Rubbing two different substances together is a common method of producing an electric charge. Is there not more electricity generated during mastication on metal fillings than when the jaws are at rest? Friction brings into close contact numerous particles of two bodies, and perhaps the electrical action going on more or less all the time through gold fillings (especially when other metals are in the mouth) accounts for a powdered condition of the dentin which is sometimes found under cohesive gold fillings, but not under tin.
Whitecaries, the most formidable variety known, may be produced by nitric acid, and in these cases all the components of the tooth are acted upon and disintegrated as far as the action extends. In proximal cavities attacked by this kind of caries, separate freely on the lingual side, and fill with tin. When such fillings have been removed the dentin has been found somewhat discolored and greatly solidified as compared to its former condition; this solidification or calcification is more frequent under tin than gold, which is partly due to the tin as a poor conductor of heat. Nature will not restore the lost part, but will do the next best thing—solidify the dentin. In some cases, under tin, the pulp gradually recedes, and the pulp-cavity is obliterated by secondary dentin. In other cases the pulps had partly calcified under tin. It has been known for years that tin would be tolerated in large cavities very near the pulp without causing any trouble, and one reason for this is its low conducting power. Attention is called to the fact that gold is nearly four times as good a conductor of heat as tin, and more than six times as good a conductor of electricity. Where tin fillingsare subject to a large amount of attrition, they wear away sooner or later, but this is not such a great detriment, for they can easily be repaired or replaced, and owing to the concave form produced by wear the patient is liable to know when a large amount has been worn away. That portion against the wall of the cavity is the last removed by wear, so that further caries is prevented so long as there is any reasonable amount of tin left. If at this time the tooth has become sufficiently solidified, proper anchorage can be cut in the tin or tooth, one or both, as judgment dictates, and the filling completed with gold. A tin filling, confined by four rather frail walls, may condense upon itself, but it is so soft and adaptable that the force which condenses it continually secures the readaptation at the margin; thus there will be no leakage or caries for years. Owing to its softness and pliability, it may be driven into or onto the tubuli to completely close them from outside moisture, and with a hand burnisher the tin can be made to take such a hold on dry, rough tubuli that a cutting instrument is necessary to remove all traces of it.
Tin foil has been found in the market that under a magnifying glass showed innumerable tiny black specks, which, upon being touched with an instrument, crumbled away, leaving a hole through thefoil. More than likely, some of the failures can be attributed to the use of such foil. Good tough foil, well condensed by hand or mallet force, stays against the walls of a cavity and makes a tight filling, and ought to be called as near perfect as any filling, because it preserves the tooth, and gives a surface which will wear from five to twenty years, depending upon the size and location of the cavity and tooth-structure. Buccal cavities in the first permanent molars, and lingual cavities in the superior incisors, filled for children from six to eight years of age, are still in good condition after a period of twenty years. Perhaps the limit is reached in the following cases, all in the mouths ofdentists: One filling forty years old; one forty-two; four on the occlusal surface, fifty; in the latter case gold had been used in other cavities and had failed several times. Lingual cavities in molars and bicuspids can be perfectly preserved with tin. Tapes of No. 10 foil, from one to three thicknesses, can be welded together and will cohere as well or better than semi-cohesive gold foil, and it can be manipulated more rapidly; therefore, if desirable, any degree of contour can be produced, but the contour will not have the hardness or strength of gold, so in many cases it would not be practicableto make extensive contours with tin, owing to its physical characteristics.
No. 10 will answer for all cases, and it is not as liable to be torn or cut by the plugger as a lower number, but one need not be restricted to it, as good fillings can be made with Nos. 4, 6, or 8. More teeth can be saved with tin than with any other metal or metals, and the average dentist will do better with tin than with gold. It is invaluable when the patient is limited for time or means, and also for filling the first permanent molars, where we so often find poor calcification of tooth-structure. In cases of orthodontia, where caries has attacked a large number of teeth, it is well to fill with tin, and await further developments as to irregularity and caries.
If cavities are of a good general retaining form, that will be sufficient to hold the filling in place; but if not, then cut slight opposing angles, grooves, or pits. Cavities are generally prepared the same as for gold, except where there is a great deal of force brought upon the filling; then the grooves or pits may be a little larger; still, many cavities can be well filled with less excavating than required for gold, and proximal cavities in bicuspids and molars, where there is sufficient space, can be filled without removing the occlusal surface, and hereespecially should the cavities be cut square into the teeth, so as not to leave a feather edge of tin when the filling is finished, as that would invite further caries and prove an obstruction to cleansing the filling with floss.
