muscular effort. Unproperly and scientifically applied, it accomplishes

less the force is

nothing but injury. If the force is applied in a proper direction,

with proper movements, the dislocation of a tooth is quite an easy
matter. The old saying that there is no rule without an exception,
and that the exception proves the rule, will apply to the rules for
extraction; for there is probably as much difference in the formation of teeth

and adjacent structure

different persons.

Therefore

which we can follow

teeth

is

it

as in the facial expression of

is difficult

literally in all cases.

best accomplished

to formulate
Still

by the application of

any

rules

the extraction of

scientific principles.

These principles properly applied will give better results than

extracting the teeth merely to get them out. For this reason avc
must study that which we wish to accomplish and how best to accomplish it, by considering the various shapes of that part of the
teeth which cause their retention in the jaw; also the structures,
strength and position of those tissues which hold the teeth in place.
Principal Retention.

The constricted portion of a tooth

233

at its

OPERATIVE DENTISTRY

234

neck serves

to retain the tooth firmly in the alveolar process,

constitutes

principal retention, by the process

its

and

grasping the

tooth at this point, assisted by natural adhesion of the tissues.

Opening Mouth of Alveolus.

tle

The alveolar process

is

just a

lit-

thicker or heavier at the neck of the tooth than just below.

The gingival part of the alveolus, the tooth's socket, is called the
mouth of the alveolus. This mouth once opened, Avhich can be accomplished by slight fracture at this point, the removal of a normal
tooth

is

made

How Can

easy.

By

This Best Be Accomplished?

application of force

This varies in different teeth, owing

in the line of least resistance.

to the difference in anatomical structure, the

number

of roots and

direction of eruption.

Three Forces Are Applied in the Extraction of a Tooth: Traction, Rotation and Pressure.
Traction
in using a

is

a pulling force

Pressure

then in another.

endeavoring to push
long axis.
in

it

is

the force

is

a motion, given the hantl

is

dental surgeon,

it

is

one direction

mouth

at

to a tooth

an angle to

its

mature years and

more strength than the
that Ave consider position and

If the patient is of

often the case possessed of as

movements and that

first in

we would apply

in or out of the

Position and Movements.

as

rotation

screw driver, but moving the hand

much

very essential

or

have so calculated these matters that the

under the control of the operator. It
is not Avell to give the patient to understand that avc think this
particular tooth is a very difficult one to extract, or that we are in
the least timid about performing the operation.

patient

is

Ave

at all times fully

Securing Patient's Confidence.

After

it

has been decided to

extract the tooth, the more precise and deliberate the operator's

more confidence the patient Avill haA^e, hence a firm but

instills into the patient's mind confidence in the operator's ability. In giving the positions of the patient and operator,
If such is not the
it is assumed that the latter is right handed.

actions, the

gentle

Ci)
'''

'-^

[[_

hand

case, the positions Avould be reversed.

The patient's head should be inshould be firmly fixed and absolutely under

Position of Patient's Head.

clined backward.

It

the control of the operator.

This can be accomplished in different

Avays in the absence of a dental chair Avith

conveniences, in Avhich case the operator

sort to very primitive means.

its

may

head

rest

and other

be compelled to

re-

EXTRACTION OF PERMANENT TEETH

With

235

All Superior Teeth the operator should stand back of the

patient and, a

little

to the right, placing the

crown of the head

against the chest of the operator, putting the left hand around to
the left of patient's head with the index finger holding the lip

Fig. 109.

An

improper position with the operator doing

his

work

at

away

arm's length.

from the alveolar process and at the same time lying against the
process, to detect at once any extensive injury which might result
from a fracture. The middle or second finger should be placed back
of the forceps Avhen the tooth

it

palatine process wlien the tooth

on the
is

left side; or

on the right

side.

against the

Then by

OPERATIVE DENTISTRY

236

Fig. 110.
Types of superior central incisor.s. The
the lingual, the third row the mesial, and the fourth

Exodontia.)

row shows the labial, the second row

(From Winter's
row the distal surface.

tirst

EXTRACTION OF PERMANENT TEETH

Types of superior lateral incisors. The

Fig. Ill
the lingual, the third row the mesial, and the fourth
Exodontia.)

lirsi

row shows the

row the

distal

237

labial,

surface.

the secoid row

(From Winter's

OPERATIVE DENTISTRY

238

pressing the patient's head firmly against the head rest, or against
the operator's chest, if using a low chair or stool, it is entirely
from under the control of the patient, Avli en inclined in a backward
position.

Fig.

The Position

112.

Position

for estracting superior incisors.

in Extracting the

Lower Teeth

is

nearly the same,

except that the relative position of patient should be lower. The

general position for all inferior bicuspids and molars is the same
In extracting inferior incisors and cuspids
as for the superior.

stand directly behind the patient, and use a straight or bayonet-

EXTRACTION OP PERMANENT TEETH

239

Tvpes ot interior central and lateral inctsDrs. The lii>i i"W sii.,i\ ilie labial, the
Kig. 11.*.
second row the lingual, the third row the mesial, and the fourth row the distal surface. (From
Winter's Kxodontia.)

OPERATIVE DENTISTRY

240

shaped forceps, such as are used in the extraction of superior incisors.

The patient's head should be the height of the operator's
waist line, he standing directly back of patient.
Position of Hands.
The index finger should press down the

Fig. 114.

Position

for extracting lower incisors.

lip and inspect the alveolar process.

The thumb should be
placed on the lingual surface of the process and the three remaining fingers should grasp the chin firmly, that the lower jaw may be

lower

fully

under control.

Operating^ at

Ann's Length.

In no case leave your patient or

EXTRACTION OF PERMANENT TEEtH

241

The first row shows the labial, the second row the
Fig. 115. Types of superior cuspids.
(From Winters Exolingual, the third row the mesial, and the fourth row the distal surface.
dontia.)

242

Ot^EftATlVE

step in front of hiiu, using the

bENTlSTRY

hand and your forceps

at arm's

length, for with the head at liberty a sudden twitch or jerk on the

part of patient would either destroy or misguide the force applied

and either thwart the

Fig. 116.

effort to

Position

injury.

is

he

(See Fig. 109.)

is

or,

wrong

direction cause permanent

Just as an operator

is

extracting the

often troubled by the patient grasping the

using the forceps.

This

perhaps, by

for extracting right superior cuspids.

increasing the pressure in the

tooth,

remove the tooth

is

arm

whicli

a serious matter, especially Avhen ex-

EXTRACTION OF PERMANENT TEETH

243

Iracting a lower tooth, as the line of force, which the operator

wishes to exert

is opposite to that in which the patient can exert

great force thus resulting in diminishing the poAver of the former.

Overcoming Resistance of Patient.

Fig.

117.

Position

At

this point the operator is

for extracting left superior cuspids.

even bordering upon crossness, perhaps getting the patient to desist for a moment, when the operation may be completed. The only precaution for guarding against
such a turn of affairs is perhaps a suggestion that the patient hold

justified in a sharp reprimand,

244

OPERATIVE DENTISTRY

the hands of a friend or grasp the

ing him

arm

or seat of the chair, instruct-

to give a vigorous pull just as

you

start to extract the

may assist him to endure the pain which is sometimes

unavoidable when local or general anesthetics are contraindicated.
tooth.

This

Mesial and distal application of forceps to a superior right cuspid when both
Fig. 118.
The forceps illustrated is the
adjacent teeth have been extracted in advance of the cuspid.
author's No. 4.

In Superior, Central and Lateral Incisors traction or force is apNext rotation. Why? Because this
its long axis.
Also,
is a single-rooted tooth and the root is slightly rounded.
should any of the adhering portions of the alveolar process be in
danger of removal, the rotary motion will loosen that portion from

plied parallel to

the tooth.

'

EXTRACTION OF PERMANENT TEETH

For example,

if

upon the removal

of a nail

245

from a board, part

would remove

of the board should adhere, the twisting of the nail

from it the adhering Avood by bringing it in contact with the greater body of the board. Next comes pressure, outAvard, or labial, because this

is

in the line of least resistance as the process

is

much

thinner on the labial than on the lingual aspect.

Do

not alternate the motion between labial and lingual pressure,

any pressure lingually accomplishes nothing but increased pain,
for before the tooth can be removed the mouth of the alveolus must
be opened and this can only be effected by labial pressure.
.

as

All change of force should be of a rotary nature, with a slight

remove the tooth upon

fracture, or giving of the process at the mouth of the

and

labial pressure,

the slightest

sufficient traction to

alveolus.

'

In Inferior, Central, and Lateral Incisors traction should be in

No

a line parallel with the long axis of the tooth.

sary because these teeth have

verse diameter, labio-lingual.

flat

rotation

is

Any

twisting or attempts at rotat-

ing these four teeth will only endanger their slender roots.
sure

is

slightly labial, because this

neces-

roots with their greatest trans-

is

Pres-

in the line of least resistance,

the process being thinner on the labial aspect.

Superior Cuspids.
to
It

remove
is

this tooth, as

considerable amount of force

it is

the longest tooth in the

is

required

human mouth.

generally most firmly seated and as a rule requires more

removal than any other. Slight rotation is required,

the first bicuspid and lateral incisor are in position.
The root of this tooth is not quite so nearly round as that
of the central incisors, but rotation should be applied to prevent
This
a fracture of the adhering process of the lateral surface.
rotation tends to peel or scale off any adhering process by bring-

force for

its

especially

ing

it

when

in contact Avith the firmer portion not disturbed.

Pressure must be steadily labial, as this

is

in the line of the least

"steadily outward," we do not mean to grasp the

tooth, and draw it out at right angles with the long axis of the

resistance.

By

tooth; but that in addition to the great

amount of

traction neces-

sary and the slight rotation there should be a certain amount of

labial pressure

upon the

process.

one case where this rule for the extraction of the superior cuspid may be ignored. That is when the first bicuspid and
In this case instead of
lateral incisor have just been extracted.

There

is

grasping the cuspid labio-lingually, place the beaks of the forceps

246

OPERATIVE DENTISTRY

rig. 119.
Types of inferior cuspids. The first row shows the labial, the second row the lingual,
(From Winter's Exodontia.)
the third row the mesial, and the fourth row the distal surface.

EXTRACTION OF PERMANENT TEETH

a short distance

up

into the cavities of the freshly extracted teeth,

thus grasping the tooth mesio-distally.

traction

and

247

also rotation in

Then give the tooth great

one direction.

This rotation should

be so applied that the labial portion of the cuspid would be moved

Fig.

120.

towards the median

Position

line.

for extracting inferior cuspids.

The reason the motion should be applied

only in this direction can be found in the fact that frequently the
roots of cuspid teeth turn or
in the process.

bend backward, as they advance up

Using traction and rotation

in this

one direction

248

OPERATIVE DENTISTRY

Fig. 121.
Types of superior first and second bicuspids. First row first four teeth,
surface of first bicuspids; second four teeth, buccal surface of second bicuspids.
Second
first four teeth, lingual surface of first bicuspids; second four teeth, lingual surface of
bicuspids.
Third row first four teeth, mesial surface of first bicuspids; second four teeth,
surface of second bicuspids. Fourth row first four teeth, distal surface of first bicuspids;
four teeth, distal surface of second bicuspids.
(From Winter's Exodontia.)

buccal

row

second
mesial

second

EXTRACTION OP PERMANENT TEETH

the principle

is

249

applied which removes a corkscrew from a cork,

right or left thread.

Inferior Cuspids.
sure.

The

Traction with slight rotation.

Labial pres-

rules for the extraction of inferior cuspids are quite

Fig.

122.

Position

for extracting right superior bicuspids.

similar to those for the superior cuspids, adding only that owing
to the curve sometimes found in its single root, it is well to direct

the line of traction force a

Superior

Bicuspids.

little

backward.

Principally

tractions,

parallel

with

the

OPERATIVE DENTISTRY

250
long axis of the tooth.

Owing

to the small size of the root in both

and the first bicuspid frequently having a double root, other

forces must be sparingl}^ used in the removal of this tooth. Minute

cases

rotation, could only be used in second bicuspid, this being a single-

Fig. 123.

rooted tooth.
roots.

When

The

Position for extracting

first

bicuspid

is

left

superior bicuspids.

generally possessed of two

not sufficiently bifurcated to be classed as two

tinct roots, they are so united as to

greatest diameter bucco-lingually.

form a very

flat

dis-

root with the

EXTRACTION OF PKHMANKNT TKETH

Types

251

of inferior first and second bicuspids.

first five teeth, buccal surFirst row
bicuspids; second five teeth, buccal surface of second bicuspids. Second row
first five
surface of first bicuspids; second five teeth, lingual surface of second bicuspids.
of
first
five
first
five
teeth,
mesial
surface
bicuspids;
second
teeth,
mesial
surface
Third row
Fourth row first five teeth, distal surface of first bicuspids; second five
of second bicuspids.
(From Winter's Exodontia.)
teeth, distal surface of second bicuspids.
Fig. 124.

face of

first

teeth, lingual

OPERATIVE DENTISTRY

>52

Pressure, which

is

outward

as this

is

in the line of least resist-

ance OAving to the thinness of process on buccal aspect, must be

sparingly used; not so

much because you would endanger

process by great force in this direction, for

Fig.

125.

Position

it is

the

considerably thick-

for extracting right inferior bicuspids.

than over the cuspid roots, but because there

danger of breaking the root just below the mouth of the alveolus,
or close to where the roots begin their bifurcation. With the second superior bicuspid the pressure outAvard may be greater, bear-

er over the bicuspid

is

EXTRACTION OF PERMANENT TEETH

ing in

mind that the

compared with

253

roots of these teeth are disproportionally long

their circumference at the neck.

Inferior Bicuspids. Principally traction. In applying this force

bear in mind that the line of the greatest length of these teeth is

Fig. 126.

