THE OPERATIYE TREATMENT IN OCCLUSION 
OF THE JAWS. 
Presented to the Section on Surgery and Anatomy, at the Forty-eighth 
Annual Meeting of the American Medical Association, held 
at Philadelphia, June 1-4, 1897. 
BY J. EWING HEARS,_MJ>, 
PHILADELPHIA, PA. 
I I * 
REPRINTED FROM'THE 
JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. 
SEPTEMBER IS, 1897. 
CHICAGO; 
American Medical Association Press 
1897. THE OPERATIVE TREATMENT IN OCCLU- 
SION OF THE JAWS. 
J. EWING HEARS, M.D. 
At the meeting of the American Surgical Associa- 
tion June 1, 1888, I read a paper on this subject and 
endeavored to collect all the information which then 
existed with regard to the procedures which had 
been in use from the first, for the relief of a condition 
which may at least be described as one very distress- 
ing to the patient. Mr. Christopher Heath of London 
in the “Jacksonian Prize Essay” of 1867 recorded 
cases in which he had performed operations for the 
relief of jaw-closure, and in a chapter devoted to the 
subject collated the work of others up to that date. 
According to Mr. Heath’s statements, English text- 
books on surgery were remarkably barren of any 
information on the subject. He alludes to a refer- 
ence of Mr. Cooper in his Surgical Dictionary, to a 
case treated by Dr. Valentine Mott in 1831, in which 
an operation was performed for closure of an opening 
in the cheek caused by sloughing and accompanied 
by closure of the jaws. In the edition of Cooper’s 
Dictionary issued in 1861, closure of the jaws is 
described as occurring “after sloughing of the cheeks 
and gums from profuse salivation, the cicatricial bands 
being so rigid as scarcely to allow of the separation of 
the teeth.” By far the most complete account is 
given in the first edition of Gross’ “Surgery.” This 
eminent surgeon had a favorable opportunity for 
studying the affection during his residence at Louis- 
ville, Ky., where, in college and hospital clinics, he 
was enabled to acquire a large experience owing to 2 
the prevalence of this condition due to the adminis- 
tration of calomel in excessive doses in the south- 
western sections of the country. 
The affection occurs in two forms—the spasmodic or 
temporary, and the chronic or permanent. The former 
usually occurs in connection with some condition which 
affects the motor filaments of the third division of the 
fifth nerve, causing spasmodic contraction of the ele- 
vator muscles of the lower jaw. Among the causes may 
be enumerated the delayed or difficult eruption of the 
third molar or wisdom tooth of the lower jaw, the de- 
velopment of tumors from the external surface of the 
ramus and body of the lower jaw, alveolar abscess 
in connection with the posterior teeth, necrosis of the 
jaws, suppurative tonsillitis, and I have observed the 
condition to follow operations on the lower jaw when 
performed in the molar region. It may be proper to 
include under the temporary form of jaw-closure the 
condition which occurs in connection with attacks of 
tetanus. This form differs from those described above 
by reason of the fact that the jaw-closure is one among 
other symptoms which are present. 
The treatment of the temporary form of jaw-clos- 
ure consists in the removal of the causes. When 
dependent upon the impeded eruption of the wisdom 
tooth, the mouth should be opened by levers, the patient 
being placed under the influence of an anesthetic, and 
the second molar tooth should be extracted so as to 
afford space for the third molar, or as the latter is not 
infrequently found to be an imperfectly developed 
tooth, the offending organ should be removed. Where 
tumors, necrosis and alveolar abscesses exist as causes, 
the treatment is obvious. For the relief of trismus, 
which is so prominent a symptom of tetanus, reme- 
dies which are efficient in controlling the general 
condition will afford relief. 
Permanet jaw-closure may be due to conditions 
which attach the alveolar processes of the jaws firmly 
together, or to those involving the temporo-maxillary 
articulation. Union of the processes of the jaws may be accomplished through the formation of cicatricial 
tissue or of an osseous band. The formation of the 
cicatricial tissue is due to inflammation attacking a 
portion or the entire buccal mucous membrane. In 
these cases the inflammation may be due to ordinary 
causes or, as was most frequently the case in former 
years, be created by the excessive use of calomel pro- 
ducing severe ptyalism, and, as a rule, it occured in 
children. As a result of its occurrence at an early 
period of life the growth of the lower jaw and the 
associated structures is very markedly interfered with. 