In proximal cavities involving the occlusal surface, cut the cervical portion down to a strong square base, with a slight pit, undercut, or angle, at the buccal and lingual corners; where there is sufficient material, a slight groove across the base, far enough from the margin so that it will not be broken out, can be made in place of the pit, undercut, or angle; then cut a groove in the buccal and lingual side (one or both, according to the amount of material there is to work upon), extending from the base to the occlusal surface; in most of these cases the occlusal grooves or pits would have to be excavated on account of caries; thus there would be additional opportunity for anchorage. In place of the grooves the cavity may be of the dovetail form. In nearly all proximal cavities in bicuspids and molars, some form of metal shield, or matrix, is of great advantage, as they prevent the tin from crushing or sliding out. By driving the tin firmly against the metal, a well-condensed surface is secured; and as the metal yields a little, we can with a bevel or thin plugger force the tin slightly betweenthe metal and the margin of the cavity, thus making sure of a tight filling, with plenty of material to finish well. After removing the metal, condense with thin burnishers and complete the finish the same as for gold. Where no shield or matrix is used, or where it is used and removed before completing the filling, it is often desirable to trim the cervical border, for in either case there is more light and room to work when only a portion of the cavity has been filled. Tin cuts so much easier than gold, it is more readily trimmed down level with all cervical margins.
Be sure that all margins are made perfect as the work progresses, and if the cavity is deep and a wide shield shuts out the light, then use a narrow one, which can be moved toward the occlusal surface from time to time.
In filling the anterior teeth when the labial wall is gone, and the lingual wall intact or nearly so, use a piece of thin metal three-quarters of an inch long and wide enough to cover the cavity in the tooth to be filled, insert it between the teeth, and bend the lingual end over the cavity; the labial end is bent out of the way over the labial surface of the adjoining tooth, as shown inFig. 4. When the labial wall is intact or nearly so, access to the cavity should be obtained from the lingual side, and inthis case the bending of the shield would be reversed, as shown inFig. 5. The shield is not absolutely essential, but it helps support the tin, and also keeps a separation.
Fig. 4.Fig. 5.
Fig. 4.
Fig. 5.
It is preferable to save the labial wall and line it with (say) five layers of No. 4 semi-cohesive gold folded into a mat and extended to the outer edge of the cavity; this gives the tooth a lighter shade, and bicuspids or molars can be filled in the same manner. Cases are on record where incisors with translucent labial walls, filled by this method, have lasted from twenty-three to thirty-seven years.
Forthe last ten years the writer has been using tin at the cervical margin of proximal cavities in bicuspids and molars, especially in deep cavities (now an accepted practice), and he finds that it prevents further caries oftener than any other metal or combination of metals he has ever seen used. In filling such cavities, adjust the rubber, and use a shield or matrix of such form as to just pass beyond the cervical margin; this will generally push the rubber out of the cavity, but if it does not, then form a wedge of wood and force between the metal and the adjoining tooth, thus bringing the metal against the cervical margin, and if a small film of rubber should still remain in the cavity, it may be forced out by using any flat burnisher which will reach it, or it can be dissolved out with a little chloroform. Fill from one-fourth to one-half of the cavity with tin, and complete the remainder with gold when the tooth is of good structure; this gives all the advantages of gold for an occlusal surface.
Before beginning with the gold, have the tin solid and square across the cavity, and the rest of the cavity a good retaining form, the same as for gold filling; then begin with a strip of gold slightlyannealed and mallet it into the tin, but do not place too great reliance upon the connection of the metals to keep the filling in place.
On the same plan, proximal cavities in the anterior teeth can be filled, and also buccal cavities in molars, especially where they extend to the occlusal surface. The cervical margin should be well covered with tin thoroughly condensed, thus securing perfect adaptation, and a solid base for the gold with which the filling is to be completed. Time has fully demonstrated that the cervical margin is most liable to caries, and here the conservative and preservative qualities of tin make it specially applicable.
"Electrolysis demonstrates to us that no single metal can be decomposed, but when gold and tin are used in the above manner they are united at the line of contact by electrolysis. The surface of both metals is exposed to the fluids of the mouth, and the oxid of tin is deposited on the tin, by reason of the current set up by the gold; thus some atoms of tin are dissolved and firmly attached to the gold, but the tin does not penetrate the gold to any great extent." (Dr. S. B. Palmer.)
This connection of the metals assists in holding the filling in place, but it is more likely to break apart than if it was all gold. After electrolysis hastaken place at the junction, it requires a cutting instrument to completely separate the tin and gold.
For filling by hand pressure, use instruments with square ends and sides, medium serrations, and of any form or size which will best reach the cavity.
