WISDOM TEETH, J. D. THOMAS, D.D.S., PHILADELPHIA, PA. S. Loag, Printer, 614 Sansom Street. NOTE> The following paper was written for the “ Dental Practitioner,” and read before the Odontological Society of Pennsylvania, in January, t886. It has been extensively quoted in this country, and translated in German, and published in the Berlin Dental Journal. More importance has been attached to it than the writer thinks its merits deserve, but, at the request of a number of friends, it is re-published in its present form. J. D. T. Wisdom Teeth. J, El, THOMAS, D, B, S,, PHILADELPHIA, PA. \ I /HE troubles arising from the growth and retarded eruption of the wisdom tooth are so many, and so severe in their character, that it seems strange so little has been done by the profession at large in mitigation of the evil, other than the heroic treatment—extraction. The growth of this tooth appears to be governed by laws entirely its own, and from malposition and crowd- ing is the source of untold distress, over which the patient has no control, and is more perplexing to the dentist than any other in the mouth presented for his skill. It shows itself sometimes with crown pointing directly towards the tongue, with roots lying almost diagonally across the jaw; at another, it will come so far imbedded in the cheek that its lingual surface will be on a line with the buccal surface of the anterior molars; and again, will be in what may be considered its normal position, but situated as in the case of inferior teeth, so far back in the angle of the jaw that perfect eruption is impossible; but the most common and trying position for both patient and operator, however, is when it comes obliquely from the angle of the jaw, with its crown pressing firmly against the posterior surface of 4 the second molar. These are the cases which cause so much suffering, not alone from the growth of the tooth in itself, but frequently from injury to the second molar also, while extraction generally entails still further suffering for days, and perhaps weeks after the opera- tion, with a possibility of ultimate loss of the second molar too. There are three forms of suffering produced by these teeth, the cause for two of which may be defined by one word “pressure.” In many instances, from defective structure, the tooth will become decayed to the pulp almost as soon as it makes its appearance in the mouth, and this form of difficulty will present itself as an ordinary case of tooth-ache, with perhaps, neuralgic accompaniments, which may be treated by remedial application, according to indications, or extraction advised. The latter course will be referred to later on. Of the two forms, the cause of which is attributed to pressure, the principal one is abscess in the angle of the jaw, sometimes of slight degree, but more frequently of such serious nature as to involve considerable swelling of the cheek and submaxillary glands, extending well into the soft tissues of the throat, so as to cause entire cessation of mastication, and greatly impede the swal- lowing of even liquid articles of nutriment. The results attending these conditions are sometimes most serious. Besides the necessary confinement of the patient, if the abscess should break on the outside of the cheek, there is the scar which he has to always carry. The prostra- tion produced by suffering and inability to take proper nourishment will require a long time to recover from 5 completely, and I have seen cases in which not only the preceding molar or fnolars have been sacrificed, but a considerable portion of the bone has become necrosed also, and in a few instances the effect upon the masseter muscle has been such that perfect motion to the lower jaw has never been regained. Such are some of the varying phases of condition which these teeth cause to exist. If our patients would come for assistance at the first appearance of the difficulty a good deal of their suffering might be averted, but as a rule they come only as a last resort, after the application of all the home remedies they know of, and perhaps after the efforts of their family physician have failed to afford relief. The third form as caused by pressure, presents itself in a condition of extreme suffering of apparent neuralgia. The patient will complain that he has been the victim of slight attacks for some time, not of sufficient severity to cause him much inconvenience, but now the pain has become unbearable and he thinks he can locate its origin in the partially-erupted wisdom tooth. These cases have been found very perplexing, for the reason that careful examination has failed to disclose the slightest delect about the tooth that could confirm the patient’s idea that it was the source of his pain. There will not appear to be the least inflammation about the parts, and everything will seem perfectly healthy. The second molar will present a like good condition, and yet the patient is suffering the greatest agony. In the first case of this character which came under the writer’s notice, examination showed the crown of the inverted wisdom pressing directly against the posterior root of the second molar, the only portion of the wisdom tooth being visible was what in its proper position would have been its posterior surface, and only enough to show how the tooth lay. There was no decay exhibited in either it or the second molar, neither was there the slightest tender- ness to the tap, or to the application of warm or cold. The pain seemed to originate in the wisdom tooth, as near as the patient could describe, though it included the