Chapter XXXVII

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The teeth are also subjects of certain tumor formations which in general are spoken of as _odontomas_, and have been mentioned in the chapter on Tumors. (See p. 281.)

Teeth, moreover, show at times excessive development or marked displacement or defects of development. Thus they erupt in abnormal positions, or fail completely in eruption, or they project in abnormal directions or are sometimes amalgamated. The art and science of the dentist permit of wonderful control of abnormal development of those teeth which once appear upon the surface. Children whose teeth are irregularly placed, or which are abnormal in any respect, should be placed under the care of a competent specialist. The most serious _tumors of the teeth_ are those connected with _cyst formation_, which may assume considerable size. A _dentigerous cyst_ is proper material for the surgeon rather than for the dentist, inasmuch as while the operation can be usually done through the mouth it may require external incision and removal of a considerable shell of bone, perhaps with plastic restoration of tissues.

THE EXTRACTION OF TEETH.

The general practitioner has often to remove diseased teeth as well as the surgeon. The theory of tooth extraction is simple. Its performance, especially when the tooth is diseased, may be exceedingly difficult, for such teeth may be crumbled in consequence of the force needed for their removal.

_Forceps_ of different shapes are required for the various teeth. At least half a dozen different patterns are requisite. A form of elevator is also of use in elevating stumps which may lie beneath the alveolar border.

The tooth to be removed should be seized along the fang and beyond the crown. The blades of the forceps should be pressed firmly down and along the tooth, in order to separate from it the softer tissues of the gum and the firmer tissue of the alveolar socket. This is thinner upon its outer aspect than its inner, save in the location of the wisdom tooth, and it is the outer border which is more easily broken away by force applied toward the cheek rather than toward the interior of the mouth. Using first one blade of the forceps and then the other to split the socket and separate the osteofibrous tissues, the tooth being then firmly grasped between them, the operator makes a series of rocking movements, by which it is itself loosened and its further attachments torn, until by a lifting effort it can be extracted from the socket. In this minor operation the head must be firmly held with the disengaged hand, or better between the forearm and the operator’s body, while with that hand he supports and manipulates the lower jaw, if it be a lower tooth which is to be removed.

The operation is painful for the moment. With timid patients local anesthesia may be produced with cocaine or one of its substitutes, the solutions being sterile, and either locally applied around the socket or injected into the surrounding tissues with the ordinary hypodermic syringe needle. Such attempts are not without their own danger, for I have seen serious infection follow the introduction of unsterile solutions by dentists not familiar with aseptic technique. Again, nitrous oxide gas may be administered, it being usually necessary to employ a mouth-gag. Recovery from anesthesia is prompt and muscle spasm may not be entirely abolished; therefore, the gag should be inserted before the gas is administered. It may be sufficient for the purpose to employ a good-sized piece of cork, to which a cord should be attached in order that it may not disappear down the patient’s throat during a violent effort at inspiration. The horizontal position is the safer for this purpose.

It is especially the removal of fangs or roots which gives the greatest trouble in these cases. For this purpose special forceps are devised, but for their use it is necessary to clear away the gum and periosteum and to cut away a portion of the alveolar process. Such broken fragments of teeth allowed to remain give rise to curious reflexes, such as convulsions, neuralgia, etc., all of which makes it apparent that the extraction of a tooth being undertaken it should be thoroughly performed. After its removal the patient should rinse his mouth with water as hot as can be borne, to check hemorrhage. The removal of the tooth having left an open pathway for infection, antiseptic mouth-washes should be frequently used and the socket packed with antiseptic gauze. Except in rare instances granulation tissue fills the cavity and the process of repair is rapid.

Among the _accidents which may follow extraction of teeth_ are _hemorrhage_, which may be checked by plugging and the use of adrenalin. Adjoining teeth are occasionally injured in clumsy efforts at extraction, while not infrequently a patient who has not sufficiently described his symptoms has indicated to the dentist the wrong tooth, whose consequent extraction has, therefore, not relieved him of his difficulty. Some teeth have such spreading roots as to make their removal extremely difficult, and even careful operators have occasionally inflicted fractures, especially of the lower jaw. The treatment of such an accidental fracture will not be different from that of fractures otherwise produced. Such an accident as forcing a tooth upward into the antrum of Highmore should be followed by its removal, even at the expense of further operation, while excessive tearing of the alveolar border, or especially of the gum, may be treated by suitable packing or by suturing. The accident of aspiration into the larynx of part or all of a tooth just removed has been known to be followed by suffocation. The operator, therefore, should not release the tooth from the grasp of the forceps until the latter are entirely out of the mouth.