For filling with the hand mallet, use instruments with medium serrations, and a steady medium blow with a four-ounce mallet; in force of blow we are guided by thickness of tin, size of plugger, and depth of serrations, strength of cavity-walls and margins, the same as in using gold. The majority of medium serrated hand mallet pluggers will work well on No. 10 tin of one, two, or three thicknesses. If the tin shows any tendency to slide, use a more deeply serrated plugger. The electro-magnetic, and mechanical (engine) mallet do not seem to work tin as well as the hand mallet or hand force, as the tendency of such numerous and rapid blows is to chop up the tin and prevent the making of a solid mass, and also injure the receiving surface of the filling. In using any kind of force,alwaysaim to carry the material to place before delivering the pressure, or blow.
In order to obtain the best results, there must be absolute dryness, and care must be exercised, not thinking that because it istinit will be all right. Skill is required to make good tin fillings, as wellas when making good gold fillings. Always use tapes narrower than the orifice of the cavity; they are preferable to rolls or ropes. After a few trials it is thought that every one will have the same opinion. A roll or rope necessarily contains a large number of spaces, wrinkles, or irregularities, which must be obliterated by using force in order to produce a solid filling; thus more force is employed, and more time occupied in condensing a rope, than a flat tape; the individual blow in one case may not be heavier than in the other, but the rope has to be struck more blows. The idea that a rope could be fed into a cavity with a plugger faster and easier than a tape has long ago been disproved. Many of the old-fashioned non-cohesive gold foil operators used flat tapes, as did also Dr. Varney, one of the kings of modern cohesive gold operators.
The tape is made by folding any portion of a sheet of foil upon itself until a certain width and thickness is obtained. This tape is very desirable in small or proximal cavities where a roll or rope would catch on the margin and partially conceal the view.
In the form of a tape, perhaps more foil can be put in a cavity, and there may be more uniform density than when ropes are used. Tapes can also be made by folding part of a sheet of foil over athin, narrow strip of metal. Fold the tin into tapes of different lengths, widths, and thicknesses, according to the size of the cavity; then fold the end of the tape once or twice upon itself, place it at the base of any proximal cavity, and begin to condense with a foot plugger of suitable size, and if there is a pit, groove, or undercut which it does not reach, then use an additional plugger of some other form to carry the tin to place; fold the tape back and forth across the cavity, proceeding as for cohesive gold. In small proximal cavities a very narrow tape of No. 10, one thickness, can be used successfully. For cavities in the occlusal surface, use a tape as just described, generally beginning at the bottom or distal side, but the filling can be started at any convenient place, and with more ease than when using cohesive gold. In any case if the tin has a tendency to move when starting a filling, "Ambler's left-hand assistant" is used, by slipping the ring over the second finger of the left hand, letting the point rest on the tin. This instrument is especially valuable in starting cohesive gold (seeFig. 6). This is the easiest, quickest, and best manner of making a good filling, relying upon the welding or cohesive properties of the tin.
Many operators have not tried to unite the tin and make a solid mass; they seem to think that itcannot be accomplished, but with proper pluggers and manipulation it can be done successfully.
Fig. 6.
For large occlusal or proximal cavities, the tapes may be folded into mats, or rolled into cylinders, and used on the plan of wedging or interdigitation, and good fillings can be produced by this method, but the advantage of cohesion is not obtained, and more force is required for condensing. They are, therefore, not so desirable as tapes, especially for frail teeth. When using mats or cylinders, the general form of the cavity must be depended upon to hold the filling in place. To make the most pliable cylinders, cut a strip of any desired width from a sheet of foil and roll it on a triangular broach, cutting it off at proper times, to make the cylinders of different sizes.
A cylinder roller, designed by the author, is much superior to a broach. (SeeFig. 7.) When the cavity is full, go over the tin with a mallet or hand burnisher, being careful not to injure the cavity-margin.Cut down occlusal fillings with burs or carborundum wheels, and proximal fillings with sharp instruments, emery strips or disks. After partially finishing, give the filling another condensing with the burnisher, then a final trimming and moderate burnishing; by this method a hard, smooth surface is obtained.
Fillings on occlusal surfaces can be faced with No. 20 or 30 tin, and burnished or condensed, by using a burnisher in the engine, but do not rely upon the burnisher to make a good filling out of a poor one.
Fig. 7.
By trimming fillings before they get wet, any defects can be remedied by cutting them out; then with a thin tape (one or two layers of No. 10) and serrated plugger proceed with hand or mallet force to repair the same as with cohesive gold.
Another method of preparing tin for fillings is to make a flat, round sand mold; then melt chemically pure tin in a clean ladle and pour it into the mold; put this form on a lathe, and with a sharp chisel turn off thick or thin shavings, which willbe found very tough and cohesive when freshly cut, but they do not retain their cohesive properties for any great length of time,—perhaps ten or twenty days, if kept in a tightly corked bottle. After more or less exposure to the air they become oxidized and do not work well, but when they are very thin they are soft, pliable, and cohesive as gold, and any size or form of filling can be made with them.
