THE 
PRINCIPLES AND TECHNIQUE 
OF ORAL SURGERY 
BY 
ADOLPH BERGER, D.D.S. 
rn 
ASSISTANT PROFESSOR OF ORAL SURGERY, SCHOOL OF DENTAL AND ORAL SURGERY, COLUMBIA 
UNIVERSITY; CHIEF OF CLINIC, ORAL SURGERY DEPARTMENT, VANDERBILT CLINIC; 
INSTRUCTOR OF ORAL SURGERY, ADVANCED COURSES, UNIVERSITY EXTENSION, 
COLUMBIA UNIVERSITY; ORAL SURGEON TO BETH ISRAEL HOSPITAL 
ILLUSTRATED WITH 355 ENGRAVINGS, MADE FROM ORIG- 
INAL DRAWINGS, RADIOGRAPHS AND PHOTOGRAPHS 
BROOKLYN, NEW YORK 
DENTAL ITEMS OF INTEREST PUBLISHING CO. 
LONDON 
CLAUDIUS ASH, SONS & CO. 
1923 COPYRIGHT, 1923, 
BY 
DENTAL ITEMS OF INTEREST PUBLISHING CO. 
Press of 
J. J. Little & Ives Company 
New York, U. S. A. PREFACE 
The past five or six years have been marked by a greater amount of 
research work in oral pathology than any previous period of similar length. 
The findings have revolutionized our views not only on numerous perti- 
nent problems but also in many respects in regard to the technique and 
practice of dental and oral surgery. Some lesions to which no special 
significance has been accorded in the past are now regarded as truly 
surgical problems. Therefore many pathological conditions, disclosed 
through the more general use of radiography, and the perfected methods 
of local anesthesia adapted to this field, have aroused a keener interest in 
the surgical treatment of diseased conditions about the mouth. 
These circumstances and the experience gained in teaching graduates 
and undergraduates have impressed me with the conception that a book, 
which would treat, in a concise and comprehensive manner, those patho- 
logical and abnormal or anomalous conditions about the teeth and their 
associated structures which are so frequently encountered in every-dav 
practice, might prove to be of interest to the profession. 
This book has not been intended to he an inclusive or complete work 
on oral surgery. My aim rather has been to present in a more assimilable 
form those minor and semi-major, more common conditions, together 
with systematized methods for their surgical relief. With this view in 
mind I have attempted to describe clearly and to stress the diagnostic, 
clinical and the surgical aspects of the various problems, giving just so 
much of the pathological and theoretical information as I deemed essen- 
tial to a comprehensive working knowledge. 
I have omitted from this hook the consideration of several lesions such 
as cleft-palate and hare-lip, trifacial neuralgia, diseases of the salivary and 
other glands, partly because they are so completely and ably presented in 
other books, and partly because their treatment requires distinct specializa- 
tion and they are, therefore, of merely academic interest to the majority 
of men. 
It is impossible to write a book upon any medical topic, at the present 
time, without consulting the vast literature already published. Still, in so 
far as this has been possible, I have attempted to avoid compilation. The 
illustrations, with the exception of two or three, have been carefully PREFACE 
selected from a large collection of original radiographs and photographs 
to illustrate points of interest. The drawings of the different operations 
have been executed after photographs made of the operations, and after 
sketches made by the artist at the operating chair. The operations illus- 
trated have all been tried and have been found to secure satisfactory re- 
sults in numerous cases throughout the past years. 
Complete originality cannot be claimed by the author of any book deal- 
ing with medical topics. I gratefully acknowledge the aid which I have 
derived from the large amount of literature which I have perused for the 
purpose of information and also to check up my own findings. Although 
the greatest part of this book is based upon personal experience, gathered 
from fifteen years of active clinic work and private practice, I cheerfully 
acknowledge and cede priority regarding any part of the contents to any 
one who has a just claim for it, although knowledge of this may be 
foreign to me. But in the final analysis, we must admit that all minds 
are cast much in the same mould, though they may be variegated in dif- 
ferent patterns by innate qualities or external influences; and who can 
deny that similar experiences, observations and impressions may not pro- 
duce similar reactions and methods of reasoning in different individuals 
relative to the same subject? 
I gratefully acknowledge my indebtedness to Dr. Rodrigues Otto- 
lengui, whose friendship and approbation have been inspiring through 
many years of trying effort. I also wish to acknowledge my indebtedness 
to Dr. Fanuel D. Weisse (now deceased) and to Dr. Flenry Sage Dun- 
ning, whose early associations in this work formed the early beginnings 
upon which this book was later based. Dr. Philip Reichert has been kind 
enough to look up some of the data, for which I am thankful. Nearly all 
of the photographic work was done for me by Mr. Silas W. Nourse and 
I am grateful for his many efforts and for the excellence of his results. 
576 Fifth Avenue, 
New York, N. Y. 
June, 1923. 
Adolph Berger. CONTENTS 
CHAPTER PACE 
I Surgical Technique i 
II Examination and Diagnosis 28 
III Hemorrhage 46 
IV Inflammation 56 
V Acute Inflammatory and Suppurative Conditions of 
the Dental Alveolus 61 
VI Chronic Inflammatory and Suppurative Conditions 
of the Dental Alveolus 75 
VII Sublingual Abscesses 104 
VIII Surgical Treatment of Periodontoclasia .... 106 
IX Necrosis 114 
X Infections and Complications Arising from Local 
Anesthesia 133 
XI Diseases of the Maxillary Sinus of Oral Origin . 149 
XII The Closing of Acquired Oral Openings into the 
Maxillary Sinus 191 
XIII Cysts of tpie Oral Cavity 203 
XIV Ranula 249 
XV A Consideration of Bone Repair and Regeneration 254 
XVI Tpie Removal of Broken-Down and Buried Roots . 263 
XVII Alveolectomy 272 
XVIII Impacted Teeth 279 
XIX Fractures of the Jaws 329 
XX Dislocation and Luxation of the Temporomandib- 
ular Articulation 391 
XXI Ankylosis of the Temporomandibular Articulation 395 
XXII Ludwig’s Angina 403 
XXIII Salivary Calculus (Sialolithiasis) 404 
XXIV Leucoplaicia Buccalis 408 
XXV Neoplasms of the Oral Cavity 411 THE PRINCIPLES AND TECHNIQUE OF 
ORAL SURGERY. 
CHAPTER I. 
Surgical Technique. 
Surgery, as a science in the truer sense of this term, dates from the 
beginning of the antiseptic period. The discovery of Semmelweis, in 1846, 
that puerperal fever is due to contamination from the hands, etc.; the dis- 
coveries of Pasteur that fermentation and putrefaction are due to the 
activities of microorganisms, led Lister to the deductions that suppuration 
may also be caused by similar agencies, and that, if they could be excluded 
from surgical wounds, the high mortality rate in surgical operations would 
he greatly reduced. The announcement of Lord Lister, in 1867, that 
deliberate surgical operations can be performed without being followed by 
suppuration, marks therefore a new era in all branches of medical prac- 
tice and separates the surgery of old from what has developed into modern 
surgery. 
The methods and experiments of Lister were rather rudimentary at 
first and consisted chiefly of spraying the atmosphere with carbolic acid, 
for it was assumed that the chief source of contamination is the atmos- 
pheric air. It was learned later, however, that the microorganisms of the 
air are, as a rule, not pathogenic, or only mildly so, and not numerous 
enough to produce disease; that the surgeon’s and his assistants’ hands, 
clothing, unclean instruments, linen and other utensils are the true 
sources of infection. 
These discoveries revolutionized our understanding of the causes and 
the treatment of many pathological conditions. They also paved the way 
for our present teaching of personal hygiene, sanitation, and our more 
precise conceptions of cleanliness, for it should be remembered that an- 
tisepsis without cleanliness would be useless. 
Cleanliness is a rather vague and relative term. 
We must rigorously differentiate therefore between 
the conception of cleanliness, as applied in our gen- 
Surgical 
Cleanliness. 2 
ORAL SURGERY 
eral mode of life, in our social intercourse, in the maintenance of health, 
and what is distinguished by the term “surgical cleanliness.” 
It seems superfluous to extol the remarkable benefactions that have 
come to mankind through surgical cleanliness, as this has been so often 
and so well done by abler writers. We may briefly state, however, that 
the marvelous and brilliant attainments of modern surgery are, in the 
largest measure, dependent upon the observation of the laws of surgical 
cleanliness, or asepsis. Without it, the entire art and science of surgery 
would crumble to pieces; without its guidance surgery would be much 
like a rudderless ship, which, through sheer accident, under most favor- 
able conditions, may reach its destination, but is much more likely to be 
foundered upon some shoals, destroyed upon uncharted rocks, or, after a 
stormy voyage, reach a strange, unfriendly port. 
Surgical cleanliness is the absence of microorganisms and other con- 
taminations. Where this is established it is termed a state of asepsis; the 
opposite of this is sepsis. Strictly speaking, scientific surgery admits of 
no degrees of sepsis or asepsis. The laws and the rites of asepsis are 
unyielding and absolute, for it should always be remembered that every 
break in the continuity of the epidermis or of the mucous mem- 
brane, made by accident or in surgical operations, is an open door for 
infection. 
In surgical operations, all efforts should be directed to secure and 
maintain surgical cleanliness. That this is not always easily accomplished, 
is indicated by the fact that the most frequent source of failure in all de- 
partments of surgery is sepsis. Though this is a well recognized fact, the 
error is often committed by surgeons, that, whenever untoward complica- 
tions of an infective nature arise, they seek the source of failure everywhere 
but in themselves. No surgeon should think himself immaculate or in- 
fallible, and in the presence of failure, he should direct his scrutiny first 
at himself and extend this to his assistants and his surroundings. 
To establish and maintain surgical cleanliness, heat, chemicals, and 
drugs which possess antiseptic and germicidal properties are used. 
Antiseptics are drugs or chemical agents which 
are in a mild degree capable of destroying micro- 
organisms and can effectively inhibit their growth and multiplication. 
Germicides are substances which are capable of 
destroying microorganisms and their spores. 
Sepsis is the presence of microorganisms and 
other contaminating factors. 
Asepsis is a state of complete freedom from mi- 
croorganisms and the products of their metabolism. 
Antiseptics. 
Germicides. 
Sepsis. 
Asepsis. SURGICAL TECHNIQUE 
3 
The processes whereby microorganisms and their products are de- 
stroyed and removed are disinfection and sterilization. 
There are two accepted methods whereby surgical cleanliness or a state 
of asepsis is attained and maintained in surgical operations—the antiseptic 
and the aseptic method; for operations in numerous parts of the body, 
however, both must be combined. 
In the antiseptic method, drugs and chemicals 
are used to secure and maintain asepsis. The sur- 
geon’s hands and the field of operation are treated 
with antiseptics after they have been thoroughly 
cleansed; the instruments are sterilized by means of drugs; and the dress- 
ings and sponges used are impregnated with germicidal agents. 
The use of antiseptics and germicidal agents is open to the grave ob- 
jection that substances which are potent enough to destroy microorgan- 
isms are also destructive of tissue cells. They also cause irritation and 
excessive exudation and through this they retard cicatrization. They can 
be used to advantage to eliminate or destroy surface infection and con- 
taminations, but they cannot be used, without detriment, to destroy 
infections which have deeply penetrated into the tissues. Such deeply 
disseminated infections can best be controlled by the vital resistance of 
the host. 
It may be well here to state that infection is de- 
termined by the following factors : (i) the virulence 
of the invading microorganisms, (2) their number; (3) the vital resist- 
ance of the host; (4) the elaboration by the tissues of the host of sub- 
stances which are inimical to the microorganisms and which can neutralize 
their toxic products. 
It is impossible, physically to remove or chemically destroy all the 
microorganisms in an infected wound. Because of this and because of the 
deleterious influence which germicidal agents have upon tissue cells, the 
general tendency is to depart from the use of drugs in surgical operations. 
Some surgeons exclude drugs completely from their field of operation or 
from the wound. This is the aseptic method. 
In the aseptic method, after the field of operation 
has been cleansed and sterilized by means of germi- 
cidal agents, this in turn is washed away with sterile 
water or saline solutions. All instruments and all 
other substances used in the operation are sterilized by heat or boiling. 
Briefly, the field of operation and all objects or substances which may 
come in contact with it are sterile, and during and after the operation the 
wound is guarded against the entrance of microorganisms. Undoubtedly 
The Antiseptic 
Method 
in Surgery. 
Infection. 
The Aseptic 
Method 
in Surgery. 4 
ORAL SURGERY 
some bacteria will find their way into the wound, but as a rule, they are 
not numerous enough to produce disease, or the few are destroyed by the 
body defenses. 
Drugs Used in Surgical Practice. 
Of the more commonly used drugs in surgical practice we may men- 
tion the following: 
Bichlorid of mercury occurs as heavy colorless 
crystals or white powder, having an acrid and me- 
tallic taste. It is very soluble in water and freely 
soluble in alcohol. It is marketed in the form of white or blue or green 
colored tablets, in combination with ammonium chlorid, sodium chlorid 
or tartaric acids. These ingredients greatly increase its solubility. 
It is a powerful antiseptic and germicide even 
in a solution of 1-50,000. It is ordinarily used for 
sterilization of skin surfaces or the hands. Formerly it was extensively 
used for irrigation of badly infected wounds. Because of its exceedingly 
irritating properties it should not be used for irrigation nor upon mucous 
membrane surfaces. In contact with albumen it precipitates a 11011-soluble 
albuminate which prevents its deeper penetration. It will readily attack 
and badly corrode metallic instruments. It is very useful, however, for 
the disinfection and sterilization of skin surfaces and the surgeon’s hands; 
and for these purposes it may be used in 1-500 to 1-5,000 strength. 
Some individuals have an idiosyncracy against bichlorid of mercury. 
A toxic dose may be absorbed through a mucous membrane surface or 
from a wound. It may cause dermatitis or give rise to stomatitis, ptyalism, 
diarrhea, cramps, and even more distressing symptoms. Upon the first 
toxic signs its use should be discontinued and the symptoms treated. 
Phenol (carbolic acid) occurs in colorless, needle- 
shaped crystals, and is obtained from coal tar by 
fractional distillation; or it may be synthetically prepared. 
Carbolic acid has decided antiseptic and germi- 
cidal properties. Because of its escharotic action— 
unless this is desired—it should never be used in a concentrated form in 
contact with tissues. In weaker solutions it is readily absorbed and may 
give rise to toxic symptoms. One of the early toxic signs is that the urine 
assumes a greenish, smoky hue; other signs are a subnormal temperature, 
feeble pulse and respiration, muscular weakness and vertigo. It coagulates 
albumen and when in contact with tissues this prevents its deeper penetra- 
tion. Being an escharotic, it is also a mild anesthetic, and for this it is 
Bichlorid 
of Mercury. 
Action and Uses. 
Phenol. 
Action and Uses. SURGICAL TECHNIQUE 
5 
often used to cauterize painful or exposed bone surfaces. Some surgeons 
use it for the destruction of the epithelial lining of cysts or ranulse. It is 
applied with a pledget of cotton and is immediately followed with pure 
alcohol to neutralize its excessive action. It is used hy some for irriga- 
tion and disinfection of infected wounds; also in mouth washes, gargles, 
sprays, and in the form of ointment in i% strength. 
Phenol is readily soluble in water; and in aqueous solution 1-20 to 1-40 
strength it may he used for the disinfection, or for the cooling of sterile 
instruments. 
Ziratol, a proprietary preparation, is a brownish, 
oily, heavy liquid and is very soluble in water. It is 
a powerful antiseptic and germicide. The manufacturers claim that its 
germicidal coefficient is much higher than that of phenol. It is only mildly 
irritating, even in a concentrated form and is practically tasteless and 
odorless. I find it very useful for the disinfection of rubber inhalers and 
for the reception of sterile instruments or trays and other utensils. 
It has been found that the greatest germicidal 
power of alcohol is at 70% strength. It may be 
used alone, or in combination with bichlorid of mercury—1 part of 
bichloricl to 1,000 parts of alcohol. It is used for the disinfection of skin 
surfaces and the surgeon’s hands; also to neutralize the action of carbolic 
acid. 
Peroxid of hydrogen is a syrupy liquid and is 
very soluble in water, alcohol or ether. It is a 
powerful germicide and kills bacteria because of its 
oxidizing power. In the oral cavity it is a valuable cleansing agent before 
operations. It should never be used for purposes of irrigation of abscess 
or bone cavities as the ebullition of the gases causes intense irritation and 
pressure, thereby spreading infection. Cryer reported several cases of ex- 
tensive necrosis of the jaws which resulted from the use of hydrogen 
peroxid in suppurating cavities. Its use in the oral cavity should be con- 
fined to surface disinfection. 
Iodin is a heavy, bluish black, readily friable 
solid, having a metallic luster, a distinctive odor and 
acrid taste. It is volatile and readily soluble in alcohol, but only sparingly 
soluble in water. 
Despite its irritating properties, iodin is one of 
the most favored and most extensively used drugs 
in surgery for surface disinfection. The official preparation of the tincture 
is 7% strong, and in this strength or in a weaker concentration, it can be 
used for sterilization of the skin and the oral mucous membrane. It pene- 
Ziratol. 
Alcohol. 
Peroxid of 
Hydrogen. 
Iodin. 
Action and Uses. 6 
ORAL SURGERY 
trates into the deeper layers of the skin and a small quantity is absorbed. 
In inflammatory conditions it acts as a counter-irritant, probably thereby 
inducing absorption of the inflammatory exudates. It acts as a direct 
germicidal agent upon surface bacteria, the more deeply localized organisms 
being destroyed, probably by the inflammatory reaction which it induces. 
In milder solutions it is a readily available irrigating substance. For this 
it should be diluted until of amber color. It acts as a stimulant upon gran- 
ulation tissues and seems to have beneficial influence upon inflamed, 
ulcerated, spongy gum tissues. 
Iodoform occurs as a fine lemon-yellow powder 
or crystals, having a peculiar, very penetrating and 
persistent odor and sweetish, unpleasant, iodin-like taste. It is slightly 
soluble in water, more soluble in alcohol and very soluble in ether. 
Iodoform is a mild local analgesic, antiseptic and stimulant. It is ex- 
tensively used in surgery for dressing infected and suppurating cavities. 
When in contact with tissue juices a slight amount of free iodin is liberated 
and other more soluble compounds are formed. It seems to exert a salutary 
stimulating influence upon granulation tissues. It may be used as a dust- 
ing powder for skin surfaces. Incorporated into gauze, in a 5% strength, 
it is used for dressing infected wounds and abscess cavities in the oral 
cavity or about the face. Several odorless iodin compounds have been 
prepared to take the place of iodoform, but they all appear less active. 
Lysol is a dark brown oily fluid having a creosote- 
like odor. 
Lysol is a valuable germicidal agent; it does not 
corrode metallic instruments and can be used for 
their sterilization. It is used by some men for the sterilization of the 
hands, but it is objectionable for either purpose because of its disagreeable 
and persistent odor. 
Boric acid occurs in colorless transparent scales 
or as light unctuous fine powder. It is slowly solu- 
ble in water, soluble in alcohol and freely soluble in glycerin. 
Boric acid is a mild antiseptic and astringent. In 
2% to 4% solution it is used for purposes of irriga- 
tion of the oral cavity, infected wounds or abscess cavities. Combined 
with starch or talcum powder, it can be used as a dusting powder, and in 
the form of ointment for dressing shallow external wounds. It is also 
used to saturate external wet dressings in inflammatory conditions about 
the face. 
Potassium permanganate occurs in slender, dark 
purple prisms, having a bluish metallic luster by re- 
Iodoform. 
Lysol. 
Action and Uses. 
Boric Acid. 
Action and Uses. 
Potassium 
Permanganate. SURGICAL TECHNIQUE 
7 
fleeted light. It is readily soluble in water and decomposes when in con- 
tact with alcohol. 
Potassium permanganate is an active oxidizing 
agent, deodorant, germicide and astringent. It is 
also an irritant. It is one of the most effective drugs used for surface dis- 
infection of the oral mucous membrane, or for deodorizing and cleansing 
of the oral cavity. It is particularly useful as a disinfectant and deodorant 
in the treatment of fractures and foul pathological lesions. For purposes 
of irrigation it may be used in solutions of 1-500 to 1-5,000. It can also 
be used for sterilization of the hands in a saturated solution, the discolora- 
tion being bleached out with oxalic acid, this being followed with rinsing 
with sterile water or saline solution. 
Dichloramin T. contains active chlorin through 
which it acts as an effective germicide. It is only 
sparingly soluble in water but it is soluble in chlorinated eucalyptol. It is 
most conveniently and effectively used, however, in the treatment of in- 
fected wounds about the jaws and in the oral cavity, dissolved in chlor- 
inated paraffin (chlorcosin). It may be introduced by means of a syringe 
or upon gauze saturated with it. 
Physiological saline solution is prepared by dis- 
solving 8.5 grams of sodium chlorid c.p. in 1,000 c.c. 
of sterile distilled water. A comparatively accurate method for its prepara- 
tion is dissolving two level teaspoonfuls of sodium chlorid in one quart 
of water. In the oral cavity this saline solution is used principally as an 
irrigating medium. It is one of the best for the purpose as it has no 
injurious influence upon the tissue cells. 
The above preparation is not to be recommended, however, for hypo- 
dermoclysis or intravenous injection in cases of shock or hemorrhage. 
For these purposes the more accurate normal saline solution should be 
prepared. This consists of 5,846 grams of sodium chlorid dissolved in 
1,000 c.c. of pure water. 
The most effective and truly reliable sterilizing 
agent is heat, and this can be used in moist or dry 
form. Boiling water will, in ten or fifteen minutes, destroy all pathologi- 
cal or pathogenic organisms and their spores. For the sterilization of 
metallic instruments it is to be preferred to dry heat or superheated 
steam. For sterilizing of dressings, linen, etc., steam and hot air may be 
used, preferably in high pressure sterilizers. 
Action and Uses. 
Dichloramin T. 
Saline Solution. 
Heat. 8 
URAL SURGERY 
Surgical Technique. 
It must be apparent that surgical technique comprises more than the 
performance of the operation alone. It rightly includes all considerations 
which may have a bearing upon the handling of the case. The surgeon 
must recognize therefore that his work does not commence nor terminate 
with the actual performance of the operation. 
A surgical procedure, thus more inclusively viewed, may he divided 
into four stages: (i) the consultation and diagnosis; (2) the preparation 
for the operation; (3) the operation; and (4) the post-operative treat- 
ment. 
(Consultation, examination and diagnosis is taken up in the following 
chapter.) 
That successful surgery is in a large degree de- 
pendent upon surgical cleanliness, regardless of the 
parts of the body involved, or the locality in which 
it is practiced, is a well established fact. Many untoward complications are 
inherent to the nature of the case itself; these are beyond the surgeon’s 
control, but complications, arising from sepsis, due to the surgeon’s negli- 
gence, cannot be condoned. 
It is exceedingly difficult, at times, therefore, to reconcile our ideals and 
our best understanding of what is requisite, with expedience and the prac- 
tical aspects of a situation. We must recognize, however, that the rigid 
and uncompromising measures for the maintenance of asepsis, which are 
inseparable parts of a well conducted hospital operating room, cannot be 
entirely instituted in office practice. Also, that the laborious preparations 
which are essential in major operations are impracticable, or well nigh 
impossible in types of surgery carried on in office practice. This statement 
is not to be construed as an excuse for a lapse in our vigilance against 
sepsis. With careful study and application, a system can be devised and 
adopted which will be simple and yet adequate to meet all requirements. 
Elaborate furnishings in an operating room are 
more effective in creating psychological influences 
than for the efficient and expeditious performance of 
operations. For example, it is very rarely essential to use an operating 
table in oral surgery, except in major cases, or where, for good reason, 
ether or chloroform is being used. In these cases, hospital facilities are 
necessary. Good light is essential. This may be natural or artificial. It is 
impossible to light up the deeper and more obscure parts of the oral cavity, 
except with good artificial light. In these cases the author prefers to use 
the headlight. The floor should be tiled or covered with cement or lino- 
Preparation for 
the Operation. 
The Operating 
Room. SURGICAL TECHNIQUE 
9 
leum so that it can be scrubbed and easily kept clean. One should have a 
good, flexible chair which can be readily adjusted to the various positions 
indicated; an instrument cabinet, which may be built into the wall or one 
of a standard make, which may be purchased; a cabinet for linen; a table of 
some type for holding at the chair the instruments needed in the operation; 
a sterilizer for instruments; where no separate plant for sterilization of 
linens is available this should also be in the operating room; a heater for 
irrigating solutions; an anesthesia apparatus; one or two waste receptacles; 
a glass table or shelf for the local anesthesia instrumentarium; a wash 
basin with running hot and cold water having foot or knee action faucets; 
a surgical engine, for those who use this instrument in their operations, 
equipped with all facilities for maintaining it surgically clean. Some men 
find it helpful to have a shadow box near the operating chair for viewing 
the radiographs during operations. This may be helpful, but it is the 
author’s belief that the radiographs should be thoroughly studied before 
the operation and the available information should be well fixed in the 
operator’s mind. Through this considerable delay in the operation will 
be avoided. Pictures, or other decorative, or non-essential furnishings are 
mere dust collectors and have no place in an operating room. 
