Literary Notices and Selections.

ON THE TRANSPLANTATION OF TEETH.

By Dr. TH. DAVID.

(From the Gazette Odontologique.')

(Continued from page 430.)

BEFORE proceeding to the operation there are a few preliminaries which must be attended to; due precautions must be taken to avoid the transmission of any infectious disease, and some retaining apparatus must be devised and prepared. With regard to the latter, the plan which has in our hands afforded the most satisfactory results is that which will be described in Case 1.

The operation itself may be divided into three stages.

1. That of extraction, which should be effected with forceps, and care should be taken to damage as little as possible the healthy tooth as well as the gum and the margins of the alveolus into which it is to be transplanted.

2. One may, without endangering the success of the operation, resect if necessary either the extremity of the root, or the crown of the tooth to be transplanted. The latter may be necessary in cases where the shape of the crown does not accommodate itself to the gap to be filled, or where it does not articulate properly with its opponents. Any carious cavities may be filled at the same time, the tooth being kept meanwhile slightly moist and as cool as possible. Any bleeding must be arrested either with cold water or with very dilute alcohol.

3. The adjustment of the tooth in its new position. This may present some difficulties when the size of the root exceeds that of the alveolus into which it has to be fitted. A resection of the root then becomes necessary, and either a portion must be taken off the extremity so as to diminish its length, or off one of its sides so as to diminish its thickness. That this latter operation is not an obstacle to success is proved by a case of replantation recorded by Bourdet; and, although the root will not become united to the alveolus throughout its whole circumference, it acquires a quite sufficient amount of firmness. In the case of a slight excess of bulk the simplest way is to push the tooth forcibly into the

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alveolus and fix it there; it need hardly be said that this is an exceedingly painful operation.

The tooth having now been placed in its new position, the next thing is to fix it there as immovably as possible. In cases of transplantation there is not, of course, the same perfect coaptation between the tooth and its socket which there is in cases of replantation, and it is only by fixing the tooth securely that this unfavorable feature of the operation can be obviated.

A few other points, connected with the neighbouring structures rather than the tooth itself, may be noticed. When the tooth which has been removed is the subject of periostitis, the alveolus is of course also affected. In these cases suppuration almost always occurs, and it is necessary to give it vent by making or keeping open a free alveolar fistula, by drilling, setons, injections, &c. Attention to this is of the greatest importance, as the omission of these precautions would lead to accumulation of pus in the alveolus and the operation would probably be a failure. Indeed, under these circumstances, the importance of a thoroughly patent fistula is so great that if one does not already exist it must be made. We have found that slight cauterisation of the free edge of the gum, which sometimes becomes a little swollen and inflamed all round the transplanted tooth, promotes consolidation; nitrate of silver may be used for this purpose, but chromic acid is better.

The results of the operation are various. If the two surfaces thus brought into apposition are healthy, they will unite by first intention and become firm in two or three days without any inflammatory or painful reaction. When the alveolus is diseased consolidation takes place much more slowly, and then all the precautions of which we have just spoken are required. In such cases it is not unusual to get a pretty sharp local inflammatory reaction, accompanied by more or less pain, and sometimes even by some constitutional disturbance. At the end of four, five, or six days the inflammation and pain disappear, and the tooth gradually becomes firm, but there is always a probability that the fistula may never quite heal.

In the absence, then, of any affection of the alveolus or other complication consolidation is complete in three or four days; but if anything of this sort occurs it may be ten or twelve days or more before the tooth becomes quite firm. The treatment of these complications when they occur is of course troublesome, but the cure may be greatly assisted by attention to the special precautions which we have mentioned. In such cases recovery is often incomplete, a very small

fistula being left, from which a slight oozing of muco-purulent matter, without any offensive characters, takes place, as in Case 4.

The cure when complete is permanent; at all events there is no reason why a tooth which has been successfully grafted should not last as long as one which has never been extracted.

Failure is due to the occurrence of acute intra-alveolar suppuration, followed by the falling out of the tooth. Generally this is decided about the third or fourth day, but when the tooth has contracted a few partial adhesions it may be delayed.

The results ought not to be less favorable than those which follow replantation. In my own practice 95 per cent. of these cases have been successful, and in that of Dr. Magitôt 92 per cent. For if the operation of transplantation is less favorable as regards the perfect coaptation of the tooth and alveolus, yet, on the other hand, the tooth which is replanted is free from any disease of the root. The number of operations of this sort which have been performed is not yet large enough to afford reliable statistics; still, a large number of successful cases have been reported by various authors. For myself, I have performed the operation five times, and in each case successfully. In four cases the tooth which was removed was a right upper lateral, and this was replaced in two cases by a lower canine, once by a lower lateral, and once by an upper lateral. In the fifth case an upper bicuspid was replaced by a tooth of the same kind.