Among the uses of tin in the teeth, the writer notes the following from Dr. Herbst, of Germany: "After amputating the coronal portion of the pulp, burnish a mat of tin foil into the pulp-cavity, thus creating an absolutely air-tight covering to the root-canal containing the remainder of the pulp; this is the best material for the purpose." There has been a great deal said about this method, pro and con, notably the latter. The writer has had no practical experience with it, and it need not be understood that he indorses it.
If a pulp ever does die under tin, perhaps it will not decompose as rapidly as it otherwise would, owing to its being charged with tin-salts.
The Herbst method of filling consists in introducing and condensing tin in cavities by means of smooth, highly tempered steel engine or hand burnishers. In the engine set of instruments there isone oval end inverted cone-shaped, one pear-shaped, and one bud-shaped. The revolving burnisher is held firmly against the tin, a few seconds in a place, and moved around, especially along the margins, not running the engine too fast. Complicated cavities are converted into simple ones by using a matrix, and proximal cavities in bicuspids and molars are entered from the occlusal surface. The tin foil is cut into strips, and then made into ropes, which are cut into pieces of different lengths; the first piece must be large enough so that when it is condensed it will lie firmly in the cavity without being held; thus a piece at a time is added until the cavity is full. The hand set of burnishers has four which are pear-shaped and vary in size, and one which is rather small and roof-shaped. In filling and condensing they are rotated in the hand one-half or three-quarters of a turn.
Dr. Herbst claims a better adaptation to the walls of the cavity than by any other method. Proximal cavities in bicuspids and molars can easily be filled; the tin can be perfectly adapted against thin walls of enamel without fracturing them; less annoyance to the patient and less work for the dentist; can be done in half the time required for other methods.
Fees should be reasonably large, certainly morethan for amalgam, for we can save many teeth for a longer time than they could have been preserved with cohesive gold. Many are not able to pay for gold, but they want their teeth filled andsaved, and it is expected that we will do it properly and with the right kind of material; thus it is our duty in such cases to use more tin and less amalgam.
We should always take into consideration the amount of good accomplished for the patient,—the salvation of the tooth,—and if we are sure, from experience and observation, that the tin filling will last as long as a gold one in the same cavity, or longer, then the fee should be as much as for gold, with the cost of the gold deducted. The amount of the fee ought to be based upon the degree of intelligence, learning, and skill required; upon the amount of nervous energy expended; upon the draft made on the dentist's vitality; upon what benefit has been given the patient; upon the perfection of the result; and, everything else being equal, upon the time occupied; the value of this last factor being estimated in proportion to the shortness of it.
Dr. Robinson'sFibrous and Textile Metallic Filling is a shredded metallic alloy, mostly tin, and has the appearance of woven or felt foil. It is prepared in a machine invented by the doctor especially for the purpose, and he gives directions for using as follows: "Cut the material into strips running with the selvage, and fill as you would with soft foil; use it in all surrounding walls, and finish with a mallet burnisher. Where the surface comes to hard wear, weld on gold with long, sharp serrated pluggers, and finish the same as with gold fillings. The advantage over gold for cervical, buccal, and lingual walls is the perfect ease with which it is adapted, and it can be burnished so as to be absolutely impervious to moisture. Sharp, coarse-serrated pluggers are particularly desirable when using hand pressure." It comes in one-half-ounce boxes, filled with sheets less than two inches square; the thin ones are used for filling, and the thick ones make good linings for vulcanite.
This material is easy to manipulate, but great care is required in condensing at cavity-margins, so as to make a tight filling, and also not injure the margins. It makes as hard a surface as tin foil, andcan be cut, polished, and burnished so that it is smooth and looks well; it can be used in temporary or chalky teeth, as a small amount of force condenses it. By using a matrix proximal cavities can be filled from one-fourth to one-half full, and the rest filled with gold, relying on the form of the cavity to hold the gold, regardless of its connection with the fibrous material. If the surface is not overmalleted so as to make it brittle or powdery, a strip of No. 4 cohesive gold, of four or five thicknesses, may be driven into it with a hand mallet and plugger of medium serrations; this union is largely mechanical, but of sufficient tenacity to make manipulation easy, as the material makes a solid foundation to build upon. After exposure to the oral fluids, electrolysis takes place at the junction of the metals.
In 1884 Dr. Brophy said, "I have used Robinson's material for two years, and find it possesses good qualities, and can be used in deciduous teeth, first permanent molars, and cervical margins with better results than can be obtained with any other material by the majority of operators."
