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This splint was made to fit the interior surface of the gums and teeth, and a wire was vulcanized therein, and so placed as to pass around the molars on each side, meeting in front of the central incisors, each end heing looped so as to admit of being tied together. October 1, at Prof. Bryant's clinic, the patient was etherized, and an attempt was made to reduce the fracture; but as a partial union

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had taken place, and the tissues of the jaw had so contracted that the united force of two men was insufficient to break up the adhesion so as to admit of placing the splint, it became necessary to cut the tissues at the point of fracture down to the bone. Then, with the aid of a wheel hook, the fracture was reduced sufficiently to allow the splint to spring into position. While placing the splint the right central incisor, which was very loose, came away. The splint was left in for two days, after which I found that the arch had widened enough to allow it to be removed and reinserted with ease.

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On October 3 a new impression was taken, the model being treated as before. A new splint was made,—differing, however, from the first in that it fitted the interior and anterior surfaces of the gums and teeth, allowing the crowns of the teeth to be exposed, as shown in Fig. 3. This splint was inserted October 4, and the fragments placed in proper position. Holes were drilled through the anterior and interior parts of the splint, between the bicuspids and between the bicuspids and molars on each side of the jaw. The lower teeth were pressed up against the upper, in order to obtain perfect articulation, and while held in that position the holes were drilled through between the necks of the above-mentioned teeth. Then a platinum and iridium wire was passed through them, serving to hold the splint and fragments in proper position. After the splint was thus secured, the patient was at once able to masticate solid food.

October 7, the parts were in proper position, but the abscess, which had been washed daily, was discharging more freely; it was washed with Listerine.

October 15, the condition remained as before; probed unsuccessfully for sequestrum.

October 18, removed a sequestrum from near the seat of fracture, one-fourth inch by one-half inch in size. The abscess was washed as before.

October 26, the discharge has stopped, and the wound is healing.

December 7, the splint is removed and the articulation is perfect.

The great difficulty in reducing the fracture in the above case gave me the idea of a mechanical appliance for this purpose, shown in Fig. 4. It has the advantage of giving a powerful but steady pressure on both sides of the maxilla, and does away with the need of an assistant. I have tested it practically, and have found it to answer in every respect. It is very simple in construction, consisting of two three-sided arms, the upper extremity of each arm being serrated to secure a better hold on the splint. The lower extremities have an opening with a screw-thread. Through each of these passes a .screw connected with a plate calculated to rest upon the lower* border of the maxilla. The plates are connected laterally with a piece of steel slotted so as to allow of their adjustment for different cases, and held in position by a thumb-screw. This arrangement affords a powerful leverage over the displaced fragments of the jaw. The serrated ends can be adapted either to a cap splint or a perforated one, which exposes the grinding surfaces of the teeth. In the latter case a small portion of the rubber is left covering one of the molars or bicuspids upon which to apply the force, which can be removed as soon as the fracture is reduced. The instrument is adapted to simple and multiple fractures, and is of great convenience.

In some cases it is desirable, in order to secure more uniform pressure, to use a serrated bar in connection with the reducing appliance, which is shown in Figs. 3 and 4.



The efficiency of the clasp matrix is mainly due to an extension, Fig. 1, A, forming a lug, B, which rests upon the approximate tooth, preventing movement of the matrix in the direction of the cervix, and parallel grooves, C, across the reverse. The edges of these grooves are sharp, and pitch away from the cervical edge of the matrix. The wooden wedge, D, will be caught in them, when pushed between the matrix and the adjoining tooth, retaining the matrix and holding the wedge free of the gum. The steel blank, F, is No. 28 thickness, standard wire gauge, and will make a matrix for bicuspids below medium size. For the medium size and above the blanks should be No. 27; for the molars No. 25.

Boxwood is preferred for wedges. They are quickly and easily formed with a new file, and should taper in two directions, G-. The width and thickness is determined by the shape of the teeth and the