CASE 1.-Mdlle. C-, aged seventeen, has two upper laterals deeply decayed so as to be in strong contrast to their neighbours which are perfect. She would like to have them replaced, but not with "false teeth." It would be in vain to search for two similar laterals to graft in their place, but Miss C-'s brother has the lower left canine placed irregularly outside the line of the other teeth. This tooth is small and but slightly convex, so that if its point was cut off it would easily pass for an incisor. The sacrifice of this tooth is offered to us, and furnishes us with one substitute.

We find the second, under almost the same conditions, in the mouth of a young collegian of fifteen years, whose lower jaw is too small to hold the two canines.

Previous to the operation I constructed a retaining apparatus thus:-A metal plate was carefully fitted over the anterior part of the arch of the palate and to the posterior aspect of the incisors; the margin of this was turned over anteriorly so

as to form a groove in which the free edge of the teeth were inserted; hooks on each side served to fix it firmly to the molars. This apparatus, which allowed almost complete occlusion of the mouth, kept the front teeth, or any others which might be put in their place, perfectly fixed.

December 6th, 1878.-Extracted the two lower canines of the young collegian and the left lower canine of the brother, all three being perfectly sound. I next extracted Mdlle. C's decayed incisors; the roots were found to be of good size and quite healthy. The dimensions of the brother's tooth were almost the same as those of the incisor except a slight excess of length, which was corrected by cutting off three or four millimètres from the apex of the root.

I took the left canine of the young collegian in preference to the right because it was flatter; the root, which was not quite fully formed, was not too long, but I cut off the point as I had that of the other, and also removed a tubercle from

the posterior aspect of the crown. I then satisfied myself that the two teeth thus prepared would fit properly in the splint in the position which they ought to occupy.

Having then carefully cleaned the alveoli, I placed the teeth in position, that of the collegian on the left, the other on the right. The first went in easily, the fang being slightly shorter than that of the tooth which had been extracted; that of the brother I was obliged to push in with some force, causing a good deal of pain. The splint was at once put on; it pressed rather severely on the right hand tooth, again causing pain. I fixed the jaws with a bandage and ordered a liquid diet.

The pain continued, on the right side only, all the evening; the patient was restless and did not get to sleep till late in the night after having taken an opiate draught.

Next day I found her free from pain; she had taken off the bandage, and could even eat with the splint on, without unduly pressing on the replanted teeth. Around these latter the gums were somewhat injected.

On the 10th I took off the splint, both the teeth being pretty firm, the left most so.

12th.-Consolidation appeared to be almost perfect. A month later the two teeth were found to be quite firm and undistinguishable in colour from the rest; this leads me to hope that the pulp, all the conditions being favorable, has re-established its vascular and nervous connections.

CASE 2.-Mons. D-, a medical student, aged twenty-one. His upper left second bicuspid had been carious for a long time, half the crown having disappeared; moreover, during the last two years it had given rise to a succession of small

gumboils. I offered to extract it and to replace it by a sound tooth which the following circumstances rendered available.

A schoolboy, aged fourteen, came to me with a very crowded upper jaw; his teeth were very irregular, especially on the left side, where the canine was descending quite outside the line of the arch. To make room for this I decided to extract the first bicuspid. Accordingly, on March 4th, 1878, I extracted the two teeth. The root of the carious tooth gave plain evidence of chronic periostitis, the apex being rough and bare, and on probing a fistula in the gum I found that it led into the bottom of the empty alveolus. The healthy tooth was found to be a good deal too long, and when this had been corrected by cutting off a piece of the root, I found that the crown was also too big and that it would not go into its new place. The extractions had taken place at the boy's college and it was not till we got home, about an hour and a half later, that I was able to grind down one of the faces of the crown so as to render it possible to implant it. This operation gave only momentary pain, and the tooth kept its place without any retaining apparatus, being well supported by its neighbours and by the pressure of its antagonists.

Next day there was a slight inflammatory reaction about the gums, and a little sero-purulent discharge through the fistula, but the tooth was in good position and there was little or no pain.

By the sixth day after the operation all inflammation had subsided and the tooth was quite firm. The fistula did not close till a month later, and since that time it has opened again three times, remaining open for a day or two. A year after the operation the tooth was firm and useful; there was, however, a slight difference in colour, due no doubt to the death of the pulp.

(To be concluded.)

THE TEETH DETERIORATED BY DISEASE.

WHEN a patient has recovered from any prolonged and exhaustive disease, such as typhoid fever, he usually devotes a goodly portion of his time to telling how fearfully the strong medicines have affected his teeth. He often finds his gums soft, spongy, and inclined to bleed from the slightest touch. And it often happens that his mouth