Fracture and Diastasis of the Su- 
perior Maxillae and Upper 
Bones of the Face, 
TREATED BY THE AID OF THE INTER- 
DENTAL SPLINT; WITH TWO CASES. 
M 
JOHN S. MARSHALL. M.D., 
PROFESSOR OF ORAL SURGERY, UNIVERSITY DENTAL COLLEGE, 
CHICAGO ; ATTENDING ORAL SURGEON ST. LUKE'S FREE HOS- 
PITAL AND MERCY HOSPITAL. 
Read in the Section on Dental and Oral Surgery, at the Thirty-ninth 
A nnual Meeting of the American Medical Association, May, 1888. . 
Reprinted from the "Journal of the American Medical 
Association," August 18, 1888. 
CHICAGO 
Printed at The Office of the Association. 
1888. FRACTURE AND DIASTASIS OF THE 
SUPERIOR MAXIEE^ AND UPPER 
BONES OF THE FACE, 
TREATED BY THE AID OF THE INTER-DENTAL SPLINT. 
WITH TWO CASES. 
Fractures of the superior maxillary bones are, 
from their protected location, quite rarely met 
with except in the alveolar process. The causes 
of such injuries are usually the result of the ex- 
traction of the teeth, or blows or falls upon the 
chin which separate or split open the walls of the 
alveoli. This is accomplished in the one case by 
the lateral force applied in breaking up the at- 
tachments of the roots of the teeth, and in the 
other by driving the teeth upwards and through 
their alveoli. 
Such injuries, however, are never very serious, 
and rarely require special apparatus to maintain 
the fractured bones in their normal positions. I 
shall therefore lay aside all consideration of this 
class of accidents, and confine my remarks to the 
more serious injuries of this location, viz.: 
Fractures and Diastasis of the Superior Maxillce 
and Upper Bones of the Face. 
This class of injuries (which I present for your 
consideration) have elicited very little attention 
either by the general surgeon or the oral special- 
ist, and several of the most noted works on 
surgery make no mention of them whatever. 
This, I think, is due to the fact that such cases 
are of very rare occurrence. 
Two cases have recently come under my care 
at St. Fuke's Free Hospital, and have led me to 2 
make a somewhat careful examination of the text- 
books and periodical literature bearing upon this 
subject, and so far, I have been able to gather to- 
gether but nineteen cases which can be fairly 
classed as similar to those which form the inspira- 
tion of this essay. 
Injuries to the bones of the face which cause 
comminuted fractures and separation from the 
bones of the cranium, are always the result of 
great violence ; like the passage of the wheel of a 
carriage over the face, falling from a great height, 
the kick of a horse, a blow in the face by some 
heavy missile thrown with great force, or a gun- 
shot wound; crushing of the head between a 
moving elevator and the floor, the overturning of 
a carriage upon the occupant, or other heavy 
crushing force. 
Such injuries are always serious and often 
prove fatal, either from shock, haemorrhage, di- 
rect injury to the brain, or later complications. 
In such cases as survive the shock of injury 
and escape immediately serious complications of 
the brain, a favorable termination may be looked 
for, and in many cases with very little deformity. 
This, however, will depend very much upon the 
character and location of the particular injury, 
the success obtained in readjusting the fractured 
and dislocated bones, and maintaining them in 
their proper positions. 
For the purpose of reference I have grouped 
together the various published cases which I have 
found in my search, but shall only mention, very 
briefly, the extent of the injury and the percent- 
age of fatality. 
In speaking of this class of injury, Erichsen1 
says, ' ' In some cases all the bones of the face ap- 
1 Erisch sen's Science and Art of Surgery, Sth ed., 1884, vol. i, 
P- 545- 3 
pear to have been smashed and separated from 
the skull by the infliction of great violence." 
He mentions four cases of this form of injury : 
one reported by South, one by Vidal, and two 
which came under his own notice. 