I have observed this condition in many of the cases 
which have come under my observation. The for- 
mation of the osseous band may depend upon injury 
to the parts or arthritic inflammation leading to a 
a deposit of plastic matter and the conversion of this 
substance into fibrous, cartilaginous or osseous tissue. 
This bridge of bone may extend from the lower to the 
upper jaw or from the lower jaw to the temporal bone. 
Closure of the jaws due to anchylosis of the tem- 
poro-maxillary articulation may occur as a result of 
inflammation attacking the joint, or of injury leading 
subsequently to inflammation which results in the 
formation of fibrous or osseous deposits. Very fre- 
quently the inflammatory action which is responsible 
for the obliteration of the function of the joints is 
rheumatic in character, and the condition is found to 
exist largely in those who suffer from rheumatic 
affections. It may also occur as the result of inflam- 
mation due to blows or concussions. The most fre- 
quent cause, according to my observation in trau- 
matic cases, is the occurrence of fracture involving 
the neck of the condyle and which has been unrec- 
ognized. Such condition shortly leads to closure of 
the jaws, and this finally becomes permanent. 
The pathologic conditions which produce jaw-closure 
may exist on one or both sides, that is, it may be unilat- 
eral or bilateral. In cases of closure due to the pres- 
ence of cicatricial tissue or osseous band the diagnosis 
may be readily made by inspection of the parts and 4 
the introduction of the finger into the buccal spaces. 
When the temporo-maxillary articulation is involved 
the diagnosis may be somewhat more difficult, by 
reason of the inability of the surgeon to decide whether 
the joint is at all affected, the closure being possibly 
due to a contracted or rigid condition of the levator 
muscles of the jaw, and also, when the affection is 
unilateral, to decide on which side the fault rests. 
As complete a history as possible should be obtained 
in every case and both inspection and palpation of the 
joints should be practiced. The index finger of one 
hand should be passed into the mouth and carried as 
fas as possible on the inner surface of the ramus of 
the jaw toward the joint, and the index finger of the 
other hand should be placed over the joint externally. 
The patient should then be requested to make an 
effort to move the jaw so as to ascertain whether 
any motion exists in the joint. This manipulation 
should be made on both sides in order to determine 
in which joint motion may exist. The history of the 
case, in the event of the occurrence of injury to the 
joint or fracture of the neck of the condyle, may give 
information as to the joint involved, but this can not 
always be depended on. Deviation of the lower jaw 
to the affected side may sometimes exist, especially 
when anchylosis has been preceded by some inflamma- 
tion. In such cases this condition aids diagnosis. 
Under the improved methods of treatment the prog- 
nosis of jaw-closure may be regarded as favorable. 
Even in the most inveterate oases, in which the entire 
buccal spaces on both sides have been obliterated by 
masses of nodular tissue, operative treatment promises 
relief. 
The treatment of jaw-closure due to the formation 
of cicatricial tissue has claimed much attention and 
has taxed the skill and ingenuity of surgeons from 
the beginning. At first, efforts were directed simply 
to the division of the tissue and the use, subsequently, 
of levers varying in power, by which the jaws were 
separated. The rapid reformation of the nodular tis- sue, with augmented induration and contractile power, 
rendered this method futile. Excision of the mass 
was then practiced with the hope of securing normal 
membrane in place of the tissue removed. This plan 
was not successful and was followed by a suggestion, 
if not the practice, of excision and transplantation of 
mucous membrane or of integument into the denuded 
buccal space, taking the flap of integument from so 
distant a point as the arm. Failure attended these 
efforts, and in 1851 Professor Esmarch of Kiel read an 
essay before the congress at Gottingen on the “Treat- 
ment of Closure of the Jaws from Cicatrices,” in 
which he advocated the formation of a false joint in 
front of the cicatricial mass by the excision of a seg- 
ment of bone of such size as to prevent union of the 
divided end and the operation was performed by an 
external incision along the base of the jaw. Pro- 
fessor Rizzoli of Bologna, in 1857, operated for per- 
manent contraction of the jaws by a simple division 
of the lower jaw in front of the cicatrix, using for 
that purpose powerful forceps applied within the 
mouth. In order to prevent union a piece of gutta- 
percha was inserted between the cut surfaces of 
the bone, which procedure, it is stated, was accom- 
plished successfully. By these two methods of opera- 
tion one half of the mouth could be opened slightly, 
and thus far the operation was regarded as successful. 
The manifest objections to these methods were; 1. 
The slight extent to which only a portion of the mouth 
could be opened. 2. The formation of a disfiguring 
cicatrix, especially objectionable in females, when the 
external incision is employed. 3. The fact that this 
method could not be employed when both buccal spaces 
were occupied by cicatricial tissue. 