The operator prepares his hands by first scrub- 
bing them with tincture of green soap and a sterile 
hand brush from three to five minutes. It is well 
recognized now that physical cleansing is more important and efficacious 
than the application of drugs upon an unclean surface. It is impossible 
to completely sterilize the hands, as even the pores of the skin, par- 
ticularly on hairy hands, contain microorganisms. These usually are not 
pathogenic. With thorough scrubbing their number is reduced and also 
the greater part of desquamated epithelial cells, which act as carriers of 
microorganisms, is removed. After thorough scrubbing, the hands are 
submerged for a few minutes in alcohol 70%, or bichlorid of mercury 
1-1,000, and dried upon a sterile towel. The hands having been prepared, 
nothing but surgically clean objects should be touched or grasped. Ad- 
justing the chair, handling of furniture or the patient must be carefully 
avoided by the operator. The author and a number of his confreres have 
found this care of the hands quite adequate for all types of minor oral 
surgery. Actual digital manipulation of the tissues in oral operations is 
rarely if ever essential, and the hands must be kept out of the wound, 
touching this only with the sterile instruments. The above preparation 
may be modified by scrubbing the hands with a small amount of chlorid 
of lime and washing soda, dissolved in the palm of the hand; this is 
The Operator’s 
Hands. 10 
ORAL SURGERY 
rinsed off and the hands are submerged into alcohol 70% or bichlorid 
of mercury 1-1,000. 
The wearing of rubber gloves is largely optional 
in minor operations and they should be used only if a 
sterile pair can be put on for every individual case. Rubber gloves are not 
essentially sterile and unless they are, they offer poor protection to the 
Rubber Gloves. 
Fig. i. Enameled trays for holding instruments. 
operator and none whatever to the patient. In major operations or where 
the deeper tissues are being invaded, rubber gloves, rigidly sterilized, 
should be used. 
After use the gloves are thoroughly cleansed with 
soap and water and submerged in bichlorid of 
mercury 1-1,000 for ten to fifteen minutes, or boiled 
for five to ten minutes. They are dried, next powdered with sterile talcum 
powder and wrapped in linen cases. They are sterilized again in the auto- 
clave, for about twenty minutes, under not more than fifteen pounds 
pressure. 
All metallic instruments should be individually 
scrubbed and cleansed from all gross contaminations 
in running water and boiled for fifteen minutes in water containing a 
small amount of sodium carbonate, about i%. After this they are dried 
Sterilization of 
Rubber Gloves. 
The Instruments. SURGICAL TECHNIQUE 
11 
upon sterile towels and replaced in the cabinet until they are used again 
and must be boiled always before using. When removed from the steril- 
izer, they should be placed in a 2% carbolic acid or ziratol solution for 
Fig. 2. Patient swathed in towels, ready for operation 
cooling. This will also prevent their contamination before being used. 
In the preparation for an operation, only the instruments to be used are 
placed upon a sterile tray or upon a sterile napkin. Other instruments 
which are likely to be required are also prepared and conveniently placed 12 
ORAL SURGERY 
so that they are ready for immediate use. Before proceeding with the 
operation, the operator himself should ascertain that all the necessary in- 
struments are prepared and laid out in the order in which they are to be 
used. The sterilization and preparation of the instruments should be 
done before the patient enters the operating room. The rattling and the 
sight of instruments is disturbing to many individuals and the unpleasant 
psychic reactions often complicate the operation. 
In operations where only a few instruments are required, the tray 
method for the maintenance of the instruments at the operating chair is 
used with a great deal of satisfaction by the author, in his private practice, 
as well as in clinic work. A number of enameled trays as illustrated in 
Fig. i, are always kept sterile and in readiness for use. They may be 
kept in a sterile basin or submerged in a germicidal solution after they 
have been sterilized. They should be large enough to hold four or five 
instruments and shallow, so that the contents are clearly exposed to view. 
In office surgery the clothing of the patient is 
not necessarily removed, except such parts as may 
interfere with the patient’s comfort or respiration. The clothes should be 
covered with a clean or sterile sheet which serves a double purpose. It 
protects the clothes and prevents them from contaminating the field of 
operation. Individual sheets or linen capes should be used for the pur- 
pose. The repeated use of rubber aprons, favored by some, cannot be 
approved. The towels used for the protection of the immediate area of 
operation are sterilized in linen packs, four towels to the pack. A fresh 
pack is opened for each operation; one of the towels is used to drape the 
patient’s head; one to cover the chin and chest; one to cover the tray hold- 
ing the instruments and one for the surgeon’s hands. (Fig. 2.) 
Sponges and dressings are made of gauze in 
various sizes, in keeping with the types of opera- 
tions practiced. Pads may be prepared in suitable 
sizes for external dressings and for packing off the pharynx during gen- 
eral anesthesia. All sponges and dressings are sterilized in smaller and 
larger linen or muslin packs and one or more of these are opened according 
to the needs of the operation. Applicators, swabs, wooden tongue depres- 
sors should also be subjected to the same degree of sterilization and kept 
in dust-proof, closed glass jars or other receptacles. 
The oral cavity is constantly infested by micro- 
organisms, many of which are pathogenic. Open 
wounds, such as are created in the ordinary removal 
of teeth, occurring in other parts of the body, if exposed to similar bacterial 
contaminations, would be followed by severe infection. This comparative 
The Linen. 
Sponges and 
Dressings. 
The Field of 
Operation. SURGICAL TECHNIQUE 
13 
immunity of the tissues of the oral cavity is not clearly understood at the 
present time. Investigations have shown that the antiseptic properties of 
the oral secretions are negligible or practically negative, but that the saliva 
is a poor culture medium. 
We may reason, therefore, that the tissues of the oral cavity are in a 
measure acclimated to this environment, or that they derive their compar- 
ative immunity from the abundant blood supply of this region. It is also 
suggested that the pathogenicity of bacteria is minimized by the presence 
of antagonistic saprophites. 
The comparative immunity to infection of the tissues of the oral cavity, 
should be used to advantage rather than abused, as it is but too apparently 
and too often done. When the deeper layers of tissues, particularly in the 
sublingual regions, are negligently handled, or when deep injections are 
made in a septic manner, infections and severe complications often arise. 
It is impossible to sterilize the oral cavity for even the shortest period. 
Still, a great deal can be done in the way of comparative disinfection, pre- 
ceding operations and this should be practiced even though many of our 
operations consist in the removal of the source of sepsis. In this we must 
depend more upon mechanical cleansing than upon powerful germicides. 
The mucous membrane and the gums are thoroughly scrubbed, with a 
swab saturated with a mild solution of hydrogen peroxid, or potassium 
permanganate. Where time permits, tartar deposits should be removed 
and inflammatory conditions, caused by septic irritation, should be cor- 
rected. Where the operation is more than the simple removal of teeth; 
surgical procedures, such as correction of a cleft palate, operation upon the 
maxillary sinus, removal of growths or the treatment of fractured jaws, 
these should always be preceded by thorough cleansing of the teeth, the 
removal of infected, carious and broken down ones, and eradication of all 
suppurative areas, or other conditions which may be regarded as con- 
centrated forms of infections. 
During operation, the direct area of operation is isolated and dried 
by packing off the salivary secretions with sterile sponges and then painted 
with tincture of iodin. The iodin is well rubbed into the mucous mem- 
brane, especially at points where deep injections are to be made. The 
principal means of disinfection should consist, however, of the removal 
of all gross sepsis, as described above. 
In the preparation of the patient we must recog- 
nize that his physical as well as his psychological 
needs must be considered. 
The majority of surgeons today recognize that psychic factors play 
an important part in the preparation of the patient and that these influences 
Preparation of 
the Patient. 14 
ORAL SURGERY 
have a decided bearing upon the sustaining of the ordeal of the operation 
and also upon the recovery. 
All profound emotions, particularly fear, grief or pain have a deleteri- 
ous influence upon individuals. The fear of pain; fear regarding the out- 
come of the operation; fear of the unknown; all of these are lodged in the 
primal instinct of conscious living organisms, the instinct of self-preserva- 
tion. Crile, in his experiments, has proven that profound emotions 
have a debilitating influence upon individuals, which is analogous to other 
factors, such as trauma, in producing shock. As in other surgical work, so 
in oral surgery, therefore, all efforts should be directed towards the elim- 
ination of all psychologic influences which may have a deleterious effect 
upon the patient. The aim should be to minimize, or entirely subdue the 
agitation and those apprehensions which the prospect of an operation, even 
though this be a minor one, creates in most people. Numerous measures 
which lend themselves towards the attainment of this desideratum can be 
made part of the routine technique. 
The following factors may be considered as the most prolific sources for 
psychological disturbances and untoward complications: (i) the surgeon; 
(2) fear; (3) pain; (4) trauma; (5) excessive loss of blood; (6) the 
anesthetic. 
Untoward complications arising from these can often be prevented by 
removing the agencies causing them. The preventive measures may be 
grouped under the following headings: (1) eliminating the psychological 
factors by proper management; (2) eliminating pain during operations by 
means of pre-operative medication and effective anesthesia; (3) skillful 
operative technique and checking of excessive hemorrhage during opera- 
tion; (4) the choice and proper administration of the best indicated 
anesthetic. 
The surgeon must be solicitous about his appear- 
ance, his manners and his general attitude towards 
the patient. He should exercise a degree of tact, instead of blunt indiscre- 
tion ; a poise of ease, instead of awing and overbearing haughtiness; a 
kindly, dignified interest, instead of studied indifference. These considera- 
tions may be deemed trivial in the estimation of many surgeons, par- 
ticularly those with whom surgical skill is the acme of importance. The 
more discerning men, however, recognize to what degree implicit con- 
fidence and a tranquil mind conduce to the best of results. 
It is also well to bear in mind that a surgical case, of whatever nature, 
should be viewed from the patient’s standpoint, although it may be a 
very minor one from a surgical standpoint. It is not essential to overstate 
the gravity of the condition; but, as a rule, patients do not react kindly 
The Surgeon. SURGICAL TECHNIQUE 
15 
when the source of their complaint is regarded lightly or with levity. 
Also, many easily controllable psychological factors, which often lead to 
physiological disturbances or even to graver states of shock, could readily 
be prevented with proper manipulation. 
This careful tact should be extended to all members of the surgeon’s 
staff, such as assistants, nurses, or office force; in short, all who may 
come in contact with the patient in connection with the work, until he is 
dismissed. Favorable, as well as unfavorable impressions, will be created 
in any detail of this association. Among other essential points to be 
observed, we may mention the washing of the hands before the patient is 
approached for examination; the cleanliness of the linen; the individualness 
of the drinking glass; the arrangement of the waiting room; the absence 
of offensive or conspicuous drug odors, etc. Frequent remarks in con- 
versation with patients assure me that, although much of this general 
detail is closely and critically observed by most discriminating persons, it 
is often overlooked or neglected by many professional men. 
The emotion of fear is lodged in the primal in- 
stinct of self-preservation. Some degree of explana- 
tion for this may be found in the psychic phenomenon which must have 
operated through the ages of conscious human development—the fear of 
the unknown. Another frequent source of fear is information obtained 
from others; this may be based upon the informant’s or secondarily ob- 
tained information of related experiences. With proper management, 
these forms of fear are often readily dispelled and the patient’s confidence 
gained. 
The most troublesome and serious source of fear is personal experi- 
ence. Fear, so created is, as a rule, more deeply rooted and more difficult 
to disperse, or to eradicate, than those above mentioned. To be frank, 
we must admit that the source of this can often be traced to methods of 
practice—legacies of the past—which, though still adhered to by some, 
are crude and cruel. We often hear of the removal of teeth, or other 
similar exquisitely painful operations, being performed without the aid of, 
or with but inadequate, anesthesia. This barbarous method is often in- 
dulged in by some practitioners in the removal of temporary teeth in 
children at an age when these early terrorizing impressions are carried 
through life. 
Besides proper management as suggested above, 
we often have to resort to preliminary medication. 
While this is not recommended as a routine practice, 
it should be judiciously used wherever the patient’s condition demands it. 
It is to be remembered that the administration of drugs carries a degree 
Fear. 
Preliminary 
Medication. 16 
ORAL SURGERY 
of responsibility with it and that this should be given only with a fairly 
complete understanding of the patient’s condition, the dosage, the physiolo- 
gical and therapeutic action of the drug. A few well selected drugs will 
prove to be adaptable in the great majority of cases. The object, in the 
use of drugs, should be to lessen the keenness of susceptibility and the 
sensibility of the patient, and to aid the action of the anesthetic. Wherever 
this is possible, it is advisable to limit ourselves to the non-habit-forming 
drugs. 
Preliminary medication is indicated in athletic and alcoholic individuals ; 
drug, particularly morphin, addicts; excessive cigarette smokers; neurotic 
and hysterical individuals; also to correct, aid or inhibit the function of 
some of the vital organs and to neutralize the immediate deleterious effect 
of the anesthetic. 
The advantages of preliminary medication are: modifying the action of 
some of the vital organs; the psychic disturbing factors are diminished; 
the amount and the concentration of the anesthetic agent may be reduced; 
the pain following the operation is decreased, rendering sleep and rest 
possible, which are important factors in the recovery of the patient. 
Whenever the surgeon or the anesthetist is hampered in determining 
the physical condition of the patient, the opinion of the medical diagnosti- 
cian or that of the physician on the case will prove to he valuable. 
The preliminary medication is largely determined by the age, sex, gen- 
eral health, the habits, idiosyncrasy, and psychic state of patient. Other 
factors to be considered are: the parts to he operated upon, the anesthetic 
to be used, and the mode of its administration; the nature of the operation, 
the duration of the operation, and the probable degree of the postopera- 
tive pain. 
Consideration of Anesthetics. 
Where ether, chloroform or some other inhala- 
tion anesthetic is to be used, which may react upon 
some of the vital organs and in which the recovery 
is often prolonged, such cases should not be under- 
taken in office practice unless equipped with hospital facilities. It is safest 
to secure hospital facilities and the services of a qualified professional 
anesthetist in all cases of this nature. All aspects of the case are considered 
in consultation with the anesthetist in which the preliminary medication, 
as well as the preparation of the patient, are decided upon. 
When nitrous oxid and oxygen is the anesthetic, no preliminary prep- 
aration is essential, so far as the regulating of diet or the evacuation of the 
Technique 
with Inhalation 
Anesthetics. SURGICAL TECHNIQUE 
17 
bowels are concerned. It is desirable, however, that no solid food be 
taken for about three hours prior to the administration of the anesthetic. 
Where prolonged anesthesia is undertaken for oral operations, preliminary 
medication has distinct advantages. In most cases the nose inhaler is used 
to best advantage, and in some individuals it is difficult to maintain a 
smooth anesthesia because of mouth breathing. 
In local anesthesia, whatever drug may be em- 
ployed, preliminary medication may not be essential 
in the majority of cases. There are, however, nu- 
merous instances in which it is almost indispensable. 
To secure adequate action of the heart muscles, digitalis may be used, 
20 min. every four hours for eight or ten doses. If nausea occurs it 
should be discontinued at once. 
Atropin, 1/60—i/ioo gr., may be administered hypodermically twenty 
minutes before the operation. 
Morphin atropin: morphin sulphate 1/6 of a grain, atropin 1/60 
grain, is administered hypodermically twenty minutes before the operation. 
Codein sulphate 1/8 to 1/4 of a grain administered hypodermically 20 
minutes before the operation. 
In the use of the above drugs, hypodermic administration is more 
reliable and the action is more adequate. 
Triple bromid, 10 grains, every four hours for three doses before the 
operation, is satisfactory to allay fear and pain. 
Other drugs are favored by different operators or anesthetists, such 
as morphin scopolamin; proprietary preparations, some of which consist 
of the coal tar derivatives, bromural, pyramidon, etc., but the writer con- 
fines himself to the use of those first mentioned. 
The principal criterion in the elimination of pain 
during operation is, after all, the establishing of 
surgical anesthesia by the administration of the anes- 
thetic best indicated for the case. With the various methods and drugs 
for anesthesia at our command, with the varied adaptable facilities for 
their safe administration, with the numerous men specially qualified in 
their administration, painful or brutal procedures in operations are 
inexcusable. 
The choice of the anesthetic should never be an arbitrary one. In the 
choice, the following factors should be held as paramount: (1) safety; 
(2) efficiency; (3) expedience; (4) the attitude of the patient towards 
the anesthetic. In these we must be guided by the general health of the 
patient; the age of the patient; the psychology and habits of the patient; 
the nature, the location, and the duration of the operation. 
Precautions with 
Local Anesthetics. 
Choice of 
Anesthetics. 18 
ORAL SURGERY 
Convenience and the patient’s desires are the last and least items to be 
placed in our scale of judgment. Only where there is an equal choice 
between anesthetics, should these factors be considered, but they must 
never be permitted to hamper the operation nor to influence the final out- 
come of the case. 
Local anesthesia, whether induced by the infusion 
or conduction method, lends itself more readily than 
general anesthesia to the needs of numerous and varied operations about 
the face and the oral cavity. To those who are accustomed to operate 
within these regions, the reasons for this are obvious. The following con- 
siderations are the more important factors in this connection: (i) the 
relationship of the oral cavity to the pharynx and larynx; (2) most opera- 
tions involve bone tissues in which hemostasis is difficult or impossible to 
maintain and a clear field of operation is essential; (3) a more bloodless 
field can be secured with a local than with a general anesthetic; (4) the 
cooperation of the patient is most desirable in these operations; (5) the 
posture essential in the administration of general anesthetics is often irk- 
some and inconvenient for oral operations; (6) many operations in the 
realm of oral surgery are of minor nature and even those which might be 
considered major cases are frequently ambulatory and comparatively rarely 
require hospitalization; (7) in numerous instances the operation is not in 
any way formidable and yet, because of the precision essential in its per- 
formance, more time is consumed than could be secured with an evanescent 
inhalation anesthetic such as would be permissible in office practice; 
(8) considering time as a factor,—and it is an important one in general 
anesthesia,—the consumption of the anesthetic must continue during the 
period of operation, whereas anesthesia induced with a given quantity of 
a local anesthetic will persist in most cases, if the time does not exceed one 
to two hours; (9) the operation can be carried on more speedily—which 
is another important factor—as we do not have to contend with the inter- 
ruptions due to nausea, vomiting, excessive secretions, or respiratory dis- 
turbances so commonly met with in prolonged general anesthesia; 
(10) shock due to the action of the anesthetic, the loss of blood, the dele- 
terious action of the drugs upon some of the vital organs is practically nil 
as compared with general anesthesia; (11) the recovery of the patient is 
more rapid and less troublesome; (12) a specialist in anesthesia is not 
necessary. 
There are, at the present time, several potent drugs obtainable, which, 
as compared with cocain, are of low degree of toxicity. This makes their 
administration possible by the perinural conduction method in large enough 
doses to secure complete surgical anesthesia. Much of the pioneer work 
Local Anesthesia. SURGICAL TECHNIQUE 
19 
in this direction was done by Braun and Fischer. Although Hallstead 
demonstrated first the injection of the inferior dental nerve, to those two 
investigators credit is due for adapting the conduction, or block method of 
anesthesia to the needs of the head, face, jaws, and the teeth. The writer 
has followed the technique as set forth by Fischer, with a great deal of 
satisfaction and with very gratifying results through a number of years, 
in almost all phases of oral surgery in which local anesthesia was indicated. 
Later authors of text books and contributors to current periodicals have 
elaborated upon some technical phases of the injections or introduced 
modifications of merit; these may find ready application in the hands of 
some operators. 
It is not intended here to treat upon the technical phases of local 
anesthesia as several excellent books have been published upon the subject. 
But it may be well to point out a few guiding points in the administration 
of any one anesthetic. Thorough surgical anesthesia depends upon: 
(i) precision in its injection; (2) the concentration of the anesthetic; 
(3) the quantity of the anesthetic used; (4) the amount of nerve tissue, 
i.e. the thickness of the nerve trunk to be anesthetized. 
It is desirable with all anesthetics to use the smallest effective quantity, 
in its least concentrated, potent form of solution. With experience, one 
must arrive at the conclusion that anesthesia is not always dependent upon 
the concentration and the quantity of the solution, but more upon accuracy 
in its administration. This is equally true of general anesthetics. An 
experienced, well trained anesthetist can maintain surgical anesthesia with 
the consumption of a comparatively small quantity of the narcotic drug. 
The writer has often induced anesthesia of the inferior dental nerve with 
1 c.c. of a 1% solution of procain, although most of our text books 
prescribe 2 to 4 c.c. of a 2% solution. 
The most valuable inhalation anesthetic, in brief 
oral operations, is nitrous oxid and oxygen. The 
numerous modern apparatus, furnished with accu- 
rate refinements for their administration, make the use of these drugs 
comparatively simple. Undoubtedly, in many respects, it is a less desira- 
ble anesthetic for oral operations than a local anesthetic is. Still, there are 
many instances and types of conditions where its advantages cannot be sup- 
planted by any other known anesthetic, and in which it is not only ideal 
but practically indispensable. Because of the exceedingly evanescent 
anesthetic effect, it is much more difficult to maintain surgical anesthesia 
with nitrous oxid-oxygen than with any other anesthetic. It is not to be 
construed, however, that prolonged anesthesia cannot be maintained with 
this anesthetic. Much of its usefulness is dependent upon the efficiency of 
Nitrous Oxid 
and Oxygen. 20 
ORAL SURGERY 
the anesthetist and the possibility of its use is also in a great degree de- 
termined by the patient. Jt is generally regarded as the safest inhalation 
anesthetic, although now and then fatalities resulting from its administra- 
tion are reported. Considering how indiscriminately and how carelessly it 
is often administered, it is surprising that these calamities have not been 
more frequent. Crile states that nitrous oxid and oxygen, unlike other 
inhalation anesthetics, does not injure the brain cells and in a measure 
offers a degree of protection against shock. 
The use of nitrous oxid-oxygen anesthesia is 
contraindicated in patients suffering from organic 
lesions of the heart muscle or valves; high blood 
pressure and vascular degeneration; asthma; respi- 
ratory difficulties; where the air passages are narrowed as in cases of Lud- 
wig’s angina; tonsillar, peritonsillar, or pharyngeal abscess; excessively 
obese patients; alcoholics; excessive users of tobacco, particularly ciga- 
rettes, and those addicted to some drugs such as morphin, cocain, etc. 
The prolonged administration of nitrous oxid and oxygen may have 
a detrimental effect upon the hemoglobin of the red blood corpuscles. 
The chief danger lies, however, not so much in an over dose of the 
nitrous oxid as in the lack or inadequacy of the oxygen. In the adminis- 
tration of nitrous oxid-oxygen the anesthetist must be much more on the 
alert than with any other anesthetic. We must not rely upon the percen- 
tage of the gases, as indicated by the apparatus for guidance, but the 
symptoms in the patient must be watched with the utmost vigilance. The 
color, the rate and quality of respiration, the pupils, the rate and quality of 
the pulse, especially in prolonged anesthesia, are the indicators of the anes- 
thetic state and the condition of the patient. Maintenance should never 
be carried on with the patient in a cyanotic state. There always is a 
degree of duskiness of the lips as well as the face, but the patient should be 
kept as nearly pink as possible. Once the difficulties in the administration 
of nitrous oxid-oxygen have been mastered, it is decidedly the most 
satisfactory general anesthetic from the patient’s, as well as from the 
surgeon’s and anesthetist’s point of view. It is not unpleasant to take, 
it is safe and the induction and the recovery are rapid. Even after pro- 
longed anesthesia, the patient is fully conscious and in complete possession 
of all his faculties, within five or less minutes after the administration 
has ceased. 
Ether or chloroform anesthesia is not to be un- 
dertaken for adults in office practice, unless the 
office is equipped with hospital facilities. The ad- 
ministration of these drugs should never be undertaken except with the aid 
Contraindication 
for Nitrous 
Oxid-Oxygen. 
Ether or 
Chloroform. SURGICAL TECHNIQUE 
21 
of a trained anesthetist. In young children, for operations, such as the 
removal of temporary teeth, cleaning out a necrotic area or the lancing of 
an abscess, ether is the ideal anesthetic. In young subjects, up to the age of 
about six, anesthesia is easily induced, little of the anesthetic is consumed 
and the recovery is comparatively rapid, leaving no untoward complications. 
