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IMPLANTA TION OF TEETH 
 
 WILLIAM J. YOUNGER, M. D. 
 
 Individual Report 
 
 of the 
 
 Committee of Pathology and Surgery, 
 
 read before the 
 
 California State Dental Association, 
 
 Inly 21, 1886, 
 
 at San Francisco. 
 
 77? ^6^CJ/t/l-lt,\ 
 
 IM-te'ttVJ. 
 
IMPLANTATION OF TEETH 
 
 sr 
 
 WILLIAM J. YOUNGER, M. D. 
 
 Ex-President of the California State Dental Association; 
 
 Ex-President San Francisco Dental Association; 
 
 Member California State Medical Society; 
 
 Member San Francisco County Medical Society. 
 
 INDIVIDUAL REPORT of the COMMITTEE of PATHOLOGY and SURGERY 
 
 read before the 
 
 CALIFORNIA STATE DENTAL ASSOCIATION, 
 
 July 21, 1886. 
 
 SAN FRANCISCO: 
 
 Wm. S. Duncombe <Sr» Co., Publishers 
 
 2ii Post Street. 
 
|OAN STACK 
 GTFT 
 
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 IMPLANTATION OF TEETH 
 
 Mr. President and Gentlemen — 
 
 Dr. "Warner, Chairman of the Committee on Surgery and 
 Pathology, did me the honor to say, to-day, that the only new 
 thing in Dental Surgery, that he was aware of, was the suc- 
 cessful transplantation of teeth into artificial sockets by Dr. 
 Younger, one of the Committee; several of which operations 
 had been witnessed by himself, and the success of which he 
 could vouch for. He, therefore, delegated to Dr. Younger the 
 task of making out the report of the Committee. Had Dr. 
 Warner informed me of this intention sooner, I should have been 
 able to present to you a report fuller in detail and more free from 
 crudities than this, of necessity, must be. 
 
 Transplantation and Implantation, as I call my new operation, 
 has so far realized my most sanguine expectations, and leads me 
 to the belief that in a short while it will become as firmly estab- 
 
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lished in professional practice as any other operation requiring 
 skill and judgment. 
 
 Since the publication of my brochure on " Transplantation of 
 Teeth into Natural and Artificial Sockets," which you have all 
 seen, and a portion of which formed a report made to this Associa- 
 tion, at its last session, I have made a discovery in regard to the 
 vitality of the pericementum, that is even more startling than the 
 success of the operation of Implantation itself. In the pamphlet 
 I recommended the use of cock's combs as a means of pre- 
 serving the vitality of the peridental membrane, and also men- 
 tioned that in two instances the life of this membrane had been 
 preserved for over fifty hours, in tepid water. I now, however, 
 have to report a case — one of several — which proves that these 
 means are not at all necessary to preserve the vitality of this, the 
 most wonderful tissue in the human body; that this vitality of the 
 pericementum is marvelous; and that it may be as tenacious as 
 that inherent in the seeds of plants. 
 
 In the early part of March, 1886, Mrs. Dr. H. G. Blankman— the 
 wife of one of the pioneer dentists of this coast — brought me a 
 bicuspid that had been extracted at her solicitation, in Sacramento, 
 on the 31st day of January, 1885, in the belief that it was the seat 
 of a neuralgic pain, which had been the cause of great anguish to 
 her. This tooth, brought to me after this long lapse of time, had 
 in the meanwhile been carried about in her portemonnaie, stowed 
 away in her jewel case and shuffled about in her bureau drawer. 
 And this tooth she wanted replanted in her jaw! My first 
 
— 5 — 
 
 impulse was to laugh, my next to argue with her about the 
 impossibility of success of such an operation, explaining to her 
 that it was due only to the vitality of the membrane covering of 
 the root that the operation owed its success; that, without 
 this living membrane, the tooth was as impossible of attach- 
 ment as so much bare ivory or porcelain; and that while I had 
 succeeded in keeping this membrane alive for over two days, it 
 was by constant immersion in warm water, at a blood tempera- 
 ture: but that the pericementum of this tooth was, as she 
 herself could see, as dry and shriveled as parchment, and as 
 devoid of life. 
 