Malleted with deeply serrated pluggers, it will make a filling which will not leak. It has saved many teeth from caries at the cervical margin where it might have recurred sooner had cohesivegold been used. In the mouth it changes color about the same as tin foil, and a few fillings did not maintain their integrity, but became crumbly and granular.
For conducting properties it ranks about with tin, and fillings can be made more rapidly than with cohesive gold. We have used ounces of it, but time has proved that everything that can be done with it in filling teeth can also be accomplished as well and in some cases better with tin foil.
In 1878 Dr. N. B. Slayton patented his Felt Foil, which was said to be tin cut into hair-like fibers by a machine, then pressed into small sheets and sold in one-half-ounce books, but it sold only to a very limited extent. Soon after this Dr. Jere Robinson, Sr., invented a machine and began the manufacture of a similar article, but he found he was infringing on the Slayton patent, so he purchased the Slayton machine and made satisfactory terms to continue his own manufacture of fibrous material. After this little was heard of Slayton's Felt Foil, but Robinson's was considerably used. The two materials look and are manipulated almost exactly alike. Dr. Robinson has both of above-mentioned machines now in his possession.
Archibald McBride, of Pittsburg, Pa., in 1838, made a roll of a portion of a sheet of tin, and thenused just enough gold to cover it, aiming to keep the gold on the surface, so as to have the filling look like one of all gold, and not with the idea of deriving any special benefit from the effects of wear or preservation as obtained by thus combining the two metals. The fee for a gold filling was one dollar; tin, fifty cents. Some operators have advocated using tin and gold (symbol Tg), rolled or folded together in alternate layers, thus exposing both metals to the fluids of the mouth; claiming that fillings can be made quicker, are not so subject to thermal changes, and can be inserted nearer the pulp than when gold is used. This may be true in comparison with gold, but these three claims are entirely met by using tin alone. Others say that this union of gold and tin will preserve the teeth as well as a correct gold filling, making no conditions or restrictions as to tooth-structure or location of cavity. They say that it preserves the cervical margin better than gold; that it expandsslightly.
A description of some different methods of combining and manipulating tin and gold is subjoined:
(a) Two sheets of No. 4 cohesive gold and one of the same number of tin are used; place the tin between the gold, cut off strips, and use with hand or mallet force the same as cohesive gold; if non-cohesive gold is used, the strips can be folded intomats or rolled into cylinders, and are used on the wedging plan, the same as non-cohesive gold, or the strips can be folded back and forth in the cavity until it is full.
(b) Lay a sheet of non-cohesive gold, No. 3, on a sheet of tin of the same number, cut off strips, roll into ropes and use as non-cohesive gold. It is easily packed and harder than tin, and has a preservative action on the teeth. Line the cavity with chloro-balsam as an insulator against possible currents and moisture; especially should this be done in large cavities or chalky teeth.
(c) A sheet of non-cohesive gold, No. 4, is laid on a sheet of tin of the same number, cut into strips and rolled into cylinders, or folded into blocks, always in equal portions; then they will unite to the extent of two leaves. These fillings sometimes become a solid mass about the color of amalgam, and last very well, as the metals have become united by electrolysis. An excess of tin will be marked by lines or pits in the filling, showing where the tin has been disintegrated or dissolved by the chemical action which occurs on the surface exposed to moisture.
No doubt, good fillings have been made by the above methods, yet some were granular, gritty, and were easily removed, while others were quitesmooth and hard; probably in the first instance the proportion of tin and gold was not proper,—that is, not equal; or it was not well condensed. Tin being the positive element, it is more easily acted on and disintegrated by electrolysis (chemical action of the fluids).
When this combination does become hard, it wears longer than tin on an occlusal surface, but we believe that in some cases where it was used the teeth could have been saved just as well with either tin or gold, or by filling part of the cavity with tin and the rest with gold.
If tin foil is laid on 22-carat gold and vulcanized, it becomes thoroughly attached and will take a tin polish; the attraction or interchange of atoms takes place to this extent.
This combination of tin and gold can be used at the cervical margin, or a cavity can be lined with it, and the remainder filled with cohesive or non-cohesive gold.
