Manual of Surgery Volume II Part 53

CHAPTER XXI

THE JAWS, INCLUDING THE TEETH AND GUMS

TEETH: Dental caries--Impacted wisdom tooth. GUMS: Gingivitis; Pyorrha alveolaris; Hypertrophy; Epithelioma. JAWS: Pyogenic affections: _Periost.i.tis_; _Osteomyelitis_; Tuberculosis; Syphilis; Actinomycosis--Tumours: _Of alveolar process_; _Of maxilla_; _Of mandible_--Fracture of maxilla--Fracture of mandible--Affections of the temporo-mandibular articulation: _Dislocation of the mandible_; _Acute arthritis_; _Tuberculous arthritis_; _Arthritis deformans_; _Closure of the jaws_.

#Dental caries# is a process of disintegration which begins in the enamel of a tooth--usually in the region of its neck--and gradually extends through the dentine till the pulp cavity is reached.

Infection of the exposed pulp cavity may set up an acute purulent _pulpitis_. This is a.s.sociated with severe pain, which is not confined to the diseased tooth, but may spread to adjacent teeth, and sometimes to all the branches of the trigeminal nerve on the same side of the face.

The infection may spread from the tooth to the alveolo-dental periosteum, and set up a _periodont.i.tis_. In the affected tooth there is at first a feeling of uneasiness, which is relieved by the patient biting against it. Later there is severe lancinating or throbbing pain. The affected tooth usually projects beyond its neighbours, and is excessively tender when the opposing tooth comes in contact with it in mastication. The gum becomes red and swollen, and the cheek is dematous.

Periodont.i.tis is usually followed by the formation of an _alveolar abscess_. The pus, which forms at the root of the tooth, in most cases works its way through the bone and into the gum, const.i.tuting a "gum-boil." The pus may then burst through the gum, or may spread underneath the external periosteum of the jaw and lead to necrosis.

In some cases the cheek becomes adherent to the gum and to the jaw before the abscess bursts, and the pus escapes through the skin, leaving a sinus which leads down to the defaulting tooth, and which is slow to heal, usually because there is a small sequestrum at the bottom of it. The opening of the sinus is most commonly situated at the under margin of the mandible a little in front of the ma.s.seter muscle. An alveolar abscess deeply seated in the maxilla may open into the maxillary antrum and set up suppuration in that cavity. To avoid a scar on the face, the abscess should be opened from the mouth. A periodontal abscess of one of the upper central incisors spreads backwards between the muco-periosteum and the bony palate, causing an elongated swelling in the roof of the mouth.

In all cases the extraction of the carious tooth is necessary before the abscess will cease discharging and the sinus heal. If a sequestrum is present it must be removed, and the bone sc.r.a.ped with a sharp spoon. Among the other effects of dental caries may be mentioned localised necrosis of the alveolar margin, cellulitis of the neck, and enlargement of the cervical lymph glands.

A _cyst_ is frequently found attached to the root of a decayed tooth.

It is lined with epithelium, and is probably derived from a belated portion of the enamel organ which has been stimulated to active growth by infective processes in the pulp cavity. It is seldom larger than a pea, and contains a pultaceous ma.s.s like insp.i.s.sated pus. It gives rise to no symptoms, and is only recognised after extraction of the root.

_Odontomas_ have already been described (Volume I., p. 192).

A localised swelling of the mandible, a.s.sociated with pain referred to the ear and neck, and in some cases with spasmodic contraction of the muscles of mastication, may be due to _impaction of the wisdom tooth_ (lower third molar). If the tooth is merely embedded in the gum, incision may allow of its eruption; if the X-rays show that it is wedged under the second molar it must be extracted, and this may prove a difficult dental operation.

#Affections of the Gums.#--Inflammation of the gums--_gingivitis_--usually occurs in a.s.sociation with a general stomat.i.tis. The gums are swollen and spongy, and may show superficial ulceration, a.s.sociated with bleeding and extreme ftor of the breath.

The teeth become loose, project from the alveoli, and sometimes fall out. These symptoms are prominent in cases of scurvy, and of chronic mercurial poisoning. In chronic lead-poisoning a characteristic blue line is seen on the gums near the dental margin. The _treatment_ consists in removing the cause, improving the hygienic and dietetic conditions of the patient, and administering lime-juice, iodide of potash, quinine, or cod-liver oil, according to the cause. Antiseptic mouth-washes and dentifrices are also indicated. Chlorate of potash, being excreted in the saliva, is particularly useful.

_Pyorrha alveolaris_ is a chronic form of gingivitis, met with after middle life, which begins in relation to the necks of the teeth and the alveolo-dental periosteum. It is due to bacterial infection, and is a.s.sociated with an acc.u.mulation of tartar between the gums and the teeth. A muco-purulent discharge escapes from within the free edge of the gum and alveolus. The alveolar borders and the gum subsequently undergo atrophy, so that the roots are exposed, and the teeth are liable to become loose and eventually to fall out. The condition may only affect a few teeth, or it may spread to them all, in which case the patient may in the course of some years become edentulous.