 Just as I had persuaded her of the impossibility of success, 
 there flashed through my mind a passage in John Bell's work on 
 the " Anatomy and Physiology of the Human Body/' that I had 
 lately read, which awoke the suggestion that success in implant- 
 ing that tooth was, after all, possible. 
 
 This eminent surgeon, in criticising an article of the famous 
 John Hunter, says: "How can such vitality exist independently 
 of a circulation? But there are not wanting examples of an 
 obscure and low degree of life existing in animals' ova, or 
 seeds, for seasons without a- circulation; and if for seasons, why 
 not for a term of life?" 
 
 While this passage did not bear directly on the subject in 
 question, it somehow awoke a train of thought that led me 
 to the conclusion, that in that dry, shriveled membrane there 
 
— 6 — 
 
 possibly lay lurking a dormant life, which under favorable condi- 
 tions would rouse its energies and make the tooth enclosed once 
 more a living, useful organ. 
 
 I had proved that the peridental membrane possesses a won- 
 derful tenacity of life, in at least two instances, where, after it 
 had been removed from all life-giving connection for fifty-two 
 hours, it was as vigorous in forming attachments as though it 
 had been planted immediately after removal. I therefore reas- 
 oned with myself, if this peridental membrane preserves a vital- 
 ity unimpaired for fifty-two hours, why not for so many weeks 
 or months? So I said: "Mrs. Blankman, the idea has just 
 occurred to me that what you want done is, perhaps, possible." 
 And I explained the cause of this revolution of opinion, as she is 
 not only a brave but a very intelligent woman; and continuing, 
 said : " I will perform this operation as an experiment, to test the 
 vitality of the pericementum; for, though I have no positive 
 expectation, I have a hope of its success." So, on the 11th of 
 last March, in the presence of and with the assistance of Dr. 
 Alexander Warner, who was acquainted with all the circum- 
 stances of the case, I drilled a socket between the first left 
 superior bicuspid and first molar; and after soaking the tooth 
 in water — temperature 120° Fah. — for twenty-five minutes, to 
 soften the membrane, restored to the jaw that which it had 
 been deprived of just thirteen months and eleven days before. 
 
 As the dental aspect of the tooth was perfect, and the approx- 
 imal not nearly so much so, I turned the tooth, thereby much 
 
— 7 — 
 
 improving the original appearance of that portion of the mouth. 
 When the operation was finished, the tooth was found so firmly 
 fixed in the socket that retaining ligatures were not applied : 
 and union took place as rapidly and as thoroughly as if it had 
 been a fresh tooth. 
 
 The tooth retaining this firmness, and no swelling nor pain 
 ensuing, the lady commenced eating with it, and at the end of 
 twelve days became so careless in her use of the tooth, that she 
 bit a hard crust of French bread with it. This was too much; 
 the tooth received a wrench that loosened it and caused the 
 gum to bleed profusely. Next morning she hurried to the office, 
 and with tears in her eyes, narrated the accident. I found the 
 tooth quite loose, but not dropping, and the gum on the pala- 
 tine surface swollen, and with the evidence of having bled at the 
 margin. 
 
 In my heart I was glad the accident had happened; for to me 
 it was a test of the question whether the retention of the tooth 
 was due simply to the nice adaptation of the walls of the socket 
 to the root of the tooth, and therefore only mechanical, or 
 whether it was really due to awakened life in the peridental 
 membrane, and cbnsequent vital connection with the living en- 
 vironment of gum and alveolar substance. 
 