"Tin and gold (Tg) folded or rolled together in equal portions possesses a greater number of desirable properties than any other material, for it is easily adapted, has antiseptic action and a lower conductivity than gold. A new filling is harder than tin, softer than gold, but after a time it becomes as hard as amalgam. It oxidizes and thushelps make tight margins, and is very useful at cervical margins; generally discolors, but not always, and does not discolor the tooth unless a carious portion has been left, and then only discolors that portion. In oral fluids it is indestructible if well condensed, otherwise it is crumbly. There is no change of form, except aslightexpansion, which does no harm. A weak electric current is set up between the gold and tin, and tin oxid is formed. The hardening and discoloration both depend upon the separation of the tin by the electrical action and its deposition on the surface of the gold. I generally prepare cavities the same as for non-cohesive gold, but a Tg filling may be held in a more shallow cavity and with less undercuts than for gold. Hand pressure is adopted, but a mallet may be used advantageously. Lay a sheet of No. 4 non-cohesive gold on a sheet of No. 4 tin, then cut into strips and twist into ropes; keep the tin on the outside, for it does not tear as easily as gold. Carry the material against the walls and not against the base, otherwise the filling will be flat or concave; but should this occur, then force a wedge-shaped plugger into the center of the filling, and drive the material toward the walls, and then fill the hole or remove all the filling and begin anew.
"In very deep cavities use a mat of Tg, dampenedin carbolic acid and dipped in powdered thymol, as a base; this has an antiseptic action, and also prevents pressure on or penetration into the pulp.
"Drs. Abbot, Berlin; Jenkins, Dresden; Sachs, Breslau, have observed tin-gold fillings from fifteen to twenty-five years, and say that for certain cases it is better than any other material. I use square-pointed pluggers (four-cornered), as part of the packing is done with the side of the plugger. Tg is useful in partly erupted molars, buccal cavities under the gums, occlusal cavities in temporary teeth, cavities where all decay cannot be removed. Use Tg with a gold capping in small, deep occlusal cavities, cavities with overhanging walls, occlusal cavities with numerous fissures, large, deep occlusal cavities near the pulp, in proximal cavities.
"Line labial walls of incisors with non-cohesive gold, and fill the remainder with Tg. For repairing gold fillings I use Tg." (Dr. Miller, Berlin,Dental Cosmos, 1890.)
Dr. Jenkins, of Dresden, says, "I use Tg in soft, imperfect teeth, of which there are plenty in Germany, because it has pliability, adaptability, slight susceptibility to thermal changes, makes a water-tight joint, very useful at cervical margins, and can be used with a minimum amount of pressure.When packed dry and with the gold next to the tooth, discoloration occurs only on the surface; packed wet, the whole discolors. I do not attribute its success to electrical action. Lay a sheet of No. 4 tin on a sheet of No. 4 non-cohesive gold, fold so as to keep the gold on the outside; use the strip with lateral pressure, doubling it upon itself."
Dr. A. H. Thompson: "After several years' successful use of tin-gold, I commend it for approximal cavities, cervical margins, and frail walls. The oxid formed penetrates the enamel and dentin; if a filling wears down, cover the surface with gold."
Dr. Pearson: "I do not like tin and gold in alternate layers. I prefer No. 10 tin foil."
Dr. James Truman: "I believe that tin-gold has a positive value as a filling-material."
"I prepare tin-gold by taking a sheet of No. 4 non- or semi-cohesive gold, fold them together (or twist them) so as to have the gold on the outside, and then fill any cavity with it. Since adopting the above combination I have almost abandoned amalgam. This is recommended on account of its density, ease of insertion, capacity for fine finish, non-conducting and non-shrinking qualities, and compatibility with tooth-substance. Those who have not used it will be surprised at the rapiditywith which it can be manipulated. It may be employed in any cavity not exposed to view, also in crown, buccal, and approximal fillings which extend into the occlusal surface, as it offers an astonishing resistance to wear. It can be used anywhere that amalgam can, and with more certainty of non-leakage, and it has the additional advantage that it can be finished at the same sitting. Care is necessary in manipulating it, so as to avoid chopping. I use hand pressure when filling, and the mallet to condense the surface." (Dr. A. W. Harlan,Independent Practitioner, 1884.)
"Pure tin foil is employed in connection with non-cohesive gold in filling proximal cavities in bicuspids and molars; a sheet of gold and a sheet of tin are folded together." (C. J. Essig: "Prosthetic Dentistry.")
Dr. Benj. Lord says, "A combination in which I find great interest is in the use of soft or non-cohesive gold with tin foil. This is no novelty in practice, but I think that, for the most part, too great a proportion of tin has been used, and hence has arisen the objection that the tin dissolved in some mouths. I am satisfied that I myself until recently employed more tin than was well. I now use from one-tenth to one-twelfth as much tin as gold, and no disintegration or dissolving away ofthe tin ever occurs. I fold the two metals together in the usual way of folding gold to form strips, the tin being placed inside the gold. The addition of the tin makes the gold tougher, so that it works more like tin foil. The packing can be done with more ease and certainty; the filling, with the same effort, will be harder, and the edges or margins are stronger and more perfect.