The injury in South's case was caused by the 
man being ' ' struck in the face by the handle of a 
rapidly revolving crank," all the bones of the face 
were ' ' separated and loosened ' ' and so com- 
minuted as to ''feel like beans in a bag." 
Vidal's case, also a man, was injured by "a fall 
from a great height and separated all the facial 
bones. ' ' 
Brichsen's cases were both the result of falls 
from a considerable elevation and striking upon 
the face. The two former recovered, the two lat- 
ter died in a few hours. 
Packard2 mentions three cases: one by Cotting, 
in which the face was crushed by a cart wheel 
passing over it; another, brought to the Pennsyl- 
vania Hospital, in which the injury was received 
by the head being caught between the platform 
of a steam hoisting machine and the floor; and 
the last one, a case reported by Heath in his 
''Injuries and Diseases of the Jaws," which was 
under the care of Dr. Fyffe. The first and last 
cases recovered, but in the other death ensued in 
a few hours. 
Heath3 describes two cases : The first came 
under his personal notice, and was ''caused by 
the passage of a wagon wheel over the face, the 
bones were completely crushed and separated one 
from another, and death was instantaneous." 
The second one is that reported by Dr. Fyffe, and 
is the same case referred to by Packard, and will 
be described later. 
2 Ashurst's Inta'l Encyclopedia of Surgery, vol. iv, p. 67. 
3Heath's Injuries and Diseases of the Jaws, 3d ed., p. 59. 4 
Tiffany4 mentions a single case which was re- 
ported by Professor Christopher Johnston. The 
patient, a gentleman, was struck in the face by 
the walking beam of a steamboat. All the bones 
of the face were crushed and ' ' seemed literally to 
consist of a bag of bones moving freely with inspir- 
ation and expiration, so extensive was the com- 
minution. ' ' This case made a good recovery and 
an excellent result was obtained by supporting 
the superior maxillae, by means of a silver wire 
passed through the cheeks and under the teeth, 
and uniting the ends of the wire over the top of 
the head by a rubber band. 
Richard Wiseman5 published the report of the 
first case on record, and described the method of 
treatment. The patient was a little boy 8 years 
of age, who was, kicked by a horse and the whole 
upper jaw driven in, so that the finger could not 
be passed behind the palate. A flattened hook 
was constructed which c ould be inserted behind 
the palate and by extension constantly maintained 
by the hand of the patient and assistants, the 
bones were held in place and a good recovery 
followed. 
Dr. Fyffe,6 of Westminster Hospital, London, 
has published the report of one case. This pa- 
tient was thrown from a cab, the vehicle turning 
over upon him. The superior and inferior 
maxillae were fractured, and the bones of the face 
detached from the skull so that the former 
' ' moved up and down in the act of swallowing. ' ' 
This patient also recovered. 
Holmes7 describes a single case, in which the 
bones of the face were crushed and dislocated by 
a carriage wheel passing over the face, and in 
4 American System of Dentistry, p. 568. 
5 Treatise on Surgery, 1734, by Richard Wiseman. 
6London Lancet, July, i860 
7 Holmes' Principles and Practice of Surgery, p. 197. 5 
which, after recovery, there "was a disagreeable 
lengthening of the face '' as a result of the injury; 
but more likely the result of the treatment. 
Among the methods of treatment suggested are 
gutta-percha moulds, cork disks placed between 
the teeth, wiring of fragments and carefully 
adjusted pressure by the Hanesby truss. 
Hamilton8 refers to one case which came under 
his own care, in which the upper bones of the 
face were fractured and torn from their attach- 
ments to the cranium, and had to be supported to 
keep them in place. The patient died on the 
twelfth day after the injury. 