 If mechanical, I argued, the irritation that has been set up 
 around it, especially in its present loose condition, will cause its 
 expulsion; but if vital, it will be retained and become firm again. 
 I therefore did not seek to retain it in place by any ligature, but 
 
— 8 — 
 
 simply painted the gum with tincture of iodine, and cautioned 
 her not to chew on that side until I gave her permission. In one 
 week all marks of the accident had passed away; the tooth be- 
 came again firmly fixed, and remains to the present moment as 
 solid as a rock. I have tried, since then, to pass a delicate instru- 
 ment, the point of which had been flattened for the purpose, be- 
 tween the gum and the tooth; but the act gave as much pain, and 
 the instrument met with as much resistance, as in the tissues sur- 
 rounding the teeth that had never been disturbed in their sockets : 
 all of which clearly proves that the pericementum of that tooth — 
 dry and shriveled as it was — had during those long months of 
 absence from any life-supporting substance, tossed about from 
 place to place, from pocket and purse to casket and drawer, pre- 
 served a vitality as fresh and vigorous as when it was removed 
 from the place in which it grew. 
 
 I am happy to say that Mrs. Blankman has kindly consented, 
 in the interest of science, to present herself to you this after- 
 noon, in order that you may examine this tooth, and satisfy 
 yourselves by personal and thorough examination, as to the 
 success of the operation. And I want each and every one of 
 you gentlemen to test in every way that your ingenuity may 
 suggest — short of extraction — the statement I have made, that 
 vital connection has been established between that tooth and 
 the walls of the socket, as perfect as that of the other teeth that 
 have grown there and never been tampered with. 
 
 I have since tried implanting teeth which have been extracted 
 
— 9 — 
 
 for weeks and months, with equal success, proving the wonder- 
 ful tenacity of life in the peridental membrane. 
 
 The question now in my mind is: " When does the pericemen- 
 tum die?" 
 
 In consequence of these experiments, and the equal success 
 of the implantation of long extracted teeth with that of fresh 
 ones, I have discarded, as unnecessary, the warm water and the 
 comb of the troublesome cock. 
 
 I now simply lay the teeth aside in a clean, cool, dry place, 
 and prepare and use them as I want them. 
 
 I have also discarded the flat drill, and use, instead, graded 
 trephines for piercing the bone and for doing the major part of 
 the work; finishing the walls, as formerly, with burs of various 
 shapes. 
 
 Much doubt has been expressed by the profession in the East 
 and elsewhere as to the stability of implanted teeth, because the 
 kindred operations of Keplantation and Transplantation that have 
 come under their observation, and which, at first, gave promise 
 of permanency, have so generally turned out failures in one or 
 two years, from absorption of the roots. They argue that if 
 Replantation, which is the putting back of a tooth into the socket 
 from which it has been but just drawn; and Transplantation, 
 which is the planting of a stranger tooth into a socket from 
 which its own has been but freshly extracted: if, they say, 
 these cognate operations, where the conditions seem so much 
 more favorable, in consequence of the sockets being natural, 
 
— IO — 
 
 are so generally failures, what better result can be expected 
 from an operation where the socket is formed by violence to the 
 jaw? 
 
 Now, if they would but consider the conditions and circum- 
 stances under which these different operations are undertaken, 
 they would readily see that the premises upon which they 
 ground their assumption are unsound and deceitful. For in- 
 stance, in replantation, as this operation is usually performed, 
 the parts — that is, the peridental membrane, the apex of the 
 root and the alveolar process immediately surrounding these — 
 are highly inflamed, in a state of disease, with pus either 
 already formed or forming at the end of the root, and the oper- 
 ation is undertaken with the view of relieving or aborting an 
 alveolar abscess. A portion of the diseased apex is then cut 
 off, and the tooth is forced back into the cavity. Here we 
 have a diseased root thrust back into a diseased socket. The 
 disease is not removed, its conditions are simply modified; 
 and while the congestion may subside, and the tooth become 
 comparatively comfortable, the disintegration of the root sub- 
 stance — already begun — is likely to continue, and in the course 
 of time the entire root becomes destroyed, or, what is called 
 absorbed; and the bodiless crown drops off. So much for 
 Eeplantation. 
 