Position

for extracting left inferior bicuspids.

normally inclined backward instead of being in

angle to the plane of occlusion.

applied in a direction wJiich- would

came

loose,

towards the

first

all

cases at a right

Therefore, the traction must be

moye

the tooth,,

if it

molar or back of where

it'

sudjdenly

normally

.^

OPERATIVE DENTISTRY

254

Fig. 127.
Types of superior first and second molars. The first row shows the huccal, the
second row the lingual, the third row the mesial, and the fourth row the distal surface.
(From
Winter's Kxodontia.)

fiXTUACTlON

Minute rotation

occludes.

are

slender-rooted

also

curved.

As a

01''

is

PERMANENT

necessary for

teeth

and

tlie

reason that these

frequently

quite

somewhat
The

rule these teeth are possessed of but one root.

pressure should be minutely buccal, for this

Figr

255

TEfiTH

128. Position for extracting

first

and second

is

ri^iht

in the line of least

superior molars.

Care should be taken not to injure the upper teeth

and first molars leave their sockets sudInjury to the other teeth through
denly, as they sometimes do.
striking them with the forceps is niore likely to occur in exti'acting
resistance.

when

inferior bicuspids

OPERATIVE DENTISTRY

256

bicuspids, as the force of traction should be applied in a direction

which would bring them in contact with the upper

teeth.

Superior First and Second Molars.

These teeth are grouped together, as in the case of the bicuspids, on account of similarity in

Fig.

129. -^Position for extracting

-first.andsecondleft superior

niolars.

)^

form, position and parts surrounding them.

Traction should be

drawn from

the central pit of this

applied in the direction of a line

tooth -i^ the apex of the lingual root.

plied.

Any motion

in the

way

No

rotation should be ap-

of rotation would not loosen the

EXTRACTION OF PERMANENT TEETH

257

Fig. 130.
Types of inferior first and second molars. First row first four teeth, buccal surface of first molars; second four teeth, buccal surface of second molars.
Second row first four
teeth, lingual surface of first molars; second four teeth, lingual surface of second molars.
Third
row first four teeth, mesial surface of first molars; second four teeth, mesial surface of second
molars.
Fourth row first four teeth, distal surface of first molars; second four teeth, distal sur-

face of second molars.

(From Winter's Kxodontia.)

Operative dentistry

258
tooth, as one root

would brace the

other.

It is therefore

advan-

tageous to apply the force in the line of the greatest length of one
of these roots, the lingual.

Pressure should be applied steadily buccally and not released

\intil

the

mouth

Fig.

131.

of the alveolus

Position

lingual root, which

is

for extracting

is

first

opened.

The process over the

and second right inferior molars.

the palatine process of the superior maxillae,

quite thick and heavy and seldom gives to any extent, but the
two buccal roots are no great distance from the soft tissues and by
is

EXTRACTION

OB*

PERMANENT TEETH

this steady buccal pressure this process gives

259

and the tooth

is

al-

Care should be taken not to make this pressure too

strong or apply it too suddenly, as the two roots in such close
proximity may act as a lever and loosen a considerable portion of

lowed

exit.

the buccal plate.

Fig.

132.

Position

Inferior First

for extracting

first

and second

and Second Molars.

left inferior molars.

Traction

is

necessary, the

force of which should be applied not only upward but backward,

remembering that the apices of the two roots are not directly un-

OPERATIVE DENTISTRY

260

Fig.

133.

Types

the lingual, the third

dontia.)

of superior third molars.

The first row shows the buccal, the second
row the mesial, and the fourth row the distal surface. (From Winter's

row
Exo-

EXTRACTION OF PERMANENT TEETH

261

The first and second rows show fourFiK 134. Types of abnormal superior third molars.
fourth row shows teeth
rooted teeth, the third row shows teeth with roots that are fused, the
fifth row shows teeth having roots in
and
the
root,
only
one
having crowns with a single cone and
which there is great variation in form. (From Winter's Exodontia.)

OPERATIVE DENTISTRY

262

der the crown but posterior to

A common

error

is

made when

it,

giving the root a curve backward.

the force of traction

is

applied at a

There should be no rotation.

I or as these are double-rooted teeth rotation accomplishes nothing
except to increase the pain by alternately increasing and releasing
right angle to the plane of occlusion.

upon the highlj^ Avascular and sensitive peridental

membrane. Pressure should be directly buccal. Although it may
seem to the operator that the process is thinner upon the lingual
the pressure

aspect of the inferior maxilla?, this

.as

with

all

is

generally not the case.

lower teeth, a malocclusion or an irregularity

Yet,

may make

the process thicker on the buccal surface.

Superior Third Molars.

one that would

roll

Rotation

is

applied in but one direction,

hand towards the median line.

the same time distal. Being the

the top of the

Pressure should be buccal and at

Fig. 135.
One of the many abnormal conditions found when extracting upper second and
In this case the first molar was the only one which had erupted. The patient
third molars.
very severe abscess appeared beneath the tissues overlying
was about forty years of age.
An incision revealed the condition. The photograph shows the
the second and third molars.
result of extracting, all three coming out attached.

last tooth in the

mouth and seated

at the angle of the jaw,

very firmly supported by the process, which in some cases

entirely

it is

is

not

almost

wanting on the posterior buccal corner.

Inferior Third Molars.

Traction should not be only upward,

but backward, which can be accomplished after grasping the tooth

with the beaks of the forceps, and allowing the handle to lie across

and near the

anterior, inferior teeth.

As

the traction

is

applied the

handles are raised and have an amount of spring which will

tilt

the

crown backwards in proportion to the distance the anterior teeth are

separated by the opening of the mouth.
Here we have the only
tooth in which there is an almost universal exception to the direction
in which the pressure should be applied to be in the line of the
least resistance.
In the case of the third inferior molar, it is to the
lingual.
The coronoid process of the inferior maxillae comes down

EXTRACTION OF PERMANENT TEETH

263

ending in the external oblique line which is an eminence and majawbone just buccal to the third molars.
It must also be remembered that there is little of the alveolar

terially thickens the

process formed around the third molar, seldom more than that por-

Fig.

136.

Position

for extracting right upper third molars.

tion which builds in around the neck to insure

when

its

retention.

There-

broken off it at once becomes a very difficult

task to remove the remaining portion, owing to the strength and
width of the bone at this point.
Care Should Be Taken Not to Employ Great Pressure Lino-ually
fore

the tooth

is

OPERATIVE DENTISTRY

264

as the anatomical structure at this point favors fracture which most

frequently extends down and back to include the inferior dental

foramen connected with the mylohyoid groove.

Fig. 137.
Position for extracting upper left third molars.
Note the hand grasp on the
forceps.
This grasp can also be used, sometimes, on the first and second molars. The grasp
is a powerful one as the bones and muscles of the arm and body are in a position to exert a
great amount of force while giving the tooth buccal pressure and rotation with the top of the
forceps moving toward the median line in the rotary motion and the handles of the forceps
are pushed out and back.
While this may look awkward in the photograph many of my
students who have tried it have been very much pleased with the results.

Injury in this

way

at this particular point

may

in its effect, as fractures are most likely to follow

be far-reaching

weakened portions

EXTRACTION OF PERMANENT TEETH

Fig.

138.

Types

the lingual, the third

of inferior third molars.

The
row the mesial, and the fourth

incomplete and malformed molar roots.

first row shows the buccal,

row the distal surface. The
(From Winter's Exodontia.)

265

the second row

fifth

row shows

266

OPERATIVE DENTISTRY

Fig.

Fig.

139."

^Elevator

140.

Position

beaked forceps for extracting third molars.

for extracting right

inferior third molars.

EXTRACTION OF PERMANENT TEETH

of the bone,

and

and in

267

this ease they overlie the inferior dental nerve

vessels.

Hemorrhage Following- Extraction.

quently follows tooth extraction, and

is

Excessive hemorrhage fremore frequently met with in

cases after extracting first or second lower molars.

Fig. 141.

Position

for extracting left inferior third molars.

In Mild Cases a tampon of cotton saturated with hydrogen dioxide or adrenalin chloride crowded well to the bottom of the alveolus
from which the hemorrhage is coming will usually be sufficient.
In Severe Cases a tampon made of the scrapings of oak-tanned

OPERATIVE DENTISTRY

268

The scrapings are made by the denby scraping shreds from the edge.
These should be previously prepared and ready for an emergency.
They should be placed in a large-mouthed bottle and sterilized by
dry heat and securely corked.
sole leather will
tist

prove

from a piece of

effective.

sole leather

of Applying. When case presents, there should be three

small, medium and large about the size of the almade,
pellets
These
should be introduced quickly one after the other and
veolus.
pressed to position and held there for some minutes with the ball

Method

of the finger.

plug the alveolus.

Also the tannin in the leather liberates the fibrinogen and an impervious clot is formed. Within twenty-four hours the last applied
pellet of scrapings will have been raised out of the socket and the
next two will soon follow.
This is recommended as a method that has never failed in a long
list of desperate cases but should not be resorted to except as an extreme measure as great soreness frequently follows the treatment
due to the interference with the circulation for some considerable

The leather scrapings

will swell

and

effectually

distance about the bleeding alveolus.

Hypodermic Injections of Adrenalin Chloride for hemorrhage

is good practice.
Load the syringe part full

folloAving extraction

with Ringer's solution to which has been added five drops of adrenalin chloride.
Introduce the needle, which should be long and
large, into the apical space

and

inject a

few drops.

Eepeat two or

three times if necessary.

If the hemorrhage is
from which the blood is coming.

Capillary Hemorrhage.
into the tissues

capillary, inject

CHAPTER

XL.

EXTRACTION OF TEMPORARY TEETH.

The extraction

of temporary teeth at the proper time

normal conditions

is

and under

not a difficult operation, owing to the amount

of physiological resorption of both alveolar process

and roots of the

teeth.

The Most Important Thing- Connected With Their Extraction is

an accurate knowledge of the order in which nature proposes to reI>lace them with the permanent set.
Results From a Disregard of This Order.
The premature or
tardy extraction of temporary teeth has more to do with irregular
and unsightly permanent teeth than any other one cause. Therefore it is well to make a careful study of the order in which the temporary set is replaced.

Time of Eruption of the First Permanent Molar. The first molar

make their appearance at between five and six years of age.
They are generally supposed by the laity to be deciduous and are
frequently allowed to decay beyond remedy before the mistake is
discovered.
They are then extracted without much thought, either
through necessity or from being mistaken for temporary teeth by
the physician on account of the youth of the patient. The parents
are wonderfully surprised to find such enormous roots on what they
teeth

believe to be a

Duty

temporary tooth.

of Dentist in This Matter.

The practitioner of dentistry

has a very important duty to perform in insisting upon the retention of this tooth for through its loss a decided derangement of the
;

permanent

set results

and lack of proper development of the jaw

is

encouraged.
First
child's
f.rst

Permanent Tooth
jaw

to Erupt.

at about the sixth year.

molar, and

is

Fig.

142

is

a side view of

No. 1 in the top row

a part of the permanent

set,

is

the

the second and third

molars coming in after the temporary set has been entirely replaced
by permanent teeth.
Reasons for a Permanent Tooth at This Time. Nature in giving
us this permanent tooth at this particular time and located at this
particular place, seems to desire to put in a permanent fixture as
a dividing line in the jaw between the teeth which are to be replaced,
and those which are not. as shown by line A-A.
Evil Effects of Early Extraction. // hy Proper Extraction and
269

OPERATIVE DENTISTRY

270

Coacliing Into Place of the various teeth in their proper order the
position of this line

A, which bisects the jaw just at the mesial

of the first permanent molar,

is

not allowed to move anteriorly, there

which the permanent teeth will occupy

when they replace the temporary set, provided the jaw development
is not interfered with, but if by the premature extraction of the second temporary molar, this fir^st permanent molar is allowed to tip
forward, thereby moving line A-A anteriorly, we have encroached
just that much upon the space required by the permanent teeth.
The Irregularity Resulting From Sucli a Mistake will probably be
shown in the cuspid as this is the last of the temporary set to be
is left

just the proper space

t-2-!^'-4-

Fig. 142.
Represents the comiilete set of deciduous teeth with the first permanent molar
Lower row of figures represents the order the deciduou steeth generally erutp.
Upper row of figures represents the order of the replacement by the permanent set.

added.

replaced.

Again,

(See Fig. 143.)

if

the

permanent molar

first

is

extracted before the temporary teeth have been replaced, nature

seems to realize that further development of the jaw on this side is

be it lower or upper will generally lack

not necessary, and the jaw

in length to correspond with its antagonist, the

extracted.

This

may

width of the tooth

not be noticed in the exhibition of faulty oc-

clusion or irregularities but a careful study of the features will

show lack of

artistic contour.

Let us here consider the ortZer in

replaced by the permanent
see that the order differs

set.

By

somewhat.

wliicli tlie

temporary teeth are

reference to Pig. 142, you will

tXTRACTIOX OF TEMPORARY TEETH

271

The lower figures represent the order of eruption of the temporary

The upper figures represent the order of the replacement by
the permanent set including this first permanent molar. Nature has
set.

wise reasons for this change in the order.

The Inferior Teeth Generally Precede the Superior in the anterior part of the mouth by a few weeks and in the posterior part
by a few months with the exception of the third molars. The inferior
third molars sometimes precede the superiors by years. It must also

mind that the variance in length of time and age of erupshorter in the case of females than of males.

be borne in
tion

is

Difference in Time as to Sex. Some females erupt their third

molars as young as the sixteenth year, some males do not erupt them
as late as the tAventy-seventh year. They may be in part or entirely
wanting in either male or female, during life. They are sometimes

Fig. 143.