Those who wish to avail themselves of the advantages of these anesthetics, 
as is often essential, should study the subject from every standpoint; 
the preparation of the patient, the various methods of administration, their 
indications and contraindications, the symptoms of the different stages of 
anesthesia and the different signs as to the condition of the patient. With- 
out such a preparation the administration of these anesthetics is somewhat 
hazardous. Regardless of who the anesthetist may be the burden of re- 
sponsibility always lies with the surgeon. The tacit understanding be- 
tween the surgeon and anesthetist as to the sharing of the risks does not 
clear the surgeon of his responsibility for the anesthetist. 
Preparation for and Conduct of an Operation. 
Preparatory to an operation, the patient is seated in the operating chair, 
in a posture to accord with the convenience of the operator and the com- 
fort of the patient. For operations upon the lower jaw the patient should 
be seated with the trunk in a reclining position and the head thrown for- 
ward just sufficiently so that when the mouth is open the lower border 
of the mandible is practically parallel with the floor. This position per- 
mits of better lighting of the parts and makes the held of operation more 
accessible. For operations upon the upper jaw, the trunk is practically in 
the same comfortable reclining position, hut the head is thrown back so 
that the palate is almost vertical to the headrest and at an angle of about 
90° to the floor. 
All dentures which are insecure in the mouth and not fixed to the teeth 
should be removed, especially if a general anesthetic is to be used. The 
clothing of the patient is not necessarily removed. When an inhalation 
anesthetic is to be given, corsets in women, or collars in men which may 
interfere with respiration should be removed. The clothing of the patient 
is covered with a linen sheet or cape made for the purpose. Over this the 
sterile linens may be placed. The patient’s head is draped with a sterile 
towel, but all other sterile linens are placed after anesthesia has been in- 
duced, and when the operation is about to be started. 
For intra-oral operations the mouth is irrigated with a mild antiseptic 
solution and all surfaces of the mucous membrane and the teeth are 
thoroughly scrubbed with a cotton swab. A mild solution of potassium 22 
ORAL SURGERY 
permanganate, peroxid, saline solution or boric acid, 2% to 4%> may he 
used for the purpose. The immediate field of operation is painted with 
tincture of iodin 7% or equal parts of iodin and alcohol. 
For extrahuccal operations, if the skin is hairy this should be shaved 
first. The surface to be operated upon is well scrubbed with tincture of 
green soap and warm water or an efficient solvent, such as benzin or ether. 
This is followed with a germicide, such as bichlorid 1-5,000 or alcohol 
70%, and dried. When the skin is dry it is painted with a 3% 
to 4% of tincture of iodin. When iodin is applied to a wet surface 
it may cause blistering, and moisture prevents its deeper penetration. 
The patient’s head is draped and the field of operation is surrounded 
with sterile towels. (Fig. 2.) The sterile field should also be covered 
to protect it from any form of contamination until the operation is 
begun. 
While this is in progress the instruments are being boiled for fifteen 
or twenty minutes, as stated before. Whenever conditions permit, the 
instruments should be prepared before the patient enters the operating 
room, if the sterilization is done in the same room. 
The now sterile instruments are placed upon small, sterile, enameled 
trays as illustrated in Fig. 1. When a larger number are to be used, 
they are placed upon a larger tray covered with sterile towels. One small 
extra tray should be handy for discarded or infected instruments, and 
receptacles are placed upon the floor for contaminated sponges, or other 
discard. Before proceeding with the operation, the surgeon should see for 
himself that all instruments which may be needed have been prepared and 
that they are laid out in the successive order in which they are to be used. 
By doing this, a great deal of time may be saved that otherwise would be 
spent in seeking an instrument. With a trained assistant, who follows and 
understands each step in the opei'ation, this is greatly simplified, as he is 
always alert in handing the necessary instrument to the operator. 
I11 a well conceived operation, all phases and 
steps in the procedure should be adequately planned. 
The patient is prepared and no case should be begun until surgical anes- 
thesia has been certainly induced. All the necessary instruments and 
utensils should have been placed to hand ready for immediate use. Con- 
siderable attention should be given to the selection of instruments best 
adapted for the expeditious performance of the operation and to meet all 
probable emergencies promptly. With such preparation, the case is ap- 
proached with greater confidence and the operation can be performed 
more speedily, more efficiently, with less wear and tear on the vitality and 
nervous energy of both the patient and the operator, with less loss of 
The Operation. SURGICAL TECHNIQUE 
23 
blood and precious time and with a smaller consumption of the anesthetic 
where inhalation anesthesia is being used. 
The surgeon’s skill and dexterity is largely augmented by the selection 
of the most appropriate instrument to perform each phase of the work 
and considerable attention should be given to their selection. All instru- 
ments are designed for the performance of different phases of the opera- 
tion. While there are many variations in the form and details of design 
in instruments intended to do the same type of work, still there is a con- 
siderable similarity in their general plan. There is a degree of individual 
leaning in the selection of instruments. While some may be effectively 
used by one operator, they may be useless in the hands of another. The 
abuse of instruments lodges rather in faulty manipulation and in their 
application for kinds of work for which they are not intended. For ex- 
ample, it should be clear that forceps are meant for grasping and the re- 
moval of teeth and not for incising soft tissue, nor for bone cutting. There 
should be no objection to the use of a surgical bur, where extensive cut- 
ting of heavy compact bone or tooth structure is necessary, as in the 
removal of some impacted lower third molars or in root amputation. The 
objection raised to this instrument, that because of the friction and heat 
generated, eburnation of the bone, necrosis, and excessive postoperative 
pain follows, is not borne out in clinical experience. In fact I have more 
often seen ill results in the way of untoward complications at the site of 
operation and in the way of psychic trauma, following the excessive and 
prolonged use of the chisel and mallet. Truly, it is a dangerous instru- 
ment when it is septic, or if injudiciously used—but so is every other 
instrument under similar circumstances. It should always be remembered 
that in all operations, undue traumatization of tissues and unduly lengthy 
operations are just as often due to the injudicious selection of instruments 
as to their faulty manipulation. 
Traumatization and rude manipulation of living 
tissues are opposed to all the principles, precepts and 
refinements of modern surgery. It should always 
be remembered that in all operations we are dealing with living, sentient 
entities,—the tissue cells,—and that their response to treatment and their 
chances of recovery are in the largest degree, inversely proportionate to 
the operative trauma. All who aspire to attain the highest degree of suc- 
cess in surgical operations must learn the value of light and delicate manip- 
ulation of living tissues and should bear in mind that, at best, aggregate 
or individual cell life is obtruded upon. Mild temporary interference may 
be followed by ready recovery; when such interference is severe, pro- 
longed, or repeated, the tissues may recover only with difficulty; they may 
Trauma to be 
Avoided. 24 
ORAL SURGERY 
undergo degeneration or even necrosis. Bruised, torn tissues are also 
more prone to infection, because of reduced vital resistance. This prin- 
ciple is equally true regardless of what part of the anatomy may be 
involved. 
Refrain from tearing, laceration, evulsion or undue force. Where the 
removal of an obnoxious or diseased member becomes essential this should 
be separated from the healthy tissues, or those to be retained, by means of 
sharp or blunt dissection. Bone or cartilage should be cut or removed by 
means of chisels, gouges, burs, and rongeur or bone cutting forceps. 
The operation having been completed, our attention is directed next to 
bringing the parts into the most favorable condition for repair and the 
restoration, as nearly as this is possible, of their anatomical relationship. 
Wounds following operations in the oral cavity 
are best closed with interrupted sutures. The sev- 
ered tissues are approximated and the lips of the wound are brought into 
apposition where primary union is desired. The sutures should be just 
tight enough to maintain this relationship until union has taken place. 
When the sutures are too tight they either cut out, or the inclosed tissues 
slough, because of strangulation. In clean, non-suppurative wounds, 
where no subsequent drainage is necessary, complete primary union is 
permissible. Where irrigation and drainage are necessary, a part of the 
wound is left open or kept apart by means of dressings. 
The intent in the use of sutures is to restore the anatomical, or to 
maintain an intended relationship of the parts. Catgut, horse hair or silk 
may be used for the purpose. Catgut is absorbable and subject to infec- 
tion ; therefore it is not the best material for infected surface wounds. 
Horse hair is more pliable and also, because of its fineness, is very well 
fitted for the needs of the oral cavity and the face. It can be obtained in 
sterile tubes, a fresh one being opened for each individual case; or the 
loose strands may be boiled. Silk twist, black or white, No. i or 2, is 
likewise very well suited for this work where no infection is feared. The 
coaptated tissues usually unite in five or six days, after which the sutures, 
having served their purpose, can be removed. In the approximation and 
coaptation of the divided tissues, care should be taken that the mucous 
membrane surfaces are not turned in, or that they do not overlap. Mucous 
membrane surfaces, when approximated, do not unite and when they over- 
lap, the union is delayed, uneven or incomplete. 
The postoperative treatment of surgical cases 
is often very important so far as the outcome 
is concerned. In a great number of cases, 
wounds in the oral cavity heal readily, with no postoperative care what- 
Suturing. 
Postoperative 
Treatment. SURGICAL TECHNIQUE 
25 
ever, despite the ever present microorganisms. The tissues are capable of 
taking care of a considerable number of these and in clean wounds, where 
there is no undue laceration, traumatization or cutting off of the blood 
supply, most wounds heal without suppuration. There are numerous in- 
stances, however, where postoperative care is essential: in chronic diseases, 
such as tuberculosis, diabetes, syphilis, arteriosclerosis, anemia, in which 
cicatrization is apt to be retarded; in acute abscesses where drainage and 
irrigation are essential; in large cysts or bone cavities following the re- 
moval of deeply impacted teeth; in operations upon the maxillary sinus, 
etc. Such treatment consists principally of irrigation, dressings, the ap- 
plication of an analgesic to prevent or alleviate pain, or some drug which 
stimulates granulation. 
Wounds upon the face may often be considered aseptic. After the 
wound has been closed, care should be taken against the entrance of 
germs, and the parts should be protected from every mechanical injury. 
Tn these wounds, where the deeper tissues have been sutured, which will 
prevent their gaping or opening, the superficial sutures may be removed 
after two or three days. This will prevent the unsightly cross marks, often 
observed where sutures are left in longer. 
We often hear the expression “packing” a 
wound. This should never be done, literally, ex- 
cept where distention or pressure is desired. Dressing of wounds in the 
oral cavity is indicated for the following reasons: (i) to secure drainage; 
(2) to arrest hemorrhage; (3) to protect the wound from the irritation of 
substances which may enter the oral cavity; (4) to bring in contact with 
the surface wound antiseptic, analgesic, or stimulating drugs; (5) to pre- 
vent the ingress and the accumulation of food substances and oral secre- 
tions in deep-seated cavities, which, if permitted to decompose there, lead 
to infection. 
For purposes of dressing, sterile gauze strips or tape impregnated with 
a drug, may be used. After having tried sterile gauze, and also some which 
was impregnated with boric acid, bichlorid of mercury, bismuth paste and 
5% of iodoform, the iodoform has been found to be best suited to the 
needs of the oral cavity. Iodoform is truly objectionable because of its 
persistent and pungent odor, which may be perceived even at a distance. 
Any one of the others, however, if left in the mouth, becomes very foul 
even after four or five hours, and is decidedly more objectionable than 
iodoform. Iodoform is a deodorant and can be left in a wound for two 
or three days without becoming foul smelling. It also possesses mild anal- 
gesic, antiseptic, and stimulating properties whereby it exerts a most 
salutary influence upon the granulation tissues. 
Dressing Wounds. 26 
ORAL SURGERY 
Drainage is of distinct advantage for the remova 
of lymph, blood or pus. The length of the perioc 
during which drainage is to be maintained is to be determined in individua 
cases. In operations in the oral cavity, drainage is principally indicated in 
acute abscesses, deep-seated, larger bone cavities, empyema of the maxil- 
lary sinus, necrosis and other suppurative conditions, for the removal o 
pus, lymph or blood, secretions of the oral cavity or other liquids which 
may find entrance there. Rubber tubes may be used upon the externa 
surfaces, as gauze is not always favorable, where active drainage is 
necessary. It is well to bear in mind that drainage is based on the principle 
of physics and not that of chemistry. Gauze, if not properly utilized, is not 
always favorable for active drainage as the exudates and the pus tend to 
coagulate upon the wound surface and upon the gauze, thereby damming 
back the fluid. In the oral cavity, glass or rubber tubes are impractical, and 
as the interior of the mouth is constantly lubricated with a liberal flow of 
saliva, no surface coagulation occurs and gauze has distinct advantages. 
In large abscess cavities upon the neck, or in the submaxillary region 
where suppuration is profuse, often gauze alone, or in combination with a 
rubber tube, may be used for mechanical reasons. If-drainage is incom- 
plete, where the incision is not made at the most favorable point for evacu- 
ation, the pus has a tendency to burrow into the deeper areas, and sec- 
ondary incisions become necessary. Where dressing is not carefully car- 
ried out so that the entire cavity is loosely lined with the gauze dressing, 
the walls may collapse and by their uniting, secondary pus cavities may 
form, and secondary incisions become necessary. 
The posture of the patient often facilitates drainage, and in large ab- 
scesses or in acute diffused cellulitis upon the face or neck, instruction may 
be given to the patient to this effect. Care should be exercised that the 
granulation tissues are not traumatized nor caused to bleed in the removal 
or introduction of the dressing. In cavities where large areas of de- 
nuded bone surfaces exist, the dressing should be left in for at least 48 
hours or even three days, for fear that reactionary hemorrhage may be 
induced. 
In irrigation of wounds of the oral cavity, little dependence is to be 
placed upon the germicidal properties of the irrigating agent. There is no 
such thing as asepsis in the oral cavity. Mechanical cleansing is of para- 
mount importance. Strong antiseptics are, as a rule, irritating and de- 
structive to tissue cells. Clean, non-infected wounds require no germicidal 
agents, and in most suppurative cases there is little indication for them 
after the source of infection has been removed. A normal saline solution 
is all that may be required in most cases; in infected conditions the writer 
Drainage. SURGICAL TECHNIQUE 
27 
confines himself to the use of a mild iodin solution—a light amber color— 
boric acid from 2% to 4%, or a physiological saline solution. 
Irrigation of a wound is generally a simple matter and should not 
offer difficulties. But it may be in point to state that force should never 
be used in this process. Have a good size smoothly working syringe. 
The nozzle of this should never be inserted into the wound in such a man- 
ner that the orifice is completely occluded. When this is done the irri- 
gating solution becomes confined and the tension causes considerable pain. 
The pressure may also injure the granulation tissues and may spread the 
infection in a pus case. The wound should be simply gently lavaged, 
until the return is clear. CHAPTER II. 
Examination and Diagnosis. 
The examination and diagnosis are just as important factors in the 
successful handling of a surgical case as the operation. A correct diagnosis 
is the foundation upon which surgical procedure must be based. 
“Diagnosis is the sum total and correlation of the history, the clinical 
findings and the result of the various specialized methods of examination.” 
It is to be deplored that, at the present time, in most branches of medi- 
cal practice, too much reliance is placed upon laboratory tests, radiographs 
and other specialized forms of examination, often leaving the clinical and 
individual phases of the case entirely out of consideration. A correct and 
complete diagnosis must ultimately be based upon the coordination of the 
clinical findings and all other data by whatever means obtained. 
Some specialized methods of examination are quite conclusive so far as 
the detection of the disease is concerned. For example, a positive Wasser- 
mann test is an indication of the presence of syphilis; radiographs will 
often decidedly determine the presence of a bone lesion or a foreign body. 
But the detection of a disease or a lesion is only part of a diagnosis. The 
patient, considered as a whole, and the clinical expression of a lesion or a 
pathological condition must always play an important part in the treat- 
ment of a case. Each and every pertinent factor disclosed should be 
coordinated. 
A reliable diagnosis can be arrived at only by a systematic and accurate 
examination of the patient. A diagnosis so obtained depends upon keen 
observation and correct interpretation of all phases of the case. 
Nothing develops more the habit of keen and accurate observation and 
an analytic comprehension in diagnosis, than systematic examination and 
the detailed writing up of the case. To this end printed blanks should be 
devised, appropriate for the type of work practiced. The headings should 
be so arranged that a logical sequence in the examination is carried out and 
that they act as reminders of the parts to be examined. By filling these 
out, many errors which might be traced to “snap shot” diagnosis will be 
28 EXAMINATION AND DIAGNOSIS 
29 
avoided. Besides, by describing the case, often some significant details 
will be considered which might otherwise be overlooked. 
In the examination of the oral cavity and the associated parts, three 
aspects of the case are to be borne in mind: (i) the local lesion; (2) the 
presence of constitutional complications and the possibility that these are 
influenced by the local lesion; and (3) the possibility that the lesion is of 
constitutional origin and the mode and nature of its local manifestation. 
The examination must be complete and wherever this is possible, a defi- 
nite and accurate diagnosis should be rendered. If laboratory tests, radi- 
ographs or other specialized means of examination are indicated, these 
should be freely and judiciously employed and the patient is advised ac- 
cordingly. The diagnosis should never be hampered nor influenced by the 
opinion of others unless such an opinion, coming from a reliable source, is 
valued. In emergency or acute conditions, many of these details, beyond a 
close clinical study of the case, may have to be curtailed or entirely dis- 
pensed with. 
Clinical examination must essentially be based upon a thorough 
familiarity with the anatomy, the normal appearance of the parts and a 
clear understanding of their histological structure and normal function. 
To this end it is desirable to have a well defined mental picture of the 
normal, so that in our examinations all departures may be compared with 
this standard. 1 he normal should not be confounded, however, with the 
imaginary ideal, and allowances must be made for a latitude of variations 
which may exist under normal conditions in different individuals. 
In the clinical study of pathological conditions, note and consider: 
(1) the subjective symptoms; (2) the alteration in the anatomical outline 
and relationship; (3) the structural changes in the compromised tissues; 
(4) the impairment or aberration of function; (5) the involvement of the 
directly or indirectly associated structures or remote organs; (6) the 
reaction upon the general health of the individual. 
In the coordination of all factors, our diagnosis is distinctly aided by 
other similar conditions. By recalling these, a more accurate valuation can 
be placed upon the different signs and symptoms, as well as all other diag- 
nostic disclosures, and we can better estimate the pathological significance 
of their different combinations. A clear and comprehensive understand- 
ing of the different aspects of the case, combined with experience in the 
treatment of other similar cases and the results obtained, insures a fairly 
definite outline of the diagnosis, the treatment indicated and the prognosis. 30 
ORAL SURGERY 
Examination of the Oral Cavity and Associated Parts. 
During examination the patient should be seated in a position which 
renders examination of the parts most convenient. Good natural or arti- 
ficial light is essential. All the necessary utensils are sterilized and placed 
conveniently at hand upon a sterile tray, napkin or towel. These ordinar- 
ily consist of a cheek retractor, a mouth mirror, a probe, a tongue depres- 
sor, thumb forceps and a few sterile gauze sponges. The hands are thor- 
oughly scrubbed before the patient is approached. All intra-oral examina- 
tions should be made with appropriate instruments and the fingers should 
be kept out of the patient’s mouth. It is a common failing with some men 
to put their fingers into a patient’s mouth without first determining, or even 
attempting to determine, whether it is desirable to do so; whether there is 
an infectious malady present. The hands are nearly always chapped and 
wherever the epidermis is broken, inoculation and infection are possible. 
Proper precautions should be observed, regardless of the appearance, the 
age, the sex, or the station of the individual. 
The examination of the patient should commence just as soon as he 
enters the consultation room. Numerous points of information are often 
disclosed by a close outer observation of the individual. Attention' should 
be paid to the general appearance of the patient, the facies, the expression, 
the complexion, the appearance of the skin. Every abnormality which may 
be present, should be noted and closely studied. 
It is fairly generally believed that pain is a pur- 
poseful phenomenon in the scheme of Nature, the 
intent being to call the attention of the sufferer to the presence of a dis- 
ease or an injury. Clinical observations, however, often remind us that 
such assumption, if not entirely erroneous, is at least full of contradictions. 
For if this assumption were true, it would be logical to assume that the 
pain would be commensurate with the gravity of the disease or the extent 
of the injury. In this contemplation we are impressed with the fact that 
the irritation of an exposed pulp of a tooth, which is so insignificant as far 
as the welfare and the life of the patient are concerned, causes excruciating 
pain, while some of the most insidious diseases and their lesions, 
such as syphilis, tuberculosis, cancer, are practically painless, even 
in their advanced stages. Whatever our views on the subject may 
be, and despite the contradictions, the fact remains that pain is always 
a distress cry of Nature and signifies some form of disturbance or 
irritation. 
The character of pain is often pathognomonic of a certain lesion or dis- 
ease, and therefore of definite value in surgical diagnosis. Pain in diag- 
Pain. EXAMINATION AND DIAGNOSIS 
31 
nosis must be studied and analyzed, taking into consideration the follow- 
ing characteristics. 
The patient should be asked to localize, as nearly 
as possible, the place or region in which the pain 
is felt. In neuralgias about the head, such statements 
are sometimes quite misleading. Pain originating in the teeth, or about 
the jaws or head, tends to radiate and it is difficult at times to differentiate 
between the true focus of pain and the reflex pain. For example, pain 
originating about the teeth often is referred to the ear, or that caused by 
disease of the maxillary sinus to the occipital regions, etc. In this con- 
nection it is well to bear in mind the atypical conditions which may occur. 
A knowledge of the mode of onset and the duration of pain is often 
helpful in determining the nature of morbid processes. Some pains are 
aggravated in the night time. This may be due to lack of diverting in- 
fluences or to a greater susceptibility of the patient during this period. 
Some aches and pains, especially those of a neuralgic origin, are often 
influenced by the weather, thermal changes, the seasons. 
Sudden onset points towards inflammation or neuralgia. Slow pain 
usually marks slow development which often leads to chronicity. Periodi- 
cal pains are usually due to temporary or intermittent irritation and are 
often observed in some constitutional diseases, such as malaria or syphilis. 
The qualifications of pain are spoken of as soreness, tenderness, ach- 
ing, lancinating, burrowing or throbbing; from these characteristics much 
about the nature and the causes of the pain may be learned. 
Soreness upon movement often indicates muscular or ligamentous 
origin. Aching, darting, or lancinating pain is more often characteristic of 
nerve involvements. Throbbing pain, which often accompanies inflamma- 
tory conditions, is usually due to pressure or distention of tissues, such as is 
observed in acute abscesses where drainage is inadequate or incomplete. 
A deep-seated boring pain is characteristic of bone lesions. Pain elicited 
by light touch of the superficial tissues, indicates affection of the cutaneous 
nerves. Pain caused by profounder pressure, usually denotes a deep-seated 
lesion. Pain increased by pressure is due to inflammation; when relieved 
it is either neuralgic or functional. Inflammatory pains are usually in- 
fluenced by temperature or position. 
I he location of pain is often an accurate guide to the point of lesion, 
provided we recall the nerve distribution, but the possibility of referred 
pain must always be borne in mind. 
The intensity of pain cannot be measured, as it is in the greatest degree 
subjective and the patient’s statement in this respect is exceedingly unre- 
liable: also, it is very much dependent upon the individual’s general health, 
The Topography 
of Pain. 32 
ORAL SURGERY 
mental state, susceptibility or temperament. Some individuals are more 
susceptible to painful sensations than others. Neuropathic patients like 
to exaggerate the degree of pain and their suffering. 
Swellings about the face and jaws should be 
examined and closely observed. The surface ap- 
pearance is often the source of hasty and erroneous conclusions. The 
predominance of swellings caused by abscessed teeth in these regions, 
should not lead to the conclusion that all swellings are caused by abscesses. 
Though a comparatively small percentage, other and often more serious 
affections should always be borne in mind when making the exam- 
ination. 
Observe the life history, the location, and the anatomy of the parts in 
which the swelling occurs; the physical characteristics, whether it is hard 
or soft, inflamed, painful, tender to the touch. Is it movable or fixed to 
the surrounding tissues? Is it fluctuating? Does it pit upon pressure? 
Is the overlying skin movable over it? Note the degree of involvement of 
the adjacent tissues; the associated lymphatic glands. If there had been 
any previous treatment, consider the nature of this and the results obtained. 
In some cases aspiration may prove helpful. 
The visual observation of tbe outer surfaces should be supplemented 
with gentle palpation of the parts. Digital manipulations should never be 
made with any degree of force. When excessive pressure is exercised, the 
examination is painful and the finer sensory perception of the fingers is 
dulled or entirely lost. 
It is good practice to pass the finger tips along the submaxillary area 
and palpate for enlarged lymphatic glands. Normal glands are, as a rule, 
not palpable; smaller shotty glands do not always have a pathological 
significance; enlarged ones should always be regarded as pathological 
conditions and their causes sought out. 