By accident or from indifference it may happen that a healthy tooth has been removed instead of one diseased. Should this happen the tooth may often be _re-implanted_ after being cleansed, and will usually resume its previous position and function. So feasible is such re-implantation of teeth that they have been frequently removed or transplanted from one mouth to another, for a compensation, a new socket being made for the reception of the healthy tooth just removed from the mouth of the individual willing to part with it.

THE JAWS.

While the jaws are not subject to affections peculiar to these parts, there may be seen in them peculiar expressions of general conditions, made so by virtue of environment or complexity of tissues. Most of the acute infections of the jaw bones are propagated from the teeth or the tooth sockets. There may be _periostitis_ and _osteomyelitis_, and these may be followed by a sclerosing process or acute suppuration. The jaws are prone to be thus affected in consequence of the acute exanthems and the infectious fevers, while the effects of mercury and phosphorus have been mentioned. The treatment of the inflammatory affections here is the same as elsewhere, _i. e._, early incision and complete evacuation of pus, with removal of necrotic bone or other tissue. Many sequestra may be removed from within the mouth in such a manner as to avoid disfiguring scars. When external sinuses complicate the case, incisions through the skin should be made. These may be so planned as to coincide with the natural wrinkles or folds of the face.

The _temporomaxillary joint_ is a locality of considerable interest. _Dislocations_ take place here in consequence of blows or of violent muscular effort, and are easily recognized because of the fixation and displacement which they produce. Ordinarily they are easy of replacement. These luxations may be unilateral or bilateral. As the result of violence the condyle has been driven upward through the base of the skull, the violence producing such injury usually being fatal. Aside from these injuries to the grosser structures the temporomaxillary joint is not infrequently the site of _acute synovitis_, or more extensive inflammation, usually propagated from surrounding tissues, but sometimes the result of distant infection. In phlegmons of this region the structures of the joint rarely escape a sympathetic participation, while parotid abscess and similar collections of pus may penetrate the joint and destroy it. Again it is occasionally the site of a _postgonorrheal arthritis_, or it may suffer as do other joints after the exanthems and acute fevers. It also occasionally becomes involved in the disturbances accompanying irregular eruption of the last molar, _i. e._, the wisdom tooth; in other words, it may suffer just as may any other joint in the body, and from similar causes.

_Ankylosis of the temporomaxillary joint_ is an infrequent result of its involvement in serious disease, or may result from lesions of the adjoining tissues, as from the cicatricial deformity following noma, burns, and the like. Thus we may have either a true or a spurious ankylosis of this joint, in either case the resulting condition being intractable and exceedingly difficult to manage. When it can be foreseen as a consequence of extrinsic disease it may be prevented by the insertion of a mouth-gag, and more or less frequent and forcible stretching, or by wearing some suitable apparatus between the teeth which shall keep the jaws apart, and which may be used at night. A pseudo-ankylosis produced by cicatricial bands, and long neglected, will become genuine, and require as radical an operation as though it had been interosseous from the outset.

For the relief of such conditions various operations have been devised, in each of which the formation of a false joint is contemplated, it depending upon the exigencies of the case whether this shall be produced by the _division of the horizontal ramus in front of the masseter_, or of the _ascending ramus behind the masseter_, or whether there shall be actual _resection of the temporomaxillary joint_, with division of the neck and removal of the condyle. The latter procedure is the more ideal, at the same time the more difficult, and the more likely to permit injury to the branches of the facial nerve, with consequent paralysis of the orbicularis and the facial muscles.

I have elsewhere described a peculiar condition of _relaxation of the temporomaxillary ligaments_, by which there is a recurring subluxation of the joint, noticed most often during eating and accompanied by a snapping sound. This is usually unnoticed by the patient, but is often observed by others. It is painless, harmless, and not ordinarily amenable to treatment. (See p. 528.)