Mason9 reports a case which was under the 
care of Mr. Biekersteth, of Liverpool. A gentle- 
man standing upon the deck of a steamer was 
struck upon the side of the face by an iron hook 
attached to the hawser, which had parted under a 
heavy strain. On examination "immediately 
after the accident, the mouth seemed to be filled 
by a piece of bloody meat, but on further exam- 
ination, this proved to be the muscles attached to 
the upper j aw ; the orbital plate of the superior 
maxilla of the injured side was found beneath the 
cheek, whilst the palate process with the alveolar 
ridge and teeth were, for the time, situated in the 
upper part of the pharynx, looking towards the 
bodies of the upper cervical vertebrae. The 
facial surface of the bone took the place of the 
roof of the mouth, jamming the jaws open. The 
soft palate was not torn, but considerably stretched. 
The superior maxilla of the injured side was 
turned completely upon its axis. 
' 'The detached mass was replaced, the lower jaw 
firmly closed upon it for support, and the whole 
rapidly united with scarcely any deformity.'' 
8 Hamilton's Fractures and Dislocations, p. 102. 
9Mason's Surgery of the Face, p. 71. 6 
Mr. John Salter10 reported a case in which the 
superior maxillae and malar bones were separated 
from their attachments with the skull, and so 
crushed as to feel like a mass of ' ' loose bones. ' ' 
Dr. Harris,11 of New York, also reported a case 
of a little child only 2 years of age, who fell a 
distance of fifty feet to the pavement, striking 
upon the face and sustaining fractures and separ- 
ation upon the median line of both superior 
maxillae and palate bones. "Union had not 
taken place six weeks after the injury." 
Mr. Houghton12 describes a case in which the 
"superior maxillae were so fractured and dis- 
placed as to make it impossible for the patient to 
protrude the tongue until after the bones had been 
adjusted to their normal position." 
Bryant13 mentions one case in which ' ' the su- 
perior maxillary bones were completely detached 
from the skull, and could be moved about in any 
direction, yet a good recovery ensued." 
Agnew11 mentions the cases of Wiseman, Fyffe 
and Packard, but describes no new cases. 
Garretson15 reports two cases. The history of 
the first was furnished him by Prof. Agnew, in 
which a lad was crushed between the bumpers of 
two railroad cars, and sustained diastasis of all 
the bones of the face from the skull, comminuted 
fracture of the superior maxillae, and four fract- 
ures of the lower jaw. The patient recovered, 
but with considerable deformity. 
The second case, a painter, came under his own 
care. The injury was caused by falling from the 
10Medical Times and Gazette, June 5, 1869, p. 600, from Mason's 
Surgery of the Face, p. 70. 
11 New York Medical Journal, vol. xiii, 2d Series, p. 214. 
12British Medical Journal, Jan. 2, 1858, p. 15, from Mason's 
Surgery of the Face, p. 71. 
13 Bryant's Practice of Surgery, p. 397. 
14 Agnew's System of Surgery. 
lsGarretson's Oral Surgery, 4th ed., p. 805. 7 
roof of a house and striking upon the pavement 
below. He sustained severe comminuted fractures 
of the superior and inferior maxillae and fracture 
of both arms and legs. Several splinters of bone 
were removed from the anterior portion of the 
lower jaw, this allowed the parts to fall together 
' ' the symphisis of junction being midway between 
its former position and the hyoid bone." The 
patient made a good recovery, but with consider- 
able deformity. 
SUMMARY OF CASES. 
Operator. 
No.of 
Cases 
Cause of Injury. 
Recov- 
ered. 
Died. 
Wiseman . . 
I 
Kicked by a horse 
I 
South . . . 
I 
Struck by a revolving crank . . . 
I 
Vidal .... 
I 
Fall from a great height 
I 
Erichsen . . 
2 
2 
Cotting . . . 
I 
Crushed by cart wheel 
I 
Packard . . 
I 
Crushed by hoisting machine . . 
I 
Heath . . . 
I 
Crushed by wagon wheel .... 
I 
Johnston . . 
I 
Blow from walking-beam of 
steamboat 
I 
Fyffe .... 