Lymphadenitis of the cervical glands may be 
acute or chronic. It may be primary (lymphog- 
enous) or secondary (hematogenous). 
Acute secondary lymphadenitis of the cervical glands is much more 
common in young children than in adults. This is often caused by 
staphylococcus or streptococcus infection lodged about the teeth, in the 
jaws, the tonsils, in adenoids, the pharynx, the sinuses, the ears, the seal}), 
the lips, the face or almost any part of the head. It is not uncommon to 
observe in young children that cervical adenopathy will come without a 
demonstrable cause, and pass off without treatment. 
The chronic types are more often caused by systemic disease, such as 
syphilis, tuberculosis, anemia. These may also have some degree of acute 
Swellings. 
Cervical 
Lymphadenitis. EXAMINATION AND DIAGNOSIS 
33 
or subacute phase; they may be secondarily involved through metastasis 
from malignant growths. 
In the examination of the cervical region we must first study the local 
features of an edema and determine whether we are dealing with a glan- 
dular swelling. Note the outline and the period of its growth; whether it 
is painful; fixed or freely movable; the condition of the surrounding tis- 
sues and the overlying skin. 
If the adenopathy is due to active staphylococcus or streptococcus in- 
fection, the gland becomes inflamed, is tender to palpation and may or 
may not be slightly fixed to the surrounding tissues. If it is fixed to the 
overlying skin, this presents acute inflammatory symptoms of a variable 
degree. The gland may become considerably enlarged and fluctuate, in- 
dicating a fluid content. Fluctuation is not essentially indicative of the 
presence of pus unless there is a positive infection present and malignancy 
is excluded; it may be due to infection even in the presence of a malig- 
nant growth. Fluctuation may be due to a breaking down or malignant con- 
dition, or an infection superseding malignancy. Many swollen glands sub- 
side completely upon the removal of the focus of infection. In numerous 
cases, however, surgical interference becomes necessary. Periodical in- 
crease and decrease in size may nearly always be considered as an inflam- 
matory condition caused by a localized infection. 
1 ubercular glands are ovoid or roundish in outline, are freely movable 
in the integument and the skin is freely movable over them. There may 
be a degree of periadenitis, in which event they are slightly fixed to the 
adjacent tissues. An individual gland may be affected, but in typical 
cases the adenopathy spreads until a chain of them becomes involved. A 
slowly progressive enlargement is observed and those first affected may 
show signs of breaking down or degeneration. They are painless, as a 
rule, but may become tender when their enlargement takes on a somewhat 
rapid course and the surrounding tissues are pressed upon. 
Enlarged glands, due to syphilis, are hard and shotty. As a rule they 
do not form chains or conglomerate masses, and are not painful nor tender 
upon palpation. I hey are freely movable in the surrounding tissues, and 
are often lodged in the posterior triangle. Other factors to be considered 
are: a probable luetic history, the clinical signs of a chancre, or mucous 
patches upon the oral mucosa, upon the lips, tonsils, or the face. A posi- 
tive Wassermann reaction or their yielding to antisyphilitic treatment will 
determine the diagnosis in doubtful cases. 
Enlargement of lymphatic glands caused by malignancy is, as a rule, of 
a slow and progressive nature. The glands may become painful, the pain 
being caused rather by the invasion of and attachment to the surrounding 34 
ORAL SURGERY 
structures, such as the bone, the skin or the muscles. They may become 
considerably enlarged and soften as a result of breaking down through 
central necrosis, or a supervening infection. In cases of malignancy many 
enlarged glands are found to be devoid of cancer cells. At this stage there 
are also other signs of malignancy. If the site of the malignant growth is 
not as yet discovered, this must be sought out. 
Lymphoma occurs more often as an individual 
enlarged gland—sometimes more than one—which 
chronically grows and becomes stationary. There are no disturbing 
symptoms, no systemic abnormality, and the blood picture may be 
normal. 
Primary lymphadenitis may occur as the enlarge- 
ment of an individual gland, but more often a 
larger number are affected, forming lobulated 
masses. The condition may be localized at first and may become widely 
distributed. The cervical glands are most often the first ones to be 
affected. The condition may be Hodgkin’s disease or lymphatic leucemia. 
There is no apparent etiologic factor, although some authorities believe 
that a secondary infection may serve as a basis for their development. 
The blood picture is helpful in differential diagnosis. 
Where there are no positive clinical signs or where the clinical signs 
are obscured, it is part of a proper technique to call in the aid of a pro- 
ficient pathologist. The advisability of this becomes even more urgent 
when we consider that besides the diseases to which the glands may suc- 
cumb in the performance of their function—acting as filters of the afferent 
lymph—they are subject to malignancy, not only through metastasis but 
sarcomatous growths may spring also from the lymphoid tissue of the 
lymph node or from the endothelial cells. 
The mandible and the maxillae should be closely scrutinized. Note: 
their formation and general outline; their symmetry and the nature of the 
asymmetry when this exists. In all abnormalities, whether of the bone or 
of the soft tissues, determine if this is a congenital or an acquired 
condition. 
In bone swellings, or tumors, note: the period of growth; the extent 
of the displacement of the parts; the nature and the degree of the de- 
formity of the osseous tissues; the degree and the nature of the reaction 
in the tissues involved; the extent and the nature of the involvement of 
the soft tissues; the presence of pain and the character of this when 
present; the condition of the teeth in the region of the lesion; the presence 
of crepitation or other signs of fracture; the nature and degree of the 
impaired function. 
Lymphoma. 
Primary 
Lymphadenitis. EXAMINATION AND DIAGNOSIS 
35 
The most common lesions in these regions are: abscesses, osteitis, 
osteoperiostitis, osteomyelitis, necrosis, cysts, fractures, impacted and 
supernumerary teeth with their complications, parotitis and diseases of 
the other salivary glands; also local manifestations of systemic diseases 
such as syphilis, tuberculosis, rickets, osteomalacia. 
In all lesions about the jaws in which the bone is structurally altered, 
radiographic examination is indispensable. 
The vermilion border of the lips is continuous 
with the oral mucosa and varies in different indi- 
viduals in size and shape. In a state of health, the lips are bright red in 
color and they can often be regarded as an index of the patient’s general 
health. They become pale in case of hemorrhage, especially internal hem- 
orrhage, anemia, parenchymatous nephritis, in aortic stenosis, and other 
vascular disturbances. They may become blue or cyanotic from cold, 
from asphyxia, an overdose of some of the coal tar sedatives, an overdose 
of nitrous oxid, in pneumonia and in some types of heart disease, such 
as valvular stenosis. 
In jaundice the lips may be of a yellowish tint; in lead poisoning they 
may present bluish patches upon their inner surfaces; brownish patches 
are suggestive of Addison’s disease. The lips are also subject to tremor 
in cases of prolonged debilitating diseases or alcoholism; to deformities 
and loss of function caused by Bell’s palsy, or paralysis of the facial 
nerve. 
Sores or ulcerations upon the lips may be purely local and may be 
caused by trauma or infection. 
Aphthous ulcers appear as small, circular, painful ulcers which tend 
to coalesce and often break down. 
Thrush is more common in young children than in adults, and appears 
as whitish streaks or patches, causing no ulceration when removed. Micro- 
scopic examination shows the presence of O'idium albicans. 
The lips are frequently the site of chancre (primary) or mucous 
patches (secondary lesions) of syphilis; leucoplakia, angioma, lymphan- 
gioma, herpes or fever sores, mucoid cysts, fissures, and epithelioma. 
Every persistent ulcer should be suspected as a probable luetic infec- 
tion or a precancerous condition. 
Chronic destructive ulcers, which commence in early life, are slow in 
their progress and are surrounded by soft nodules, some of which are 
breaking down, are characteristic of lupus. Other signs of tuberculosis 
should be sought for. 
Syphilitic rhagades appear at the angles of the mouth as chronic fis- 
sures, with a thin serumal discharge. 
The Lips. 36 
ORAL SURGERY 
Strumous hypertrophy—chronic thickening of the lips with eversion of 
the red border and ulceration of the mucosa, is often due to syphilis. 
Double lip or hypertrophic changes may also be congenital, or caused 
by enlargement of the lymphatic vessels. 
The lips are also subject to inflammatory diseases and congenital 
deformities, such as harelip. 
The gingiva, according to Black, is that portion 
of the oral mucoperiosteum which covers the alveo- 
lar ridges, and the gingival portion of the roots and crowns of the teeth. 
In a state of health, these tissues are of a dense texture and uniformly 
bright pink in color. The edges are finely scalloped and closely hug the 
necks of the teeth. 
The first evidence of disease in these tissues is probably a break in 
the gingival ligament. This cannot always be demonstrated clinically. In 
the more advanced inflammatory stages the gums become discolored, 
assuming a deep red, or cyanotic hue and become tumefied or spongy, with 
a tendency to bleed. This alteration in texture is often accompanied by a 
change in the outline, manifesting as hypertrophy, or atrophy and reces- 
sion, leaving part of the root of the tooth denuded. The formation of 
pockets and suppuration (pyorrhea) is an almost constant feature of these 
somatic changes. 
The gums are frequently the site of neoplasms, most of which are 
benign. Some of these, however, are malignant, semimalignant, or may 
have tendencies towards malignant degeneration, and must therefore be 
carefully observed and examined. 
The lesions enumerated above most frequently can be traced to some 
local causative agency. There are diseases of the gingiva in which con- 
stitutional conditions play an important part. 
In scurvy, the gingiva and the gums become swollen and spongy; 
they bleed readily, and, if the disease is not checked, the teeth become loose 
and eventually drop out. In mercurial or in lead poisoning, there is a 
bluish discoloration of the gingival tissues; they become exceedingly ten- 
der and painful; they bleed readily and lose their firmness of texture, 
becoming tumefied and spongy. Malnutrition, unbalanced diet, tuberculosis, 
the absorption or elimination of drugs, often result in changes or lesions 
of the gingiva in which the alveolus and the bone become progressively 
involved. 
In the various kinds of stomatitis, due to parasitic infections, the gingi- 
vae are almost invariably involved. In some of these, such as thrush, 
aphthous stomatitis, or the milder states of Vincent’s angina, they are only 
temporarily affected. In severer ulcerations, Vincent’s angina or trench 
The Gingiva. EXAMINATION AND DIAGNOSIS 
37 
mouth, a considerable amount of the soft and osseous tissues are destroyed, 
so that their original outline is never restored. 
The gums are continuous with the gingiva and 
cover the alveolar process and the hard palate. These 
tissues, like the gingiva, consist of mucoperiosteum and often are invaded 
by the extension of the lesion from the gingiva. They may also present 
lesions or signs of disease in which the gingiva is not involved. In their 
examination, note every irregularity in outline, every discoloration, points 
of tenderness or the yielding of the bone upon palpation. These always 
indicate the presence of pathological conditions. Sinuses are often clearly 
visible; some present as small depressions, others as small elevations or 
pimples and smaller or larger hypertrophied tissue rings. Still others are 
discovered only when, upon pressure, pus exudes through them. Sinuses 
should be carefully probed. The sites of sinuses and discoloration should 
always be critically examined and radiographed to determine the presence 
of abscesses, pericementomas, suppurative bone lesions, cysts, etc. 
The gums are quite often the site of neoplasms, leucoplakia, tubercu- 
lar or syphilitic lesions and parasitic infections which may affect the 
gingiva. 
The teeth are the most prolific sources for the 
formation of pathological conditions in the oral cav- 
ity. Morbid conditions about the teeth always manifest as localized lesions 
at first. I he lesion may be lodged in and confined to the tooth substance 
proper, or the investing and surrounding structures may be affected first 
and the tooth secondarily involved. It is noteworthy that most dental 
lesions proper are easily detected in their incipient stages. These could 
readily be corrected at first, but when neglected they become progressively 
larger and more difficult to remedy. Diseases of the teeth are rarely self- 
limiting ; through extension, the disease may, in a variable time, succes- 
sively involve some of the adjacent structures, or spread to remoter areas. 
Through metastasis, constitutional diseases or diseases of remote organs 
may develop. 
In the examination of the teeth, therefore, not only the obvious and 
troublesome lesions should be observed, but every predisposing or incipient 
condition, which may later lead to morbid degeneration, must be carefully 
noted and, whenever possible, corrected. 
In the examination, every tooth which should be present in a normal 
mouth must be accounted for. Isote: their occlusion, the correctness of 
their position in the arch, their formation; their structure, the development 
of the enamel, discoloration, the presence of caries, fillings, inlays and 
other prosthetic restorations. Note their firmness in the jaws, whether they 
The Gums. 
The Teeth. 38 
ORAL SURGERY 
are tender upon percussion; their response to physical tests, such as heat, 
cold and electricity; the formation of the surrounding alveolar ridges and 
other tissues; the condition of the edentulous parts. 
No oral examination is complete without a 
thorough radiographic examination of the teeth. In 
obscure cases, or where more than purely dental 
lesions are sought, the jaws and the sinuses must likewise be radiographed. 
Many pathological conditions or abnormalities may exist about the teeth, 
the jaws, or within the sinuses, sometimes for a period of years, without 
causing palpable signs or disturbing symptoms. On the other hand, there 
are numerous cases in which all the parts are so obviously normal that a 
radiographic examination is entirely superfluous. 
In the routine interpretation of oral or dental radiographs, numerous 
practitioners have fallen into the error that radiographic examination is 
the sole and absolute means of diagnosis and that the entire science in this 
connection devolves upon the differentiation of dark and light areas, or the 
presence and absence of so-called shadows. The assumption is that the 
darker areas (in the film) denote infection and the absence of such varia- 
tion in the film indicates the absence of, or freedom from pathological 
conditions. 
To those who, through a number of years, have been in the habit of 
identifying these radiographically demonstrable pathological lesions by 
comparison with the clinical findings, and who have combined this with a 
close observation of the macroscopic appearance and microscopic examina- 
tion, it must be evident that where diagnosis is rendered from radio- 
graphic interpretation alone, errors are inevitable. The fallacy of such a 
procedure does not end with the misinterpretation of the radiographs, as 
this often serves as a basis for therapeutic treatment and also surgical 
operations. 
To be accurate, it is sound policy, therefore, at all times to regard the 
radiograph as one of the most valuable accessories in diagnosis, but the 
findings must be compiled from this together with all other available data. 
A sound interpretation of radiographs must be based upon: (i) clinical 
examination; (2) a clear understanding of the anatomy of the parts 
radiographed; (3) knowledge of the coordinate relationship of the anatomi- 
cal structures when in a normal state: (4) differentiation of the tissues as 
denoted by the radiograph ; (5) the latitude of radiographic variation which 
may exist under normal conditions; (6) variations in the radiograph pro- 
duced by identical lesions; (7) identifying different pathological condi- 
tions in which the radiographs are similar; (8) a complete understanding 
of the pathological condition. From these data and experience derived 
Radiographic 
Examination. EXAMINATION AND DIAGNOSIS 
39 
from the handling or observation of other similar cases, treatment can be 
prescribed and the prognosis suggested. 
In the study of dental radiographs, the following structures pertaining 
to the tooth proper may be differentiated : (i) the enamel; (2) the dentin ; 
(3) the pulp chamber and the root canal; (4) the cementum, and 
(5) the peridental membrane. 
The conditions of the teeth and their lesions which may be investi- 
gated by means of the radiograph are: the formation, the size and the posi- 
tion of the tooth proper; the number, formation and direction of the roots ; 
obscure carious cavities; secondary caries underneath fillings ; pulp nodules ; 
retrograde or senile degeneration of the pulp; secondary dentin; absorption 
of the root; fracture of the tooth; perforation through the pulpal floor 
or the root canal wall; foreign bodies in the root canal. Sometimes early 
stages of caries of the enamel may be discerned. Often the proximity of 
a filling to the pulp may be judged. 
The cementum may present pathological absorp- 
tion at any point where a pathological condition 
exists; also hypercementosis, excementosis or cementoma. 
The peridental membrane may present a break 
in its attachment at the gingival margin. This may 
be due to traumatic injury; the irritation of a for- 
eign body, such as calcific or serumal deposits; some form of prosthesis or 
appliance, or it may be caused by septic irritation. There may be a thick- 
ening of the peridental membrane in which only part or all of this tissue 
is involved, which may be due to acute inflammation with the incidental 
enlargement and swelling of the part; it may be hypertrophy brought about 
by a milder chronic irritation, by excessive, inadequate, disordered, or 
lost function. The irritant may be traumatic injury; traumatic occlusion, 
which may be congenital or acquired through the improper coordination 
of fillings, inlays or any form of restoration; filling materials pushed 
through the side or the end of the root; broken instruments projecting into 
the tissues; chemical, toxic or septic irritants. Other pathological condi- 
tions commonly observed are: senile atrophy, pericementoma or dental 
granuloma; cystic degenerations. Lesions in which the gingiva or the 
gums are affected often create temporary or permanent impairment of the 
peridental membrane. The extent of degeneration or destruction of this 
tissue in pyorrhea can often be judged by means of the radiograph. 
The alveolar process may present partial or com- 
plete breaking down or pathological alteration. The 
pathological change may involve only a part which 
corresponds to a lesion in the soft tissues, or it may extend into the areas 
The Cementum. 
The Peridental 
Membrane. 
The Alveolar 
Process. 40 
ORAL SURGERY 
beyond. Here we often observe that similar or identical agencies create 
varying conditions, or that different agencies may create similar conditions 
as depicted by the radiograph. It is often observed, where we may justly 
assume the irritating factor to be infection, that hypertrophic and alsc 
atrophic changes may occur. 
Atrophic changes are characterized by breaking down of the peridenta 
lamella, indicated by its greater radiolucency in the radiograph, and 
variable invasion of the surrounding bone structures. In some cases this 
is very likely a mere alteration in the histological elements, which may 
be merely a temporary change in the chemical composition of the histolog- 
ical units of the tissues, which often returns to normal with the removal 
of the etiological factor. In others, there is a complete breaking down of 
the bone, which condition is often spoken of as a rarefied or decalcified 
area. That this last conception is erroneous in chronic cases is proven by 
the fact that upon exposing these regions, we find that these points are not 
occupied by decalcified bone, but most often by seemingly organized new 
tissue proliferations, such as pericementoma and cystic degeneration. 
The more common osseous change observed is hyperplasia of the peri- 
dental lamella. This is often spoken of as condensation osteitis, sclerosis, 
hypertrophy. Of the many theories as to the nature of this tissue change, 
the following two are the more acceptable ones: (i) that there is an in- 
crease in the calcium salt content; (2) that there is an increase in the bone 
lamellae, that is, a hyperplasia, or an increase in the histological elements 
which make up the bone. It is reasonable to assume that this osseous 
alteration is the result of the protective mechanism which is often observed 
in other regions in inflammatory or suppurative conditions in bone. The 
fact that upon the removal of the irritating agencies, the bone tends to 
return to normal, is in favor of this last supposition. 
The radiograph is helpful in the study of the nature and the extent of 
these bone lesions and tissue changes as to whether they are circumscribed 
or dififuse; whether there is involvement of the adjacent and surrounding 
structures and the extent thereof. 
The radiograph is also of inestimable value in the study of pathological 
conditions or abnormalities about the jaws and teeth, such as impacted 
teeth, supernumerary teeth; foreign or misplaced bodies; developmental 
or acquired abnormalities; periodontoclasia; fractures; necrosis; cysts ; 
salivary calculus; the examination of the sinuses; in the study of neo- 
plasms involving the bone, such as osteoma, odontoma, sarcoma, etc. 
Note the formation, the color, the outline of the 
papillae. The tongue may become coated as a result 
of gastro-intestinal derangements or local infection. 
The Tongue. EXAMINATION AND DIAGNOSIS 
41 
Thrush is more common in children and infants than in adults. It 
appears as milkish white deposits or streaks upon the dorsum or sides of 
the tongue, which can be readily scraped off without leaving an ulcerated 
or denuded surface. Microscopic examination shows the presence of 
O'idium albicans. 
Chancre and mucous patches appear as smaller and larger raised dirty- 
gray, opalescent ulcers with indurated base. Microscopic examination of 
the exudates shows the presence of Spirochseta pallida. There may also 
be submaxillary and cervical adenopathy. 
Leucoplakia appears as a whitish, glistening, raised patch, and may be 
well defined or irregular in outline. The papillae of the tongue are lack- 
ing at the site. In a percentage of cases it was found to have a syphilitic 
background although irritation is believed to be the direct cause, chiefly 
excessive use of tobacco. It has a tendency towards malignant degenera- 
tion, and when furrows or points of breaking down present, radical sur- 
gical measures are indicated. 
Papilloma appears as a pinkish projection upon the dorsum or about 
the edges of the tongue. They are not ulcerating, are not indurated, and 
may present a constricted or pedunculated base. 
Epithelioma of the tongue is believed to be caused by some form of 
irritation. The most frequent causes are: sharp edges of the teeth, den- 
tures, excessive use of tobacco, etc. Such etiological factors cannot always 
be traced. Even smaller, innocent looking ulcerations or growths which 
appear different in color and texture from the tongue, having a somewhat 
granular surface, and indurated base, should be suspected as being a 
precancerous or cancerous condition. 
Herpes or herpatic ulcers appear as small white blisters upon the tip 
or about the edges of the tongue. They are painful and when they break 
down the ulcer presents a punched out appearance. 
Traumatic ulcers are due to some form of traumatic injury, such as 
biting of the tongue, or the irritation of a sharp tooth or denture. These 
usually present an irregular, ragged appearance, but there are no enlarged 
glands. With the removal of the irritant, the ulcer heals very readily. 
Furrowed fissures and superficial cracks along the edges or upon the 
dorsum of the tongue, with the intervening tissues in a healthy state, are 
suggestive of syphilis, especially if they are recurrent. 
Gumma of the tongue occurs as an indurated hard mass at first, which 
may eventually break down. The ulcer so formed presents a dirty-gray 
sloughing appearance and is not painful, as a rule. 
Tuberculosis of the tongue may present circumscribed submucous 
nodules, which may eventually break down and ulcerate. Tubercular 42 
ORAL SURGERY 
ulcers may be single or multiple. They are not indurated; they present 
overlapping edges and a punched-out appearance. It is believed to be 
caused by infections from the sputum. Other signs of tuberculosis are 
helpful in making the diagnosis. 
Geographical tongue is characterized by crescentic or circular des- 
quamated patches. The patches may be single or multiple and may be 
localized upon the dorsum or along the edges of the tongue. They may 
come and go and may be altered in form and size very suddenly. They 
may display a degree of sensitiveness or burning sensation. The etiology 
is unknown. Gastro-intestinal disorders and heredity are suggested. 
Syphilis is not responsible. 
Black tongue (lingua nigrce). This is not always a constant affection 
and may come and go with no apparent reason. It appears as brownish 
or black patches upon the posterior part of the dorsum of the tongue, in 
the region of the circumvallate papillse. The etiology is not known. It 
is believed that the filliform papillse become hornified and pigmented; 
others believe that it is congenital in origin; still others believe that it may 
be caused by a mold and also found in syphilis and diabetes. 
Glossitis, acute, may be caused by infection or injury, mercurialism, 
iodism. The condition is usually painful and is accompanied by fever and 
other constitutional symptoms. 
Macroglossia is a congenital affection, in which half of or the entire 
tongue is enlarged. The papillse may also become enlarged. The surface 
may present elevations which are believed to be caused by enlarged or 
dilated lymphatics. The tongue may attain such large size that the lower 
jaw becomes deformed from its pressure. 
The tongue may also be the seat of abscess, angioma, benign growths, 
such as fibroma, papilloma, cysts. 
The floor of the mouth is frequently the site of 
pathological conditions. These may originate in the 
structures of the region or may result as an exten- 
sion from the adjacent and surrounding areas. Inflammatory, acute lesions 
are often caused by the spreading of infection from the alveolus or from 
about the teeth; sepsis, following operations about the teeth or upon the 
jaws; septic injections of a local anesthetic; excessive operative trauma. 
Salivary calculus and obstructions of some of the glands almost always 
give rise to inflammatory symptoms and subsequent suppuration. Other 
pathological conditions are cystic degeneration of the submaxillary gland 
ranula and mucoid cysts. These last conditions are, as a rule, not painful 
and are rarely inflammatory. 
Malignancy is more frequent as an extension from the tongue, the 
The Floor of 
the Mouth. EXAMINATION AND DIAGNOSIS 
43 
jaws, the fauces, but may also spring from the tissues constituting or 
lodged in the floor of the mouth proper, or from the salivary glands. 
Other lesions found are leucoplakia, angioma, ulcerative and specific 
lesions. 
Trismus or locked jaw is the partial inability to 
open the mouth and pain is experienced upon doing 
so. This should be differentiated from true 
ankylosis. 