Gastro-intestinal disturbances, chronic joint affections of the nature of arthritis deformans, a form of pernicious anaemia, and other general conditions have been attributed to the absorption of toxic products.

The _treatment_ consists in removing the tartar from the teeth, applying strong antiseptics to the groove between the teeth and the gums, and employing mouth-washes and dentifrices. Ma.s.sage of the gums night and morning, and rubbing in a paste of chlorate of potash and menthol, is often of great value. Good results have followed the use of vaccines and improvement of the general health.

_Hypertrophy of the gums_ is occasionally met with in children and young adults who are mentally defective, and the teeth appear early and are abnormally large. The gum almost buries the teeth, and large polypoid ma.s.ses form which tend to fungate. The treatment consists in removing not only the hypertrophied gums, but also the affected alveolus (Heath).

A localised hypertrophy--_polypus of the gum_--sometimes results from the irritation of a carious tooth, or from the pressure of an artificial denture, and may simulate an epulis (p. 513). The swelling is usually pedunculated, and if cut away close to the alveolar margin does not tend to recur.

_Epithelioma_ sometimes originates in the gum in relation to a carious tooth or to an artificial tooth-plate. The growth tends to invade the bone and to spread to the cheek or buccal mucous membrane, or to the maxillary antrum, and its malignant nature is suggested by its persisting after the removal of the irritation. The only treatment is early and complete removal of the growth and the adjacent segment of bone.

Other tumours of the gums, such as angioma and papilloma, are rare.

THE JAWS

#Pyogenic Infections.#--The jaws may be infected in fractures communicating with the mouth or as a result of the unskilful extraction of teeth, but the majority of pyogenic infections originate in relation to carious teeth, beginning as a periodont.i.tis which is followed by diffuse periost.i.tis that may lead to necrosis of considerable portions of bone. In workers exposed to the fumes of yellow phosphorus, the bone may be so devitalised that it readily becomes infected with pyogenic organisms and undergoes a process of cario-necrosis--the _phosphorus necrosis_ of the older writers.

[Ill.u.s.tration: FIG. 247.--Cario-necrosis of Mandible.]

_Acute osteomyelitis_ occasionally attacks the mandible, less frequently the maxilla. Pus rapidly forms under the periosteum, and a considerable area of bone may undergo necrosis.

In _cancrum oris_, also, the bones are frequently attacked and may undergo necrosis.

The _treatment_ is to let out the pus, and, whenever possible, this should be done from the mouth to avoid a cicatrix on the face. When the angle or the ascending ramus of the mandible or the facial portion of the maxilla is involved, it is not possible to avoid making an external opening. Drainage is secured, and the mouth kept sweet by the frequent use of antiseptic washes. When the condition is due to a carious stump or to an unerupted tooth, this should be extracted at the same time as the abscess is opened.

The separation of a sequestrum is usually slow, taking from two to four months according to the acuteness of the infection and the extent of the necrosis. In the mandible the sequestrum becomes surrounded by a sheath of new periosteal bone, so that, even if the greater part of the jaw undergoes necrosis, the arch is reproduced, and after removal of the sequestrum little or no deformity results. The sequestrum can usually be removed after dividing the mucous membrane and gouging away a portion of the outer aspect of the new sheath. The cavity is packed with iodoform or bis.m.u.th gauze. When the ascending ramus is involved, precautions must be taken to prevent fixation of the jaw taking place during the healing process. In the maxilla no new case is formed, and deformity results from sinking in of the cheek, unless this is prevented by wearing a plate made by the dentist.

#Tuberculous disease# is comparatively rare. It is occasionally met with on the orbital margin of the maxilla and in the region of the zygomatic (malar) bone. In the mandible it usually occurs near the angle. Stockman isolated the tubercle bacillus from a series of cases of "phosphorus necrosis" investigated by him. The sinuses that form when a cold abscess bursts on the surface are peculiarly intractable and only heal after the diseased bone has been removed, leaving a characteristically depressed scar, which is adherent to the bone.

#Syphilitic# affections are also rare. A localised gumma may develop in the neighbourhood of the angle of the mandible, or the whole of the body of that bone may be the seat of a diffuse gummatous infiltration (Fig. 248). In either case the clinical importance of the condition lies in the fact that it is liable to be mistaken for a new growth, such as an osteo-sarcoma, or for actinomycosis.

[Ill.u.s.tration: FIG. 248.--Diffuse Syphilitic Disease of Mandible.]

#Actinomycosis.#--This condition is met with in the jaws more frequently than in any other part, and the mandible is attacked oftener than the maxilla. The actinomyces gain access to the bone through a carious tooth or through the gum.

