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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
ing THE Angle.
XIV.
Page
Cavities in Incisoes and Cuspids
Not Involv-
(Class Three.)
72
CHAPTER XV.
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 alAAâys 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.
wâll 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;î,:^
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
lê 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 remoAêd.
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 haAê 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

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

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
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.
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 prcAênted 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.

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
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.

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 obAîous
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
haAê
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-
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.
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 Betwêen 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
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
IcAêr 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.

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 aboAê

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
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.

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

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.
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
îther 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

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.
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
OtÊRATlVlS
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

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
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.
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.
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
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
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.
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
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

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.
'
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.
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.
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 saliAâ 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 wôuld
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
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^waîf^fef^tffibsii
aa
i.MMIMI.IIl
'^
"
'"f.
riiiniin'^'
^1
^^K 1^
^^
~.
^^^K^g?t^^^û^t^mî^fM
H
1
-'"'
M ttfek
iwrJl'HBIî
^^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
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.
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
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
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
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
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
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
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 indiâduals,
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.
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
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-
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-

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.
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
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

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
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.
'
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.
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 wâter 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 iûtrescence 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
rôt
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 haAê, 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-
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
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
OtÊftATlVE
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-
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.
'
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.

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.
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.
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

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
riîht
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
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-
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
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
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
265
the second row

fifth
row shows
266
OPERATIVE DENTISTRY
Fig.
Fig.
139."
Êlevator
140.
Position
beaked forceps for extracting third molars.
for extracting right
inferior third molars.

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
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
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

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.
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
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
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.
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
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
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
tî
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
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

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
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

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,
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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Essentials of Operative Dentistry PDF

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Incorporated Dental Society,

12, Tavistock Square, London, W.C.I.

be added fronn time to

be retained for Four V /eeks.

Incorporated Dental Society, Ltd,,

Digitized by the Internet Arciiive

DEAN AND PROFESSOE OF OPERATIVE DENTISTRY AND TECHNIO, LINCOLN DENTAL

SECOND REVISED EDITION

Copyright, 1916, by C. V. Mosby

PREFACE TO SECOND EDITION.

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

and yet cover a wide field in operative dentistry.

PREFACE TO FIRST EDITION.

In the preparation of this text-book

terms at his disposal.

The subject matter selected is that which is generally taught

a study of these teachers' courses of instruction

seem that the definition of Operative Dentistry as commonly used

has seemed wise in several instances to go beyond

the exact limitations of this definition to get a better correlation

of the subject matter

in accordance with the usual line of progress

The author claims little originality in the essentials presented,

individuality to his course of instruction.

ative Dentistry" that

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

tend his studies to more voluminous reference books, Avhen time

(Class One, Concluded.)

Large Proximal Cavities Endangering the Pulp.

Cavities in Bicuspids and Molars.

(Class T-wo, Con65

Cavities in Incisoes and Cuspids

Cavities in Incisors Involving the Angle.

of Cavities in the Gingival Third.

Cavity Preparation for Gold Inlays

Manipulation of Cohesive Gold in the Making of Fillings by Classes

Finishing Gold Fillings

of Gutta-Percha in Filling Teeth

Extraction of Temporary Teeth

Local and Regional Anesthesia

of Fused Porcelain in Filling Teeth

Class Two cavity filled

Class Four cavity filled

Lingual pit cavities

cases in which the step

molar and bicuspid suitable for cohesive gold or

shown in Fig. 25 contacted, illustrating the marble contact

Cavities showTi in Fig. 31

Three cavities prepared for cohesive gold

to illustrate the principle of the lever in the dislodgement of

to illustrate the retention at the incisal angle of Class Three

of the Fourth Class, plan one

to illustrate the principle of the lever in the dislodgement of

of the Fourth Class, plans one and two

importance which should be given to the proper

of the superior cuspid

54. Cavities Class Five for cohesive gold or