I 
Crushed by overturned cab . . . 
I 
Holmes . . 
I 
Crushed by carriage wheel . . . 
I 
Hamilton 
I 
Not stated 
I 
Bickersteth 
I 
Struck by iron hook 
I 
Salter (John) 
I 
I 
Harris . . . 
I 
Falling from a window 
I 
Houghton . 
I 
I 
Bryant . . . 
I 
Fall from a great height 
I 
Agnew . . . 
I 
Crushed between car bumpers . . 
I 
Garretson . 
I 
Falling from a housetop 
I 
Total, 
19 
14 
5' 
Per cent, of mortality, 26.34. 
With regard to gunshot fractures of the bones 
of the face, the Surgeon-General10 of the United 
States reports that from the beginning of the Civil 
War to October, 1864, there were reported 4,167 
cases of gunshot wounds of the face of all kinds. 
16Surgeon-General's Reports, vol. i, p. 289. 8 
Of this number 1,579 were fractures of the various 
bones of the face ; 891 recovered, 107 died, and 
in 581 cases the results had not been ascertained. 
The greatest cause of fatality in these cases was 
secondary haemorrhage. 
In the Medical and Surgical History of the War 
of the Rebellion'7 the whole number of gunshot 
fractures of the various bones of the face is stated 
as being 4,502; recoveries 3,700, deaths 404, un- 
determined results 398, and the percentage of 
fatality 9.8. "The results of shot injuries of the 
face confirm the opinion that these wounds com- 
monly do well, notwithstanding the amount of 
destruction apparent at the time of the injury.." 
The reasons for the apparent lower rate of mor- 
tality in this class of injuries is doubtless due to 
the fact that all forms of fractures of bones of 
the face have been included in this table. If, 
however, the more serious cases (similar to those 
covered by the title of this essay) could be grouped 
together, I should expect to find the percentage 
of fatality considerably higher. 
With this brief summary of the history and 
results of the various cases which I have been 
able to find on record, I will present those which 
have lately come under my own observation, with 
the hope that they may prove interesting, and 
that the means used in their treatment will be 
helpful and suggestive to others who may be 
called upon to treat this class of injuries. 
Case -Mr. Conrad A., Swede, aet. 28 years, 
occupation, sawyer, employed at the Pullman 
Palace Car Works, Pullman, Ill., was brought 
into St. Lukes's Free Hospital on March 15, 1887, 
in an unconscious condition, with an incised 
wound of the right cheek, starting from a point 
17 Part iii, vol. ii, p. 688. 
18 St. Luke's Free Hospital Reports. 9 
just below the inner canthus of the eye and ex- 
tending obliquely backwards and downwards a 
distance of four inches, exposing the superior 
maxillary bone and completely penetrating the 
cheek, leaving a considerable external opening 
into the mouth. 
This wound had been sewed up by the surgeon 
at the Works. The right malar was crushed, 
both nasal bones were fractured and separated at 
the naso-frontal suture. The left zygomatic pro- 
cess was fractured near its union with the malar 
bone, both superior maxillae were torn loose from 
the bones of the cranium, so that the whole mass 
was loose and freely movable in any direction, and 
suspended by the soft tissues. When the mouth 
was opened to its fullest extent the teeth of the 
upper jaw rested upon those of the lower. Both 
superior maxillary bones were also fractured on a 
nearly perpendicular line; on the right side be- 
tween the first and the second molar teeth; on the 
left, between the second bicuspid and first molar 
teeth. Openings existed in both antrae. The 
right could be entered with the probe through the 
wound in the cheek and also through the alveolar 
process on the buccal aspect between the roots of 
the first and second molars, while the left could 
be penetrated through the buccal surface of the 
aveolar process on the line of the fracture between 
the second bicuspid and the first molar teeth. 