 Again, in Transplantation there is a healthy tooth, but it is 
 usually made to take the place of a miserable, old, diseased 
 root, that has been growling and festering in a diseased 
 
— II — 
 
 socket for years, to the discomfort of its unfortunate possessor. 
 The diseased root is pulled out, but is the disease in the 
 surrounding alveolus extracted with it ? On the contrary, 
 enough is usually left in its tissue to make war upon the 
 new occupant, and either cause its expulsion, or eat away its 
 substance. You must remember, that while the old root 
 remained, there was sufficient vent through its decayed or 
 broken structure to permit the gases of decomposition and the 
 pus to escape, and thus prevent active trouble. But when the 
 new tooth is put in, the vent is entirely occluded, and if there 
 be sufficient disease in the alveolus, the retained gases and 
 pus effect the expulsion or the painful elongation of the intruder. 
 If not enough disease is left to do this, then the slow process of 
 erosion is apt to ensue, and the root becomes, in time, absorbed. 
 
 Now, in Implantation we have a healthy root in a healthy socket; 
 and, therefore, the factors that tend to the destruction of the root 
 in Keplantation and Transplantation are not present, and, there- 
 fore, not operative in Implantation. 
 
 As to the seeming violence to the bony structure of the jaw, 
 I will state that there is no substance in the human body that 
 seems so tolerant of abuse as this same alveolar process. And 
 my experience is, that union takes place more readily and kindly, 
 and the teeth become much sooner firm and serviceable in Im- 
 plantation than in either of the other operations. 
 
 I trust, my brother practitioners, that what I have read to you 
 will serve to dispel whatever gloomy forebodings you may also 
 
— 12 
 
 have entertained, in considering tl^e future of Implantation, 
 and that you will apply yourselves at once to master this opera- 
 tion, for the benefit of your patients and of yourselves. Also, I 
 urge on you the practice of Eeplantation and Transplantation, 
 for they can be made uniformly successful, if you but follow the 
 system I have made you acquainted with, and the primal rule 
 of which is, to allow no disease to remain in socket or in root. 
 Do not wait half a lifetime, as the pessimists in the profession 
 would have you do, in order to find out if the operation is going 
 to be successful, but commence now. 
 
 In this paper I have summarized these operations as per- 
 formed by our Eastern brethren, in order to make their argu- 
 ment as effective as possible, and so to impress upon you the 
 reason of the failure of Replantation and Transplantation, as 
 practiced by them, and to demonstrate that to the disease left in 
 the socket and root, or in the socket alone, must be attributed 
 the failures caused by absorption of the root; otherwise, why 
 should the result of my experience in these operations be so 
 different from theirs ? In all my practice of these kindred 
 operations — and it has probably far exceeded that of any other 
 practitioner in the United States — I have had but one case 
 of non-success, due to the absorption of the root. As it has a 
 lesson in point, I will narrate it. 
 
 In this case, the tooth inserted was but poorly covered with 
 pericementum, and the socket had been diseased for eighteen 
 years, and was, moreover, so much larger than the root that the 
 
— 13 — 
 
 tooth had to be held in by ligatures. The evening after its in- 
 sertion, the ligature loosened and the tooth fell out and dropped 
 on the carpet. The gentleman placed it immediately back in the 
 socket, and being unable either to tie it or find me, retained it 
 in position by closing his jaw and keeping his teeth tightly 
 pressed together by means of a handkerchief passed under his 
 chin and tied over his head. At nine o'clock the next morning 
 I found that attachment had already taken place, which assured 
 me that it had not been fatally injured by the episode of the 
 night previous. I therefore renewed the ligatures, and when 
 the gentlemen started for his English home, two months later, 
 the tooth was well attached, though not firm. This operation 
 was performed March 2d, 1885; and a letter, dated more than a 
 year later, informed me that the crown had broken off, and he 
 was puzzled to know why it should have done so, when he was 
 not cracking nuts with it! He also wrote that the fangs re- 
 mained imbedded; but in this he must be mistaken. It is, in 
 my mind, a case of absorption of the roots. 
 
 It is the only case where I did not either cut out the disease 
 nor treat it sufficiently long to satisfy myself that it was all 
 gone from the socket; and it is the only tooth I have lost by 
 absorption. I may say that in cases like this, where the size of 
 the socket is in excess of the diameter of the root, either from 
 natural causes or alveolar disease, I form an artificial root of gum 
 shellac, of the shape and a trifle smaller than the body of the 
 root to be inserted; to which I attach an artificial crown. This 
 
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