Irregularity

resulting from premature extraction of the

first

deciduous molar.

so far retarded that they do not erupt until after the extraction of

the

first

an idea

and second molars late in life. This sometimes gives rise to

mind that he has at least part of a third set

in the patient's

of teeth.

Compare Orders

of Eruption.

careful consideration of the

show that in the temporary set the cuspid teeth erupt

before the temporary molars, while these are replaced by the permanent teeth in a different order. The first temporary molar is replaced by the first bicuspid. Then the second temporary molar is
replaced by the second bicuspid and next we have the cuspid tooth
coming into place, forming the keystone of the arch.
The Reason for Nature's Change of This Order. At five years
we find the full coinplemcnt of temporary teeth in place, only twenty
Then nature puts in this dividing line by putting into
in number.
tooth, the first permanent molar, before she
permanent
place one
two tables

will

OPERATIVE DENTISTRY

272

makes any attempt

at interfering with the

temporary arch already

established.

When

this tooth

placement.

First

is

fully in place nature begins her

come

work
and

the centrals, then the laterals,

of reif

we

were to follow the order in which these same temporary teeth

were erupted Ave would next have the cuspid, but not so, Ave have
the first temporary molar lost and replaced by the first bicuspid,
and as this temporary molar is lost, the first bicuspid has a space
to occupy betAveen tAvo teeth, Avhich should be in position to guide
and assist it to proper place, leaving the second temporary molar
in position to hold the first permanent molar in its correct posiThen nature replaces the second temporary molar with the
tion.
second bicuspid. Note that these tAvo temporary molars are AA'ider
than the permanent bicuspids taking their place, but the cuspid
of the permanent set is Avider than the temporary cuspid.
Loss of Temporary Cuspid. As soon as the temporary molars
have been replaced by the bicuspids, the temporary cuspids should
be lost and replaced by the permanent cuspids, AA^hich as stated
before, forms the keystone of the arch, and being a little Avider
Avedges the tAvo bicuspids quickly back into position against the
Coming into position just in this order
first permanent molar.
and at this time it is easily seen hoAV the first permanent molar is
kept in its proper place. At this time the question may arise as to
hoAV the permanent centrals and laterals find sufficient room, being so much larger than their predecessors. This is compensated
for by the development of the maxillae at this age. Some authors
advance the idea that the difference in the space occupied by these
four teeth Avas compensated for by the permanent bicuspids being
smaller than the temporary molars. We cannot agree Avith this.
For Avhen the four incisor teeth are erupted in position in almost
every instance the temporary cuspid retains its former and original
place.

Having completed the changing

add teeth to the posterior part

Avill

of the temporary teeth nature

of the jaAv Avithout

any danger

of subsequent irregularities.

Evils Resulting

From

Disregarding- the Order

in

Which

the

Temporary Teeth Are Replaced by the Permanent in Their Extraction.

For instance, if, as Ave are frequently requested by our

we extract lateral incisors before the central incisors have

attained nearly their proper height in the process of eruption, either
one of the two evils may result.

patrons,

EXTRACTION OF TEMPORARY TEETH

The central

273

incisors in the inferior maxilla stand on either side

where the two segments of the jawbone unite.

In the superior maxilla the central incisors stand on either side of
the median line in the intermaxillary bones.
If the temporary
laterals are extracted before the centrals are fully erupted, should
the jaw continue proper development, the central incisors will stand
apart as they do not have the lateral incisors to hold them toward
of the symphysis, or

the

median

line.

Thus when the

their space has been encroached

come into place,

upon and they may fail to crowd

laterals attempt to

the centrals over to place.

However in most cases the bones do not continue proper development and the space between the two temporary cuspids occupied
by the four temporary incisors, is not sufficiently increased to accommodate the permanent incisors; hence the crowded condition
frequently met with.
Therefore no lateral incisors should be extracted until the cenIf the central incisors do not
seem to have sufficient room, instruct the patient to put pressure
tral incisors are quite in position.

with the tongue or fingers in the labial direction which will put
them into proper position; but for no reason whatever should the
laterals be extracted before the centrals have attained their proper
height in the line of occlusion.

Next we lose the lateral incisors. As this tooth erupts after the
temporary lateral has been extracted, it very frequently loosens the
temporary cuspid, which by this time has had its root quite freely
Patients then request that the cuspid be extracted as
resorbed.
the lateral has not sufficient room. Very frequently it will look
as though this was necessary. However if we extract the cuspid
at this point rest assured that there will not be

when

room enough

for

wishes admittance to the arch. "We

should insist upon the retention of the cuspids and as the lateral
crowds for room, development all through the jaw and especially at

the permanent cuspid,

it

the median line will take place.

In the superior jaw the intermaxillary bones materially develop

and as the temporary cuspid is not lost until between
So
the eleventh and thirteenth year the development is ample.
at this age,

the incisor teeth (the two centrals and two laterals), have allotted
to them the space between the temporary cuspids, as well as that

which

is

made

bj^

eruption and the

the growth of the jaw between the time of their

loss of the cuspid teeth.

Therefore the lateral, which did not seem to have space enough
when it erupted will have ample space in five years as it is that

^1*4

OPEttATIVfe DfiNTlSTtiV

long before any teeth in its immediate vicinity are disturbed. Nature then skips this cuspid tooth which is to hold the incisors in
place, and the first temporary molar is replaced by the bicuspid

which has ample room and needs little attention beyond the removal of its predecessor at the proper time. Just at this point the
second temporary molar may become decayed or lost and patients
will insist upon its extraction but if by any means the patient can
;

be

made comparatively comfortable

it

should not be extracted as

removal allows the first permanent molar to move forward

caused by the growing and developing second permanent molar at
this age.
When the first bicuspid is fully erupted to the line of
mastication, we are justified in removing the second temporary
molar to give place to its successor. During the eruption of the
first bicuspid, the cuspid will very frequently become loose and possibly hard to retain, and the patient will again insist upon its removal but it should not be extracted at this time.
Leave the temporary cuspid in position until all of the other
teeth have been replaced. If the order which nature has mapped
out has been preserved, an even set of teeth will result in almost
every instance. If the order has been interfered with in the least,
the patient's mouth is placed in a condition where gross irreguits

faulty occlusion, and great disfigurement

is almost sure to
Therefore the great necessity for the preservation of nature 's order in the extraction of the temporary teeth. It is the one
thing to be looked after and adhered to and should be disregarded
only in extreme cases, which does not mean merely the satisfaction

larities,

result.

The operation

of extracting temporary
have carefully looked the mouth over and
decided that it is necessary to extract any tooth, it can be accomplished with almost any pair of forceps.
Great care should h?
taken not to take too deep a grasp upon the tooth, that the developing permanent tooth, which is supposed to be close to its temporary predecessor, may not be injured in the removal of the temporary tooth. It is also advantageous to use a lance separating the
gum from the tooth as the gum at or near the neck of the tooth
frequently adheres quite strongly to the cementum. By using the

of the ideas of parents.

teeth

is

simple.

If Ave

lance, laceration of the parts

When

is

avoided.

but the separated or decayed points

or unabsorbed portions of roots, it is best to remove them with a
root elevator or chisel.
there

is

nothing

left

CHAPTER

XLI.

LOCAL AND REGIONAL ANESTHESL^

Definition.

obtained

Local anesthesia

is

that term applied to the results

when only a circumscribed part

of the

body

is

rendered

without sensation.

'

Fig.

144.

Horizontal

injection,

o represents place of puncturing the soft tissues.

Divisions of Local Anesthesia are surface anesthesia, infiltration

anesthesia, intra-alveolar anesthesia, and regional anesthesia (fre-

quently called conductive).

275

276

OPERATIVE DENTISTRY

Fig. 145.

Perpendicular injection,

Uses in Dentistry.
successfully used

is

a represents place of puncturing the soft tissues.

Local anesthesia when rightly practiced and

the most practical anesthesia for exodontia,

minor surgical operations about the mouth, as well as most of the

delicate dental operations connected with pulps of teeth. The sue-

LOCAL AND REGIONAL ANESTHESIA

cess of local anesthesia

anatomy, scrupulous

is

277

based on a working knowledge of the oral

drugs and a correct technic in

asepsis, fresh

their use.

Anatomy. The knowledge of anatomy should embrace a clear

understanding of the muscular attachments, the position of the
foramen and a knowledge of the position of the trigeminal nerve
Avith its

complete ramifications.

For many years cocaine has been almost universally

used by the dental profession as the principal local anesthetic. Its
Cocaine.

Drawing representing the positions of needles in local anesthesia. A, position

Fi^. 146.
This will refor sub-periosteal injection for surgical anesthesia; B, intra-alveolus injection.
This injection is subject to very severe
sult in surgical and sometimes dental anesthesia.
of
infection.
introduction
intra-alveolar
C,
injection.
This
criticism due to the liability of the
will result in dental anesthesia and quite frequently surgical anesthesia on the side toward
which the injection is made.

was not clearly understood at the beginning and thus occurred overdosing particularly with stale solutions. It has been
fully demonstrated that some individuals could stand heavy doses
without showing systemic ill effects, while death would result in
other cases where only a small dose had been used. For these reasons the profession has been hunting a substitute. That substitute

toxicity

seems to have been found in novocain.

Novocain is equal to cocaine in anesthesia producing power.

It

OPERATIVE DENTISTRY

278
is

the most delicate tissues.

It is easily

and, so combined, does not loose

Neither does

it

affect

even on
combined with suprarenin,
anesthesia producing power.

It is particularly non-irritating

relatively non-toxic.

the

its

action

of the

suprarenin.

It

can be

-llPb^^^H

JjJ M

4^

W^^k
^

'

j^^.l^^pk

^m

*"

Fig.

147.

First

position in the mandibular injection.

boiled for the purpose of completing sterilization.

Novocain

is

non-habit producing drug, and, as claimed by the manufacturers,

is derived from an entirely different source than cocaine, to which
it is in no way related.
The general effects upon the system after it has

been absorbed are scarcely perceptible. Neither the cirand the blood pressure is not

culation nor the respiration suffers

LOCAL AND REGIONAL ANESTHESIA

279

From experiments it has been found to be only oneseventh as toxic as cocaine.

Doses. The best solution for dental uses is probably the two

increased.

rig.

148. Second

This position
position in the mandibular injection.
of the anesthesia for the lingual nerve.

is

taken for the deposit

per cent solution for both the infiltration and the regional methods.
The maximum dose of a two per cent solution is twenty-four cubic
Such a quantity would never be called for in any
centimeters.
dental operation.

OPERATIVE DENTISTRY

280

Suprarenin

is

added

to contract the capillaries

and prevent

ab-

sorption and infiltration into the tissues beyond the field of operation, thereby increasing the duration and strength of the anesthesia.
It is also

added

Fig.

in certain cases to decrease the flow of blood.

149.

Third

position for the mandibular injection.

Dosage of Suprarenin. Differing from the amount of novocain

used the suprarenin should be varied for individual cases. In fact
it has probably been the practice of surgeons to use too strong a
solution of suprarenin in their local injections.
Preparing the Solution. In a dissolving cup, place a tablet of

LOCAL AND REGIONAL ANESTHESIA

281

novocain and suprarenin to which add Ringer's solution Q. S. to

make a two per cent solution of the novocain. Boil over the open
flame for one-half minute to sterilize.

Fig. 150.

Fourth

Ringer's Solution
chloride, 0.050

is

gram;

chloride, 0.002 gram.

and

last position for

made

the mandibular injection.

as follows: Ringer's tablets; sodium

chloride, 0.004 gram; potassium

Dissolve ten tablets in 100 cubic centimeters

calcium

OPERATIVE DENTISTRY

282
of aqua dest.
to

Sterilize

be ready for use

by boiling and put in

bottle double corked

when needed.

and suprarenin should not be used.

mixed
fresh
for
each
operation. It should not come in
It should be
the
boiling
contact with anything but
cup and the syringe and
Stale solutions of novocain

should not be

left

longer than necessary in either of these.

Care of Novocain Tablets. The tablets should not be touched

with the hands and should be kept in a bottle, rubber-stoppered.
The solution should be as clear as water and discarded as soon as
it shows a light pink color.

Fig. 151.

case with the needle

A very clear and easy
mandibular injection.

Surface anesthesia

The method

is

is

in the best position for the

anesthesia produced by topical application.

upon mucous membranes, as they abThe effect is generallj^ not deep. Howthe gum it is usually sufficient for fitting bands

of advantage

sorb the solution rapidly.

ever, applied to

A
fillings at the gingival margin.
with a tAventy per cent solution of novocain and packed on the floor of the nasal cavity over the incisor
and crowns or the finishing of

pellet of cotton saturated

teeth will

many

times anesthetize the incisors of the respective side

LOCAL AND REGIONAL ANESTHESIA

sufficient for operations

upon the dentine and even for pulp

283
extir-

pation.
Infiltration Anesthesia

duced by injection of the

is

the

method Avhereby anesthesia is proThe sue-

tissues about the nerve endings.

entirely wanting and

Fig. 152. This represents a difficult case where the lingula is almost
tissues of the external
the needle has entered the sulcus too low and may yet be engaged in the
position.
this
reach
to
penetrated
have
which
it
must
pterygoid muscle

method depends upon the thoroughness with Avhich the

If any nerve endings
tissues to be operated upon are infiltrated.
The infiltration
obtained.
is
are missed only partial success

cess of the

OPERATIVE DENTISTRY

284

method is of advantage in the extraction

and parts of roots. It is the best method
deciduous teeth and roots. This method

of non-vital teeth, roots

for the extraction of all
is

used for any of the

is with the single-

teeth in the maxilla, but the greatest success

Fin

153.

The

same mandible shown

rooted teeth.
service

in Fig. 152 with the needle passed to position sufficiently

high to be above the lingula represented by a.