The palate process and palate bones were also 
badly crushed, forming a compound comminuted 
fracture, with loss of bone tissue, leaving an open- 
ing in the hard palate on the right side near its 
posterior edge and the median line, through which 
the index finger could be freely passed. The 
bones of the internal nose were badly comminuted 
and several pieces which were loose were removed. 
The left side of the face was completely anaes- 10 
thetic over the whole region supplied by the infra- 
orbital nerve, while upon the right side the upper 
lip and the wing of the nose only had lost sensa- 
tion. The inferior maxilla was not injured and 
none of the teeth lost by the injury in either jaw. 
The accident occurred by the patient being 
struck in the face by a piece of oak timber 12 
inches long and 9x8 inches in diameter, which 
was thrown by a circular saw 18 inches in diam- 
eter, and revolving at the rate of about 3,000 revo- 
lutions per minute. 
Case No. i. Cut. No. I.-Three years before the injury. 
When the patient was admitted the chances for 11 
recovery seemed very small. Cold applications 
were ordered over the face, and stimulants hypo- 
dermically, if the temperature should fall below 
normal and the pulse below 60. Nourishment to 
be given if possible, and X grain of morphia to 
allay pain. 
March 16th.-Swelling of parts very great, 
both eyes closed and nasal passages completely 
plugged. Pulse 84, temperature 101.80. Would 
arouse when spoken to. 
May 17th.-Patient has rallied. Pulse 74, tem- 
perature ioo°. Seems to be conscious. Swelling 
less. 
On the 18th his temperature was normal and did 
not rise again above that point, and he rapidly 
improved in general condition from this date. 
The treatment of the jaws was begun on the 
17th, and consisted of first wiring the posterior 
fragments of both superior maxillae to the anterior 
or middle portion by means of silver wire passed 
around the teeth on either side of the fractures. 
The fractured palate bones and the palatine pro- 
cesses were then moulded into place as nearly as 
possible with the fingers, and the nasal bones lifted 
into position by means of the handle of an instru- 
ment. The lower jaw was then closed upon the 
superior teeth, care being taken to get a correct 
occlusion, and held in position by means of an 
occipito-frontal and occipito-mental bandage. 
The following night the patient tore off the 
bandages several times. The nasal passages being 
closed he had great difficulty in breathing when 
the jaws were held tightly together. The band- 
ages were therefore reapplied more loosely, but this 
allowed the inj ured bones to fall out of place, and 
defeated the object in view. This is the plan oi 
treatment usually recommended by such authors 
as mention this class of injuries, but in my hands 12 
it has proved a signal failure, from the fact that 
the nose was so injured and the parts so badly 
swollen as to close the nasal passages for several 
Case No. i. Cut No. 2.-Shows condition after union of the frac- 
tured bones. 
days, and therefore making it impossible to breathe 
with any degree of comfort except through the 
open mouth. 
There must be considerable difficulty in any 
severe case in maintaining the position of the 
fractured and dislocated bones when this 
plan is adopted, and nearly impossible in 
those cases in which all the teeth were lost prior 
to the accident, for it is a well-known fact that as 13 
a rule endentulous jaws do not come in contact, 
and if they should, a normal occlusion would not 
be obtained, nor the injured parts prevented from 
slipping out of position. The plan of treatment 
adopted by Prof. Johnston is also objectionable by 
reason of the wounds made in the cheeks. In this 
Case No. i. Cut No. 3.-Shows the apparatus in position. 