Trismus of the jaws may be extra-articular or intra-articular. The 
extra-articular types, as a rule, are acute and are more common. In most 
instances they are caused by the extension of inflammation from injuries 
or diseases of the adjacent or associated tissues and structures. The most 
frequent etiological causes are acute abscesses of the teeth, particularly 
lower third molars. Less frequently, similar conditions may arise from 
the upper teeth and the muscles of mastication may become directly or in- 
directly involved. Other acute causes are abscesses of the soft palate; 
tonsillar and peritonsillar abscesses; abscesses caused by septic injections 
in the mandibular region ; parotitis ; faulty technique in the practice of con- 
duction anesthesia; postoperative trauma; traumatic injuries caused by 
external violence; fracture of the ramus or the neck of the condyle. 
Intra-articular conditions may develop as a result of extension of 
inflammation to the structures of the joint proper, or, in rare instances, 
the extension of the suppurative condition, causing absorption of the 
articular surfaces. There may be a limited motion of the jaws and pain 
upon so doing, accompanied by a slight grating, which may be appreciated 
by the examiner; this is indicative of arthritis. 
Reflex trismus may exist as a result of trifacial neuralgia or facial 
neuralgia caused by diseases or abnormalities about the face and jaws, 
particularly impacted lower third molars. 
Extra-articular, false ankylosis, is characterized by limited motion of 
the jaws. As a rule there is no acute inflammation causing it, and it is 
painless. The most frequent causes are cicatrices following deep ulcera- 
tion due to malignancy, syphilis, scarlet fever, etc., or following injuries 
and surgical operations. In some instances this may be traced to deform- 
ities following early traumatic injuries. 
True ankylosis is characterized by complete or a very limited motion 
of the jaws. The condition is always chronic and can be traced to some 
early trauma in most instances. The attempt should be made to determine 
whether the condition is unilateral or bilateral; whether it is intra-articular 
or extra-articular. In unilateral cases the affected side appears more 
rounded, while the normal side appears to be flattened. The ramus of 
The Temporo- 
Mandibular 
Articulation. 44 
ORAL SURGERY 
the affected side may also appear to be slightly shorter. The radiograph 
is very helpful in confirming the diagnosis. 
Subluxation of the temporomandibular joint is attended with a dis- 
tinct crepitus or more often a click. The sound produced can sometimes 
be heard even at a distance, and movement of the joint may or may not 
be painful. The condition is often observed to follow excessively force- 
ful opening of the mouth in yawning or after lengthy dental operations. 
The condition may become corrected of its own accord, or it may remain 
permanently. 
If, in the absence of localized symptoms, or operative history, the 
muscles closing the jaws become rigid, and there are severe painful spasms 
which extend to the muscles of the trunk, tetanus should be suspected. 
Dislocation of the jaws is almost always forward and bilateral. It is 
characterized by inability to close the mouth, and its staying ajar. 
Offensive breath is most frequently due to local- 
ized conditions or diseases lodged in the oral cavity. 
The most frequent causes are: carious teeth, poorly executed restorations 
in the way of fillings or artificial crowns, ill-fitting dentures, particularly 
bridgework of the fixed type, which permits of no cleansing ; the decom- 
position of food particles wedged into carious teeth, into the interdental 
spaces, or adhering to prosthetic restorations. Other local causes are sup- 
purative conditions in the way of chronic abscesses or infected cysts, com- 
municating with the oral cavity; periodontoclasia; the various forms of 
stomatitis; necrosis of the jaws; diseases of the tonsils; adenoids, syphi- 
litic gumma; empyema or malignancy of the maxillary sinus; malignancy 
of any of the tissues of the oral cavity, of the pharynx, of the larynx; 
indigestion and gastric disturbances; stomach ulcer and malignancy of 
the stomach; diseases of the liver; abscessed conditions of the lungs. 
A sweetish breath is observed in individuals suffering from diabetes; 
a urinous odor in uremia; in diphtheria and in most of the febrile diseases 
the breath has a peculiar and often characteristic odor. 
In the further examination of the oral cavity, our attention should 
be extended to the parietes, the hard and soft palate, the tonsils, the 
pharynx, and all other associated structures. A partial examination and a 
diagnosis based thereon is often less helpful to the patient than no 
examination. We should be guarded in expressing an opinion in reference 
to structures with which we are not thoroughly familiar, but dealing 
with those structures or parts in which unqualified reliance is placed 
upon our examination our diagnosis must be complete from every stand- 
point. In obscure cases our findings should be coordinated with those of 
other specialists. Examination of the teeth proper should be supple- 
Offensive Breath. EXAMINATION AND DIAGNOSIS 
45 
merited with the investigation of all related structures, and the pneumatic 
cavities of the head, by means of radiographs and transillumination. 
Numerous pathological lesions, though widely different in character, pre- 
sent symptoms and signs which are similar in their clinical manifestations. 
1 he differential diagnosis is most vividly aided by detailed and close 
study of individual cases. 
Complete records should be kept of every case that may come under 
our care. Well kept records tend to broaden our knowledge by making 
it so much more possible to understand the progressive stages of a disease. 
They are also of great value as a matter of reference. CHAPTER III. 
Hemorrhage. 
Hemorrhage is the escape of blood from its proper channels. This 
may arise from wounds of the arteries, veins, or capillaries. 
The causes of hemorrhage are: direct injury caused by accidental 
trauma; surgical operations; irritation of foreign bodies or loose frag- 
ments of bone; pressure, followed by necrosis of the soft tissues; sepsis 
and the spreading of infection; invasion of malignant growths. 
Hemorrhage following minor operations upon the structures of the 
oral cavity proper is rarely troublesome in the largest proportion of 
the normal run of cases. In operations upon the deeper portions of the 
mandible or the maxilla, upon the tongue, the sublingual structures, the 
maxillary sinus, upon the soft palate, or upon the lips, hemorrhage may 
be considerable. In some instances even the removal of a tooth is followed 
by hemorrhage which is difficult to control, and the untoward complica- 
tions are much more severe than such minor operations would warrant. 
The cases which are prone to give rise to complications of hemorrhagic 
nature may be stated to be of three classes: (i) those cases in which the 
soft or osseous parts bleed as a result of the surgical trauma; (2) patients 
who are suffering from constitutional dyscrasia which prevents the normal 
coagulation of the blood; (3) hemophiliacs or congenital bleeders. 
It may be stated that hemorrhage in operations performed anterior to 
the bicuspid teeth is less likely to be excessive than in those performed 
posterior to these teeth. Following up the reports of the recent war * it 
was found that even in extensive, disastrous oral and facial mutilations, 
such as we but rarely encounter in civil practice, a comparatively small 
percentage of cases was complicated with severe hemorrhage. Some of 
these were controlled only after the ligation of the external carotid artery, 
and a small number, despite all controlling efforts, terminated fatally. 
Taking the normal individual as our standard, there are three elements 
to consider in the prognosis of a case: (1) the amount of blood lost; 
(2) the rate of loss; and (3) the blood pressure. 
* Kazanjan, Valadir. 
46 HEMORRHAGE 
47 
Henderson, in a series of experiments upon 53 
dogs, found that if the animal was bled 0.25% of 
its body weight every five minutes for one or two 
hours, until the blood pressure had fallen to about 28 mm. and the animal 
was left alone, the chances of recovery or death were about equal. Those 
that were bled to even a slightly less degree survived. All of those which 
were bled at this rate, or even a slightly greater degree, died within two or 
three hours, or even less time, after the termination of the hemorrhage.* 
The results of these experiments are not to be regarded as definite 
standards to be guided by, however, as there are numerous other condi- 
tions which must enter into our considerations in this connection. Some 
surgeons believe that in strong, healthy adults the loss of half of the total 
amount of blood is certain to be fatal. In some young children, even a 
slight loss of blood may be fatal. Old, fat, weak, anemic individuals, or 
those suffering from debilitating diseases, are very susceptible to the loss 
of blood, and the more rapidly the hemorrhage takes place the more dan- 
gerous it is. 
The theories regarding the direct cause of de- 
pression and death following severe hemorrhage 
vary. From an extensive series of experiments, 
Crile concludes that: “It may be assumed that the 
primary factor is anemia with a consequent lessening of the immediate 
nutrition of the active physiological mechanism for the maintenance of 
the normal blood pressure.” ** Among the secondary factors Crile places 
the failure of the vasomotor center first. Henderson and Mann hold the 
view that, as the peripheral reservoirs are depleted, the venous return to 
the right auricle of the heart is reduced and finally becomes inadequate.*** 
As the left ventricle of the heart can discharge into the arteries only the 
amount of blood which flows into the right auricle from the veins, the 
weakened pulse, the decreased blood stream, the lowered blood pressure 
are the resulting consequences. 
The treatment and untoward results in severe cases of hemorrhage 
seem to indicate, however, that the mechanical failing of the circulation in 
itself does not explain all of the phenomena which occur. Thus, it has 
been found that the infusion of saline solution, intended to overcome this 
particular defect, gives only temporary relief, and it soon passes from the 
blood vessels into the tissues. Bailiss and his collaborators attempted to 
overcome this tendency by modifying the saline solution with gum acacia. 
Effects of 
Hemorrhages. 
Causes of Death 
Following 
Hemorrhage. 
♦Henderson and Haggard, Journ. A. M. A., Mar., 1921. 
** Crile, Surgical Shock. 
*** Henderson and Mann, Journ. A. M. A., Mar. 11, 1922. 48 
ORAL SURGERY 
The properties of this solution more closely resemble that of the plasma 
of the blood; nevertheless it was found to he equally inadequate. Blood 
transfusion alone has given lasting and satisfactory results. This strongly 
suggests, therefore, that besides the mechanics of circulation, the chemical 
and vitalizing properties of the circulating fluid are of paramount impor- 
tance in the maintenance of life. 
Henderson * believes that a sufficient role has not been ascribed to the 
loss of the red blood corpuscles and that the effects of hemorrhage must 
be considered not only from the standpoint of circulation but also from 
that of respiration and energetics. Hemorrhage, according to this in- 
vestigator, produces a condition which may be regarded as a form of air- 
hunger—a symptom of asphyxia. Acidosis, or the concentration of the 
H-ion, is created as a result of inadequate oxidation, through the breaking 
down of the carbonic acid and sodium bicarbonate balance which normally 
exists in the animal body. 
Hemorrhage may be; (1) primary; (2) reactionary; and (3) sec- 
ondary. 
Primary hemorrhage begins with the operation and continues after 
this has terminated. In normal individuals, when operating upon the jaws 
proper, this occurs but very rarely, unless a large blood vessel is severed 
or injured, such as the posterior palatine, the inferior dental, the facial, 
or the coronary artery in operating about or upon the lips. Yet, in rare 
cases, even the removal of a tooth is followed by a persistent, uncontrol- 
lable hemorrhage, so that the patient’s health or life may become endan- 
gered and even fatal terminations have been recorded. 
Reactionary or delayed hemorrhages are just as irksome as they are 
troublesome. Where the patient’s history or some existing dyscrasia 
indicates, proper precautions must be taken to prevent it. In the oral 
cavity this is more likely to follow operations under local than under 
general anesthetics, when immediate steps may be taken to control a bleed- 
ing surface or vessel. The suprarenin content of the local anesthetic, on 
the other hand, acts as a temporary hemostatic and with the wearing off of 
this effect, hemorrhage may occur. 
When a patient is in the hospital, a capillary hemorrhage is not, as a 
rule, of immediate or grave concern, as the rate of flow is usually slow 
and is easily controlled. Most of these patients, however, are ambulatory 
cases and their homes may be at a distant or inaccessible place or out of 
town. It is judicious precaution to permit no patient to leave the office 
until the hemorrhage is absolutely under control. 
Secondary hemorrhages occur as a result of insecurely ligating a 
* Henderson and Mann, Journ. A. M. A., Mar. n, 1922. HEMORRHAGE 
49 
severed vessel, undue lacerations of the soft tissues, comminution of the 
bone and mangling of the structures operated upon; sepsis; sloughing of 
the tissues resulting from undue trauma; the action of a toxic drug or 
toxic dose or toxic concentration of a less toxic drug used as a local 
anesthetic. It may also occur following operations in which large areas 
of bone become denuded or exposed, as in large cyst cavities or operations 
upon the maxillary sinus; in operations upon the hard or soft palate or 
in the sublingual areas. 
The treatment of hemorrhage may be divided 
into five phases: (i) prevention; (2) immediate 
treatment; (3) the prevention of recurrence; (4) 
operative treatment; (5) the recovery of the patient. 
Hemostatic agents comprise: (1) ligatures and sutures; (2) torsion; 
(3) acupressure; (4) pressure and compression; (5) the use of drugs in 
the way of styptics, or hemostatics which may be applied locally or those 
which may be administered hypodermatically, intravenously or by 
ingestion. 
In the treatment of hemorrhage we must recognize first the point where 
the blood issues from. When this is obscure, palpation of the soft parts 
or digital pressure upon the vessel, distal to the bleeding point, will stop 
the hemorrhage if this is lodged in the soft tissues or between the 
overlying soft tissues and the bone. If the rate of flow cannot be 
influenced with digital manipulation we may conclude that the hemor- 
rhage very likely comes from the bone or a vessel which has not been 
reached. 
In operating upon the face, jaws, or upon any tissues of the oral cavity, 
we should consider: (1) the tissues which are attached to or associated 
with the bones, such as muscles, fascia, integument, etc.; (2) the muco- 
periosteum which is closely stretched over the bone and (3) the osseous 
tissues. Ihese parts and their vascular supply must be clearly understood, 
as the treatment of the hemorrhage is in a large degree determined by: 
(1) the degree and nature of the hemorrhage; (2) the location; and (3) 
the type of tissue in which the hemorrhage occurs. 
I he most frequent and troublesome source of hemorrhage in opera- 
tions in the oral cavity is capillary ooze from both the hard and soft tis- 
sues. This, in many instances, is very persistent and profuse and entirely 
out of proportion to the extent of the operation or the injury, and may 
occur as a primary, reactionary, or secondary hemorrhage. 
Compression of the tissues and direct persistent pressure upon the 
bleeding surface, in most instances, will control the hemorrhage, even in 
cases of hemophilia or in the presence of other constitutional dyscrasia in 
Treatment of 
Hemorrhage. 50 
ORAL SURGERY 
which the coagulation of the blood is delayed. The method of doing this 
could perhaps be best illustrated by the citation of a case in point. 
The patient was a male, white, 23 years of age. 
Medical examination disclosed no functional nor 
organic abnormality. He gave a history of persistent hemorrhage from 
severe injuries or cuts. He had had his upper right bicuspids and 
first molar removed, under nitrous oxid-oxygen anesthesia, four days be- 
fore I saw him. There was a moderate amount of bleeding for the first 
six hours and thereafter it stopped, though not completely, for about 
eight hours. After this the bleeding became quite profuse and a physician, 
who was present at the extraction, was called to the aid of the dentist on 
the case. The bleeding continued for three nights and three days, with 
slight temporary remissions, when the writer was invited in for consulta- 
tion. The patient was found lying in bed. He was dull and listless and 
seemed considerably exhausted. He was extremely pale, his eyes were 
dull and expressionless, his skin cold and clammy, the pulse rapid and of 
poor quality, and respiration slightly labored. The temperature was 
slightly below normal, 970 F. The physician stated that he had been trying 
to supply all the nourishment the patient would retain. Saline hypo- 
dermoclysis had been given several times and considerable quantities of 
thromboplastin were hypodermatically administered; the latter was also 
locally applied, with only slight periodical, incomplete stoppage of the flow 
for brief periods. 
Upon examination, I found the tooth sockets quite open, with a wad 
of absorbent cotton thrust in, with the larger part projecting outside the 
lips of the wound. This was saturated with blood clot, mixed with saliva 
and food, and was rather dirty and foul smelling. I explained that I 
would try to control the hemorrhage with local treatment, and if this 
failed in three to five hours, owing to the rather bad state of the patient, it 
would be advisable to transfer him to a hospital, that blood transfusion 
might be performed. The wad of cotton was removed, and with palpation 
it was ascertained that the largest degree of bleeding came from the palatal 
aspect. Pressure was exerted upon this point with a sterile sponge, held 
with a pair of thumb forceps, while the wound was cleaned of all foreign 
substances with a quite warm solution of peroxid of hydrogen. Peroxid 
of hydrogen, applied in this manner, has some degree of hemostatic prop- 
erties. The clot occupying the deeper portion of the wound was not 
disturbed. The jagged edges of the bone were trimmed away next with 
a pair of rongeur forceps, just sufficiently to prevent them from lacerating 
the overlying gums. A piece of iodoform gauze was saturated with 
adrenalin chlorid and packed firmly into the wound and the gums were 
Case History. HEMORRHAGE 
51 
pressed firmly over this; the tissues were compressed next with a gauze 
sponge: all this while the assistant, with a gauze pad and finger pressure, 
held down firmly the anterior palatine artery. During this time a piece of 
modeling composition was softened and molded next over the area, 
bringing this up considerably both on the palatine and buccal surfaces. 
The patient was asked to bite upon this, without completely closing the 
teeth; the compound was slightly chilled and the patient asked to bite 
down a little more, without, however, completely closing the teeth. While 
doing this, the compound was firmly pressed down with the fingers on the 
buccal side and the patient did the same with his tongue on the 
palatal side. Now the compound was chilled completely and the patient 
requested to bite down firmly. To secure constant pressure and to aid the 
strain upon the muscles, a Barton bandage was put on. The patient was 
fed through a glass tube with liquid food, such as eggnog, milk, broth, 
etc. After staying at the bedside for two hours, no bleeding whatever 
was noted. After twenty-four hours there was scarcely a trace of blood 
in the saliva. The compound was gently lifted off. The iodoform gauze 
packing within the wound was not disturbed at all, but the outer gauze 
layer was replaced with a fresh one, saturated with adrenalin chlorid. 
The compound was replaced and the biting pressure secured again with a 
bandage. This maneuver was repeated for three days and on the fourth, 
the inner iodoform pack was loosened with a warm peroxid solution and 
removed without inducing hemorrhage. The compression of the tissues 
was continued for an entire week, when healing was fairly well under way. 
The error that a number of men make is that they thrust a portion of 
cotton, saturated with a styptic, into the wound, which, thanks to the 
temporary action of the medicament, seems to abate the hemorrhage. With 
the passing off of this, the swelling cotton wad tends to spread the tissues 
and practically acts as a wick. In the method above described, direct 
pressure and also compression is exercised. Ligating of the anterior 
palatine artery did not seem advisable in this case, for fear that hemorrhage 
at the stitches might further complicate the case. 
When operating upon a clearly exposed bone 
surface, a severed vessel is indicated as a spurting 
jet or pulsating welling up of the blood. A severed 
vessel lodged in the bone substance can often be 
stopped by a rotary crushing force, applied over the bleeding point with a 
blunt instrument, such as a curette. In many instances a spurting vessel 
will stop with no interference whatever, because of its retraction, the 
formation of a hlood clot and the pressure of the unyielding walls of the 
channel in which it lodges. This often occurs even in instances where 
Treatment 
of Severed 
Blood Vessels. 52 
ORAL SURGERY 
larger vessels are severed, as it is often observed in complete fractures of 
the mandible. The structures contained in the mandibular canal are com- 
pletely torn and yet complications from hemorrhage are very rare. In the 
removal of larger cysts or other pathological conditions in which the 
inferior dental canal is involved, it is good practice to clear the posterior 
parts first and stop off the canal by means of gauze packing which may 
be saturated with adrenalin chlorid. This will greatly decrease the loss 
of blood and will also secure a clearer field of operation. 
Capillary ooze from bone tissue during operation 
can best be controlled by pressure. The ooze may 
be confined to some parts only, or the entire exposed surface may bleed. 
Pressure may be exerted by means of sponges held down for a few min- 
utes until the area is cleared and the operation may be proceeded with. 
Where the operation is a prolonged one, sterile hot water may be applied 
upon sponges. The water is kept handy in an enamel basin. The same 
method may be applied to control hemorrhage of the gums and other soft 
tissues where the hemorrhage is not very profuse. 
When operating upon the soft tissues of the oral 
cavity, upon the lips or the face, or when large 
portions of the gums are detached from the bone 
during operation, bleeding vessels are best secured with catgut ligatures. 
Because of inaccessibility of some of the parts, or because of the retraction 
of the severed vessel, acupressure is often more expedient. This consists 
in first determining the point where the vessel lodges and by passing a 
ligature about the tissues containing it the compression of the tissues will 
stop the hemorrhage. This method often has been successfully employed 
in instances where the branches of the anterior palatine artery have be- 
come severed through too extensive lacerations in the removal of upper 
molars. A needle, conforming to the curvature of the palate, is passed be- 
tween the mucoperiosteum and the bone and the constriction of the silk 
or catgut ligature will arrest the hemorrhage. 
In the removal of teeth, the tooth socket becomes 
filled with a blood clot which acts as a tampon and 
also protects the deeper parts of the wound from 
infection by the ever present microorganisms. It 
is good policy to thoroughly compress the tissues, as in many instances the 
alveolus is essentially spread, split or fractured in the removal of the 
tooth. By compressing this, the wound is decreased and therefore the 
healing will be more prompt, the jagged outline of the wound is in a great 
degree corrected and this will also aid hemostasis. The wound should 
always be closely inspected and loose portions of the alveolus removed; 
Capillary Ooze. 
Bleeding Vessels 
in Soft Tissues. 
Treatment of 
Root Sockets 
After Extraction. HEMORRHAGE 
53 
frayed or torn portions of the soft tissues should be trimmed away. In 
many instances, where the bleeding is likely to he troublesome, cold or 
hot water irrigation, as cold or as hot as the patient can bear, will aid in 
inducing hemostasis. Where the bleeding does not seem to stop with 
these measures, it is a good plan to pack the cavity with iodoform gauze, 
saturated with adrenalin chlorid, 1-1,000. Place a gauze plug over the 
wound and let the patient firmly bite upon this. The patient is kept in the 
office for about ten or fifteen minutes, when it will be found that the 
bleeding ceases in most instances. Particular precautions should be taken, 
however, in patients who are suffering from hemophilia, leucemia, purpura, 
anemia or some other dyscrasia in which the coagulation of the blood may 
be delayed. 
Hemophiliacs, or congenital bleeders, are indi- 
viduals in whom the coagulation of the blood is pre- 
vented or unduly retarded because of some inherent, probably chemical, 
deficiency of the blood constituents. 
Nasse, who was one of the first investigators of this affliction, formu- 
lated the law that the malady is limited to the male and is transmitted 
through the unaffected female offspring to the male progeny. 
Morawitz and Lessen state that the delay in 
coagulation is due to a deficiency of fibrin ferment 
factors, especially thrombokinase. Duke believed 
that uncontrollable hemorrhage is due to insufficient blood platelets and 
advised blood transfusion. Still others believe that there is a lack of cal- 
cium which plays an important part in the coagulation of blood, and the 
inability of some individuals to assimilate the calcium content from the 
food taken. (Kahn.) Wright held that lack of calcium salts in the blood 
is the cause. 
Very often the surgeon has to operate upon a 
patient without knowing that he is suffering from a 
constitutional malady which makes hemostasis dif- 
ficult. It should be remembered therefore that evidences of this affliction 
are noted in early infancy. The most common characteristic is severe 
hemorrhage from injuries or bruises which would scarcely bleed in normal 
individuals. Epistaxis and swelling of the joints is common among 
bleeders and they usually give a history that small cuts or minor operations, 
such as the removal of a tooth, have been followed by severe uncontrollable 
hemorrhage. A single instance of hemorrhage, however severe, does not 
necessarily determine hemophilia. 
In doubtful cases, it is good practice to test the blood of the individual. 
The blood specimen is best taken from a vein by means of a hollow needle, 
Hemophilia. 
Causes of 
Hemophilia. 
Symptoms of 
Hemophilia. 54 
ORAL SURGERY 
as the capillary blood taken from the skin, with its admixture of tissue 
juice, may fail to show the characteristic delay in coagulation. Normal 
blood, drawn in a clean test tube, usually clots in twenty to forty minutes, 
at room temperature. 
To test the coagulability of the blood, Duke's modification of Williams’s 
method is most acceptable for office practice. A microscopic glass slide 
is mounted with two small glass disks, five millimeters in diameter. Drops 
of blood, large enough to cover the disks, are taken and the slide in in- 
verted over a glass of warm water, 38° C. After the coagulation has pro- 
ceeded to a degree the form of the drops will not change if the slide is 
held in a vertical position. Normal blood, under these circumstances, clots 
in six to nine minutes. 