"The two metals should be thoroughly incorporated by manipulation. Then, after a time, there will be more or less of an amalgamation. By using about a sixteenth of tin, the color of the gold is so neutralized that the filling is far less conspicuous than when it is all gold, and I very often use such a proportion of tin in cavities on the labial surfaces of the front teeth.
"If too much tin is employed in such cases, there will be some discoloration of the surface of the fillings; but in the proportion that I have named no discoloration occurs, and the surface of the filling will be an improvement on gold in color."
"Dr. Howe. I would like to ask Dr. Lord whether, in referring to the proportions of tin and gold, he means them to be considered by weight?
"Dr. Lord. No, not by weight, but by the width of the strip of tin and the width of the strip of gold. I get the proportions in that way, thenlay the tin on the gold and fold the gold over and over, which keeps the tin inside the gold.
"Dr. Howe. Will Dr. Lord tell us whether he refers to the same numbers of gold foil and tin foil; as, for instance, No. 4 gold and No. 4 tin?
"Dr. Lord. I use the No. 5 gold, and tin, I think, of about the same number, but I always use No. 5 gold, both cohesive and non-cohesive."—New York Odontological Society Proceedings, 1893, page 103.
"Tin and gold, in the proportions generally used, do not present a pleasing color; when finished, it looks but little better than tin, and after a short time it grows dark, and sometimes black. I use five parts of gold to one of tin, prepared as follows: Lay down one sheet of Abbey's non-cohesive gold foil, No. 6; upon this place a sheet of No. 4; upon this place a sheet of White's globe tin foil, No. 4; upon this another sheet of Abbey's non-cohesive gold, No. 4; upon this a sheet of No. 6. Cut into five strips and crimp; the crimped strips are cut into pieces a little longer than the depth of the cavity to be filled; some of the strips are rolled into cylinders, others are left open, because easier to use in starting a filling. The color of this combination is slightly less yellow than pure gold, and hardens just as rapidly as when the proportions are one to one,but does not become quite as hard. This preparation is non-cohesive, and should be inserted by the wedge process. I use it in the grinding surface of molars and bicuspids, buccal cavities in molars and bicuspids, cervical fissure pits in superior incisors, proximal cavities in bicuspids and molars. If proximal cavities are opened from the occlusal surface, the last portion of the filling should be of cohesive gold to withstand mastication. In simple cavities I place as many pieces as can be easily introduced, using my pliers as the wedging instrument to make room for the last pieces, and then condense the whole. If the cavity is too deep for this, I use Fletcher's artificial dentin as a base, because it partly fills the cavity and the ends of the cylinders stick to it. After an approximal cavity is prepared, use a matrix held in place by wooden wedges; the cylinders are about one-eighth of an inch long, and condensed in two or three layers so as to secure perfect adaptation; hand pressure is principally used, but a few firm strokes with a hand mallet are useful. When ready to add the cohesive gold for the grinding-surface, a few pieces of White's crystal mat gold should first be used, because it adheres beautifully; thus a perfect union is secured, but I never risk adding the gold without leaving a little undercut for it in the tooth. Bythis method we obtain a beautiful contour filling in a short time. Fillings should be burnished and then polished with a fine strip, or moistened pumice on a linen tape. Where cohesive gold is used for the entire filling, in many cases the enamel-walls, already thin near the cervical margin, are made thinner by the unavoidable friction of the polishing strips, but tin and gold is so soft that a good surface is obtained in a few moments, and this danger is reduced to a minimum. The surface is as smooth as a cohesive gold filling, while such a surface is impossible with non-cohesive gold. In cavities which extend so far beyond the margin of the gum that it is impossible to adjust the rubber-dam, I prepare the cavity as usual, then adjust a matrix, disinfect, dry, and fill one-third full with tin and gold, then remove the matrix, apply the rubber, place matrix again in position, and complete the filling by adding a little tin and gold, then pure gold." (Dr. W. A. Spring,Dental Review, February, 1896.)
Dr. T. D. Shumway says, "To have a scientific method of treatment, there certainly must be a recognition of what is known of the nature of tooth-structure. The method adopted more than a quarter of a century ago, and which is at present employed, does not accord with the teachings ofthe physiologist and microscopist; it is in direct opposition to natural law. Each new discovery in the minute structure of the teeth makes this more plain; pounding the teeth with a mallet cannot be defended on scientific grounds. That it has not resulted more disastrously is due to the wonderful recuperative energy of nature to repair injury. No one would think of attempting to arrest and prevent disintegration in any other vital organ by abrasion. Why, then, in operation on the teeth, should we reverse the plain, simple teaching of nature? Placing cohesive gold against the dentinal walls by pounding it to heal a lesion is opposed to natural law. Cohesive gold will not be mastered by force; if compelled to yield by superior strength, it seeks a way to release itself; it is easily coaxed, but not easily driven. Cohesive gold will unite with tin at an insensible distance just as cohesive gold unites with itself; this union takes place without force or pressure. Exactly what takes place when gold and tin are brought in contact in the way described we do not know; we can only say that there appears to be a perfect union. When cohesive gold was introduced to the profession, while it was softer than non-cohesive foil, it was found to resist under manipulation. This resistance is in accordance with the well-known law that all crystallinebodies, when unobstructed, assume a definite form. With gold the tendency is to a spherical form. The process of crystallization is always from within outward. The mallet was introduced to overcome the resistance caused by the development of the cohesive property. Pounding gold with a mallet only increases its crystallization. A crystalline body coming in contact with a fibrous one can neither be antiseptic nor preservative; a filling-material which possesses these properties must be one that corresponds or is in harmony with tooth-substance.