case I was compelled to devise some other means, 
one which would maintain the position of the 
fractured bone and at the same time leave the 
lower jaw free, so that the mouth could be open 
for the purpose of breathing. This was accom- 
plished by adapting the principle of the Kingsley 14 
interdental splint to the upper jaw. Impressions 
of the upper and lower teeth w7ere taken in model- 
ing compound, by first moulding it on the upper 
teeth and while it was yet soft forcing the lower 
jaw upward till a correct occlusion of the teeth 
was obtained. This impression was trimmed to 
the desired shape and a one-eighth inch steel wire 
was imbedded in the sides upon a line with the 
ends of the teeth and then bent backwards upon 
itself opposite the cuspid teeth, and allowed to 
extend outside the cheek nearly to the lower bor- 
der of the ear. From this was constructed a hard 
rubber splint with the wires attached. The splint 
was held in position by means of double straps 
attached to the wire upon each side and buckled 
to a close-fitting leather cap laced firmly upon the 
head. This proved to be a very successful appli- 
ance, as it held the bones in their proper position, 
permitted comfortable breathing and free move- 
ment of the lower jaw, which enabled him to talk 
and after a few days to masticate soft food. 
Deep indentations were left in the under side of 
the splint in which the lower teeth fitted accur- 
ately when the mouth was closed. The object of 
this was to furnish a sure guide to the normal po- 
sition of the upper maxillae. Without this the 
correctness of the adjustment of the bones could 
not have been verified. The importance of 
this cannot be overestimated. The only other 
treatment was good feeding and thorough irriga- 
tion of the wounds, antrae and the mouth, with a 
2 per cent, solution of carbolic acid every two or 
three hours until the discharges ceased, and the 
removal of a few spiculae of bone from the nose 
and the wall of the right antrum. 
The patient was discharged on May 14th, with 
small fistulous openings through the gums lead- 
ing into both antrae at the points of fracture, and 15 
a small opening in the hard palate which was 
gradually growing less. There was also a slight 
deflection to the left of the nasal septum. The 
opening into the right antrum soon closed, as did 
that in the hard palate. 
June 22.-Patient returned for the removal of 
the cicatrix in the right cheek, which was adher- 
ent to the maxillary bone. 
Case No, 1. Cut No. 4.-Shows final result after the operation 
on the cheek. 
June 25th.-Stitches removed and the patient 
discharged. 
The opening into the left antrum remained pat- 
ulous for some months, with slight discharge into 16 
the mouth, but finally closed. Sensation has been 
entirely restored in both sides of the face. 
Case 2.19-Henry S., German, aet. 35, occupa- 
tion laborer, employed at Armour Packing House. 
Was admitted Oct. 7, 1887, one hour after the ac- 
cident, which was caused by being struck across 
the bridge of the nose by a descending elevator 
while he was looking up the shaft. Was suffer- 
ing from concussion of the brain when admitted. 
Examination disclosed the fact of a lacerated 
wound over the left eye and extending across the 
nose to the right eye, the finger could be intro- 
duced and readily passed down into each orbit and 
against the fractured edges of the nasal and 
sphenoid bones. By taking hold of the upper 
teeth all the bones of the upper face were found 
to be movable, and when the mouth was open the 
the upper teeth rested upon the lower and there 
was a peculiar and disagreeable elongation of the 
face. A later examination revealed the fact that 
the frontal sinus was crushed in, the nasal and 
lachrymal bones comminuted, and that all the 
bones of the face were torn loose from the skull 
on a line passing through the orbits; and that the 
superior maxillae were separated from the other 
bones of the face. The inferior maxilla was not 
injured. Several loose pieces of bone were re- 
moved from the region of the inner canthus of 
each eye by the house surgeon. The wound was 
stitched, drainage tubes inserted, the lower jaw 
bandaged tightly against the upper teeth, and 
iced cloths ordered over the face and head. Pulse 
60, temperature 97.40. Stimulants administered 
freely. Profuse haemorrhage occurred during the 
night, and vomiting of blood every few hours un- 
til two o'clock on the following day. He became 
conscious during the night, but the other symp- 
19St. Luke's Free Hospital Reports. 17 
toms seemed to give but little hope of a final re- 
covery. 