ear and the whole side of the face, yet nothing could be made to appear that would confirm it. Being averse to counsel extraction without a clear understanding that good would result from the operation, the patient was about being advised to look elsewhere for the cause, or at least defer until later, to see if something might not show itself to indicate more clearly that he was right, when upon final examination it was found that pressure against the second molar towards the wisdom tooth would start the pain. This was convincing. After extracting the second molar there was found, three-six- teenths of an inch from the apex of the root, an opening into the pulp canal caused by the anterior cusp of the wisdom tooth in its lateral position pressing against the dentine, until by absorption it had penetrated into and was pressing against the pulp, which was much inflamed. Since meeting this one I have seen several cases of like character, sufficient to show that this forni of disease is by no means uncommon among the ills to be charged to this unruly organ. I do not wish to be considered as asserting that these teeth in their malposition are always the cause of trouble to the patient. On the contrary, many of them will become fully developed in the jaw and never perfectly erupted, yet will not' have caused the slightest incon- venience ; though in a paper read before the New York Odontological Society by Dr. La Roche, and published in the July number of the Dental Advertiser, a case is described of a gentleman whose mental condition bordered upon insanity, diagnosed to be caused by the retarded eruption of his wisdom teeth, and the result of a cure following their extraction, proved the diagnosis correct. From his description, Dr. La Roche seemed to form his opinion entirely from the one fact that the teeth were present in an unerupted state. I have seen a number of cases where patients have suffered in like manner, if not so severe, and the cause has been attributed by themselves and their family physicians to these partly-erupted teeth, but where, upon examina- tion, there could be nothing found to satisfy one posi- tively that there was the seat of the trouble, relief has not always been obtained by their extraction, from which experience I hold to the opinion that because a wisdom tooth maybe, as we call it, inverted, it is not always the cause of the suffering from both aural and facial neuralgia which is attributed to it, any more than an unerupted tooth anywhere else in the mouth. We all know that it is not an uncommon occurrence to see among our patients a mouth in which a bicupsid, a lateral, or even an eye tooth is wanting, even in persons advanced in years, and upon extracting an adjoining tooth the missing one is frequently found fully grown, but so crowded in the jaw, that eruption has been im- possible, yet in its healthy state it is doubtful if it would 8 be the cause of neuralgia. In one case of this kind that came to my care for extraction the patient was a great sufferer from neuralgia, which was attributed by her physician to her teeth, of which all in the upper jaw were more or less badly decayed. In extracting, it was noticed that the canines were absent, but the patient could not recall ever having had them extracted. Upon examination after the operation the crowns of the eye teeth were distinctly felt imbedded in the jaw in an almost lateral position. The patient was nearly sixty years of age. Owing to the depth of the position of the teeth, extraction was not advised at that time, but relief was obtained for the space of two months, at which time the neuralgia recurred more severely than ever, and it was decided to extract the eye teeth. There was nothing in the appearance of the gum to lead to the supposition that they were the cause, other than the knowledge of their presence in the jaw, but there was hope that their extraction might exercise some influence to give her relief. The cessation from pain lasted only for about three weeks after the operation, showing that the teeth were not the cause_of the neuralgia. To return to the consideration of the wisdom teeth. The prescribed treatment in most cases is extraction, and there is no doubt that many people would be better off without them ; but extraction, besides being difficult for the operator, becomes a matter in so many instances of such serious consequence to the patient, that there ought to be such consideration given to the subject that would result in sparing him much that he now has to bear. I do not mean that extraction, in all cases, is 9 productive of so much annoyance. There is as a rule little to apprehend with the superiors, and many of the inferiors are accompanied with no more after pain than any other tooth ; but I refer particularly to the irregular ones of the lower jaw. In the first place, they grow out of the solid bone, right at the angle, where there is no alveolar process. The bone broadens here and is very dense, so we have solid bone on both the buccal and lingual sides, the ramus over the roots and the second molar in front. In the second place, they invariably grow with curved and distorted roots, so, extract them any how you will, it can be done only by great effort and with subsequent suffering on the part of the patient. If it should be a badly decayed one, the chances are that there will not be strength enough in the tooth to bear the force necessary to loosen it, in which case it becomes neces- sary to cut it down as deeply as possible, extract the pulp and leave the remaining portion to work up to