At the outset the patient complains of pain and tenderness referred to one or more carious teeth. Within a few weeks a swelling forms--in the mandible near the angle as a rule, and in the maxilla in some part of the cheek. The swelling, which varies in consistence, implicates the bone and cannot be moved apart from it. The skin over it becomes red, suppuration occurs, and sinuses form and give exit to a sero-purulent fluid in which the characteristic yellow "sulphur grains" may be detected. The surrounding soft tissues are infiltrated, and the part becomes riddled with sinuses, which lead down to bare bone. The disease usually runs a chronic course, lasting for one or two years, and, unless pyogenic infection is superadded, is not attended with fever.

In the absence of the characteristic yellow granules, actinomycosis may readily be mistaken for tuberculous or syphilitic disease, or for sarcoma.

The _treatment_ consists in removing the diseased tissue with the knife or sharp spoon, and in the administration of large doses of pota.s.sium iodide. The insertion of tubes of radium has a beneficial effect.

#Tumours of the Alveolar Process.--Epulis.#--The tumours that grow from the alveolar processes of the jaws appear at first sight to spring from the gums, hence the term _epulis_, generally applied to them. They really originate in the periosteum of the alveolus or in the periodontal membrane, and are essentially of the nature of fibro-sarcoma. In some, the fibrous element predominates, but the frequency with which they recur after removal, unless the segment of bone from which they spring is also excised, indicates their malignant tendency. In most cases the tumour is of the myeloid type--myeloma; in others new bone is formed in its substance--osteo-sarcoma.

An epulis usually begins in the gap between two teeth, and grows slowly, either towards the cavity of the mouth, or more frequently towards the lip or cheek, where it appears as a bright red, smooth, firm, rounded swelling, which is adherent to the jaw, and may be sessile or pedunculated (Fig. 249). It causes little pain, but is liable to interfere with mastication. As it increases in size it spreads over the alveoli of several teeth, becomes softer, and a.s.sumes a dark violet colour, and if subjected to pressure or irritation may ulcerate and bleed.

[Ill.u.s.tration: FIG. 249.--Epulis of Mandible.

(Anatomical Museum, University of Edinburgh.)]

The true alveolar tumour is to be diagnosed from a ma.s.s of redundant granulations such as may form in relation to a carious tooth, from a polypus or an epithelioma of the gum, a tumour of the body of the jaw, or an angioma.

The _treatment_ consists in removing the tumour together with a wedge-shaped or quadrilateral portion of the alveolar process from which it grows. A dental plate should be fitted to fill up the gap in the alveolus. After such free removal these tumours show little tendency to recur and metastases are rare.

#Malignant Tumours of the Maxilla.#--All varieties of _sarcoma_ and _carcinoma_ are met with; of the former, the round and spindle-celled are the most common. Carcinoma occurs chiefly in two forms, less commonly a columnar epithelioma arising from glandular epithelium, much more commonly a squamous epithelioma either originating within the antrum and causing its expansion, or spreading to the maxilla from the mucous membrane of the nose or mouth. Clinically it is practically impossible to differentiate sarcoma from carcinoma; in the later stages the infection of the glands below the mandible is more marked in carcinoma. An important point to determine is whether the growth arises within the maxilla or has spread to it from adjacent parts, such as the base of the skull, the nose, or the palate. In this the X-rays are helpful. Their malignancy is evidenced by the rapidity of their growth, the manner in which they infiltrate adjacent parts, and the frequency with which they recur after removal. They occur at all ages, and have been met with even in children.

The _clinical features_ vary according to whether the tumour originates on the anterior aspect of the bone, in the maxillary antrum, or on the posterior aspect.

When the tumour originates in the periosteum covering the front of the bone, it forms a swelling under the cheek, usually in the vicinity of the zygomatic (malar) bone, and grows towards the mouth as well as towards the surface. The cheek is gradually invaded, and in some cases the growth extends into the maxillary sinus.

The typical malignant tumour of the upper jaw originates in the lining membrane of the antrum; it first fills the cavity and then bulges its walls in every direction, so that, on pressure being made over the swelling, the osseous sh.e.l.l of the sinus dimples and crackles under the finger. The sinus is dark on trans-illumination. The tumour may obstruct the nostril on the same side, and, by pressing on the tear duct, may cause the tears to flow over the cheek. It may be seen through the anterior nares, and may be attended with a sanious discharge from the nose. The eyeball is liable to be displaced upward, and if the ethmoid cells are invaded, it is also pushed outward; the palate may be depressed and the cheek projected (Figs.

250, 251).

[Ill.u.s.tration: FIG. 250.--Sarcoma of the Maxilla.]

[Ill.u.s.tration: FIG. 251.--Malignant Disease of Left Maxilla, which displaced the eyeball and caused double vision.]

When the tumour grows from the periosteum of the posterior aspect of the bone, and extends into the spheno-maxillary or pterygo-maxillary fossa, the eyeball is usually protruded by the invasion of the orbit from behind, and a swelling appears in the temporal region. If the sinus is invaded, the tumour spreads in the various directions already indicated. Not infrequently a tumour, which appears to have its seat in the maxilla, is really a downward prolongation of a growth originating in the base of the skull, a point on which the X-rays may yield valuable information.