_Tumors of the jaws_ proper include mainly _cysts_, which are often connected with odontomas, _benign tumors_, such as fibroma, chondroma, and osteoma, most often of mixed type, and the _malignant tumors_, _i. e._, sarcoma, carcinoma, and endothelioma. Malignant tumors primary to the bone are usually of sarcomatous type, though these may include the endotheliomas. Carcinoma and epithelioma do not originate in bone texture, but may easily spread to and involve it. Thus many cases of advanced epithelioma of the lip involve the bone as well as the other neighboring tissues.

_Epulis_ is a somewhat vague term, which has been applied to tumors which spring from and mainly involve the fibrous texture of the gum and the periosteum covering the alveolar process. The term itself simply implies a tumor upon the gum. Microscopically these tumors are usually of the giant-cell type of fibrosarcoma, and are among its least malignant varieties. They pursue a slow course, gradually loosening one tooth after another as they invade the tooth sockets, show very little tendency to spread rapidly, and are usually sharply circumscribed growths, tending to ulceration. They seem to be products of irritation. When removed they rarely recur. The surgeon should excise involved tissue in order to be on the safe side, sacrificing teeth, gum, and alveolar process as widely as necessary for the purpose. Formerly the _epulides_ were made to include different expressions of fibroma and sarcoma involving the gum, but the name is so vague that it would be better to speak of each of these cases as its histological characteristics may indicate.

Benign tumors involving the entire bone may necessitate its removal, but most of the dentigerous bone cysts may be laid open, their contents evacuated, their size reduced, and the remaining cavity allowed to fill with granulation tissue; while malignant tumors call for sacrifice of every portion of tissue involved, often including the skin, and in the upper jaw much of the complicated structure of the nasal cavity, or in the lower jaw the loss of the tongue or a large portion of the floor of the mouth. A cancer of the lower jaw may be removed, with permanent good result, but a true cancer of the upper jaw should be seen early and mercilessly extirpated if the result is to be more than temporary.

OPERATIONS UPON THE JAWS.

Aside from those already mentioned the principal operations upon the jaws consist of _partial_ or _complete excision_.

_Removal of the upper jaw_ is a rather formidable procedure, frequently made so by extent of the disease which requires its performance. The presence of an extensive and ulcerating tumor, by which normal anatomical outlines are obliterated, will cause mechanical difficulties as well as unusual liability to hemorrhage. During some portion of its performance a temporary control of the vessels of the neck may be of assistance. This can be usually afforded by external digital pressure. In serious cases a ligation of the external or the common carotid may be of assistance. If soft, vascular tumors protrude into the nasopharynx a _preliminary tracheotomy_ should be performed, tamponing the pharynx in order to prevent escape of blood down the throat. The position of the patient with the down-hanging head may be also of assistance in these cases. Of the various incisions employed one should be selected according to the nature of the case. Most of the operations include a splitting of the upper lip near the middle, with continuation of the incision along the margin of the nose, upward toward the orbit and outward along the orbital border, as originally suggested by Fergusson. This permits of completely raising the cheek from the underlying bone in one extensive flap and turning it backward, with complete exposure of the anterior surface of the superior maxillary. The operator next proceeds according to the desired extent of removal. If the roof of the mouth is to be sacrificed the osteoperiosteal and soft tissues composing the palate should be divided as far from the middle line as may be permitted, then reflected, and the bone divided with chisel or with cutting forceps. It may be necessary to remove one of the incisor teeth to permit the insertion of the chisel for division of the anterior part of the jaw. Bone forceps or a chain or wire saw will serve for division of the zygoma and the external or lower wall of the orbit, while with chisel or forceps the nasomaxillary region is divided. The loosened bone can now be seized with strong lion-jaw forceps and wrenched from its attachments, which may then be divided with scissors or knife as they are encountered (Fig. 474).

[Illustration: FIG. 474

Resection of superior maxilla. (Farabeuf.)]

Hemorrhage will be profuse at this juncture, when the internal maxillary artery is, with many of its branches, thus torn across or severed. The surgeon should be ready with tampons and forceps to check the bleeding and secure the vessels. The complete Fergusson operation includes removal of the entire upper maxilla, but oftentimes much less than this will suffice. On the other hand it is necessary sometimes to go still farther and remove more bone from the orbit or the nasal cavity, or perhaps to clean out the orbit entirely. A case which necessitates one of the more formidable operations is too unpromising to make it often judicious to perform it.