The temperature reached 102.2° on the 8th, at 
4 p.m., and fell to normal on the 9th. No brain 
symptoms developed and the patient rapidly im- 
proved in general condition from this time. Swell- 
ing and suppuration were so extensive for several 
days as to render the adjustment of a splint im- 
possible. The treatment consisted of stimulants 
and thorough irrigation of the wounds. The old 
method of bandaging was resorted to but proved 
a failure, for the reason that the lower jaw could 
Case No. 2. Cut No. I.-Six years before the injury. 18 
not be held sufficiently closed to support the frac- 
tured bones in their proper position without ob- 
structing breathing by the mouth. This was 
necessary as nasal breathing was at the time im- 
possible. 
Oct. 24th.-Inserted an interdental splint, con- 
structed after the plan of the one used in the pre- 
ceding case, and supported it from the head by 
the same means. The case progressed favorably 
and was discharged on Dec. 3d, the bones having 
all united. 
Dec. 24th.-Patient returned complaining of 
Case No. 2. Cut No. 2.-Final result. 19 
double vision. The lens of the left eye looked 
cloudy and traumatic cataract was feared. 
April i, 1888.-Patient seems entirely well. 
The double vision complained of has passed away 
and the lens has cleared up. 
From the casts of the jaws in Case 1, it will be 
seen that the occlusion of the teeth is nearly, if 
not quite, normal. And by the photographs taken 
before the accident occurred (which I have been 
so fortunate as to obtain in both cases) and those 
taken since the patients were discharged, that in 
Case 1 the only deformity visible is a slight flat- 
tening of the right superior maxilla and the faint 
line of the cicatrix resulting from the incised 
wound in the cheek. 
In Case 2 the occlusion of the jaw is equally 
good but the deformity is greater. This is the 
result of the loss of portions of the nasal bones 
and the external wall of the frontal sinus, and the 
adhesion and contraction of the cicatricial tissue 
over these places. 
No. 9 Jackson Street. 
Dr. E. S. Talbot, of Chicago: We have all 
listened to Dr. Marshall's paper with unusual in- 
terest, as it treats of cases which demand prompt 
and positive treatment. Great force is required to 
produce an injury of this nature. Other compli- 
cations, such as shocks, inflammation and second- 
ary haemorrhage are liable to ensue on account of 
the locality. If nature or treatment can overcome 
these difficulties another serious one presents itself 
in devising a means to hold the parts in place 
after putting them in proper position, until they 
have united. 
A few years ago I was requested to assist Dr. 
Powell, of Chicago, in a case somewhat similar to 
one mentioned by Dr. Marshall. A girl, about 8 20 
years of age, was leaning over an opening in an ele- 
vator shaft, head down, when she was struck on the 
back of the head by the elevator, the face forced 
to the sill of the building. She sustained a com- 
pound fracture of both superior and inferior max- 
illary bones. The parts were put in their natural 
position, the teeth being the guide. The jaws 
were bandaged together in the usual manner. The 
next morning we found the bandage off, with the 
bones slightly displaced. This is the point I wish 
to make: that where a bandage is used it is not 
certain it will remain in position twenty-four 
hours. After a little study we concluded upon 
the following plan, which I believe to be an infal- 
lible method of treatment: A skull-cap was made 
of cotton cloth to fit the head as far as the eye- 
brows and occipital protuberance. - A splint for 
the inferior maxilla was made of gutta-percha 
(card-board, tin, or anything that can be moulded 
to the jaws will do as well). Having placed the 
pieces of bone in position and brought the jaws 
together so that the teeth occluded properly, adhe- 
sive strips were cut one inch in width, wound and 
fastened not only to the splint and the skull-cap, 
but also to the cheeks. The strips were applied in 
such a manner as to exert the proper force in the 
right direction. Three or four were then applied. 
One or two strips fastened to the splint, the cheeks 
and back of the neck, held all firmly in position. 
The patient can be fed with liquids through a 
rubber tube. Should the teeth be missing, or but a 
few in position, occlusion would be impossible and 
the dental splint must be used. The adhesive 
strips can then be used in the manner described.