Hemostatic agents or styptics applied locally are 
of little real value in hemophilia. Their use may be 
helpful as a temporary measure or in combination with other means. The 
application of adrenalin chlorid is very valuable but is often followed by 
even more severe reaction unless it is combined with pressure and com- 
pression. Searing the bleeding surface with a hot (not glowing) steel 
cautery may prove effective in giving temporary relief. The local applica- 
tion of serum or thrombokinase is often valuable, but the attempt should 
be made to force these into the bleeding tissues by gentle massaging. 
Sayer * reported cases in which he succeeded in stopping severe hemor- 
rhage by applying his own blood to the bleeding tissues. Other cases have 
also been reported where persistent hemorrhage was arrested by this 
means. This rather suggests that the agents essential to the coagulation 
of the blood can be absorbed in this way. 
Fresh human serum has long been considered as the most effective 
agent for controlling all kinds of severe hemorrhage. Fresh sera from 
lower animals, such as the ox, sheep, horse, goat, have also been found to 
be very valuable. The dosage depends upon the individual case. Usually 
100 c.c. is given subcutaneously the first day, the dose being diminished 
from day to day. Intravenously a smaller quantity is sufficient, as no part 
is absorbed by the tissues. Baum considers that serum is indicated in all 
cases of hemorrhage except true hemophilia. In securing the serum the 
donor must be healthy. Wassermann reaction should be made. A hollow 
needle, the size used for a Wassermann reaction, is plunged into the median 
basilic vein and the blood is collected in a flask. The flask is placed in a 
slanting position and left there for six hours. After this the serum will 
have separated and is ready for use. 
As a preventive measure in cases of hemophilia, blood transfusion was 
Treatment. 
* Journal A. M. A., Jan. 13, 1912. HEMORRHAGE 
55 
used by Meyer in jaundice. Human serum may be administered subcu- 
taneously, 30 c.c. three times a day the first day and 30 c.c. each day for 
three days before the operation. This dosage may be decreased when 
administered intravenously. Calcium lactate or calcium chlorid, 30 to 35 
grains in 5 to 7 grain doses, may he taken by ingestion during the twenty- 
four hours before the operation. This, combined with thorough packing 
off of the wound or other local measures for hemostasis, has been success- 
fully used in numerous cases by the writer. CHAPTER IV. 
Inflammation. 
A change in the environmental conditions vital to an organism consti- 
tutes a stimulus, and calls forth a characteristic reaction. If a stimulus 
is below the threshold of irritability of the protoplasm of the cell, the 
characteristic reaction does not occur; if the stimulus is within what 
might be termed the normal range, the response is functional. If the 
change is excessive, the stimulus becomes an irritant and may have a de- 
leterious effect upon the tissues of the organism, and the reaction that takes 
place becomes an inflammatory reaction. 
The irritant may be a mechanical injury; it may be extremes of tem- 
perature, the effect of radiant energy as from the Roentgen ray, chem- 
ical substances, electricity and sepsis or bacteria. Bacteria may act as 
mechanical irritants or may produce substances which cause chemical 
irritation. These agents rarely act singly. Traumatic injuries are nearly 
always accompanied, or succeeded by bacterial invasion, and a combination 
of any of the others may coexist. 
The severity and course of the inflammation depends upon (i) the 
kind of irritant; (2) its intensity; (3) the extent of tissue subjected to it; 
and (4) the length of time that the irritating action is in force. Time is 
relatively more telling than the intensity of an irritant, and a compara- 
tively slight irritation, continued through a longer period of time, will give 
rise to a disproportionately intense inflammatory reaction. This is true 
of all types of stimuli, and what may be a slight stimulus at first becomes 
a severe irritant if prolonged or repeated. 
In bacterial invasion, besides these, a number of other elements which 
control the nature and intensity of the reaction must he considered. These 
are the number and virulence of the microorganisms antagonized by the 
vital resistance of the host, and the elaboration of substances which are 
inimical to bacterial growth and capable of neutralizing their toxic 
products. 
The phenomena of an inflammatory reaction are more conveniently 
56 INFLAMMATION 
57 
explained by their arbitrary division into a number of stages. It must be 
remembered, however, that no definite lines of demarcation exist and 
that the process is a continuous one; that throughout almost its entire 
duration all of the phenomena may he present in the whole or in different 
parts of the same lesion. 
The first stage of inflammation is marked by 
hyperemia. Hyperemia is an intravascular change 
in which an increased amount of blood is present in the vessels of a 
part. Ordinarily it may be produced in two ways. If there is an ob- 
struction to the venous drainage of a capillary system we have a passive 
congestion in the affected part—so-called passive hyperemia. If the 
venous drainage is not affected, but there is an increased arterial supply 
to the part, this also causes congestion; but in this case it is termed active 
hyperemia. Hyperemia which occurs in an acute inflammatory process 
is of the latter or active type. The phenomena can be demonstrated by 
experimental irritation of membranes under the microscope. In these ex- 
periments the mesentery of a frog or the wing of a bat is commonly used; 
in these tissues the capillaries, the arterioles, and the circulation of the 
blood are plainly seen, and when an irritant is applied, the entire course 
of the reaction may be directly observed. 
At first there occurs a slight and rapidly disappearing constriction of 
the arterioles, which is succeeded immediately by a relaxation of these 
vessels. The increased blood supply causes enlargement of the capillaries, 
and this is the active hyperemia of inflammation. In a variable time the 
observer will note that an adhesive cjuality appears to develop between 
the white blood corpuscles and the capillary wall. Occasional cells cling 
to the wall for a moment and then are swept along with the blood current. 
This adhesive quality becomes more and more marked; the occasional 
cells become more numerous and remain adherent, until the dilated capil- 
lary wall is covered with so thick a layer of white blood cells that the 
rapidity of the blood stream is retarded. The next phenomenon leads to 
the assumption that another change has taken place in the vessel wall— 
an increase in its permeability, which permits the passage of the white 
blood cells into the surrounding tissue spaces. The process of these 
ameboid cells leaving the capillary is called migration of the leucocytes. 
In this manner great numbers of leucocytes infiltrate the tissues of the 
inflamed area. This is accompanied by exudation of fibrinous coagulable 
serum, and the emigration of red blood cells or so-called diapedesis. 
These experimental observations help us to understand the clinical 
symptoms of inflammation which, in the classical description, comprise 
redness, heat, swelling, pain and impaired function. The redness is caused 
Hyperemia. 58 
ORAL SURGERY 
by hyperemia. The increased temperature is explained by the greater 
influx of blood and its rapid flow through the enlarged capillaries from 
the comparatively warmer interior of the body. The temperature of an 
inflamed outer surface is perceptible only by comparison, and is never 
above that of the internal organs. The hyperemia, with the exuded 
fibrinous serum, causes a swelling of the tissues, which, in typical in- 
stances, is hard and not easily displaced by digital pressure; the firmness 
is due to inundation of the tissues and the coagulation of the fibrinous 
elements. Pain is caused by the distention of the affected tissues and 
pressure upon the nerve endings of the part; or there may be some chem- 
ical agents present which cause the painful irritation. In clinical experi- 
ence, however, we find that with the relief of turgescence the pain is 
immediately decreased, or entirely ceases. Each heart beat causes a momen- 
tary increase of pressure, and this imparts to the pain a throbbing character 
which is peculiar to an inflammatory lesion. The swelling can be so great 
that it will in itself interfere with the normal use of the part. In addition, 
the pain may cause a reflex protective muscular spasm which contributes 
to the impairment of function. 
This fairly completes the characteristic clinical picture of the imme- 
diate local reaction to irritation. We may adduce that the purpose of this 
reaction is, (i) through phagocytosis to combat the invading foreign 
agencies; (2) to neutralize the toxic chemical elements; (3) to supply an 
increased proportion of nutritive elements for the rebuilding and rehabil- 
itating of the injured cells; (4) to carry away debris which may result 
from the broken down tissue cells themselves, or from the introduced 
foreign substances; and (5) to prevent the extension of the disease and 
prepare the way for the process of repair. 
An inflammatory process may proceed in one of three ways:—-(a) it 
may subside and terminate in resolution; (b) it may go on to suppuration, 
ulceration or gangrene and subsequent healing by the formation of granu- 
lation tissue; or (c) it may pass into a chronic process. 
In the first case, resolution, there is practically 
an inversion of the process already described. The 
exudates are returned into the blood vessels and lymphatics; some of the 
fibrinous elements serve as a basis for repair; the wandering cells, having 
ingested the debris of the injured tissue, or the dead bacteria, return to the 
blood current, and the symptoms subside. The process of resolution be- 
gins, as a rule, only after the irritation has ceased, or has been removed. 
There may be, however, resolution at one part of the lesion while at 
another the irritation continues and the inflammation progresses. 
The second outcome, that of suppuration or the 
formation of pus, follows when a considerable num- 
Resolution. 
Suppuration. INFLAMMATION 
59 
ber of cells have been killed directly or have been injured so that, as a re- 
sult, they die in a short time. These masses of dead tissue become sep- 
arated from the living by a zone of liquefaction which results from the 
action of a digestive ferment. Thus, the dead tissues, partly liquefied, 
with dead and living bacteria, white blood cells living and dead, and the 
fibrinous, serumal blood exudate, form the pus. 
A localized and circumscribed collection of pus 
forms a typical abscess. Nature accomplishes the 
evacuation of pus by digestive liquefaction of surrounding tissue. Mechan- 
ical factors of structure and pressure will force this burrowing in the 
direction of least resistance. The abscess will finally point either on the 
external surface of the body or into a body cavity and there discharge 
its contents. The space that the pus has occupied becomes obliterated by 
the formation of new tissues, so-called granulation tissue, and the sur- 
rounding inflammation which has contributed the defensive cells and 
exudate will subside by the process of resolution. 
The formation of new tissue to replace that which has been destroyed 
may be initiated during the presence of pus, but complete repair can never 
be affected until the pus has been evacuated. It is well here to state 
that repair is not essentially a part of inflammation. Repair of tissue 
is a distinct phenomenon in its process and also in the activating forces 
which induce it. These forces are not very distinctly understood at the 
present time. The two processes of inflammation and repair are closely 
associated, however, and greatly overlap. 
We can now understand that while the inflammatory process is de- 
fensive and protective in its purpose, it is both destructive and constructive 
in its course. There is a destruction of tissue cells in the path of the 
burrowing of an abscess towards more yielding areas. The constructive 
factors are the bringing of a larger amount of blood to the part, the neu- 
tralization of the toxic or irritating substances, the carrying away of some 
of these agents, and also the induction of repair and the stimulation of 
granulation. 
The third termination of inflammation is chro- 
nicity. Here there are few of the classic clinical 
symptoms, for the irritant is a mild one and the reaction is low grade. The 
marked vascular changes do not occur; there may or may not be pus. The 
response of the tissues is either an overproduction of repair tissue, or a 
constant, slow circumferential destruction. In the presence of a constant 
irritant, even though it is of a mild degree, the process cannot go to com- 
pletion. This picture may be frequently complicated by acute exacer- 
bations, with all the clinical features of heat, redness, pain, swelling, and 
Abscess. 
Chronicity. 60 
ORAL SURGERY 
impaired function. In chronic abscesses where a sinus has formed for 
the evacuation of pus, the orifice may become obstructed or closed. 
When this occurs, the retention of pus produces acute exacerbations and 
evacuation will be followed by subsidence into a chronic low grade re- 
action. These acute exacerbations should impress us with the fact that a 
chronic inflammation is a latent and slowly acting danger, which may at 
any time, and we find that in many instances it does, produce a sudden 
and extensive lesion. 
A thorough understanding of the phenomena of inflammation is essen- 
tial to a consideration of pathological conditions and the rationale of 
their surgical relief. CHAPTER V. 
Acute Inflammatory and Suppurative Conditions 
of the Dental Alveolus. 
Inflammatory conditions of the dental alveolus may be classed under 
two general headings. In the first group may be gathered all those 
pathological lesions which originate with a diseased tooth or pulp of a 
tooth and develop into one of the various abscess formations, or tissue 
degenerations prevalent about the teeth and in the jaws. We shall desig- 
nate these under the collective term of apical inflammatory conditions and 
they will be taken up in greater detail later. 
In the second group we may place those pathological conditions which 
originate in lesions of the gingival tissues and the alveolar process and 
are known under the collective term of pyorrhea alveolaris, or more 
latterly, as periodontoclasia. 
The etiology of apical inflammatory conditions 
may he non-septic or septic. 
The non-septic are: mechanical trauma, such as 
a blow or some other external violence; traumatic 
occlusion of the teeth, which may he congenital or caused by improperly 
coordinated inlays, fillings or prosthetic restorations; or by other factors 
which interfere with the occlusal plane; a chemical substance forced 
beyond the apex of a tooth; filling materials or broken instruments pro- 
jecting beyond the tooth; perforations through the pulpal floor or through 
a root canal wall. Any of these may establish a point of lesser resistance 
either through irritation or the outright destruction of the tissues which 
may be followed by a septic invasion. 
Apical septic inflammations, however, are usually dependent upon the 
decomposition of organic substances, due to bacterial activities. In this 
event the products of decomposition, the microorganisms or the toxic 
products of bacterial metabolism may he the irritants, individually or, 
most likely, in combination. The decomposition of a devitalized pulp 
or a remnant of a pulp, the putrefaction of organic substances which 
find their way into the pulp cavity of a tooth from which the organ 
Apical 
Inflammatory 
Conditions. 
61 62 
ORAL SURGERY 
itself has been removed, may give rise to gases and acids which, passing 
through the apical foramen, cause irritation of the peridental structures. 
The infecting organisms may find their way to these parts through the 
root canal from the decomposing pulp, or they may he deposited there 
from the blood current. Gingival tissue destructions, likewise, when 
unchecked, may include the apical region and so cause infection and 
devitalization of the pulp. Broken-down roots are nearly always in- 
fected, or they may act as physical irritants and cause inflammatory 
conditions in the alveolus. 
As the most prolific source of diseases of the periapical tissue is 
decomposition of a pulp or other substances within the pulp chamber 
and root canal of a tooth, the influences which are conducive to the 
devitalization of the pulp may be regarded as indirect etiologic factors of 
the conditions to be described. 
The agencies or conditions causing devitalization of the pulp are: 
1. Deep seated caries or erosions exposing the pulp to chemical, 
mechanical and thermal shock, or infection from bacteria of the oral 
cavity. 
2. Exposure and trauma of the pulp caused in dental operations. 
3. Thermal irritation due to the proximity of large metallic fillings. 
4. The action of a chemical poison contained as an impurity in a 
plastic filling. 
5. Traumatic injuries to sound teeth, such as a direct blow, or the 
continued stress of orthodontic appliances or bridge work. 
6. Application of a gold shell crown over a vital tooth. 
7. Microorganisms sealed by filling, within apparently good structure 
of dentin. 
8. Deliberate devitalization of a pulp by the dentist, under septic 
conditions. 
9. Pathological conditions external to the tooth, but involving it, 
such as necrosis, cyst formation, periodontoclasia. 
Inflammatory reactions in the alveolar tissues, as elsewhere in the 
body, are determined by the kind, period and intensity of the irritation, 
opposed by the vital resistance of the tissues. The resulting phases are 
analogous to those described in the general description in the chapter 
on “Inflammation” and their termination may be simple resolution, sup- 
puration, or chronicity. The clinical pictures do not always lend them- 
selves to exact classification. 
The most common inflammatory conditions af- 
fecting a tooth where surgical interference is in- 
dicated are acute inflammations of the pericemental 
Septic Apical 
Pericementitis. ACUTE SUPPURATIVE CONDITIONS 
63 
membrane. The septic cases may or may not be suppurating. The patient 
complains of a throbbing or gnawing pain; the tooth feels elongated, is 
tender to percussion, and the overlying gum tissues may present signs 
of discoloration and swelling. 
Fig. 3. Acute abscess caused by infected lower second molar. In this case earlier 
external incision was indicated and was unduly delayed after the pus had burrowed 
into the submaxillary regions. Note that the deformity is confined to the part which 
immediately surrounds the pus and that the facial outline is practically undisturbed. 
In recent lesions the radiograph is often negative; this determines a 
state where as yet no gross change in the involved bone has taken place. 
In the more advanced stages there may be a thickening of the peri- 
cemental membrane, and a non-circumscribed rarefaction, radiating fan- 
wise over the apex or the apical third of the tooth which blends into the 
surrounding bone. 
Chronic cases, of long standing, may assume acute 
or sub-acute states through the action of inherent or 
external agencies and may present similar disturbing 
symptoms. These conditions frequently exist for a long time before 
Acute Exacerbation 
of Chronic Cases. 64 
ORAL SURGERY 
the first disturbing symptoms are manifest. The acute symptoms in 
all types of cases often subside without any interference and recur 
periodically until the etiological factor is removed or corrected. In these 
cases the radiograph usually discloses a thickening of the pericemental 
Fig. 4. Typical acute alveolar abscess in the upper bicuspid region. Note the 
diffused edema extending to and closing the eyelids. 
membrane, well defined, circumscribed, larger or smaller area of rare- 
faction, or complete breaking down of the bone, and, in some instances, 
an absorption or corroded condition of the root apex. 
Assuming that the causative factor is a tooth con- 
taining a putrid pulp, or decomposing organic mat- 
ter, the course of treatment is partly determined 
by the consideration whether the tooth is to he 
letained or removed. In the latter event, early removal is followed 
by amelioration or the entire cessation of the symptoms. Where the 
tooth is to he retained, the thorough cleansing of the root canal in 
which all infected and decomposing substances are removed; the at- 
tenuation of the microorganisms by means of therapeutic measures; 
Treatment of 
Septic Apical 
Pericementitis. ACUTE SUPPURATIVE CONDITIONS 
65 
and the neutralization of the toxic substances, will often abort the 
progress of the inflammatory condition. In the presence of a constant 
mechanical irritant, such as the protrusion of a root canal filling, a 
compensatory adaptation in the surrounding tissues often occurs. 
Fig. 5. Acute abscess pointing upon the palate in a child 7 years of age. It 
was caused by the infected roots of the temporary second molar. Note the extensive 
burrowing of the pus and the sagging of the mucoperiosteum passing over the 
median line. 
Acute Alveolar Abscess. 
An abscess which is primarily inaugurated in the alveolus of a tooth, 
and is caused by a dental lesion, is a dento-alveolar abscess. 
The general symptoms are those of an acute, 
violent infection. There is a rise of temperature 
and the patient complains of malaise and of intense throbbing and burrow- 
ing pain, which is accentuated when in a recumbent position. The tooth 
causing the abscess becomes elongated and tender to touch; often the adja- 
cent teeth are affected in a similar manner, the overlying gums and mucous 
membrane becoming discolored, swollen, and tender upon pressure. 
Symptoms. 66 
ORAL SURGERY 
When pus is formed in the apical region of a tooth, this at first is 
lodged in the surrounding bone structure. Owing to the unyielding nature 
of the hone, the tension is considerable until, by the process of pointing, 
the pus escapes through the bone into the overlying soft tissues. With 
this, the pressure is decreased, the pain diminishes, and the soft tissues 
being invaded, the swelling becomes larger. 
Fig. 6. Abscess in a young woman 18 years of age. This was caused by a carious 
infected second molar and was poulticed until it opened upon the face. The pus 
discharge continued for over three months as the removal of the tooth was 
overlooked. 
Pointing is the process whereby pus, seeking a 
point for evacuation, passes in the direction of least 
resistance. This is aided by circumferential me- 
chanical pressure and is accompanied by caseation and liquefaction necrosis 
of the obstructing tissues. 
The severity of the symptom is often proportionate, therefore, to the 
degree of resistance offered by the tissues to the pus in its course of point- 
ing. Idence we find that alveolar abscesses located in the mandible are, 
Pointing of 
an Abscess ACUTE SUPPURATIVE CONDITIONS 
67 
as a rule, more severe and of longer duration than those occurring in 
the maxilla. The reason for this clinical fact is obvious. While the 
maxilla is constituted largely of cancellous bone, enclosed within thin plates 
of compact bone through which the pus finds a more ready egress into 
the overlying soft tissues, the mandible is formed of rather thick plates 
of compact bone, enclosing a scant amount of cancellous tissue in which 
the roots of the teeth are deeply lodged. This is particularly true of the 
lower third molars. As these teeth are often malposed or impacted, their 
Fig. 7. Acute abscess caused by erupting third molar. Note the marked swelling 
and diffused cellulitis. These conditions should be opened externally even at an 
earlier stage, as they can be rarely controlled with intra-oral drainage. 
roots are so imbedded between the internal and external oblique ridges, 
or into the ascending ramus, that the abscesses caused by them frequently 
present rather distressing symptoms. (Fig. 3.) 
Acute abscesses in the upper molar and especially the bicuspid and 
cuspid region usually cause an early swelling of the cheek and the edema 
may include the lower eyelid, so that the eye becomes completely closed. 
(Fig. 4.) The swelling in these cases rarely penetrates below the line 68 
ORAL SURGERY 
of the upper lip. Abscesses of the six anterior teeth, when pointing labi- 
ally, usually cause swelling and tenderness of the lip and also the ala of 
the nose on the affected side. 
In a comparatively small percentage of cases, the pus points toward 
the palate. This is most frequently true of abscesses of the upper lateral 
incisors, rarely of the cuspids and still more rarely of bicuspids and 
Fig. 8. Chronic alveolar abscess of about three years’ standing in a man 23 years 
of age. The abscess was caused by a tardily erupting third molar. The pus bur- 
rowed underneath the periosteum and evacuated through the fistulous opening in the 
bicuspid region. 
molars, (rig. 5.) in the lower jaw the abscesses very rarely point toward 
the lingual aspect. The pus having burrowed through the alveolar process, 
raises the mu coperiosteum where it may remain lodged between the peri- 
osteum and the bone, causing a bulging of the mucous membrane of the 
buccogingival fold. Very often it spreads to remoter areas. 
The surgical treatment of abscesses in general 
consists of removing the cause, evacuation of the 
pus, and the securing and maintenance of adequate 
drainage to prevent retention. When the diagnosis 
Surgical Treatment 
of Acute 
Alveolar Abscess. ACUTE SUPPURATIVE CONDITIONS 
69 
has been made, our effort should be directed to immediate evacuation and 
drainage. 
The consideration of whether the offending tooth is to be retained 
or not, in a measure will modify our surgical procedure. Where removal 
of the tooth is decided upon, this should be done at once. By so doing, 
three important steps of the treatment are accomplished. First, the cause 
is removed; second, evacuation and direct drainage are secured; third, 
Fig. 9. The size of incision illustrated here is quite adequate for thorough drain- 
age. The lips of the wound are not gaping nor displaced by the gauze and will 
leave just a fine linear scar. 
the initial focus of infection is rendered accessible for treatment with 
antiseptic solutions. 
For abscesses located in the maxilla, where ex- 
traction is the resort, in the majority of cases no 
other operative measures will be required. Owing 
to the anatomical relation of the soft tissues connected with and attached 
to the maxilla, the pus in these abscesses is, as a rule, more localized and 
evacuation is greatly favored by gravitation. It occurs but rarely that 
Maxillary 
Abscesses. 70 
ORAL SURGERY 
an abscess in the maxilla points so that external incision is indicated and 
such a procedure is only rarely justifiable. But where, through injudicious 
treatment, poulticing is employed, the pus may so penetrate toward the 
outer surface that an external incision becomes necessary, or it may of 
itself break and evacuate on the external surface. (Fig. 6.) Here the 
extraction of the offending tooth will almost invariably secure sufficient 
drainage. When the pus seems copious and has penetrated through the 
bony walls of the alveolus and is lodged between the periosteum and 
the bone, drainage through the tooth socket is not always adequate. In 
this event the removal of the tooth should be supplemented with a free 
incision of the mucoperiosteum. Drainage should be maintained through 
both channels. Where the radiograph shows no pathological change in 
the bone of the involved area curetting is contraindicated. Where there 
is a chronic degeneration of the surrounding bone tissue this should 
be removed by means of a curette until healthy areas are reached. 
Curetting should always be performed with great 
discretion and confined to the removal of those sub- 
stances which result from the degenerating proc- 
esses and suppuration, and those tissues which have 
become so impaired that they may act as latent foci of infection if left in 
place and that their return to normal is not likely to occur. Care 
should be taken in the surgical procedure to avoid, or minimize injury to 
the tissues which are surrounding the pus, as these tend to limit the extent 
of the infection and are active in repair. 
In the mandible, once the pus has reached sub- 
periosteal areas, the process rapidly becomes more 
diffuse and more complicated, and cannot always 
be controlled by the removal of the offending tooth alone. While it is still 
confined between the periosteum and the bone, the immediate removal of 
the offending tooth and an intra-oral incision may abort the pointing of 
the abscess externally. These cases frequently result in aggressive diffuse 
cellulitis, involving the submaxillary region and the entire side of the neck. 