When the tumor involves the overlying skin this should also be sacrificed, and a plastic operation should be made to cover the defect. The skin flaps required for this purpose may be taken from the temple, the forehead, the neck, or adjoining parts of the face.

Bardenheuer has suggested the raising of osteoplastic flaps for removal of tumors lying within the jaw, and their replacement at the conclusion of the operation. He has also devised ingenious methods of making immediate plastic repair which are worthy of study, but which are so seldom required as to not justify description in this place.

After operation the bleeding should be checked by torsion, by ligation, by sutures _en masse_, by application of hot water, and by securely tamponing with antiseptic gauze, by whose pressure oozing is checked and protection from infection afforded. The patient is allowed to sit up as early as possible, meanwhile being made to lie upon the affected side in order to avoid danger of aspiration pneumonia, and using an antiseptic mouth-wash with relative frequency.

It is sometimes possible to perfect an artificial substitute for tissues removed, which can be inserted after the operation. The loss of tissue will cause more or less disfigurement by sinking in of the cheek and side of the face. After the parts are healed an apparatus made of gutta-percha or metal, and adapted to each case, by which most of the lost symmetry may be restored, should be worn, in the same manner as an artificial denture.

The _lower jaw seldom requires complete removal_. It is rarely necessary to go so high as the joint or the coronoid process, although occasionally the condyle must be avulsed and the coronoid either cut away or its temporal tendon detached. Most of the exsections in this location are confined to some portion of the horizontal ramus. Except in rare instances it is not possible to make a complete excision of the lower jaw through the mouth, and nearly all operations are practised through external incision, carried along the lower border for a sufficient length, and extended upward along the posterior border beyond the angle, if necessary. In most instances the facial vessels are directly exposed and should be secured before division. Masseteric attachments are separated and the instruments are kept as near to the bone as the circumstances of the case will justify. In well-marked ulcerating cancer, however, the surgeon should go nearly an inch beyond its apparent border and remove still more if it be visible, taking everything which seems involved. Here the bone is usually divided with a chain saw, although stout cutting forceps may suffice. It may be necessary to remove a tooth in order to clear a place for the action of the chain saw. Growths involving the skin necessitate not merely linear incisions, but extensive oval excisions of the overlying tissues. All the involved structures should be removed in one mass; if it be necessary to remove the floor of the mouth the divided bone section is seldom cut away until it can be removed with the rest of the tumor. The healthy mucous membrane should be preserved and brought together with catgut sutures at the conclusion of the operation, as the more carefully the cavity of the mouth can be shut off from the balance of the wound the more prompt and satisfactory the healing (Fig. 475).

[Illustration: FIG. 475

Resection of inferior maxilla. (Farabeuf.)]

In a few cases it may be possible by the use of stout silver wire, or some other substitute, inserted between bone ends to keep them apart and thus nearly preserve the contour of the lower part of the face; but this can be expected to succeed only when the cavity of the mouth can be completely closed, so that the wire or other material may be quickly incorporated in granulation tissue, where it is expected to remain.

When it is necessary to remove the joint end of the bone the operator should work carefully along the bone toward the joint in such a way as not to injure the facial nerve, the external maxillary artery, or Stenson’s duct. With a sharp separator it is possible to thus expose the joint, and after opening it to avulse the articular surface. In operating for necrosis the healthy periosteum should be preserved, while in the removal of cancer it should be sacrificed to the same extent as the bone itself.

The same rules apply here as above with reference to the closure of the wound and the construction of flaps; an extensive plastic operation being sometimes necessitated, as when a large portion of the lower lip, the chin and the bone are removed for extensive epithelioma. Dead spaces should be avoided, any cavity should be packed sufficiently, opportunity for drainage afforded, and the mouth cavity closed. Mouth-washes should be frequently used.

These cases should be prepared for operation by a careful cleansing of the mouth and the local use of antiseptics. During any of these operations, diseased teeth which may require it should be removed, whether they occupy the site of the operation or some other portion of the jaws. The cleaner the mouth the more prompt will be the healing process.

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