With the mandible

posterior to the

cuspids

the infiltration method

when

vital

teeth

is

of little

are involved.

There are but two injections to consider with the infiltration method
in dental operations, namely, the horizontal and perpendicular.

LOCAL AND REGIONAL ANESTHESU

285

The Horizontal Injection for the bicuspids and molars excepting

By this method several teeth may be injected

the third molar.

only the one puncture of the tissues, thereby materially lessening the liability of infection. This injection is contraindicated

A\'ith

in diseased tissue.

The Perpendicular Injection is applicable for all single-rooted

The needle should generally be inserted just below the gum
margin and the point carried lingually or buccally of the apex of

teeth.

mandible which belongs to a class on which it is very hard to give a

Note that the internal oblique line is continuous up to the sigmoid
notch.
The lingula (a) is one cm. higher than normal and is only about four mm. back of
Conditions like this possibly explain why even the most expert
the internal oblique line.
sometimes do not get results upon first attempt.
Fig.

154. This

is

mandibular injection.

the tooth the anesthesia of which

is

desired.

The solution

is

in-

jected without pressure and the needle does not go sub-periosteal

The quantity of soluas in distinction from the intra-alveolar.
tion to inject is about one and a half cubic centimeters for the
horizontal injection and about one cubic centimeter for the perone-inch needle of small size is best suited for all
pendicular.

infiltration work.

Intra-alveolar Anesthesia has for

its

object the blocking of the

OPERATIVE DfiNTISTHY

286
nerve before

it

enters the pulp of an individual tooth

deeply into the alveolus.

They
Tlie

are the pericemental

by injecting

There are two injections in this method.

and the subperiosteal, or intraosseous.

Pericemental Injection has been the most widely used of

all

up to this time, for the reason that

requires the minimum amount of the drugs used. This is a point

the methods of local anesthesia

it

First and ideal position for giving the menial iujccuuu.

a rcprescnls the posiFig. 155.
With fleshy patients the syringe barrel will of necessity
tion of puncturing the soft tissues.
to be more anterior.

have

of great importance in the use of cocaine. However, with the advent of novocain the method will be used less frequently, owing
The method has been useful in surto the liability of infection.

gery, in extracting teeth, due to the

accompanying

infiltration of

surrounding tissues. The needle should be short, say one-fourtli

of an inch, and of twenty-eight or twenty-nine gauge.

LOCAL AND REGIONAL ANESTHESIA

287

The Suh-periosteal Injection in intra-alveolar anesthesia is of the

greatest use in operating upon vital dentine and pulp extirpation.

The needle should be short and

stocky, twenty or twenty-two gauge.

beneath the periosteum and even into the alveolar
process itself, as near as possible to the apical foramen of the
tooth to be operated upon. Considerable force is used in both of

It is inserted

Second position for giving the mental injection, showing the finger compressing
Fig. 156.
the tissues over the needle inside of the mouth to facilitate injecting the canal.

the intra-alveolar injections in counter distinction of

other methods of

all

of the

local anesthesia.

Regional Anesthesia Conductive Anesthesia is strictly a nerve

blocking process Avhereby a region of the desired extent is anesThe method is not new, having been practiced more or
thetized.
less since the latter eighties,

but has received a great impetus, due

OPERATIVE DENTISTRY

288
to the production of

an agent

like

novocain which

Regional anesthesia

safe for general practice.

limited to the field of dentistry, but

its

use

is

is

comparatively

is

by no means

as broad as the field

The

of surgery on mankind, as vrell as that on the lower animals.

surgeon has but to know his anatomy to be able to render a region

as void of sensation as though the part had been amputated from
the body. For instance, the arm is now operated on without pain,
even to amputation, by surrounding the axillary nerve with a
puddle of a two per cent solution of novocain with suprar6nin,
reached with a needle in the top of the shoulder posterior to the
clavical and internal and anterior to the scapula. Aside from the
completeness of the anesthesia obtained, regional anesthesia has
to

recommend

field

it

the fact that the injection

of operation,

which

is

many

is

made

far

from the

times undergoing pathological

About the

changes often due to bacterial invasion.

face,

we have

seven separate and distinct nerve blocking operations for regional

anesthesia. The injections are Gasserian ganglion, Spheno-maxil;

lary,

Pterygo-mandibular, Mental, Infra-orbital, Zygomatic, and

Posterior and Anterior palatine.

The Gasserian and Spheno-maxillary Injections are employed for

major surgical operations about the face and will be passed over
by simply mentioning them, as the strictly operative dentist will
have no need to employ them. However, the remaining five injections are of vital interest to the general practitioner of dentistry

and

taken up in the order given.

will be

Pteryg-o-Mandibular Injection has for

its

object the blocking of

the nerve supply to the lateral half of the mandible and the im-

mediate overlying

tissues.

Technic of Injection.
ing

first sterilized the

phenique.
sues over

Then
its

Palpate the posterior molar triangle havfield of puncture with campho-

immediate

find the internal oblique line.

Puncture the

tis-

inner edge, using a forty-five millimeter iridio-platinum

needle, one centimeter above the plane of the inferior teeth with

the barrel of the syringe resting on the occlusal surfaces of the

bicuspids of the opposite side, as

shown

in Fig.

147.

needle point four or five millimeters into the tissues.

the syringe to the position

Again swing the syringe

shown

Push the

Now

swing

in Fig. 148 for the lingual nerve.

into the position

shown

in Fig. 149.

Push

the needle into the tissues, closely following the inner surface of

ramus for a distance of about two centimeters in all (see Fig. 150),
varying with the size and age of the patient. To folloAv the inner

LOCAL AND REGIONAL ANESTHESIA

289

(f)

Fig. 157.
Position of needle in giving the infra-orbital injection,
a represents the place
of puncturing the soft tissues.
If it is desired to accompany this injection with the perpendicular infiltration injection, the soft tissues should be punctured midway between the point
marked o and the gingival margin of the gum.

surface of the ramus will necessitate the swinging of the syringe

to the

median

very essential
above the
will pass over this into the pterygoid muscle, of-

line as the needle progresses.

It is

that the needle passes into the sulcus mandibularis,

lingual, or else

it

OPERATIVE DENTISTRY

290

resulting in false unilateral ankylosis, generally temporary,

but sometimes more or less permanent and always to be avoided.
If anesthesia of only the pulps of the teeth is desired, the special
part of the injection for the lingual nerve should be omitted, as
there is less liability of injecting bundles of muscle fibers. In case

ten

injection
first

is

made

for surgical purposes, as the extraction of the

molar and bicuspid, an

infiltration injection

had best be made

buccal to the tooth or teeth to be extracted to include the descend-

ing branch of the buccal branch of the third division of the fifth,
which is given off just above the pterygoideus internus and enervates the soft tissues of the biscuspids and molars buccally. Anesthesia occurs in fifteen to twenty minutes and lasts about one
hour, sometimes longer. If longer anesthesia is desired, the amount
of the injection is to be increased up to four cubic centimeters.

The
tongue

first
if

sign of anesthesia

is

the numbness of the side of the

the injection for the lingual nerve has been included and

foramen on that side. These are the

and occur in a very short time, yet
the deepest state of the anesthesia may not work back to the posterior molars for twenty to thirty minutes, as frequently happens
of the lip above the mental

signs of a successful injection

^,

Avith operations for the extraction of

(O
,

'

''

(1)
'

->
'

'

lower third molars.

Mental Injection. The mental injection is made Avith a one or

two centimeter needle passed as shown in Fig. 155. The operator
should compress the mucous membrane and tissues over the
foramen. When the needle is felt under the finger (see Fig. 156)
one cubic centimeter should be injected while pressing which will
direct the solution through the foramen into the mandibular canal,
anesthetizing the first bicuspid, cuspid and incisors of the respective side.

same way
same length of
needle and one cubic centimeter of the solution. Dental and surgical anesthesia is obtained in the bicuspids, cuspid and incisors of
Infra-Orbital Injection.

This injection

is

made

in the

as that described for the mental foramen, using the

the respective side.

Zygomatic Injection.

The long needle

is

inserted over the roots

of the second superior molar progressing upward, backAvard and

inward, depositing some of the solution as the needle progresses,

until the position of the needle

is

as shoAvn in Fig. 158 Avhere the

last of the solution is deposited, in all tAvo cubic centimeters.

injection will reach the posterior superior alveolar nerve

middle superior alveolar in case

it is

This

and the

given off before the maxillary

LOCAL AND REGIONAL ANESTHESIA

I'*ig.

158.

rinal

position

of the needle in giving the zygomatic injection,

place of puncturing the soft tissues.

nerve enters the infra-orbital canal.

add

It is

many

to this the horizontal infiltration injection as

291

a represents the

times advisable to

shown

in Fig. 144

of which
anastomose wdth the branches of the middle alveolar.
This
zygomatic injection especially when assisted by the horizontal into reach the anterior snperior

alveolar,

the

branches

OPEfeATIVE DENTISTRY

292

dental and surgical anesthesia of the biscuspids

and molars of the respective side.
Palatine Injections. The needle is inserted above the gingival
margin of the mesial part of the third molar for the posterior
palatine and passed upward and backward to the palatine process,
injecting one-third of a cubic centimeter. For the anterior palatine the needle is inserted lingually and above the gingival margins
of the superior central incisors and passed upward and backward
jectioii will give

the anterior palatine canals, depositing one-third of a cubic

to

centimeter.

the

gums

These injections will anesthetize the palatal part of

for surgical work, as extractions.

In Conclusion.
successful.

Do

Use only fresh

tion that
ful study

is

Always use the simplest method that will be

Avoid infection.

not inject pathological tissue.

Do not inject muscle tissue. Use a

Attempt regional anesthesia only after

solutions.

isotonic.

and preparation.

solu-

care-

CHAPTER

XLII.

THE USE OF FUSED PORCELAIN IN FILLING TEETH.

Definition. A porcelain inlay is a filling made of dental porcelain

and retained

in position by cement.
Dental Porcelain is a solidified mass of
suspended in a flux of fused silicate.

Composition.

Dental porcelain

is

ingredients which are refractory, as

composed:

silex, kaolin,

silicious substances

First, of the basal

and feldspar.

Sec-

Those in common use are

(Na2B407), sodium carbonate (NagCOa),

ond, fluxes used to increase the fusibility.

sodium borate, or borax,

and potassium carbonate (K2C03).

Third, metals and oxides used as

pigments.
Silex (SiOa)

is

the oxide of silicon.

insoluble except in hydrofluoric acid

the porcelain.

It gives it

It is

and

is

an infusible substance,

used to give strength to

more translucent appearance.

Kaolin [Al4(Si04)3.4H20]

is

the silicate of aluminum.

to the porcelain to give stability,

It is added
and permits unfused porcelain to

be molded and carved in the shaping of the contour.

Feldspar [K20Al203(Si02)G] is the double silicate of aluminum

and potassium. It forms over eighty per cent of the basal mass of
porcelain and adds translucency.
Pigments. The various shades and colors in porcelain are produced by the addition of precipitated gold, platinum, purple of
cassius, oxides of cobalt, titanium, iron, uranium and silver, producing the colors of red, yelloAV, blue, green, broAvn and gray.
High-Fusing Porcelain. By high-fusing porcelain is meant a
porcelain that requires five minutes or more to fuse at a temperature exceeding the fusing point of pure gold.

Low-Fusing Porcelain.

This

is

a porcelain that requires less than

minutes to fuse at a temperature not exceeding the fusing

point of pure gold. This division is one of creation by the manufacturers and commonly accepted by the profession. However the
distinction is only relative as porcelain has no definite fusing point,
as any enamel or tooth foundation body may be fused on a matrix
of pure gold if enough time is given to the fusing process.
Effects of Fusing at Lower Temperatures and a Longer Time.
five

A
A
A

more homogeneous mass is produced.

more characteristic color is maintained.
less friable filling is

produced.
293

OPERATIVE DENTISTRY

294:

High-Fusing Porcelain

May Be Made Low-Fusing

by repeated

fusing and grinding.

In Building a Filling by Layers the first layer should be fused

high biscuit otherwise the process of fusing the sub-

to a state of

sequent layers will over-fuse the

first.

High Biscuit Fuse. Heating the porcelain sufficient to obtain

shrinkage, but not enough to glaze.
Fine Grinding. The more finely porcelain is ground the lower
the fusing point from the same formula and the greater the shrinkage.

The larger the mass the greater the length of

Size of Mass.

time required to fuse.

Amount

The more flux a porcelain contains the greatwhich liability increases as the tempera-

of Flux.

er the liability to bubble,

ture

is

raised.

High fusing porcelains shrink from fiftwenty-five per cent. Low fusing porcelain shrinks from

Shrinkage in Fusing.
teen to

twenty to

thirty-five per cent.

All porcelains have a great tendency to spheroid

Spheroiding.
Avhen over-fused.

Basal

Body

is

porcelain composed of basal ingredients and the

l>igments.

Foundation Body is one composed of basal ingredients to which

has been added a flux to increase fusibility, and has been ground
less fine than enamel body to raise fusing point and give stability
as to form.

An Enamel Body
ground and

to

is a basal body which has been more finely

which there has been added more flux to increase

fusibility.

The Advantages

of the Porcelain Inlay.

When

skillfully

made

they more nearly harmonize with tooth structure in appearance.

Thermal changes do not readily affect the pulp

is not as good a conductor as metal.

in vital cases as

porcelain

Margins of cavities Avell filled with porcelain are not readily attacked by caries, as cement dissolves out of the margin to a depth
only equal to the breadth of the line exposed.
of sitting Avith the rubber

dam

The Disadvantages of the Porcelain

porcelain restricts
It is

its

Patients are relieved

in position for protracted periods.