Having failed, as others before me had done, by 
the employment of the different methods in vogue, I 
was led, in a study of the character of the pathologic 
structure which existed and of its marked tendencies 
to union after section as well as its reproductive 
power, to the adoption of a method by which normal 6 
mucous membrane should form behind the cicatricial 
mass. It was evident that if such a line could be 
formed the pathologic tissue in front could be severed 
without fear of union occurring, and the divided por- 
tions could be kept separated and their nutrition mod- 
ified. In performing the operation a long-handled, 
slightly curved needle armed with a strong aseptic 
twisted-silk ligature of sufficient length is introduced 
at the angle of the mouth on the inner surface and 
carried carefully into the space between the cicatricial 
mass and the buccinator muscle and the point made 
to emerge at the position of the last molar tooth of 
Fig. 1.—Closure due to cicatricial tissue. Operation by introduc- 
tion of ligature and division of cicatricial tissue. 
the lower jaw—at which point the posterior border of 
the cicatricial tissue can usually be felt. The ligature 
is now seized with the toothed forceps, the needle 
withdrawn and the ends tied, the ligature lying 
loosely in the channel thus formed. As the intention 
is not to divide the mass by the ligature it is per- 
mitted to remain without traction, the formation of 
the canal lined by normal mucous membrane being 
facilitated by drawing the ligature backward and for- 7 
ward, and thus destroying any adhesions which may 
form. The introduction of a probe curved so as to 
easily take the direction of the canal is also of service, 
and gives the surgeon information as to its condition. 
When the probe passes readily and smoothly and 
without provoking bleeding, it may be assumed that 
the canal is lined by normal mucous membrane. 
When this condition is established beyond a doubt, 
in my experience usually at the end of three weeks, 
a grooved director curved in proper manner, is intro- 
duced into the canal and a blunt-pointed bistoury is 
JFig. 2.—Author’s gag. 
carried along the groove dividing the tissue as it 
advances. This being accomplished a gag is placed 
between the teeth and the mouth forced open to its 
widest extent. The buccal space is then packed with 
5 per cent, iodoform gauze, which is replaced the third 
day, the cavity being thoroughly cleansed with a dis- 
infecting solution at each dressing. At the expira- 
tion of the second or third day the gag should be used, 
opening the mouth to its widest extent, and each day 
this should be practiced until there is evidence of the 
formation of normal membrane lining the buccal 8 
spaces, and the patient can without the aid of the gag 
open the mouth freely, the iodoform packing may be 
diminished as the reparative process advances. In 
some instances I have provided patients with a gag 
and advised its use from time to time, in order that 
the newly formed membrane may be kept pliable. In 
a few months, three to four, its use may be dispensed 
with. My experience with the method above described 
has demonstrated its value. It overcomes all the 
objections to the plan which involves the creation of 
a false joint in front of the cicatrix, and secures as 
perfect a result as possible. 
Fig. 3.—lmpression of mouth before operation. 
As the result of jaw-closure which has occurred at 
an early period of life; dentition is seriously interfered 
with. In some oases in which I have operated I have 
found the teeth projecting in all directions, crossing 
the oral cavity at various angles and forcing the tongue 
to rest on its edge. In such cases I take advantage 
of the anesthetic state of the patient at the time of 
operation to extract all of the teeth and roots which 
require removal, and thus prepare the alveolar borders 
for the adaptation of artificial dentures. 
I referred above to the interference with the devel- 9 
opment and growth of the bones and soft structures 
of the face which sometimes occur in cases of jaw- 
closure. I exhibit a photograph of a case in which 
this condition occurred to a marked extent, the patient 
being at the time of operation 37 years of age, and 
had suffered from jaw-closure in its severest form for 
a period of twenty-seven years. 
The relief of jaw-closure due to the formation of an 
osseous bridge is easily accomplished by section of 
Fig. 4.—Showing condition of non-development of lower jaw. 
the bridge, a metacarpal saw being introduced and 
division effected from within outward. If the space 
between the teeth does not permit introduction of the 
saw into the oral cavity, section may be made from 
without inward from the buccal cavity. The disuse 
to which the temporo-maxillary joint has been sub- 
jected by reason of the closure frequently renders the 
joint rigid and motion painful; the use of the gag for 
a short time overcomes these conditions. More or 10 
less absorption of the divided bony bridge occurs after 
a time. If the mass is large it may be necessary, in 
order to overcome deformity, to remove the segments 
with the chisel or dental saw or burr. 