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space between them. It is most convenient to press the teeth apart until there is sufficient space to allow for the contour of the filling and the thickness of the matrix. Should the cavity be extensive, the preparation can be completed at once, a thin, tempered matrix adjusted, and the filling inserted. The teeth can be separated by a screw-separator and the filling finished, or by cotton tape and finished subsequently. The preparation of approximal cavities should be the same as is usual for contour fillings, excepting when the gold is to be inserted in the cylinder or mat form so much cutting away for access is not required. If a suitable matrix is not among those previously used, a blank should be fitted to the tooth to be filled much the same as a clasp for plate work. The matrix near the ends, E, should press the sound surfaces of the tooth with a moderate amount of pressure, sufficient to spring the face of the matrix clear of the cervical margin of the cavity. The lug, B, should next be bent to rest upon the approximate tooth, the cervical edge dressed (filed or burred) until it passes a little below the cervical margin. The grooves on the reverse of the matrix are now cut with a fine, thin-edged jeweler's file so that they will lean or pitch away from the cervical edge. The matrix should next be hardened and the temper drawn until it will spring and not bend nor break. The face should now be polished to reflect light. When adjusted it should be clear of the cervical margin of the cavity, and have sufficient spring to pinch the wedge, so that, with the aid of the grooves, it will be retained as intended, and also allow the filling material to overlap the cervical margin. Should the tooth be of such shape that a part of the cervical margin only is free, the filling may be commenced at that point, a suitable cylinder or mat of gold being securely wedged there between the matrix and floor of the cavity. This done, the matrix will have moved a little away from the tooth —provided the boxwood wedge has not been too tightly inserted. A^ the filling progresses all margins may be slightly and securely overlapped with the gold. The filling, if large, may be commenced at a starting point and completed after any of the methods for inserting cohesive gold fillings—the matrix merely moulding the filling. It is preferred to commence the filling with mats or cylinders of soft gold (Globe, semi-cohesive, No. 4), securing one or more of them at some point or points along or across the cervical wall, depending entirely upon the hold in the tooth to prevent movement of the gold during its insertion. The surface to be in contact and those exposed to attrition are finished in cohesive gold impacted with the aid of a mallet. The removal of the matrix demands care. The wooden wedge should be withdrawn; the matrix next drawn directly away from the neck of the tooth until the grooves offer resistance. The teeth are now gently forced apart by pressing the soft steel probe, H, between them below the matrix, when it will readily come away. When the filling is amalgam the matrix can be removed in this way without fracturing the filling. The filling and approximate tooth are generally in contact after the removal of the matrix, and care must be exercised to avoid an excess of of filling material approximately, particularly when pulpless teeth are present. A saw or separating file will clear the way for the finishing appliances. Little Tabor is required, the margins of the filling being readily trimmed flush and polished.

A, A, Fig. 2, represent the band matrix. It is almost indispensable where large fillings restoring the whole or parts of the crowns of molars and bicuspids are to be quickly and comfortably inserted. An impression of the tooth for which the matrix is to be made is taken in modeling compound. A piece of straight-grained pine wood, about four inches in length and a half inch square, is next whittled and filed to fit the impression, and should taper slightly so that the matrix will have a little less diameter at the cervical edge. A strip of phosphor bronze, No. 30, standard wire gauge, as wide as the matrix is intended to be, should be bent around the pine stick and overlap about one-sixteenth of an inch. The threaded post should be set with binding wire or a clamp made of piano-wire, about one-eighth of an inch from one end, B, of the strip of bronze, and soldered with silver solder. The post in which the screw turns free is set near the other end, C. The distance the post, B, is from the end of the strip is the amount of variation in the size of the matrix. German silver No. 16, standard wire gauge, answers nicely for the threaded post; the other post may be lighter, No. 19. The screws are of steel, and have a square head which will fit a largesized watch-key, which after filing off the ring may be fastened in any kind of a handle. The screws should generally be about sevensixteenths of an inch in length over all, D. When the posts have been soldered, the matrix should be bent around the pine stick and secured with the screw. The cervical margin can now be trimmed

Fig. 2.

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to follow the line of the gum, with a corundum point or finishing bur, and the matrix polished. The threaded post must be set distally, so that the screw-head may be directed mesially, and it is most conveniently turned with the key when it is on the buccal surfaces of the teeth. The cervical and all margins of cavities which will come close to the matrix are best prepared before the matrix is adjusted. This done, the matrix is secured on the tooth by closing the band with the screw, after which the rubber-dam is passed over it and such adjoining teeth as may be thought best. The dam will readily pass between the matrix and approximate tseeth, and, with little discomfort to the patient, can be easily carried below the cervical edge of the matrix. The preparation of the cavity can now be completed. The bronze being soft and tough, can be burnished to mold the filling, as the conditions present demand, care being taken that a little space is left to allow the filling material to overlap all margins. The removal of the matrix requires no particular care. The screw is disengaged from the threaded post, the ends are spread apart, the matrix is pushed slightly towards the tongue, and is then easily withdrawn. Vol. xxvii.—22.

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