Inlay.

The

friability

of

use to locations removed from great stress.

necessary to omit the marginal bevel in

all cavities,

as the

USE OF FUSED PORCELAIN IN FILLING TEETH

edge strength of porcelain

is

no greater than

full

295

length enamel

rods.

The Cavo-surface Angle should be that which the cleavage

the enamel gives, or about a right angle.

tage

is

of

Its greatest disadvan-

the fact that the inlay must be set upon unclean walls as

must be done under moist conditions; moisture

being necessary to maintain the color of the teeth while trying to
imitate their shade. This prevents the placing of the filling upon
the whole process

freshly cut surfaces which have not been moistened, the greatest

enemy

to all inlay fillings.

Another disadvantage is that the retention of the porcelain depends upon the integrity of the cement, which is not wholly protected at the margins. While porcelain inlays fit the cavity from
a practical standpoint, the fact exists that they never exactly

fill

the cavity, the cement taking up the space resulting from the misfit, and is exposed in proportion to the amount of existing space
at the margins.

Indication for Porcelain Filling.

Porcelain

is

indicated in the

following

In cavities in the anterior location in the mouths of patients who

have an appreciation for esthetic qualities of dental operations.
In cavities of Class One when they occur in defects on labial
surfaces.

In cavities of Class Three

when much

of the labial wall

is

gone

and rather strong lingual wall remains.

In cavities of Class Four, plan three, vital teeth with rather
thick incisal edge, not subjected to great stress in articulation.
In cavities of Class Four, plan one, when proximating tooth is
not in position as when the missing tooth is worn upon a plate or
is to be subsequently replaced with a crown or bridge.
In cavities of Class Four, plan four, in upper teeth when the
lingual surface does not articulate.

In gingival third (Class Five) in anterior teeth exposed to view

when

patient smiles.

In cavities of Class Six on the six anterior teeth, Avhen the porcelain is built to a thickness of at least two millimeters, and in pulp-

lower molars, restoring the entire occusal surface.

Contraindications. Porcelain is not indicated in the cavities not

less

above mentioned, and in all locations subject to great stress and

where good access form is difficult to obtain.

CHAPTER

XLIII.

PREPARATION OF CAVITIES FOR PORCELAIN INLAYS

The

filling of teeth

with porcelain demands some change in the

usual and accepted form of cavity preparation for other materials.

Access Form.
filling.

Access form reaches

Even greater

access

is

its

maximum

Hence preliminary separation should be practiced with

fillings, before forming the matrix, and
generally
separation

Outline

of

is

Form

in porcelain

required than for the gold inlay.

advantage when setting the

for Porcelain Inlays.

proximal
mechanical

all

filling.

Outlines must be extended

sound enamel. The obtaining of full length enamel

bj^ sound dentine is imperative.
Extending to selfcleansing margins is of additional advantage, yet not so imperative as with gold filling, as secondary decay is not as liable to take
place about a porcelain filling.
to regions of

rods supported

The

outline should not follow a developmental groove nor cross

extreme eminence. Sharp angles in outline should

Extension for prevention as applied to the embrasures
is not as great as with metal fillings.
Extension for Resistance to Stress at margins is more essential
than with gold, due to the friability of porcelain margins.

a ridge at

its

be avoided.

Resistance

Form

for Porcelain Inlays.

The

rules for flat seats

The use of the

Four is essential to give added resistance to the tipMargins should be extended to locations less fre-

for all fillings apply equally to porcelain fillings.

step in Class

ping strain.
quented by the crushing strain.
Retention Form for Porcelain Inlays. JMaximum retention form
is required in all directions except one, until the matrix has been
formed and the filling made ready for setting, when retention
should be added in the remaining direction.

Acute line and point angles should be avoided; all angles being
rounded angles until the matrix is formed.
Convenience Form for Porcelain Inlays. The filling of teeth
with porcelain requires more cutting for convenience form than
for any other method.
This fact makes such fillings contraindieated many times, due to the great loss of tooth substance necessary to properly form the matrix and introduce the filling. Previous separation will overcome this cutting to a large extent with
this as well as other fillings.

296

PREPARATION OP CAVITIES FOR PORCELAIN INLAYS

297

Finish of Enamel Walls. All finishing of enamel walls must be

completed before forming the matrix.
The cavo-surface angle
should be a right angle as the strength of fused porcelain is about
equal to supported enamel margins.
If a bevel angle exists it
should be deeply buried.
Toilet of the Cavity.

This

is

attended to the same as with other

inlay fillings before forming the matrix.

Another Cavity Toilet is necessary just before setting the inThis consists in washing the cavity with chloroform to dissolve any oily substances adhering to the cavity Avails.
This is
lay.

Fig. 159.
Cavity preparation for a Class Two porcelain inlay,
porcelain occupying a portion of the pulp chamber.

non-vital

followed with absolute alcohol and moderately dried.

desiccation

is

liability to

is

Excessive
is

injured

Defects in enamel.

Porce-

marginal checking increased.

Preparation of Cavities of Class One.

lain

with the

not required and in fact should not be practiced as

the integrity of the ceniental substance in the enamel

and

case

indicated in cavities on the labial surfaces of the six an-

due to faulty enamel. These are shoAvn as small orifices

enamel surface, generally rounded in form, and is the result
of imperfect development. The cavity should be not less than two
millimeters in width at its narrowest point, as a smaller cavity
than this hinders proper working.
terior,

in the

OPERATIVE DENTISTRY

298

Avoid the Exact

Circle in outline, as this will bewilder the oper-

ator as to the position

a circle as to

make

when

In case the outline

setting.

is

so near

position questionable, the axial wall should

have a small rounded pit at one side to guide the operator in

set-

ting.

The Axial Wall should,

tooth surface in which

in large cavities,

be the miniature of the

The axial wall of small cavities

should have a rounded groove cut around the entire circumference.
The Surrounding Walls should meet the axial at an obtuse angle
to relieve any undercuts before the matrix is formed.
When the

160.

Fig.

it

occurs.

Class Three cavity labial

Fig.

approach for porcelain inlay.

inlay

is

ready to

161.

a|)proach

set give the cavity retentive

Class Three cavity labial

for porcelain inlay.

form by making the

base line angles acute.

Cavities in Proximal of Bicuspids

and Molars.

perience has taught us that porcelain

is

Class Two.

Ex-

not indicated in this class

Their location subjects the filling to extreme crushing

which porcelain will not stand. The occlusal surfaces are of
an irregular shape and made up of a great varietj^ of forms with
This makes the right angle
surfaces in any number of planes.
cavo-surface angle demanded in porcelain filling improbable and
results in exposing porcelain margins of an acute angle.
(Fig.
of cavities.

strain

159

may

be used.)

PREPARATION OF CAVITIES
Cavities in Proximal of Incisors

Angle.

Class Three.

FOR,

PORCELAIN INLAYS

299

and Cuspids Not Involving the

This class of cavity

is

ideal for porcelain in-

and is by far the most sightly filling Avhen properly done.

These Cavities Should be Divided Into Two Classes in accord-

lays

ance with the three different lines of approach.

approach;

First division, labial

second

division,

lingual

ap-

proach.

Fig. 162.

Class Three cavity lingual approach for porcelain inlay.

Labial Approach.

any considerable

This approach should be decided upon when

of the labial enamel is to be replaced and

amount

(Figs. 160 and 161.)

is possible.
The Gingival Wall should be extended gingivally

a lingual wall

affected enamel.
axial wall at

It

should be

an angle

flat

to include ail

axio-proximally and meet the

slightly acute.

It should

meet the lingual

wall at an angle slightly obtuse.

The Axial Wall should be flat labio-lingually and be continuous from the axio-lingual line angle to the labial cavo-surface angle
which results in the entire removal of the labial wall. This wall
should meet the lingual and incisal walls at an acute angle. The
incisal

lingual line angle should be slightly obtuse.

This results

OPERATIVE DENTISTRY

300

in a cavity retentive in all directions except to the labial Avhich

gives

"draw"

it

in this direction.

Lingual Approach.
ing in the retention of

The whole general plan is reversed resultall or a good portion of the labial wall and

an entire absence of the lingual wall resulting in the draw being

to the lingual.

To

Resist the Tipping Strain the lingual

step

may

be

added.

done by cutting away a sufficient amount of the lingual enamel resulting in two axial walls. One will face the proximal and

This

is

Fis

163.

Class Four cavity incisal

approach for porcelain inlay.

the other the lingual.

164.
A Class Four, plan one, incisoproximal approach for porcelain inlay.

Fig.

This creates a line angle where the two

walls unite, the axio-axial line angle which should be a rounded

angle.

Just before setting the inlay the axial wall should be slight-

ly grooved next to the surrounding walls, except in the region of

the incisal point angle.

Cavities in Proximal of Incisors

and Cuspids Involving the Angle.

may be sucaccomplished with porcelain when the conditions of

stress would permit of this plan being used with any other maClass Four, Plan One.

cessfully

This plan of angle restoration

PREPARATION OF CAVITIES FOR PORCELAIN INLAYS

The cavity form

terial.

is

301

the same as that just described for a

gold inlay.

Proximal Approach May be Used in this instance under some

The incisal approach may be used when excess separation has been produced a little greater than the length of the incisal line angle, as well as more than the thickness of the inlay
measuring from contact point to the greatest depth of the axial
wall, which permits the filling entrance from the incisal.
To Break the Cement Line on the Incisal Edge a rounded groove
conditions.

Fig. 165.

Class Four, plan two, with double step for porcelain inlay.

should be made from the external end of the incisal line angle to
the incisal cavo-surface angle.
Plan Two, Class Four, is suitable for porcelain filling provided
the material will stand the strain at union of step and cavity
proper.

The double step

is

Plan Three, Class Four.

many

advised.

(Fig. 164.)

The addition of the lingual step makes

angle restorations with porcelain practical, as the tipping

by grooving in the lingual axial

strain can be well provided for

wall next to the distal or mesial wall according to whether the

cavity is distal or mesial.
The cavity should be so shaped that
the

draw

is

directly to the incisal.

The gingival wall should be

OPERATIVE DENTISTRY

302
flat

and meet both

line angle

cave.

axial walls at an acute angle.

should be acute.

The axio-axial

The lingual

The

axio-labial

axial wall should be con-

line angle should be a

rounded angle and

continue out to the incisal cavo-surface angle.

Plan Four, Class Four.

In angle restoration the creation of both

and lingual steps is most popular. The incisal step is formed

in much the same way as when gold is to be used.
However the
pulpal wall should be placed farther from the incisal edge and
incisal

be laid in a plan less acute to the axial wall than for gold.

The angle formed by the junction

of these walls, the axio-pulpal

In forming the lingual step the enamel

angle, should be rounded.

may be removed entirely to a level of the gingival wall, or it may

much of the incisal portion as may seem necessary to

be only as

strengthen the body of porcelain in the incisal region and resist

the tipping strain.

Fig.

166.

The Double Step

tensive

loss

of

Class Four, plan three, for porcelain inlay.

of service in cases

is

tooth

structure,

where there has been

particularly

in

ex-

non-vital cases.

This plan results in a gingival wall and two pulpal walls; also in

two short axial walls placed on an equal number of levels. The

gingival and pulpal walls should be made to meet the axial walls
Each of the two pulpal walls should be grooved
at acute angles.
from the connecting axial walls, and each axial wall in the central
portion resulting in a continuous groove from the gingivo-axial line
angle to the incisal edge.

This cavity has

draw

directly to the

incisal.

Cavities Occurring in the Gingival Third of Class Five.

Laliial

cavities in the gingival third are favorite places for porcelain

should to a large measure displace gold.

neath the

gum

line,

the

gum

and

If the cavity extends be-

should be forced from position by

PREPARATION OP CAVITIES FOR PORCELAIN INLAYS

303

previous packing of gutta-percha or cotton saturated Avith chlorapercha.

Outline Form should be the same as for other filling. The axial
wall should be the miniature of the tooth surface wherein the
cavity occurs. The gingival wall should be flat and meet the axial
at

an acute angle.

All other surrounding walls should meet the

This gives a cavity with draw to

axial at slightly obtuse angles.

the labial allowing the incisal portion to swing out in advance,

the inlay going to place gingival first.

This hinge movement

Fig.

in

167.

is

Class

slight but constitutes a valuable point

Five cavities for porcelain inlay.

subsequent retention.

incisal line angle

Just before setting the inlaj- the axioshould be sharpened to add retention form. In

where the decay resulting in a cavity is materially iiorseshoe

form the cavity may be filled by two distinct operations.
This is accomplished by filling the cavity with cement and cutting out one-half and filling with porcelain.
This completed, the
other half is cut out and the operator then proceeds to fill that poreases
in

tion.

This results in two porcelain

One Point Must Be Observed.

will necessarily slightly
this portion of the inlay

fillings

The

with cement between.

first

overlap a cement

must be ground

portion of porcelain
Avail.

Before setting,

at the expense of the ex-

ternal surface of the filling to reverse the draw, or this portion of

OPERATIVE DENTISTRY

304
the remaining cavity

"will

be found with an objectionable under-

cut hard to manage.

Restoration of a Portion of the Incisal Edge.

The general

out-

when they are simply a notch in the

body of the tooth, is that of the half moon when viewed either from
the labial or the lingual. However the lingual enamel should be
line in this class of cavities

removed for a greater distance root-wise resulting in a lingual

step to provide against the tipping strain. The pulpal wall should
have a groove mesio-distally in its central portion and extend well

Fig. 168.

Incisal

cavity for porcelain inlay.

up along both mesial and distal walls, and with the larger cavities
coming out to the cavo-surface angle.
Restoration of the Entire Incisal Edge Outline Form. The enamel is chiseled root-wise till it is firm and will result in a thickness of porcelain at all points equal to at least two millimeters.
Retention is accomplished by the addition of pins, or a generous

lingual step, or both.