the surface for future operation ; or go over and cut through the bone, with the alternative of extracting the second molar to give a better opportunity to extract the wisdom root. In either case the patient will have a very sore mouth, which will require treating for perhaps several days. If the case be one causing trouble from pressure alone, extraction is likely to be attended with better success, but the immense strain upon the parts already inflamed by the process of eruption will cause a still greater amount of inflammation, with perhaps a severe abscess as a result. It is always necessary to have the patient pay repeated visits, or visit them at their homes, 10 for after-treatment, and in a few cases where they have neglected to pay attention to instructions and have applied home remedies in the shape of poultices to the outside of the face, and have called in their family physician, I have been invited to pay for his services and even threatened with suit for damages for loss of time and suffering. Being a witness to so much that is unsatisfactory, I have been led to advise, in many cases, the removal of the second molar, in preference to dis- turbing the wisdom. If the latter is growing straight it will move forward and prove a very useful organ, and should it be one with the crown pressing against the second molar, I prefer the anterior tooth, for the reason that from the position of the wisdom its removal will cause so much friction against the posterior root of the second molar as to cause serious injury there. I have seen several in which the pulp has died, accompanied by ultimate loss of that tooth as a result. To relieve the pressure is the object sought, and in cases where the pain after extracting the wisdom tooth is likely to be severe, the removal of the second molar has been found to give the greater satisfaction. After extraction is decided upon, how it shall be done is a question for each operator to elect for.himself. I lay no claim to superiority for my own methods over those of others, preferring the general success attending the operation should speak for itself. Since reading an article in the February Deiital Cosmos, in which the writer claims at this day, that the key will extract certain teeth “more readily, easily, quickly and successfully than any other instrument ever invented,” I am willing 11 to admit that it makes very little difference with what instrument it is done, if only the operator has become accustomed to its use and it suits his purposes best. A former professor in one of our dental colleges has said that to be a proficient dentist one should be able to fill a tooth with a rusty nail, and upon the same teaching a man ought to be able to extract teeth with a pair of gas-plumber’s pliers, but I cannot see the policy of becoming so accustomed to their use that they will be claimed as the best instrument extant for that purpose. Some operators recommend the use of the physic forcep for the extraction of these teeth, but I fail to see wherein their advantage lays over the regular forcep; but prob- ably, like the key, it may be from ignorance of its proper use. It is necessary that instruments should be so con- structed in their beaks as to insure a firm hold upon the tooth, without slipping ; there should be as little curving in the handles as possible, so as to bring the force in extracting as near a direct line from the hand to the tooth, as possible, and the operator should assume a position with the patient that will insure the greatest amount of force with the least physical effort. To the wisdom tooth the exertion must be applied to the pro- cess of loosening in its socket before any attempt at pulling should be made, after which its removal depends upon whichever way the position offers the best advan- tage. In cases where it is locked in by the second molar, after loosening, it can be turned and worked in its socket until the bone on either side is sufficiently distended to allow the tooth to be taken from under the second molar, but it is just this distention of the bone 12 that causes after-trouble. Sometimes, instead of giving, a considerable portion of the bone will break away on the sides to which the force is applied. This will cause no permanent injury, provided the broken portion is removed and the wound left to heal without irritation, but it adds to the serious consequences of extraction as a remedy for these conditions. I would suggest judicious extraction for children from ten to fourteen years of age, as a prevention of the evils produced by the retarded eruption of these teeth. Though not an advocate of the removal of all sixth-year molars, I am confident there are thousands whose mouths would be benefitted by that practice. Never until a month ago have I seen a case of difficult eruption of ihe wisdom tooth where there had been a tooth extracted on its side. In that case all four of the second bicuspids had been extracted for regulating, and yet the right lower wisdom had not room to grow in place, but that is the only one I have ever noticed, and there is no doubt, if upon careful examination of the mouths of young persons the removal of a tooth was advised, all around, either the first or second molar, or one of the bicuspids, as good judgment would dictate, that the operation would be productive of great good to the patient and would entirely obviate the difficulty attending the crowding of the wisdom teeth, taking, of course, due consideration of the development of the jaw, the size of the teeth generally, and the prospect of future growth.