Various methods of operative procedure have been 
resorted to for the relief of closure due to anchylosis 
of the temporo-maxillary articulation; these have dif- 
fered from each other in the selection of the ramus or 
the condyle as the point at which an effort has been 
Fig. s.—One year after operation. 
made to establish a false joint. Fibrous anchylosis 
can be removed by forcibly breaking the adhesions 
by movements as in the case of any joint. 
To Dieffenbach is due the credit of having first 
practiced division of the ramus of the jaw, and by 
this operation creating a false joint for the relief of 
synostosis. Accompanying this method section of 
the masseter and temporal muscles has been performed. 11 
In 1863 Grube, as stated by Professor Gross, formed 
a false joint by dividing the neck of the bone with a 
straight chisel introduced through the mouth. Exci- 
sion of the condyle by external incision in front of 
the ear, was practiced by Professor Gross in 1874 with 
excellent results in a case of complete synostosis of 
the lower jaw on the left side in a girl 7 years of age. 
Figure 6. 
Fig. 7.—Closure due to formation of bridge of bone. Operation by 
section of bridge by Law. Four years after operation. 
A review of the results obtained by these methods 
shows that neither accomplished all that was desira- 
ble. Section of the ramus was frequently inadequate 
and as frequently failed entirely by reason of reunion 
of the bone. Exsection of the condyle, while afford- 
ing greater motion than section of the ramus, did not 
secure the establishment of as freely movable a joint 12 
as desirable, and moreover was performed by an 
external incision, which is always an objection by 
reason of the cicatrix formed on the face. 
In order to secure a more freely movable false 
joint I have practiced excision of the upper half of 
the ramus, removing both coronoid and condyloid 
processes by an incision within the mouth. The 
operation is performed by introducing a tenotome 
beneath the masseter muscle and forming a opening 
into which an Adams saw is passed, and dividing the 
ramus. The upper segment of bone is seized by the 
Fig. B.—Closure due to fracture of the neck of the condyle 
lion-jawed forceps and a probe-pointed bistoury is 
carried through the wound to the position of insertion 
of the temporal and external pterygoid muscles. The 
tendons of these muscles are severed and the segment 
twisted out of its position by the forceps. It may 
happen that the bone is broken in this effort and the 
coronoid portion alone removed. When this occurs 
the chisel is used to remove the remaining portion, 
including the condyle. In all events enough should 
be removed to insure ample space for the formation of 
a large joint, and also prevent, what is not likely to occur, reunion of the bone. The cavity formed is 
packed with 5 per cent, iodoform gauze for the pur- 
pose, not only of separating its surfaces and expand- 
ing it, but also for its service in controlling hemor- 
rhage. The position of the inferior dental and the 
internal maxillary arteries are to be borne in mind, 
and injury to them avoided. In the event of their 
being wounded the hemorrhage may be controlled 
by the gauze packing. Repacking of the cavity 
should be made on the third day, and then every 
Fig. 9.—Operation by section of ramus and removal of upper seg 
ment of bone. Condition 2% years after operation. 
other day, the cavity being cleansed by the injection 
of a disinfecting solution. The mouth should be 
opened by the gag, which should be used daily for 
the purpose of overcoming the rigidity of the oppo- 
site joint and of the muscles, occurring as the result 
of disuse. At the same time its use facilitates the 
formation of the false joint. Lateral displacement 
of the jaw does not follow this method as might prob- 
ably be expected, as may be seen in the photograph 14 
exhibited. In one case it is seen but it will be 
observed that the deviation existed before the oper- 
ation and was caused by the inflammatory action 
which accompanied the necrosis from which the pa- 
tient had suffered and which produced the anchylosis. 
The conclusions which I present are: 
Fig. 10.—Lateral deviation due to necrosis preceding operation 
Fig. 11.—Ten months after operation. 
1. Jaw-closure due to the presence of cicatricial 
tissue in the buccal spaces can be most efficiently 
relieved by the formation of a canal lined by normal 
membrane, by means of a ligature passed behind the 15 
cicatricial mass. Reunion of the divided tissue and 
reformation of the nodular tissue not occurring after 
division when this canal has been formed, 
jf 2. Synostosis of the temporomaxillary articulation, 
producing jaw-closure, can be best relieved by 
removal of both coronoid and condyloid processes 
with the upper portion of the ramus, thus affording 
ample space for the formation of a freely movable false 
joint. The operation should be performed through 
the mouth, thus avoiding disfiguring cicatrices.