In vital cases where pin retention

is

cut a V-shaped groove mesio-distally,

to be used there should be

the

spreading

angles

of

PREPARATION OF CAVITIES FOR PORCELAIN INLAYS

which should come just short of the dento-enamel junction

and lingually. Mesially and distally it should continue

305
labially

to the
pin hole should then be bored in the extreme ends of this groove not a great distance from the dento-enamel junction in the dentine to receive the pins. When the lingual

cavo-surface angle.

step is to be added the enamel on the lingual is removed additionally to a distance root-wise at least equal to the labial exposure also
;

an amount of dentine sufficient to make the newly created axial

wall meet the two pulpal walls at right angles. If pins are to be
added the holes should be bored in the floor of the pulpal wall
nearer the labial surface.

In Pulpless Six Anterior Teeth the pulp chamber may be rounded

out and porcelain so baked as to form a post of porcelain for retention.

Fig. 169.
A Class Six cavity using pin anchorage for porcelain
used with the gold inlay.

inlay,

This plan

is

also

Pulpless Molars are treated in the same way.

Treatment of Teeth With Malformed Enamel.

The major por-

tion or all of the enamel can be successfully replaced with porcelain.

The enamel

is

removed

to the desired

gingival wall entirely encircling the tooth.

removed

point

resulting

in

Sufficient dentine is

in the incisal region to render the largest girth at the

This
is continuous around the tooth.
body of dentine over which the porcelain is
telescoped. The method is termed the jacket crown and the method
of construction and setting is fully described in the writings of
others on crown work.
gingivo-axial line angle which
leaves a peg-shaped

CHAPTER

XLIV.

THE CONSTRUCTION AND PLACING OF A PORCELAIN

INLAY
Following the completion of cavity preparation the next step in
is the formation of a matrix.
A Matrix is a thin piece of metal shaped to the cavity form in
which the porcelain is fused.
porcelain inlay filling

Matrix Material. The matrix materials in common use are pure

platinum and platinized gold. Pure gold and platinized
gold can be used only with what is termed low fusing bodies,
while pure platinum can be used Avith either high or low fusing
bodies. Gold is more easily shaped to cavity form, but tears more
easily and does not hold its shape as well after burnishing.
Thickness of Foil. The most popular thickness of platinum foil
to be used in the construction of a matrix is 1-1,000 of an inch.
Thicker than this is difficult to manipulate, while the thinner foils
tear too easily, and are more liable to distortion during the
processes of building and fusing.
gold, pure

Annealing of Matrix Material.

placing the entire sheet of material as

it

best accomplished by
comes from the supply

house in the electric oven and bringing

it

to the desired

This

is

tempera-

ture before cutting off the piece desired for the case in hand.

Pure

gold and platinized gold should be brought to the full red heat or

about 1,200 or 1,300 F. Platinum should be carried up as high as

expected to carry the temperature during the process of fusing
and held there for two or three minutes. It is not necessary to anneal several times during the process of shaping the matrix.
it is

Methods of Forming the Matrix. There are three general

methods in use for the construction of a matrix. First, burnishing
Second, swaging over an impression of
directly into the cavity.
the cavity. Third, swaging into a model of the cavity.
Each has its advantage in different cases and are recommended
by all porcelain workers. However, the combination of the first
and second methods will bring good results and is the method requiring the least time.

Technic of the Combination Method.

of the cavity.

If the cavity is large

pound, trimming

off that part

it is

which
306

First take an impression

best to use modeling com-

flares out

over the external

CONSTRUCTION AND PLACING OF PORCELAIN INLAY

surface of the tooth.

The matrix

is

307

then shaped over this impres-

sion with the fingers, using the soft part of the ball of the

thumb

as a counter die.

The most prominent parts

of the impression will represent the

deepest portion of the cavity and will assist in causing the matrix

which is accomplished by using the

crowd the matrix to position.
The impression
should be removed leaving the matrix, which has been by this
means partially swaged, in the cavity.
to reach this without tearing

impression

to

The Removal of the Impression Without Carrying Away the

is accomplished by bending the portions of matrix exposed
above the cavo-surface angle away from the impression.
The

Matrix

matrix should not be burnished down onto the external surface of

the tooth until the other portion has been

form

made

to thoroughly con-

to the cavity walls.

When the impression has been removed the matrix should be

thoroughly burnished to all cavity walls beginning at the seat of
the cavity first.
This burnishing is done with suitable smoothfaced instruments, keeping moistened chamois skin discs between
the instrument and the matrix.
The cavity should now be packed with daynp cotton

halls

ing the matrix ahead of them to every part of the cavity.

crowd-

While

matrix should receive thorough burnishing at the cavity margins and finally be turned out on to the ex-

this cotton is in position, the

ternal surface of the tooth a distance of one-fourth of a millimeter

to one full millimeter in all locations except one,

which may be

two or three millimeters.

This one place will facilitate handling during the process of
ing in the porcelain.

fill-

may now be removed and gum

wax croAvded into the cavity over

The cotton

camphor or gold inlay casting

the matrix, filling the cavity nearly full with one piece of material
packed to place with a flat-faced amalgam burnisher as large as
the cavity will admit.
is then removed from the cavinto the body of the camexplorer
an
ity by
The matrix and wax or
portion.
its
central
near
or
wax
plior
camphor still on the tine of the explorer should be immersed in
alcohol if camphor has been used or chloroform if wax has been
used, which will immediately loosen the tine and dissolve the ma-

Removal

of Matrix.

The matrix

sticking the tine of

terial

from the matrix, after which the matrix should be picked up

OPERATIVE DENTISTRY

308

ia the lock tweezers at that portion

where the metal has been

left

from the cavo-surface angle.

The matrix should now be passed through the alcohol flame when
the camphor or Avax remaining will be burned off leaving no ash.
Wood as an Impression. In simple small cavities it is well to

to extend the farthest

shape a piece of soft pine (as cork pine) to proximately fit the cavity.
This should be then introduced against the deepest portion
of the cavity and given a few blows from the mallet which will
cause the wood to conform to the floor of the cavity. This should
then be used as an impression and the matrix forming proceeded
with, as described when modeling compound has been used. The
use of the stick with modeling compound on the end is of advantage in large deep cavities where the pulp chamber is to be filled
with porcelain in place of metal pin. By this means it is possible
to place a matrix well to the bottom of any cavity without tearing,
provided the walls are regular and have the proper draAv devoid of
under cuts.

Taking the Spring- Out of a Matrix.

If a

matrix seems to retain

''spring" and does not seem to lay well on all surfaces, as frequently met with in complex cavity outlines, this may be removed

by the following method

When cavity is thoroughly packed with
wet cotton, stretch a piece of rubber dam over the matrix, cotton
and all, and thoroughly burnish the entire outline. If ** spring"
still persists, remove the matrix and anneal, and then repeat the
method when it will be found that the fault has been removed.
:

The selection of that portion of the inand that which replaces enamel should
The part
be attended to before the process of building begins.
replacing dentine should be of foundation body coarsely ground
and of a yellow color in all vital cases. In devital cases this shade
may be darkened by the addition of the brown shade, and in vital
teeth for young patients, particularly if the cavity is shallow, or
on a distal surface, the addition of white powder is of advantage
Selection of Porcelain.

\ay which replaces dentine

to lighten the

shade of yellow.

The enamel shades may be decided upon after a careful study of

the shades and hues found in each case. Delicate shading is secured by building one layer upon another, thus getting the benefits
of reflected light. The deep and pronounced shades and colors are
best obtained by building in sections. Teeth that are much of one
color and not pronounced in lines of shades will be best represented
by the layer method, while teeth that are decidedly yellow at the

CONSTRUCTION AND PLACING OF PORCELAIN INLAY

309

cervix and pronouncedly blue at the incisal edge are best represented by building in sections provided; the cavity involves both

regions spoken of as in Class Four (proximo-incisal).

After the different sections have been applied and brought to a

hard biscuit fuse, a uniform layer of neutral color is applied over
the whole and all fully fused.

Applying the Porcelain to the Matrix.

put upon the porcelain or glass slab and

The foundation body

is

sufficient distilled water,

or alcohol or a mixture of both, added to

make a

stiff paste, stiff

shape when taken up on the point of a spatula.

A small quantity of this is laid in the bottom of the matrix and
by a little jolting made to flow over the surface. This jolting is
best produced by drawing the edge of a fine gold file over the
tweezers holding the matrix. The additions should be continued
until sufficient body has been added. Excess moisture is removed
by repeated jolting and absorbing with blotting paper. Dark colored blotting paper is used so as to detect any paper fibers Avhich
by accident adhere, which should be removed. The addition of
dry porcelain of the same color will take up the excess moisture,
the surplus adhering poAvder being brushed off with a small brush.

enough

to retain its

In Case the Matrix

is

Tom,

the opening has to be comparatively

large to cause the porcelain to run through, unless the matrix

damp on

the cavity side or too moist a

mix

is

is

being applied.

Should any of the porcelain flow through, it can be removed with

a dry brush provided the porcelain has been rendered quite dry.
Do not apply a wet brush to the cavity side of the matrix. The
inlay should now be placed in the oven and fused sufficiently to
produce the greater part of the shrinkage, but not to a full gloss.
When removed from the oven if more foundation is needed it
should be added and fired to a high biscuit.

The Enamel in Proper Shades is now added, either in layers or

and again fired to a high biscuit. The inlay should then
be tried into the cavity for bulk and contour. If not correct more

sections,

enamel

is

added.

When

the contour suits, the inlay

the oven and fired to a full glaze.

The

skill

is

replaced in

necessary to reproduce

the colors of the teeth comes Avith practice and the longer one en-

gages in this Avork the more often

Avill

the results please the oper-

ator,

The furnace should be firet heated

and held there for a minute or tAvo, to thor-

Technic of Fusing* Porcelain.

up

to a bright red

OPERATIVE DENTISTRY

3]0

oughly warm the fire clay entirely tliroiigh, and then the lever returned to the first button to maintain a v.arm oven.
When ready to fuse, the furnace is completely shut off provided
the oven shows any redness. Never put an inlay mix into a hot
oven, as it causes too rapid evaporation of the moisture, producing
checks and an extremely friable porcelain.
When the inlay is in position in the oven the lever is put on the
second or third button and advanced only

when

the needle of the

milliamperemeter ceases to advance. The heat should be increased

gradually and when it has reached the desired degree immediately
shut

off.

Each furnace has a way peculiar

and each oper-

to itself

ator should learn the time for perfect results.

Grinding' to Contour.
tried in

and ground

After the

final

fusing the inlay should

and articulation on

to contour

l)e

the incisal or

occlusal surface before removing the matrix.

To Remove the Matrix.

Drop the inlay and the matrix in alcoremove and peel the matrix from the inlay, draAving from the margins all around first, then from the body of the
hol or Avater, then

This procedure prevents chipping at the margins.

Etching the Cavity Side of Inlay. When the matrix has been
removed the inlay should be embedded, contour surface down, into
With a warm spatula it is sealed
a sheet of pink base plate wax.
entirely around, being sure to cover the edges of the inlay on the
filling.

cavity side for a short distance,

leaves the cavity side exposed,
acid.

This

is

say

one-half

upon which

is

applied by dipping a stick in the

millimeter.

This

applied hydrofluoric

wax

bottle in Avhieh

the acid is delivered, and painting the inlay with a small quantity
of the acid. Two minutes will generally be sufficient to thoroughly

etch the surface.

Toilet of Inlay.

moved from

The inlay should

be, flooded Avith Avater, re-

the Avax and placed in boiling Avater for a few minutes

and then given a chloroform bath, and dried Avith Avarm air Avhile
laying on spunk or blotting paper, and should not be again contacted Avith the hands on the caA^ty side.
The cavity should be rendered dry. All inand particularly the large ones, are best set Avith Avhite cement with the faintest tinge of cream. The attempt to match the
color of tooth substance Avith the cement is an error as the pigment
in the cement increases the shadoAV line Avhich is objectionable.
Use a AA^hite cement mixed to the consistency of greatest adhesiveness yet thin enough to floAv from betAveen inlay and cavity Avails
Toilet of Cavity.

lays,

CONSTRUCTION AND I'LACING OF PORCELAIN INLAY

311

with light pressure. This will be about the consistency of thin

cream. The cement should be thoroughly and rapidlj^ spatulated
and when the "stick" is felt under the spatula it should be ap-

and the surface of the inlay which is immediateUse a non-corrosive spatula, preferably bone or agate.
Apply to the cavity with a flattened orangewood stick. Press inlay to position with a stick of orangewood using gentle pressure,
gently tapping the end of stick with the knuckle of the forefinger,
plied to the cavity

ly placed.

or blows of equally cushioned nature.

In labial and buccal

fillings

(Class Five)

the inlay should re-

In proximal (Classes
Three and Four) the filling should be gentlj^ wedged against the
proximating tooth or tightly ligatured to position and so left for
some hours.
The Finishing should be left till another sitting. If the building
has been well done there will be little to do. All overhanging margins should be dressed down with fine stones and disks and the
surface polished with small Arkansas stones, using a light hand
and keeping the stones well watered.
ceive gentle pressure for five or ten minutes.

APPENDIX
As a suggestion to those Avho use this book as a text in college
teaching, the author submits the following courses based on the
subject matter of the foregoing chapters and illustrations.

shown the author's selection

work and Dr. Rathbun's "dentech"
are also

Herein

of instruments for doing the

to take the place of the pa-

tients.