(Fig- 7-) Sometimes the pus may burrow and the cellulitis extend as 
far down as the clavicle. The pain is severe; the tissues appear discolored, 
presenting all symptoms of an acute inflammation; the swelling becomes 
boggy and pits upon digital pressure. With careful palpation fluctuation 
may be discerned indicating the presence of pus. In this way the most 
dependent point of the fluctuating area, where the incision is to be made, 
can be determined. When the pus has burrowed into the submaxillary 
regions, the case can but rarely be controlled with intra-oral incision and 
drainage must be established externally. Too much emphasis cannot be 
Curetting 
In Acute 
Alveolar Abscess. 
Mandibular 
Abscesses. ACUTE SUPPURATIVE CONDITIONS 
71 
laid upon the advantage of early incisions for securing evacuation and 
adequate drainage of pus, whether this is to be done ultra- or extra- 
orally. 
Cases are frequently seen where incision is delayed in order to avert 
scaring the patient. Experience shows, however, that early incision leaves 
a less marked scar, as the tissue destruction caused by a well executed in- 
cision is infinitely less than is caused by the pointing of an abscess. When 
an abscess is permitted to break of its own accord, the scar becomes 
attached to the bone, or a pit forms which is disfiguring and impossible 
to correct. (Fig. 8.) 
If the retention of the tooth is decided upon, the tooth itself should 
be treated with the accepted therapeutic measures, which largely consist 
of the cleansing, sterilization and sealing of the root canal. The root canal 
itself may provide in some cases sufficient drainage. If this is inadequate 
and surgical interference becomes necessary, measures should be directed 
towards the evacuation of the pus as described above. If the pus is still 
confined in the bony cavity, evacuation can be secured by raising the 
mucoperiosteum and cutting through the outer plate of the alveolus with 
a surgical bur or a chisel over the apex of the tooth. Dental treatment 
should be deferred until all active symptoms have subsided and are thor- 
oughly controlled. After the root canal has been freed from all debris 
and infected pulp tissue, it should be thoroughly sterilized and ultimately 
hermetically sealed at its apical end. 
Abscesses of the lower jaw, particularly of the 
molar region, are usually complicated by partial or 
complete false ankylosis of the jaws. Whether an 
intra-oral or an extra-oral incision is to be made, a 
general anesthetic is indicated. For extra-oral incisions the operative field 
should be prepared by washing the skin surface with a solvent such as 
benzin or ether, or tincture of green soap and warm water. This is to 
be followed by a germicidal agent, such as bichlorid of mercury, of i to 
2,000 or i to 5,000 strength, or 70% alcohol, and painted with tincture of 
iodin. After this, it should be surrounded by sterile cloths or towels and 
none hut surgically clean objects should be brought in contact with this 
now sterile field of operation. The operative field in itself should be like- 
wise protected from all possible sources of contamination, as the chain 
of asepsis is often broken in these operations by the anesthetist in the 
application of the inhalers. 
The line of incision should be made parallel with the lines of the 
features, or with the natural skin creases. (Figs. 9 and 10.) 
The lancet is passed through the dermis, the superficial fascia and 
Technique of 
External Incisions. 72 
ORAL SURGERY 
the outer layers of muscle tissue. If the pus has not been reached 
at this point, deeper penetration with the knife must not be attempted be- 
cause of the danger of severing some important structures that traverse 
the deeper strata. A pair of blunt scissors, of the Mayo type, may be in- 
serted through this incision until pus is reached. These are then opened 
widely in several directions, so as to break down all tissues which may 
Fig. io. Diagram showing the anatomical relationship of the parts and their dis- 
placement by the pus. The lowest part of the pus collection is at (A). The more 
marked point of fluctuation is at (B) where the abscess should he incised. When 
the distention of the tissues is reduced this will be the more favorable point for 
drainage. 
he dividing the abscess into pockets.* This can be done with a pair 
of blunt scissors or with a large curette. The external incision may now 
be enlarged to the size needed for adequate drainage. In all this procedure 
undue laceration or invasion of the tissues surrounding the pus collection 
must be carefully avoided and the surgical trauma should be reduced to 
the minimum consistent with thorough evacuation. It is this tissue sur- 
rounding the abscess which initiates repair and finally brings about 
the obliteration of the abscess cavity. 
* The scissors should never be closed in the wound. ACUTE SUPPURATIVE CONDITIONS 
73 
Frequently it is found that the approximating surface of the bone 
communicates with the abscess cavity. Curetting of this, or any inter- 
ference with the bone through the abscess incision, is contraindicated. 
Additional injury to this already impaired bone, probably devoid of peri- 
osteum, may lead to necrosis. 
If ankylosis is present, the patient’s mouth must be pried open under 
the same anesthesia, and the infected tooth removed. The socket should 
be cleansed of all pathological and non-vital tissue with a curette. 
Both the tooth socket and the abscess cavity is thoroughly irrigated 
with a mild antiseptic solution and lightly packed with iodoform gauze. 
The gauze is inserted so that the entire abscess cavity is loosely lined with- 
out undue pressure. The gauze should be all in one piece; if more than 
one length is used, this must be remembered, and an end of each piece 
should project through the outer orifice. Many troublesome abscesses 
have been traced to forgotten pieces of gauze left in the deeper recesses 
of such a cavity. 
The external wound is covered with a gauze dressing wet with a 
boric acid solution; this is covered with gutta-percha tissue and bandaged 
into place, or secured with adhesive strips. 
The postoperative treatment consists in changing 
both the external dressing and the iodoform pack- 
ing. The abscess cavity is thoroughly irrigated with 
a non-escharotic and non-irritating solution. A sterile normal saline, 
boric acid 4%, or a mild iodin solution may be used. In doing this we 
depend more upon the mechanical cleansing than upon the actual germi- 
cidal value of the irrigating medium. Solutions which are actually bac- 
tericidal are also destructive of tissue cells, and will hinder repair. The 
one agent that is most perfectly balanced as to the potency of its bac- 
tericidal action and its acceptability to the tissue cells, is the normal in- 
flammatory serumal exudate elaborated by the body itself, and we can- 
not hope to adjust so finely a chemical preparation. 
Care must be taken that in the irrigation, no pressure, undue trauma- 
tism nor disturbance of this now progressively active repair tissue be 
created. Insert the blunt nozzle of the irrigating syringe without ob- 
structing the entire opening so that the irrigating solution may escape 
without creating pressure. Pus coagulates and necrotic tissue fragments 
will thus be gently lavaged from the cavity. The irrigation should be 
continued until the return is clear, except for the discoloration due to 
hemorrhage. The subsequent iodoform packing should be rather loose 
and so introduced that it acts as a wick and does not clog up the external 
orifice. The tooth socket may be irrigated and packed in a similar manner. 
Postoperative 
Treatment. 74 
ORAL SURGERY 
The irrigation and dressings are repeated at twenty-four hour intervals 
until the more active symptoms have subsided. Thereafter this is re- 
peated every forty-eight hours and just sufficient packing is inserted to 
keep the drainage space patent until the cavity is obliterated by granulation. 
There should be, in general, a marked abatement of the more dis- 
tressing symptoms within twenty-four hours after the operation. Where 
the symptoms do not progressively subside, retention of pus, due to one 
of the following conditions, is to be suspected: (i) the drainage is in- 
adequate, due either to the size, or the position of the original incision; 
(2) faulty packing, causing a damming back of the pus and clogging the 
orifice of evacuation; (3) a pus pocket may not have been reached and is 
acting as an independent abscess; (4) or there may be an independent 
abscess in an adjacent point which might be reached through the first 
incision, or else a separate incision and treatment may be indicated. Sec- 
ondary incisions are at times necessary when the abscess is deeply located 
in the lower part of the neck. Because of the great tendency to diffusion 
in these regions “counter drainage” may be essential and is established 
by a free passage between the upper and lower incision. CHAPTER VI. 
Chronic Inflammatory and Suppurative Conditions of the 
Dental Alveolus. 
To the more comprehensive further study of the subject, the consid- 
eration of the present status of pulpless, or devitalized, teeth will prove 
helpful. That pulpless, or devitalized, teeth may act as foci of infection 
and as such become etiological factors in the causation of systemic diseases, 
or lesions of remote vital organs, is not a new thought. The subject has 
gained what would seem a disproportionate impetus, however, within 
recent years, through a closer study of focal infection in general. The 
findings of the numerous investigators, clinicians, and research workers 
in both the medical and dental professions leave no doubt regarding 
the validity of the contention that the teeth are among the principal sources 
of infection. Many aspects of this subject are so beset with complexities 
presenting so many moot problems that the subject can scarcely be con- 
sidered settled at the present time. 
The difference in the views expressed by the various investigators has 
created a veritable chaos about which, what appears to be an inter- 
necine contest, is being waged, and in which millions of human teeth are 
being wantonly sacrificed. 
The advocates of these different views may be classed in three groups: 
(i.) Those who believe that all pulpless, or devitalized, teeth are patho- 
genic and analogous to infected foreign bodies and that as such they must 
be radically removed in every instance. This is done with no attempt at 
discrimination, based on clinical findings or radiographic examination. 
(2.) In the second group we may classify the men who are guided en- 
tirely by the utility of the tooth, by clinical signs and the occasional radio- 
graphic examination of sporadic cases. (3.) In this group we may place 
those men who exercise individual selection in all cases. This selective 
discrimination is dependent upon the following considerations: (a) the 
general health of the patient; (b) the probable susceptibility of the patient 
towards infection; (c) the age, sex, and the probable vital resistance of 
the patient; (d) the nature of the infection and its clinical manifesta- 
75 76 
ORAL SURGERY 
tion; (e) the extent of the pathological condition and the tissues involved 
as determined by clinical findings and radiographic examination; (f) the 
number of devitalized teeth present in the mouth; (g) the history of the 
tooth itself and the condition of its structure; and finally, (h) the com- 
parative value and the importance of the individual tooth. 
It is quite generally conceded by all who have studied the subject that 
infected teeth may act as foci of infection; on the other hand it is main- 
tained, with equal justification, that not all pulpless, or devitalized, teeth 
if properly treated are essentially diseased or pathogenic. It logically 
follows, therefore, that the men who adopt a selective individualization 
are most likely to be right, and the method commends itself in the rational 
consideration of the subject. 
It is often argued that the loss of a tooth is, comparatively, of minor 
importance where the patient’s general health, or a lesion of some vital 
organ, is concerned. This truism, however, should not he permitted 
to impel us to a haphazard, wholesale removal of teeth and must not over- 
balance our better judgment as to the value and the utility of the teeth 
in the human economy. In contemplating the subject and its many angles 
and aspects as they impress us in our daily contact with patients, we are 
keenly conscious of the fact that the loss of a useful tooth is an irre- 
trievable, permanent loss and that many would more cheerfully submit 
to what might be considered a more serious operation instead. 
The further treatment of the subject will be based upon the assumption 
that a great many pulpless, or devitalized, or infected teeth must be 
removed and that a great many can be conservatively treated, cured and 
retained as innocuous members of the host. 
Chronic Dento-Alveolar Abscess. 
Chronic alveolar abscesses may be loosely grouped into the fistulous 
and the non-fistulous types. 
In the fistulous group belong those abscesses 
which have passed through the acute stage and in 
which the pus has established for itself a point of 
evacuation, thus passing into a chronic state. The presence of the 
etiologic factor maintains the abscess and, because of the drainage, the 
disturbing symptoms may be slight, periodical, or entirely absent. The 
point of evacuation may be alongside the gingival margin, upon the gum 
tissues about, or at some distance from the diseased tooth. It may evacuate 
into the maxillary sinus, into the nasal cavity (which is rare), or upon 
the external surface of the face. (See Figs. 6 and 8.) The discharge 
may be copious or scant, constant or periodic. While the orifice stays 
Fistulous Type 
of Abscess. CHRONIC SUPPURATIVE CONDITIONS 
77 
patulous the disturbing symptoms are very slight, or absent; if the orifice 
closes, the retention of pus causes an exacerbation with the characteristic 
symptoms of an acute abscess. The turgescence may cause the orifice to 
reopen, or gentle pressure will do it; upon evacuation of the pus, the symp- 
toms subside until retention again occurs. This varying picture is typical 
of a chronic abscess having a sinus. This pathological process is usually 
accompanied by suppurative osteitis and the radiograph shows destruc- 
Fig. ii. Lower left first bicuspid, containing an infected pulp. Note the thickening 
of the peridental membrane and hyperplasia of the corresponding peridental lamella. 
Fig. 12. Infected upper bicuspids with smaller types of pericementomas about their 
apices. 
tion of the surrounding bony tissue. In many cases, a well defined abscess 
sac will be found, suggesting cystic degeneration, or tissue proliferations 
may form which do not appear to be hollow, and rather resemble a 
pericementoma. 
The non-fistulous type of abscesses may or may 
not he preceded by an acute stage. They are often 
discovered only in a radiographic examination. 
They may at any time, however, assume an acute or subacute state, when 
disturbing symptoms arise. They are invariably associated with devital- 
ized teeth and their insidiousness lies in the fact that they may exist for 
any number of years, causing no clinical signs, nor symptoms. In the ab- 
sence of these, therefore, every pulpless, devitalized, discolored or crowned 
tooth, or teeth containing large fillings should be radiographed to ascer- 
tain their condition. 
The pathological state of the tissues involved as disclosed by the 
radiograph, may be a mere thickening of the peridental membrane and 
hyperplasia of the corresponding peridental lamella. (Fig. n.) There 
may be a pericementoma (Fig. 12) or cystic degenerations are quite com- 
mon. (Fig. 13.) The pathological process is not always confined to the 
Non-Fistulous 
Abscesses. 78 
ORAL SURGERY 
affected tooth alone, but quite frequently progresses until a considerable 
area of bone and probably some of the adjacent teeth become involved. 
(Fig. 14.) The overlying mucous membrane very often appears normal. 
In some instances there is a marked discoloration. This should always 
be noted as a likely sign of a chronic pathological process underneath. 
Such a condition can be detected by digital pressure in those cases where 
the outer layer of bone is thin or thinned out. 
Fig. 13. Infected upper right lateral incisor presenting what may be considered a 
smaller type of cystic degeneration. 
Fig. 14. Involvement of two adjacent teeth by the spreading of the diseased area 
from a primary focus. The source of the infection was most likely the lateral 
incisor, as the cuspid and central still gave signs of a degree of vitality. 
As in acute, so in chronic cases, in disposing of pulpless or infected 
teeth, one of two measures may be pursued; i.e., radical or conservative. 
We will consider first those conditions in which 
the retention of a pulpless or infected tooth is con- 
traindicated. We may here state that its removal 
and the eradication of the infected area surround- 
ing it must be based on sound pathological and surgical principles. It is 
essential therefore that the operator should thoroughly understand bone 
tissue, its histological structure, its reaction to injury, and the possibilities 
of its repair and regeneration. 
The radical measure comprises the removal of the tooth and all 
palpable pathological conditions associated with it. As there is a varia- 
tion in these diseased areas, it must be clear that the extent of the opera- 
tion is to be determined by the nature and the extent of the pathological 
condition. 
The theory that in the removal of an infected tooth a goodly amount 
Radical 
Treatment of 
Chronic Abscesses. CHRONIC SUPPURATIVE CONDITIONS 
79 
of the surrounding bone also must be removed has neither a pathological 
nor a surgical foundation. This is advocated and practiced on the assump- 
tion that the bone about an infected area must also be infected. It may 
be conceded that some microorganisms will find their way into the sur- 
rounding tissues, but it is impossible at the present time to grossly de- 
termine just where the invasion terminates. The focal infection theory 
in itself presupposes that the infecting organisms are not confined to tne 
immediate surroundings of the primary nidus. Besides, bone tissue is not 
a constant structure, but is subject to continual breaking down and build- 
ing up. Incidentally, much of the damaged tissue is constantly being car- 
ried away and replaced with new bone. 
Here, as elsewhere, we must depend more upon the protective mechan- 
ism provided by Nature to take care of all non-concentrated infectious 
agencies, than upon uncertain and often harmful attempts at actually re- 
moving them. Clinical evidence has proven that such nitraradicai meas- 
ures often open up new channels which tend to add to the local spreading 
and to the possibilities of absorption of the infection. Were we to leave 
out Nature and her protective mechanism from our consideration and base 
our surgical procedure upon such erroneous concepts in pathology, a great 
many good teeth adjoining an infected area would be sacrificed; the max- 
illary sinus, the nasal cavity, the mandibular canal would very often, 
necessarily, be invaded and many jaws would be mutilated in an unthink- 
able fashion. 
Where these facts are overlooked the operator is laboring under a de- 
lusion which is inconsistent with rationality, for we must assume that any 
one, or all approximating surfaces are uniformly invaded. Fortunately 
the most ardent advocates of such a technique fall short in their aggres- 
sions and their own contradictions prove their fallacy. The best of sur- 
geons, trustfully courting her aid, are but the willing and respectful hand- 
maids of Nature. Those who are studying her ways and who work hand 
in hand with her are less frequently disappointed than those who have 
the presumption to assume too much of the burden. 
A complete radiographic examination is always essential in the treat- 
ment of pulpless, or devitalized, teeth. The radiograph may be negative; 
this, however, must not be taken as a proof that there is no infection 
present. This simply means that there is no radiographically demonstra- 
ble change in the bone tissues surrounding the tooth; or the radiograph 
may have been taken at such an angle that the lesion is obscured, or not 
disclosed. A pulpless, or devitalized, tooth in which the root canal work 
seems faulty, the obturation being incomplete, or entirely lacking, should 
be regarded as being infected. It is also contended that a tissue change, 80 
ORAL SURGERY 
Fig. 15. The infected teeth in this series present types of lesions in which the gross 
change seems to be confined to the peridental membrane. Complete removal of the 
teeth alone is indicated. Any degree of curetting or bone removal is superfluous. CHRONIC SUPPURATIVE CONDITIONS 
81 
expressed as a bone absorption, or lack of bone substance about the apex 
of a pulpless tooth, is not necessarily an infected condition; that infection 
is a matter of microscopy and riot of radiography. We know of no nor- 
Fig. 16. In this series the infected teeth present smaller and larger pericementomas. 
These often remain attached to the teeth in their removal. In this event no curetting 
is necessary. If it becomes detached and remains in the bone it can be removed 
with a fine curette through the tooth socket. 
mal condition which will produce such a phenomenon and where it can- 
not be explained as a radiographic error, as a normal or anomalous 
anatomical relationship, or in the absence of prior operative history, it 
should be regarded as a pathological condition, most likely caused by 
infection. 82 
ORAL SURGERY 
From the standpoint of surgical technique we 
may differentiate chronic infections which are con- 
fined to the tooth and the pericemental membrane, 
which is often thickened and shows evidence of de- 
p-pn oration. Tn these eases the removal of the tooth and the nericemental 
Infections Limited 
to Teeth and 
Pericementum. 
Fig. 17. Smaller and larger cystic degenerations. In these, blind curetting through 
the tooth socket should not be depended upon. The part should be clearly exposed 
and the cyst completely removed. (See Cysts.) 
membrane is the only measure that is necessary. It is of paramount im- 
portance that no part of the tooth or diseased portion of the peridental 
membrane which may act as a latent focus of infection should be left 
in the alveolus. (Fig. 15O 
In the second group we may consider those con- 
ditions in which the infection and diseased area are 
circumscribed and confined within the limitations of 
a pericementoma (Fig. 16), or a cystic degeneration. (Fig. 17.) 
These tissue proliferations are the result of a productive inflammation 
and are very probably part of the protective mechanism of the body. 
Circumscribed 
Areas of Infection. CHRONIC SUPPURATIVE CONDITIONS 
83 
This suggestion is strongly supported by the clinical experience that in 
the conservative treatment of these teeth to which they are attached with 
removal of the source of the infection, retrograde changes and often 
complete obliteration and replacement with bone is observed. Their patho- 
logical significance lies in the fact that they contain microorganisms and 
Fig. 18. Cases of suppurative osteitis having no well defined organized tissue limi- 
tations. Note particularly the jagged edges of the bone, the enlarged bone spaces, 
and the irregularity of outline. 
their toxic products, whence they may be carried away by the blood 
stream or the lymphatics and so disseminated throughout the system. 
A pericementoma, or, as it is more commonly called, a dental granu- 
loma, is not a neoplasm in the true sense of that term. It is rather the 
result of a productive inflammation induced very probably by the irrita- 
tion of microorganisms of a low grade of virulence, such as the strepto- 
coccus of the viridans group, which is very frequently found associated 
with these areas. Depending upon the nature of the infecting organisms 
a pericementoma may or may not contain pus. It may be solid and 
composed entirely of connective tissue, or it may have a lumen. The inner 84 
ORAL SURGERY 
surface often presents epithelial chains or rests, dipping down into the 
deeper strata of the tissue. In others, the inner surface is partly or in its 
greater part covered with epithelium, showing tendencies towards a cystic 
Fig. 19. The diseased teeth in this series present a complete degeneration of the 
peridental membrane, a breaking down of the peridental lamella, and invasion of the 
surrounding bone. In these, the removal of the teeth must be supplemented by the 
removal of the diseased and degenerated tissues. 
degeneration. The theory that they are the precursors of radicular cysts 
is maintained by some investigators and is rather suggested by clinical 
findings. CHRONIC SUPPURATIVE CONDITIONS 
85 
The bone immediately surrounding such a pathological area appears 
more dense and presents a fairly smooth surface. It most properly may be 
considered as a hyperplasia which often occurs in the vicinity of, or within, 
inflamed bone and is probably dependent upon an increase of the bone 
lamellae, or an increase in the calcium salts, or both. It has not been 
demonstrated as yet that the percentage of calcium salts content is greater 
in this bone than it is in normal bone. 
The treatment of these cases consists of the removal of the tooth and 
the enucleation of all tissue proliferations induced by the pathological 
process. Small growths often remain attached to the extracted tooth. In 
these cases no further surgical measures are necessary. Small growths 
which remain attached to the hone cavity may he removed through 
the enlarged tooth socket by means of a curette. There are many in- 
stances, however, in which the pathological area is extensive, or not quite 
clearly outlined. In these cases it is more advisable to reflect the over- 
lying mucous membrane, remove a portion of the onter plate of the bone 
and expose the operative field to view. The growth is completely re- 
moved and the surrounding bone is left intact. 
Thirdly, there is a type of cases in which the 
pathological area is not circumscribed. (Fig. 18.) 
These are usually suppurative and the pus, mingled 
with unorganized, sickly, granulation tissue, is lodged in an irregular, 
jagged bone cavity. The radiograph does not show a clearly defined 
radiolucent area and we must depend upon clinical signs for our guidance. 
This often consists of gross changes in the bone structure, marked with 
discoloration and the permeation of the enlarged bone spaces with pus. 
The part should be well exposed to view. The bone which is impaired 
readily crumbles under the pressure of a steel instrument; where the 
bone presents a healthy appearance removal should terminate. 
Lastly, there are types of degenerative conditions about the teeth which 
cannot he classified with accuracy. The initial lesion may be at the gingi- 
val margin which extends until all of the peridental membrane is involved, 
and the pulp becomes infected or devitalized, so that the tooth becomes 
virtually a foreign body and is gradually exfoliated. In other cases there 
may be a coexisting apical lesion and the two progressively merge until the 
tooth is completely surrounded by pathological tissue. The peridental 
membrane and the cementnm are badly degenerated, or entirely destroyed 
by the suppurative process. The peridental lamella is completely broken 
down, the surrounding bone is somewhat more deeply invaded, and there 
is no circumscribed line of demarcation formed. (Fig. 19.) The ex- 
traction of the tooth should be followed by the removal of all broken 
down tissues and curetting of the bone until healthy areas are reached. 
U ncircumscribed 
Areas of Infection. 86 
ORAL SURGERY 
Indications and Technique of Root End Amputation. 
Where the tooth is to be retained, there are 
three possible courses of procedure: 
(i) Root canal therapy alone will suffice in 
the type of cases where the tissues involved, com- 
prising the cementum, the pericemental membrane, and the alveolar 
process, are damaged only to such an extent that with the removal of the 
Treatment 
When Tooth Is 
Retained. 
Fig. 20. In these cases root canal therapy alone will clear up the infection. 
infecting agencies, their return to normal and their physiological co- 
ordination may be hoped for. (Fig. 20.) 
(2) Curetting is indicated in those cases where there is no complete 
denudation nor corrosion of the apex of the tooth, and the involved area is 
too large, probably containing a larger amount of degenerated and broken 
down tissues than might be expected to be carried away by natural proc- 
esses or eliminated by drainage through the root canal. (Fig. 21.) The 
root canal is first sterilized and thoroughly sealed; the apical region is then 
exposed by making an incision and raising the flap of mucoperiosteum. 