"In the interglobular spaces there is a substance which is called amorphous or structureless, and a filling to be in harmony with this substance should be amorphous or structureless in its composition. The only materials we have which meet these conditions are gutta-percha and tin. It is its structureless character that gives to tin its value. Coming in contact with the living dentin, it is easily adapted, and does not excite inflammation; it does not interfere with the process going on within the teeth to heal the lesion caused by caries. A wound from a bullet made of tin, unless it struck a vital part, nature would heal, even if the cause of the wound was not removed, by encysting the ball. This process of nature of repairing injury by encystingthe cause is of interest to the dentist in the study of suitable filling-materials. Tin is very useful at the cervical margin of cavities; it acts as an antiseptic or preservative, and reduces the liability to subsequent decay. It is our endeavor to obtain a filling that will preserve the teeth and reduce the liability to, if not wholly prevent, secondary decay. The law of correspondence is of more consequence than the mechanical construction of the filling. Tin can be used without that rigid adherence to mechanical rule that is necessary to retain a filling of cohesive gold; thus less of the tooth needs to be sacrificed.
"Gold will unite with tin under certain conditions so as to form apparently a solid mass. By a combination of these metals, not by interlacing or incorporating one in the other, but by affinity, secured by simple contact, we have all the preservative qualities of tin combined with the indestructible properties of gold. For the base of the filling we have a material in harmony with tooth-substance, introduced in a way that is in accord with the law that governs all living bodies, and for the outside a crystalline substance that corresponds to the covering of the teeth. This covering of gold is a perfect shield to the base, and the field for the display of artistic skill in restoringcontours is as broad as though gold was used entirely. Will a filling of this kind withstand mastication? There is in the economy of nature a provision made to overcome the resistance of occlusion. The teeth are cushioned in the jaw and yield under pressure. The elasticity of the substance of which the teeth are made is well understood. Ivory is the most elastic substance known. The teeth coming together is like the percussion of two billiard balls. Now a filling to save the teeth should correspond as nearly as possible with the tooth-substance; it should not be arbitrary, but elastic and yielding. Tin is interdigitous; it expands laterally, and is almost as easily introduced as amalgam, and when put in place does not have to be bound to be retained. Tin, with an outside covering of gold to protect it, makes a filling to which amalgam bears no comparison. In the light of scientific investigation there can be but one method—a method based upon the recognized principle that thefilling-materialand themannerofintroducingit shall correspond to and be in harmony with the living, vital organism with which it comes in contact.
"After excavating, the cavity is treated with absolute alcohol, as cleanliness and thorough dryness are absolutely essential.
"Thetinis put in with steel pluggers, after the method of wedging; it must be thoroughly condensed, so as to leave a smooth surface, and enough used to come up to where the enamel and dentin join.
"The effect is not produced by incorporating or interlacing the gold with the tin; we rely upon the affinity of the two metals to retain the gold; no undercuts, angles, or pits are made in the tin, dentin, or enamel. The gold, extra cohesive from No. 4 to 40, is made to adhere to the tin by simple contact, without pressure or force; the union is not mechanical.
"The instruments used for filling the remainder of the cavity with gold are Shumway's ivory points, which adapt the gold nicely to the margin.
"The set consists of five and were patented in 1881, and have been used by me since that time for manipulating cohesive gold. One 'point' is for proximal cavities in the anterior teeth; three 'points' of different sizes are for occlusal cavities; one 'point' for proximal cavities in bicuspids and molars and labial and buccal cavities; the sides, edges, and ends of the 'points' are used, as the purpose is simply to obtain contact.
"The 'point' shown full size inFig. 8is of more general application than any of the others, and isused for proximal cavities in bicuspids, also labial and buccal cavities. The handle is made of ebony, and has a silver ferrule, from which the ivory extends to the end and completes the instrument.
"The metal pin in the end of the handle is for picking up and carrying the gold."