While carrying out this course the freshman completes the first
During the second year the student hurriedly
revicAvs the first seventeen chapters and completes the remainder of
the book. The courses in both the first and second years are quiz
courses.
The third year students review the book entirely with
the teacher giving lectures elaborating on each subject by adding
personal ideas to give individuality to the course.
The fourth
year is devoted to a study of the subject as presented by other writseventeen chapters.

ers,

member

each

of the class writing papers for the consideration

of his fellow-classmen,

who should be allowed

to discuss the papers

presented.

Operative and Dental

Anatomy Technic Courses

FRESHMAN YEAR.
First Semester.

Fourteen plaster tooth carvings, three times Black's measure-

(1)

ments.

Second Semester.
Fourteen bone tooth carvings, average measurements.
(2)
(3)

Six bone tooth carvings from models of extracted teeth.

(4)

Nine

cavities as assigned in technic block, finished

Twenty-four

(5)
finished

May

1st.

March

Ist.

cavities as assigned in fourteen plaster teeth,

(See Figs. 13 and 14.)

JUNIOR YEAR.
First Semester.
(6)

Fill nine cavities in technic block.

(7)

Mount bone carvings and natural

teeth on "dentech."

(See

Fig. 177.)
(8)

A.

Fill natural teeth as per following

Second lower molar.

Occlusal.
313

list.

Class

One

cavity.

Expose

314

OPERATIVE DENTISTRY

Fig. 170.

Excavators,

group one.

Chisels for securing outline form.

APPENDIX

Fig. 171.

ICxcavators,

group two.

Spoons for .removing softened dentine.

315

316

Fig.

OPERATIVE DENTISTRY

172.

Excavators,

group three.

Enamel hatchets

flattening dentine walls.

for completing outline

form and

APPENDIX

Fig. 173.

Excavators, group four.

317

Instruments for cutting point angles and sharpening

base line angles.

OPERATIVE DENTISTRY

318

Fig.

17-1.

Excavators,

group

Hatchets and hoes for cutting ascending line angles and

completing retention form.

five.

APPENDIX

Fig.

175.

nxcavators,

group

six.

Gingival marginal trimmers.

finishing gingival walls.

319

Instruments for shaping and

320

OPERATIVE DENTISTRY

id

>-i

Fig.
Figs.

176,

Numbers one

y4

to

and B.

176 B.

Gold

building

pluggers.

seven inclusive are for building

These instruments have the same sized

serrations and are made in conformity with the
principles taught in Chapters XIX and XX.
Instruments numbers eight to twelve inclusive are
for building fiber gold.
These five instruments
have serrations specially adapted for use on this
form of gold. In changing from foil builders to
foil

gold.

fiber gold builders or vice versa the surface of

the gold should be gone entirely over, before adding the differently prepared gold, with the instrument with which the operator expects to condense
the new gold.

zS
cs

E'^

^1

Fig.

176-^.

APPENDIX

321

^mm^

Dr. Rafhbun's dentech with teeth in position ready tor practice work.
This
Fig. 177.
appliance may be used either on the bench or head rest of any operating chair. The author
advises the advanced work with this on the dental chair to familiarize the student with
positions.

OPERATIVE DENTISTRY

322
I>ulp.

Devitalize.

Remove

pulp.

Fill

pulp canals.

Fill cavity with

silver cast inlay.

Upper

B.

putrescence.

Fill

C.

Second lower bicuspid.

Fig.

178.

Deutech."
the

Lingual
pulp canal.

lateral.

same

as

Occlusal

Class

pit.

treat for

amalgam.

One

cavity.

Open

Upper

Devitalize.

E.

Open and

Class One.

Fill cavity with

This shows a student who has kept his appointment with his patient, "Mr.
The student is required to keep an appointment book with this dummy patient
though the mouth to be worked on was animate.

and treat for putrescence.

Z>.

pit.

central.

Fill

pulp canal.

First lower molar.

Remove pulp.

Fill

Fill

Distal.

pulp canal.

Fill cavity

Class Three cavity.

with

tin.

Expose pulp.

Fill cavity with cement.

Mesial.

pulp canal.

Class

Two

Fill cavity

with

cavity.
tin,

Devitalize.

restoring con-

tact.

F.
Fill
tact.

First superior molar.

pulp canals.

Fill with

Mesial.

amalgam

Class

Two

cavity.

Devitalize.

restoring the contour and con-

APPENDIX

323

Second superior molar. Class One cavity. Central pit rather

Prepare so as not to injure the pulp in vital case. Fill with
amalgam.
G.

large.

H.

First and second superior bicuspids.

Mesial cavities.

Class

t^i

The middle and right hand

Fig. 179. Forceps made after the patterns of the author.
pairs are spoon beak forceps, hollow ground and should be kept reasonably sharp by grinding.

Use pressure anesthesia. Remove pulps. Fill

Fill both cavities with tin.
First inferior molar. Class Five. Prepare cavity and fill with

Two. Expose pulps.

pulp canals of both.
I.

amalgam without injury

J.

Admitted

to the pulp.

to infirmary practice.

OPERATIVE DENTISTRY

524

Second Semester.
Twenty-four
(9)

cavities in carved

bone teeth mounted on ''den-

tech," duplicating those in plaster teeth of the freshman year.

and

fill

Cut

in the order listed, completing each filling before cutting the

next cavity.

c^

Fig. 180.

Forceps made after the patterns of the author.

of

cow horn and hawk

bill

The

right
beak.

hand pair

is

a combinotion

INDEX
Amalgam
Abrasion:

properties of, 139

proportion of alloy and mercury,

97

mechanical, 195

142

Abscess:

reception of, 129

alveolar, acute, 179

trimming the

alveolar, chronic, 224

Absorbent cotton, use

of,

175

Access form, defined, 31

importance of, 31

and

sensitive

method, 58
second method, 59
third method, 59

surface, 282
Angles, avoided in outline, 34
avoided in outline, class two, 61

102

two,

general for,

dentine,

202

99
three,

line,

105

class two, 62

Angle restoration:
conditions demanding,

150

Affected dentine, 29

class four,

78

Alloy,

plans of, class four, 78

ageing of, 140

annealing of, 141
Alveolus, opening mouth

plan one, class four, 85

of,

plan two, class four, 87

indications for, 88

234

Amalgam

plan three, class four, 89

indications for, 88

cavity preparation for, 141

contraction of, 140

plan four, class four, 90

Appendix, 313, 324

cutting from the margins tor, 144

defined, 139
edge strength of,
expansion of, 140

Arsenic trioxide:
140

caution in use

seats for,

141

retainer,

technic

flow of, 140

history,

of,

matrix, use

141

maximum

of,

strength

use of, 216

as

cement as

a,

a,

216
217

217
217
soreness from, 217
cotton as

a,

stopping as

114
of,

217

217,

216,
in,

amalgam

139

making the filling, 144

making the mix, 142
matrix, removal

of,

combination, 215
poisoning from, 217

expressing mercury from, 143

flat

292

275,

202

dentine,

sensitive

72

class

201

regional,

pulp, 212

first

class

144

pressure, for pulp, 213, 214

class two,

silicate,

285
282

local

Access form for:

inlays,

conductive,
infiltration,

intra-alveolar,

surgical for, 31

three,

of,

filling

Anesthesia:'

Absorbents, 187, 194

class

'd

polishing of, 145

causes not clear, 96

incisal,

Cont

objections to, 139

a,

time of application

140

325

of,

217

INDEX

^26

Cavities
class

Bevel angle, base

defined,

of,

28

Cont 'd
three,

form

27

defined,

management

Broach, cotton carrying, 226

Burnishing cohesive gold, 137

22

72

of,

class four,

72

of,

78-92

defined, 22
inlay, 63

class five,

Calculus:

prevention

salivary:

composition

of,

removal

183

of,

class six, 96, 97

cause

of, 183
182
distinguished from, 184
removal of, 184

occlusal surfaces, 97

complex,

as,

21

superior

distal

pulp:

chlora-percha

divisions

227

groups

general, 225-228

as

of,

to

cuspids,

91
manipulation,

21
increased outline

as, 227
immediate, 215, 218
material for, 225

dangers

in,

most popular, 227

laying of outline, 37
mesio-disto-occlusal,

perfect,

mesio-disto-occlusal,

225

point angles

225

vital,

68

25

simple, 21
stress

from within, 38

toilet

of,

45-47

dentine:

Cavity nomenclature, 21-28

in large decays, 44
in large proximal cavities, 44

predisposing causes, class one, 48

class two, 58

removal of

remaining,

defined,

44
Cavities:
axial

in,

proximal, 21

progressive stage of, 207

rapid, indications of, 167, 195

base

non-vital,

68

Caries:

Carious

surface,
of,

buccal and lingual surfaces, 55

cavo-surface angle, defined, 27
for fused porcelain, 295
class one, defined, 22
class two, defined, 22
early

detection

necessity of, 21

names,

how

derived,

21

Cavity preparation:
completed, defined, 29
general consideration of, 30
gold inlay, 98-111
modification of form. 29
order of procedure in, 29

21

24

non-vital, 67

of,

37

necessity of, 225

objective point in, 225
for,

22

21

how named,

gutta-percha

ready

97

in,

line angles in, 25

227

of,

96

early restoration

deposited,

filling,

96

of,

defined,

appearance

Canal point, size

93

of,

tendency to spread, 93

181

seruraal:

Canal,

93-95

22

defined,

essential,

58

porcelain inlay, 296-305

Cements:
amalgam, and, 170
cavity preparation for, 146
cement, int. v. defined, 148
cement, n. defined, 148
cement, t. v. defined, 148

INDEX
Cements

Cont 'd

Convenience form, 42-43

abuse of, 42

cementation, n. defined, 148

gold, and, 169

class one, 50

and, 171

porcelain,

class two, 63, 66

retainer of arsenic, 217

defined, 42
distal superior cuspid, 92

Cementum, exposure of, 196

Children's teeth, management

of,

two,

class

previous separation lessening, 42

cavities, class three, in, 231

cavity preparation

imperative,

attention

early

exposed pulp,

in,

in,

230

visit of child,

229
grinding

Deposits,
in,

231

of,

Chloroform, 202
cervical, use of, 194

methods of applying,

191, 194

Cocaine:

277

local anesthesia, with, 277

170
gold and platinum, 170
gold and

tin,

celain,

171

and gold, 171

Contact point, proper, 32

build of, amalgam, 144
class six,

position of,

are

strips,

of,

132

132

in use

E
Electric lamps, use of, 176

edge, 97

por-

182

protection,

187

of,

malformed, 305
margin, 27
plane of, 45

Enamel
axial,

class

walls, 45

surface
one,

pit,

56

50

class two, 63, 67

class three, 77

97

condensing

pulp

of,

46

defined, 97

169

and amalgam, 172

cement and fused

and

Disinfection

Enamel:

object of, 169

silicate

181

of,

neglect of, 187

defined, 169
gold and cement, 170
gold, cohesive and non-cohesive.

silicate

prevention

time

46
Dryness, 187
importance

Combination fillings,
cement and amalgam, 170
cement and porcelain, 171

silicate

salivary,

Disks and
dentine,

sensitive

181

to,

181

as to,

kinds, upon the teeth, 180

mouths most subject to, 181

176

Clamp

for

food as related
habits

root filling in, 232

Chip blower, use

D
Dentech, 321
180

229

difficulty in,

first

inter-proximal

230

in,

230

in,

first

sparingly used, 42
suitable instruments for, 42

extension for resistance

materials

229

231

extension for prevention

filling

154

silicate,

230

in,

required, 42
required, 42

porcelain inlays, 296

230

in,

inlays, 99

maximum
minimum

229-233
cavities, class one, in, 230

cavities,

77

class three,

146

varieties of,

327

inlay,

class two,

104

inlay, class four, 109

of,

328

INDEX

Enamel

walls

inlay,

Cont'd

porcelain,

Extraction of teeth:

297

rules for

154

silicate,

Examination of mouths:
care

temporary teeth, 269-274

instruments needed

hand

light

third, superior molar, 262

175

in,

in,

175

174
completed, 176

when

Cont'd.

third, inferior molar, 262

early extraction, evil results of,

269

in,

Exclusion of moisture, 186

as a time saver, 189

first

molar, related

first

molar,

to,

time of

reasons for,

269

eruption,

269

better view of the cavity, 188

decalcification

detected,

189

for proper canal treatment, 188

for sterilization, 188

methods

186

of,

pain decreased by, 189

use of, 175
External enamel line, defined, 27
Extensions gingivally:
Explorer,

buccal, class one,

56

F
Feldspar, formula of, 293
Finishing cohesive gold filling, 137
abrasives in, 138

burnishing in, 137

gingival excess in, 137
knife, in, 138
strips,

138

in,

Floss silk, waxed, use of, 176, 186

buccal, class two, 60

Extension for prevention:

approaching the gum, 56
buccal

56

pits,

defined, 35

esthetic

reasons,

Extraction

of

Gingival Angles, class four, S3

Gingival outline,

74

teeth,

permanent,

233-268
care

forces used

general

in,

Gold:

234

consideration

of,

233

hemorrhage following, 267, 268

movements

73

class five, 94

263

in,

class two, 61, 65

class three,

in,

234

annealing

of,

124

application of, 127

bridging

of,

125

positions in, 234

building of class

five,

136

position of arms in, 240

building of class

six,

136

position of hands in 240

cement and, 169

position of operator for inferior,

238
position of operator for superior,

235
resistance of patient in, 243
rules for,

cohesion of, 125

cohesive physical properties,

condensing of, 127

covering of pulpal wall, wdth, 131
hand pressure in use of, 127

inferior bicuspids, 253

last portions

superior bicuspids,

layers

249
inferior cuspids, 249
superior cuspids, 245
inferior incisors, 245

123

condensation, secondary, 137

of,

class

135
objectionable qualities,

two, 133

of,

order of stepping, 129

buccal cavities, 129

superior incisors, 24t

class two, 130

inferior molars, 259

irregular outline, 129

superior molars, 256

occlusal cavities, 129

of,

123

329

INDEX

Cont

Gold Cont 'd

Hypersensitive dentine

treatment

platinum and, 170

preparation of, 126
specific

gravity
a

starting

zinc chloride

129

Incisal abrasion, class six, 97

two, 129

Incisal angle:

class three, 133

and,

class three, filling of, 87

135

class four,

tin

class four, 78

169

class

use of, in class

welding of, 123

95

five,

Incisal

massage, 185
Gutta-percha, 164
base plate, 164
canal points of, 165
filling root

angle,

74

class three,

class four, plan one, 87

class

94

five,

Infected dentine, 29

filling,

164

Inlays

165

separation with,

temporary stopping

beveling of
165

of,

cavo-surface

wax,

the

114

defined, 98

finishing

pressure, cohesive gold, 12S

the,

gold used,

122

in,

121

heating the gold,

for,

120

Health of patient, 207

Hydrogen dioxide, 185

history of, 112

Hyperemia

hole leading to model, 121

passive,

indications for, 98

206

177,

investing, pattern of, 119

178

stages of,

line of approach, for, 100

206

Hypersensitive

dentine,

defined,

195

making pattern, for, 113, 119

making the cast, of, 120

caustic potassa in, 200

materials for, 98

chloroform

matrix for, 119

not indicated, 98

202

in,

cold air in, 199

dessication

current

formaldehyde

object of, 112

198

of,

destroying agents
electric

in,

in,

in,

199

199

200

moisture, heat and cold in, 199

in,

202

of cloves in,

201

nitrous oxide

occlusal restoration, with, 118

pin for, 116

placing spruce wire for, 115
porcelain,

phenol in, 200

potassium bromide in, 202
rapid breathing in, 203
sharp instruments in, 203
silver nitrate in, 200
somnoforme in, 202

construction

of,

311

applying

novocain, 201
oil

angles,

100

carving

active,

75

class three,

Incisal outline:

164

preparation of

81

of,

porcelain inlay, 304

edge,

Incisal line

canals with, 164

filling with,

direction

four,

class four, to assist the, 86

Gum

Hand

200

in,

125

of,

filling,

class one,
class

'd

195-203

of,

of,

309

etching of, 310

finishing of, 310
of, 310
matrix for, 306
pushing technic of, 310
selection of, 308

grinding

toilet

of,

310

306-

330
Inlays

INDEX

Cont

'd

retention form for, 51

retention
temporarily

removed,

class three,

51
retention form of pattern, 115
saturating the model, 120

sponge gold as pattern, 119

sweating the contour, 118, 119
temperature of the model, 120
toilet for, 100

Instruments, 17-20
angles

how made,

salts

192

in

Line angles,

bur, 19

solution,

precipita-

(see Cavity),

care of, 20

axio-labial,

chisel,

axio-lingual, class three, 76

use

77

Lingual approach:

IS

of,

advised, 135

ii

contra anglos

class

18

in,

three,

cohesive gold,

dental engine, use of, 19

17

Lingual outline:

few

class four, plan one, 87

lower incisors, 87
Local anesthesia:
anatomy, related to, 277
cocaine in, 277
defined, 275

class three, 75

ex'iavators,

174

sight,

formula names, for, 18

gingival marginal trimmer, 18
hatchets, defined, 18
hoes,

18

defined,

how named,

17

nomenclature, for, 17-20

plugger, point serrated,
126

horizontal injection
.19,

125,

126

and

sharpening

lefts,
of,

in,

17

19

spoon, use of, 18

doses of, 280

name, 17

suprarenin,

sub-order name, 17

suprarenin

test for

uses in dentistry, 276

sub-class

sharpness, 20

in,

280

triple-angles in, 18

Instrumentation,

lingual

K
Kaolin, formula of, 293

285

283

novocain in, 277

pericemental injection in, 286
perpendicular injection in, 285
preparing solution for, 280
Ringer's solution for, 281

rotating the, 126

rights

infiltration in,

intra-alveolar in, 285

novocain, doses of, 279

amalgam, 143
size of,

135

inlay illustrated, 105

cuts of, 314, 324

in

76

Linen, 174

18

name,

class

class three,

gingivo-axial,

18

defined,

edge,

230

tion of, 181

18

in,

(children),

caution in use of, 192

cutting ends of, 193

Lime

18

in,

sitting

Ligature, 192

knot in, 193

removal of, 193
Wedelstaedt tie, 193

undercuts, filling of, 113

wax pattern, for, 113

bin-angles

74

class four, plan one, rule for, 86

class four, plan three, 90

Length of

122

setting,

Labial outline:

pit,

57

Mallet force:
alone, 128
automatic, 128

INDEX

Outline form

Cont'd
curving to the axial, class four,
86
defined, 34

Cont'd
hand, 128
power, 128
rule of, 128

Mallet force

331

Marginal bevel:

superior cuspids, 91

distal

angle of, 45

for silicate, 151

defined, 27

inlays,

depth

of,

45

one,

101

class two,

103

class

necessity of, 27

Matrix:
annealing of, 306
applying porcelain to, 309
material, for, 306
methods of forming, 306
porcelain inlay, 306
removal of, amalgam, 144
removal from porcelain, 310
taking the spring out of, 308
thickness of, 306
torn, 309
use of, class two, gold, 133
use of, in silicate filling, 162
use of, with amalgam, 141
Mouth mirror, use of, 175

class three, 105

large class one, 52

lingual pits, 55

porcelain inlays, 296

rule one of, 34

rule four of, 34

rule five of^ 34
rule six of, 34

rule seven of, 34

rule eight of, 34
rule nine of, 35

rule ten of, 35

step omitted in class two, 59

dessication, 71

Oxyphosphate of copper, 147

Oxyphosphate of zinc, 146

Novocain:

manipulation

sensitive dentine, 201

cf,

34

Oxychloride of zinc, 146

care

of,

rule three of, 34

Over

tablets,

two

rule

of,

147

spatulation of, 147

281

Nitrous oxide, 202

O
Pain, dental:

Objects in

filling teeth,

29, 96

alleviations of, 177

Occlusal defects, 48

cold,

causes,

177

Occlusal outline:

divisions of,

177

class

two, 66

class five, 94

Operative technic courses, 313, 322,

323, 324
Order of procedure:
cavity, 29
for inlays,

Outline

99

form:

buccal pits, 55
class one, 48
class two, 59, 65

class three, 73
class five, 303

foreign

substances,

patents

in,

causes,

178

175

diseases,
causing,
pericemental
179
symptoms, aggravated, 177
treatment for, 177, 178, 179
Passive hyperemia of pulp, 178

Pins:

placing for inlay, 116

soldered to matrix, 116

Tungsten, 116
Planes of a tooth:
bucco-lingual, 28

INDEX

332
Planes of a tooth
horizontal,

Cont'd

Pulp:

28

devitalization

mesio-distal, 28

Porcelain:

arsenic

advantages

294

of,

trioxide,

for,

215
211

to,

care exercised in, 214

294

determining the
method
212
high pressure for, 213
methods of, 212
technic of, 213

build of layers, 294

cavo-surface angle for, 295

cement

'd

bacteria as related

basal body, 294

biscuit fuse,

Cont

anesthetization for, 212

line

in,

301

composition

of,

293

of,

contra-indications for, 295

exposed, class one, 53

dental, fused, 293-295

exposure, dangers in, class two, 65

exposure feared, class one, 52

disadvantages of, 294

double step in, 302

infected with bacteria, 206

involved, class five, 95

enamel body, 294

fine

grinding

of,

294

lesions of, 177

flux,

amount

of,

294

normal, 204

foundation body, 294

high fusing, 293, 294
indications for, 295
lingual approach, class three for,
300
low fusing, 293
methods of fusing, 293
pigments in, 293
proximal approach for, 301
shrinkage in, 294
size of mass, 24
spheroiding of, 294
Potassium bromide, 202
Preventive dentistry, 180

Primary decay,
three,

location of,

class

72

Prophylactic treatment, oral, 180

brushing, technic of, 186

importance

of,

instructions
oral

to

180
patients

in,

186

hygiene, children, 229

Proximal Space, restoration

of,

Pulp:

31

partially devitalized, 218

peripheral
protection,

in

deep seated cavities, 207

indications for, 205

materials used

animal fats

207

in,

221

autogenous, symptoms

of, 222
treatment of, 222
classes of, 219
closed, symptoms of, 222
closed, treatment of, 222
complicated, symptoms of, 223
complicated, treatment of, 223
defined, 219
open, symptoms of, 220
open, treatment of, 220
treatment of, general, 220
recuperative powers of, 204

autogenous,

bent, 226

canal

of,

214-218

dressing
filling

225
228

of,

of,

pains following, 215

sensations are conveyed

devitalization,

stimuli, abnormal,

agents for, 212

215

hemorrhage following, 215

chief idiosyncrasy of, 204

causes for, 211

215

following,

following, 215

discolorations following,

management

chamber, cleaning

in,

putrescence, 219-224

canal

small,

210

in,

in class two, 66

air in, 227

putrescent, 219

212

irritation,

204-210

gutta percha

removal

canals,

nerve

preservers, 209

to,

211

stimuli, normal, 211

traumatic injuries to, 211

195

INDEX
Pus

333

Retention form:

in apical space, 179

Putrefaction defined, 219

flat seats in

Pyorrhea alveolaris, 184

Cont'd

class two, 103

class four, plan two, 107

for porcelain inlays, 296

for silicate, 153

Regional anesthesia:
defined, 287
gasserian injection

little,

288

in,

infra-orbital injection in, 290

mental injection
palatine injection

290

in,

292
pterygo-mandibular injection in,
288
spheno-maxillary injection in, 288
zygomatic injection in, 290
in,

Removal of remaining decay:

in enamel, 41

maximum
maximum

not required, 40
required, 40
step as a portion of, 40
Ringer's solution, 281

Rubber dam:
before applying, 38
class one, 52
essential in filling with

for silicate, 154

class one, 50

gingival side of, 191

class two, 66

holes,

distance between, 190

holes, location of, 190

77

class three,

for silicate, 154

holes, size of, 190

inlays, 99

invented by, 187

leaks in, 46

Resistance form:
applied to filling material, 39

buccal

55

pits,

method of applj-ing

the,

number

isolated with,

75

191

placing of, 191

extension for, defined, 38

force to provide for in, 38

for porcelain inlays, 296

for silicate inlays,
inlays,

teeth

objections to use of, 187

occlusal side of, 191

class two, 62, 66

importance

of
191,

class one, 49

class three,

amalgam,

141

of,

151

38

prevent leakage in, 192

removal of, 194
size and shape of, 190
thickness of, 189

99

class one, 101

class

two,

103

class four, plan one, 106

involves a consideration of, 38

Secretions, abnormal, oral, 196

Separation:
class

two

cavities, 59

Retention angles for inlays, 99

for amalgam, 142

Retention form:

class one, 49

gutta-percha for, 165

immediate, 33
inlays, class two, 102
methods of, 32

class two, 62, 66

preliminary, 33

class three, 75

soreness resulting from, 33

acute angles required

buccal pits, 56

78-81

class four,

40

inlays,

class

40

mechanical not essential, 176

use of, class two, gold, 133

class five, 94
flat seats in,

in,

Silex,

formula

of,

293

Silicate:

one,

102

amalgam, and, 171

334

INDEX

Silicate

Cont

'd

Toilet of cavity:

applied to prosthetic work, 172

cavity preparation for, 150
defined, 148

with, 163

fillings

finishing the filling, 162

51

one,

gold, and, 171

the

for

154

silicate,

Tooth:
158

materials,

brush, use of, 185

form, restoring

proper consistency, 159

time in mixing, 160
use of matrix, 162
defined,

defined, 45

for porcelain inlays, 297, 310

making the filling, 155

making the mix, 159

Silicatization,

class

class two, 67

facing metal

preparing

best accomplished by, 45

32

of,

picks, 186

substance, saving of, 32

148

Tubuli, contents

195

of,

Somnoform, 202

Sordes, consistency of, 183

Sordes, removal of, 183, 185
Stains on the teeth, 183

green stains, color due

injury to teeth, 183
removal of, 185
where found, 183

Wall:
183

to,

class two, 62

class three,

for porcelain, class one, 298

area included, class two, 61

depth of class four, plan two, 87
superior cuspids,

distal

technic

of

cutting,

for porcelain, class three, 299

buccal, class two,
distal

91

gingival,
four,

class

plan two, 88

gingival,

class

gingival,

class

three,
three,

77
inlay,

105

defined, 24

labial, 77

lingual,

order,

lingual, axial, 62
in,

271

disregarding

of,

lingual,

272

occlusal,

of eruption, 270

outside,

(^Tin:
amalgam

92

23

defined,

compared, 270

changes

91,

88

gingival, class two, 66

inside,

Teeth:

62

superior cuspid,

freshly cut,

forming of, 61
omitted in class two. 51

is

77

23

defined,

Step:

VJj
'6

axial,

77
class

two, 92

class

inlay,

five,

defined,

110

22

pulpal, class two, 62

pulpal, defined, 22

and, 168

23

as a filling material, 166

sub-pulpal,

cavity preparation for, 167

weakened enamel, 38

discoloration,

amount

discoloration,

by,

of,

166

defined,

Wide enamel margin,

indicated, 46

166

forms of, 167

C^ gold and, 168, 169

P5>

Zinc:

history of, 166

in teeth of children,

methods of introduction,
therapeutic action

of,

thermal conductivity

chloride of, 200

167
167,

166
of,

166

oxychlorate

of,

146

oxyphosphate of, 146

sulphate of, 147

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