The overlying bone tissue is removed by means of gouges and rongeur 
forceps. When the parts are well exposed all the diseased tissues are re- 
moved by means of spoon-shaped curettes until healthy tissues are reached. CHRONIC SUPPURATIVE CONDITIONS 
87 
When the area is small, packing of the cavity may not be necessary. 
If the area is so large that ready repair is not likely to occur, the cavity 
should be dressed with iodoform gauze and irrigated until cicatrization is 
fairly well under way. 
Fig. 2i. Types of cases in which the root is not involved to any extent and the 
pathological area, though confined to the bone, is larger than might be expected 
to clear up without surgical interference. Curetting alone is indicated. 
Root End Amputation (Apicoectomy). 
Where the apex of the tooth and the pericementum are irreparably 
injured or destroyed, the cementum and the dentin become exposed and in- 
fected and show signs of absorption and corrosion; there is a decided break 
in the continuity of the peridental lamella (cribriform plate) which merges 
into an area of bone absorption. Where this condition obtains, we cannot 
hope that the once denuded surface of the dentin will again he covered 
with cementum and pericementum, and that physiological coordinate 
relationship between these tissues and the alveolar bone will ever be re- 
stored. It must be clearly understood that while all highly specialized 
tissues have potentialities of repair if merely injured, they have but a 
slight power of regeneration if once destroyed. To accurately determine 
clinically just where the one condition ceases and the other begins is 
practically impossible. It is good practice therefore to remove by the 
operation of amputation all such portion of the affected tooth root upon 
which the cementum and pericementum are in a doubtful state, or com- 
pletely destroyed. Where such measure cannot be carried out with a 
fairly definite hope for a favorable final result, conservative measures 
should be abandoned. 
Root end amputation must not be looked upon as an abscess cure. It 88 
ORAL SURGERY 
is essentially an auxiliary measure for the eradication of pathological 
tissue proliferations and detritus which result from protracted suppura- 
tive and degenerative processes. In the removal of these should be 
Fig. 22. Smaller and larger pathological areas in the apical region. The root ends 
are denuded, some of them resorbed and they merge into the pathological area. A 
normal attachment and physiological coordination between these parts and the sur- 
rounding tissues cannot be established and therefore amputation is indicated. 
included such portion of the tooth root as has been rendered permanently 
diseased, and the presence of which must exert a baneful influence upon 
the surrounding tissues. 
The most frequent indications for this operation are conditions where, 
through a pathological process, portions of the pericementum are detached 
or destroyed; the cementum becomes infected and partly or completely CHRONIC SUPPURATIVE CONDITIONS 
89 
disintegrated, leaving the underlying dentin in a denuded or semi-denuded 
state. 
The pathological conditions which bring about these tissue changes 
are almost always chronic in their course and they may or may not he 
Fig. 23. Infected upper first molar in a man 32 years of age. The mesial root is 
completely denuded. In cases of this type if the lingual and distal roots can be 
adequately treated and their enveloping tissues are in favorable condition the mesial 
root may be amputated. 
Fig. 24. Pericementoma upon the lingual root of the upper first molar. The apex 
of this can be amputated provided complete sterilization and sealing of the remain- 
ing parts can be achieved. 
Fig. 25. Types of cases in which complete sealing of the root ends was impossible 
because of curved formation of the root, or some physical obstruction. The root 
is sterilized and filled as far as possible and the unfilled part amputated. 
accompanied by suppuration. The area may be filled with unorganized 
masses of tissue, or it may be occupied by a pericementoma or a radicular 
cyst. 
Black * maintains that when this occurs, the normal physiological co- 
ordination of the tissues concerned cannot take place, and that such a 
process can be induced by no therapeutic measures. Like all specialized 
tissues, so the cementum and pericementum are capable of repair when 
* Black: Special Dental Pathology, 90 
ORAL SURGERY 
injured, but they have a very limited power of regeneration when de- 
stroyed. Black believes therefore that such a portion of a root, devoid 
of cementum and pericementum, or where the tissues are impaired to such 
Fig. 26. Broaches broken in the apices of roots. Remove if possible and treat the 
root. If removal is impossible fill completely up to the broach and amputate the 
part containing the foreign body. 
Fig. 27. Perforation through the side of the tooth close to the apical third. Ampu- 
tation just below the perforation indicated. 
an extent that a return to normal cannot occur, acts virtually as an 
irritant not unlike an infected foreign body. 
In operation, upon exposing a root which is so affected, it is found 
that it presents a smooth, almost polished surface, or a corroded and 
absorbed condition; still others have smaller or larger patches of cementum 
in a state of disintegration adherent to the dentin. This portion of a root 
is projecting into a diseased area and offers no support whatever to the 
maintenance of the tooth in position. (Fig. 22.) CHRONIC SUPPURATIVE CONDITIONS 
91 
Fig. 28. Root amputation is contraindicated because of the proximity of the 
maxillary sinus, although with care it might be done without invading the cavity. 
Fig. 29. Types of cases in which root amputation is contraindicated because of the 
scanty tissue whereby the tooth might be retained. 92 
ORAL SURGERY 
Besides these conditions, the following will prove to be amenable to 
root end amputation: 
(i) Where an individual root of a multirooted tooth has lost its peri- 
dental membrane and alveolar process through extensive pyorrhea, or 
Fig. 30. Types of cases in which root amputation is contraindicated because of 
extensive absorption of the alveolus, and infection and destruction of the cementum 
and the pericementum. 
through atrophy; or when one of these becomes infected and thorough 
therapy cannot be done. This may be amputated after the portions to 
be retained have been adequately treated. (Figs. 23-24.) 
(2) Where the tortuosity of the root does not permit of thorough 
cleansing and sealing, the canal can be filled as far as possible, and the 
remainder of the root should be amputated. This would be more of a 
prophylactic or preventive measure. (Fig. 25.) 
(3) Where a broach, broken at about the apical third of the root canal, 
prevents its proper treatment, the part containing the foreign body may 
be amputated after the remainder has been properly cleansed, sterilized 
and filled. (Fig. 26.) 
(4) Where the root has been perforated at about its apical third, this 
may be amputated at the perforation. (Fig. 27.) CHRONIC SUPPURATIVE CONDITIONS 
93 
(a) The operation is contraindicated in all cases 
where the general health and vital resistance of the 
individual are low, or where for any reason re- 
taining a devitalized tooth is contraindicated. 
(b) If the tooth structure shows signs of disintegration or marked dis- 
coloration, suggesting an infection of long standing, this operation must 
Contraindications 
for Root End 
Amputation. 
Fig. 31. Types of cases in which root amputation is contraindicated because of pass- 
age of communication between apical and gingival areas. In some of these the in- 
fection began at the apex and passed towards the gingiva; in others the other way 
round; in still others infection may have existed at independent points and with 
their progress they coalesced. 
not be used, even if the surrounding bone conditions seem favorable, as 
evidenced by the radiograph, (c) An inaccessible position of the tooth, or 
the proximity of important structures such as the inferior dental canal or 
the maxillary sinus, are contraindications for the operation. (Fig. 28.) 
In the selection of cases, care must be taken that the infected tooth 
root still retains a goodly amount of healthy pericementum attachment, 
apico-gingivally on its entire circumference. Where such attachment is 
lacking, or where there is a path of communication between the tooth 
apex and the buccal cavity along the gingival margin, produced by the 
progressive tissue destruction of the abscess, by pyorrhea, a lateral ab- 
scess, or by traumatism, this operation should not be undertaken. (Figs. 
29, 30 and 31.) Reinfection will always follow and the tooth will have to 
be removed. Lastly, it must be understood that where thorough steriliza- 94 
ORAL SURGERY 
tion of the tooth structure to be retained cannot be secured, this operation 
is not to be undertaken. 
The operation of root end amputation recently has been quite tersely 
discredited in current dental literature, as well as in society discussions. 
Fig. 32. Presents what may appear to be a good root canal filling. Closer inspection 
shows that it is faulty and this is indicated by the presence of the infection and 
the pathological area. Root amputation would be a failure unless it is preceded by 
the complete removal of the old filling, sterilization of the root canal and its complete 
sealing. 
Fig. 33. Types of cases in which root canal therapy alone should not be depended 
upon because of complete denudation of the apices. They are favorable cases for 
root amputation, but the pivots must be removed first and the root canals treated 
. and filled. 
These expressions of disappointment reach us from varied sources, but 
unfortunately the real cause of dissatisfaction must be guessed at, as 
analytic, scientifically tenable reasons are not offered in explanation. The 
condemnation generally comes from those men who do not approve of CHRONIC SUPPURATIVE CONDITIONS 
95 
retaining a devitalized tooth under any circumstances; secondly, from men 
who meet with a large percentage of failures. 
In a symposium upon the subject * compiled by 
Dr. R. Ottolengui and published in Dental Items 
of Interest, to which men with many years of ex- 
perience and whose names are fairly identified with this work, con- 
Causes of 
Failure. 
Fig. 34. Incision of the mucoperiosteum for amputation of the first bicuspid root, 
tributed, the consensus of opinion was that, in properly selected cases, 
the favorable results are practically 100 per cent. It is the author’s 
impression that the greatest number of failures can be traced to: (a) the 
utter misunderstanding of every vital phase of the subject: (b) many have 
grasped this as a sort of a short cut for the removal of awkward apical 
infections; (c) the improper selection of patients as well as individual 
* Dental Items of Interest, 1922. 96 
ORAL SURGERY 
Fig. 35. The mucoperiosteum retracted and the bone exposed. Note the alveolar 
ridge indicating the outline of the root and thinning out of the bone over the 
pathological area. 
cases; (d) negligence in some preliminary measures preceding the opera- 
tion; (e) faulty operative technique; (/) faulty postoperative treatment. 
It must be definitely understood that without precise root canal work 
this operation is foredoomed to failure, and where this cannot be secured 
it should not be undertaken under any circumstance whatever. In other 
words, all conditions which conduce to reinfection must be absolutely 
eliminated first. Regardless of what the past treatment of the tooth might 
have been, whether the tooth is pivoted, inlayed or filled; whether the root 
or roots appear completely empty or partly or entirely filled, the first step 
must be to render, the tooth substance proper, innocuous. This is accom- 
plished by first removing all restorations and the root canal contents; the 
pulp chamber and the root canal or canals are mechanically cleansed, next 
sterilized and effectively filled and sealed. 
We find numerous cases in which the root canal work seems fairly 
complete or even perfect. These radiographic appearances cannot be 
relied upon in this event, as the presence of infection decidedly indicates 
the presence of sepsis in the root canal or in the filling material itself, or 
in both. (Figs. 32-33.) CHRONIC SUPPURATIVE CONDITIONS 
97 
Fig. 36. The outer plate of bone removed; the pericementoma and the root apex 
exposed. 
It is my custom to have all therapeutic and 
dental operations, including the prosthetic restora- 
tions completed, and to amputate the root end sub- 
sequently, so that when cicatrization ensues, the tooth is not disturbed 
again. From this we infer that root end amputation is preceded 
by a series of steps. To secure success, each one of these must be 
perfect. 
Let us assume, then, that we have selected a case where we have 
determined upon the necessity for root end amputation. By means of a 
radiograph, we ascertain that the root has been well filled to the apex. 
Note the direction and position of the root; the proximity of the 
adjacent teeth; the amount of tissue destruction. With a sharp lance, cut 
through the mucoperiosteum to the bone, and produce a semi-lunar 
incision with its crescent towards the crown of the tooth. The line of 
incision should be made at about the apical third of the root to be ampu- 
tated. The crescent is to be deep enough to permit of a convenient 
retraction of the mucoperiosteal flap in exposing the bone. (Fig. 34.) 
Flaps with narrow pedicles will often slough away and so complicate the 
Technique for 
Apicoectomy. 98 
ORAL SURGERY 
Fig. 37. The root divided by means of a fissure bur, 
after treatment. The incision should be made just large enough to permit 
of clearly exposing the root to be operated upon. 
It is important that we should have a good view of the root to avoid 
injuring the adjacent teeth or resecting the root end in a faulty way. In 
inaccessible locations, as in the case of posterior teeth, larger incisions 
will be necessary. Raise the mucoperiosteum next and expose the bone. 
(Fig- 35-) A sinus in, or a thinned out condition of the bone, or the 
alveolar ridge produced by the root of the tooth will usually guide us in 
determining the location of the apex. By means of a gouge or a chisel, 
the outer plate of bone is cut and lifted away, and the root exposed. 
Simultaneously, the pathological area will be disclosed to view, which, in 
the great majority of instances, will be found to be lined or filled with 
tissue proliferation. This may be a pericementoma, or a cystic condition 
and may or may not contain pus. (Fig. 36.) 
At the point where the normal tissue attachments terminate, the root 
can be divided with a fissure bur (Fig. 37) and with a fine curette the 
entire pus sac or pericementoma may be lifted out from its bony crypt. CHRONIC SUPPURATIVE CONDITIONS 
99 
Fig. 38. The root end and the pathological area cleared. 
Fig. 39. Diagram showing the relationship of the tissues 
I he bone beyond this tissue is, as a rule, intact, shows signs of con- 
densation osteitis and presents almost a burnished surface. While it is 
desirable that all of the contents of the cavity be removed, the curetting 
away of bone structures beyond this is not indicated. (Fig. 38.) 
Some operators prefer to remove the portion of root to be amputated, 
with a sharp blow of a mallet and chisel. This is a somewhat risky pro- 
cedure. A blow which is forceful enough to separate the root is likely to 
fracture the already weakened alveolus, or even dislodge the entire tooth. 
Besides, the root end cannot be divided with precision and will present 
a jagged surface which may become a source of irritation. Others base 
the success of this operation upon dividing the root within healthy tissues. 
In so doing, of necessity, some of the healthy and useful tissues will be 
sacrificed. While it is essential that all of the diseased tissues be removed, 
it is equally essential that all of the healthy tissues should be retained. 
After all tissues thought necessary have been removed, the hone edges 
of the cavity are smoothed off and the nuicoperiosteal flap returned to 
its former position. 
The object of sutures is to approximate and keep in apposition the lips 100 
ORAL SURGERY 
Fig. 40. The mucoperiosteum restored and sutured into position and dressing 
introduced without disturbing the coaptation. 
of the wound. By so doing, we restore the normal contour of the parts 
and induce primary union between those parts of the severed tissues which 
are held in apposition. Where the incision is not too large and gaping, 
suturing may be omitted. Where the incision is made as illustrated by 
Fig. 34, and made just large enough for the amputation of an individual 
tooth, the resiliency of the tissues and the pressure of the lips, or the 
cheek, are quite sufficient to retain the mucoperiosteal flap in its normal 
relationship. Where suturing is resorted to, the suture should be intro- 
duced at the farthest point possible from the gingival margin and care 
should be taken that these parts be not injured. Silk, horse-hair, or cat- 
gut may be used for the purpose. (Fig. 40.) 
Where the abscess cavity is small, and the vitality of the patient is 
normal, cicatrization will very readily follow and few or no dressings will 
be necessary. But even in these cases it is advisable to keep the patient 
under observation for at least ten days or two weeks, and to keep the 
wound irrigated with a mild antiseptic solution. Where the wound is fairly 
large and age or the vital resistance of the patient does not warrant such 
procedure, the cavity should be dressed with iodoform gauze, which may CHRONIC SUPPURATIVE CONDITIONS 
101 
be changed first every twenty-four, and later every forty-eight hours. 
The dressing should be lodged within the cavity. The exposed bone sur- 
faces of the cavity will soon be covered by cicatricial tissue; it gradually 
diminishes in size and eventually becomes obliterated. If we are to trust 
Fig. 41. A case of root end amputation before and after treatment. 
Fig. 42. A case of root end amputation before and after treatment 
our radiographic records, a great part of this new tissue undergoes 
ossification. 
To substantiate this claim, I submit two of many case histories which 
will be more illuminating than haphazard statements or the most eloquent 
arguments. The clinical presentation, the radiographic examination and the 
general health of these patients assure me that these conditions may justly 
be regarded as cured. 
The ages of these patients are given at the time of the operation. 
Miss I. L. Age 20. The original radiograph of 
this case was lost. The upper lateral incisor had 
become abscessed as a result of caries. This case was treated in associa- 
Case 1. 102 
ORAL SURGERY 
tion with Dr. R. Ottolengui for research purposes. At the time of root 
amputation a pericementoma was found to be present. Figure 41A was 
taken within a month after the operation was performed on May 22, 1917- 
Figure 41B was taken April 20, 1921—four years later. 
Miss M. N. Age 18. The pivoted right central 
incisor was amputated in March, 1912, and shows 
complete normal bone surrounding the entire tooth after ten years. (Fig. 
42A.) The left central incisor shows a root canal filling and pathological 
Case 2. 
Fig. 43. 
Fig. 44. 
Fig. 45. 
Fig. 43. Shows the condition about a root immediately after implantation. 
Fjg. 44. Shows considerable absorption of the root as early as five months later. 
Fig. 45. Shows rapid progress of the absorption of the root three weeks later than 
the last illustration. 
area. This was amputated on June 15, 1921. Figure 42B shows the 
condition five and a half months later, taken on December 6, 1921. 
To further supplement the stand that a pulpless 
or devitalized tooth is not a foreign nor a dead body 
the following case might be considered. 
Patient J. H. Age 9 years. He fell on the street and had his upper 
left central incisor knocked out, also fracturing the mesial tip of the 
right central. The patient was seen five or six hours after the accident. 
The tooth was immediately placed into Ringer solution, the socket was 
cleaned, treated with antiseptic and packed with iodoform gauze. The 
tooth was opened under sterile precautions, the pulp was removed and the 
root canal was filled with chloropercha and gutta-percha. The next day the 
tooth socket was thoroughly irrigated with a warm saline solution and 
the tooth, which had been kept meanwhile in Ringer solution, was re- 
planted. A splint was cemented in place October 28, 1922. (Fig. 43.) 
Possible Retention 
of Pulpless Teeth. CHRONIC SUPPURATIVE CONDITIONS 
103 
The tooth was quite firm two months later when the splint was removed 
and the surrounding tissues appeared to be entirely normal. 
Fig. 44 was taken March 15, 1923, and Fig. 45 on April 6. These 
radiographs show rapid and progressive absorption of the root. This 
replanted tooth evidently was accounted a foreign body, and we note 
Nature’s osteoclastic processes in getting rid of it. Such summary de- 
struction and exfoliation are never seen in connection with pulpless teeth. CHAPTER VII. 
Sublingual Abscesses. 
Abscesses in the sublingual region present distinct characteristics which 
make their special consideration and description desirable. 
Sublingual abscesses may occur at any point between the median line 
and the pillars of the fauces; they often present more severe complications 
than those which point towards the buccal aspect, or into the submaxillary 
region. Rise of temperature, general malaise and constitutional toxic 
symptoms are, as a rule, more pronounced than in other abscesses about 
the teeth and jaws. 
Infection and abscesses in the sublingual region often occur as a result 
of comparatively slight injury of the mucosa; irritation and subsequent 
infection of the submaxillary, or sublingual salivary glands; injury and 
infection of these structures, or obstruction of a duct caused by salivary 
calculus, often lead to suppuration. They occur more commonly, however, 
as a result of the spreading of infection from an abscessed tooth; sepsis 
following operations, such as the removal of teeth; sloughing of the tissues 
resulting from severe laceration; traumatization; mangling and fragmen- 
tation of the bone and necrosis; excessive sloughing and infection of the 
soft tissues due to the toxic action of a local anesthetic; septic injection 
of a local anesthetic or injecting into a septic area. 
The more severe and complicated abscesses in 
this region could almost invariably be traced to the 
injection of a septic local anesthetic. In these the 
following clinical symptoms are observed, and they run a fairly uniform 
course: The patient gives a history of having had a troublesome (not 
necessarily infected) tooth removed three or four days previously. The 
tooth is removed successfully, and there are no untoward complications 
for the first two or three days. On or about the third or fourth day a 
sense of discomfort begins to develop at the base of the tongue; there is 
a slight amount of pain and the temperature rises to about 99-100° F. 
Twenty-four or forty-eight hours later the pain becomes more trouble- 
some, the swelling becomes larger and is now perceptible on the external 
surface of the submaxillary region as a deep-seated swelling. The mucosa 
underneath the tongue may be but slightly or considerably displaced 
Abscesses from 
Septic Injections. 
104 SUBLINGUAL ABSCESSES 
105 
and may or may not be discolored. Upon palpation the tissues feel tense 
and deeply indurated. The epidermis and the underlying tissues in the 
submaxillary region present no signs of direct involvement, and upon 
palpation a deep-seated swelling between the oral mucosa and the hyoid 
muscles may be discerned. The infection often spreads into the deeper 
parts at the base of the tongue, or to the pillars of the fauces; the soft 
palate may become involved to such an extent that a complete half of the 
oropharynx is obstructed, simulating a peritonsillar abscess. The pain is 
now intense and radiating to the ear, to the temporal and cervical region, or 
the entire side of the head becomes sore and painful. The temperature 
may rise to 102-103° F.; reglutition and the movement of the tongue are 
difficult and painful, and there is a variable degree of trismus. 
In the anterior part of the mouth, these abscesses are, as a rule, not 
quite so diffused; they are not so painful and are somewhat more easily 
controlled than those occurring more posteriorly. The infection does not 
tend to diffuse so readily here as in the posterior parts. All the tissues 
lodged underneath the anterior part of the tongue become considerably 
discolored and swollen to such an extent that the tongue becomes dis- 
placed and the swollen tissues appear fringed and ulcerated along the 
edges where they rest against the teeth. 
As in the treatment of all abscesses, evacuation 
and thorough drainage are important. This can be 
secured almost invariably intra-orally. External incision in the treatment 
of these cases is rarely essential. The span of the geniohyoglossus, the 
geniohyoid and the hyoglossus muscles serve as a barrier to the penetra- 
tion of the pus to the external surface. 
The displacement of the tissues is not to be taken as the sole guide in 
making the incision. The incision should always be close to the bone and 
as close to the floor of the mouth as possible, to secure a more ready point 
of drainage. 
The mucosa having been incised and the opening enlarged to the de- 
sired size, a pair of blunt scissors are inserted and gradually insinuated 
into the deeper regions until pus is reached. Iodoform gauze is introduced 
to secure drainage and ice packs are applied on the external surface over 
the submaxillary region. 
These abscesses are often mistaken for Ludwig’s angina, or, when 
occurring in the anterior part of the mouth, for a ranula. In differential 
diagnosis, the clinical history is of distinct aid. A ranula can easily be 
differentiated from the abscess by the history, the inflammatory symp- 
toms, the appearance of the tissues and by the general condition of the 
patient. (See “Ranula.”) 
Treatment CHAPTER VIII. 
Surgical Treatment of Periodontoclasia. 
The treatment of diseases of the investing tissues of the teeth, known 
under the collective term of “pyorrhea alveolaris,” or more lately as 
“periodontoclasia,” is a specialized field. By far the greatest number of 
these conditions can be successfully treated by means of prophylactic 
measures and so-called “root surgery.” This comprises, mainly, the re- 
moval of all gingival and subgingival irritating factors, and also broken 
down and infected tissues, through the gingival opening created by the 
disease. Considerable importance is assigned, in this treatment, to the 
correction of traumatic occlusion, where this exists. It is not the author’s 
intention, therefore, to enter here into a complete consideration of the 
subject, but rather to treat upon those types of conditions only, where these 
efforts in themselves are inadequate. To control all of the pathological 
phases presented and to secure better results, these measures must be 
supplemented with a degree of true surgical interference. 
It is not always a simple matter to determine just 
where surgical measures are indicated and where the 
more conservative means will be sufficiently effec- 
tive. It may be stated that surgical interference should never be preferred 
and should be employed only where the nature of the pathological condi- 
tions permits of no alternative. In this we must be guided by close clinical 
examination and by thorough radiographic study, the exposures being 
made at different angles to disclose as accurately as possible the state of 
the investing tissues. Ofttimes the response to previous treatment may be 
the guide. The radiographs are not always reliable. They often repre- 
sent the lesions as hopeless for any kind of conservative treatment in 
opposition to our clinical experience. Also, because of the angle at which 
the exposure is made, some lesions may not be well defined. 
Despite the intense study and close investigation 
which these diseases have been subjected to, through 
many years, the etiology is still obscure in many 
respects. It is fairly generally conceded, however, that, in numerous 
instances, the disease is caused by purely local agencies and that in others, 
both local and constitutional factors are present. 
Surgery in 
Periodontoclasia. 
Etiology of 
Periodontoclasia. 
106 PERIODONTOCLASIA 
107 
The local etiologic factors are always some forms of irritation, of trau- 
matic or septic nature, or both. Of these the more frequent ones are 
salivary or serumal calcific deposits; traumatic occlusion of the teeth; 
ill-fitting restorations in the way of fillings, inlays, crowns, bridges and 
partial dentures. 
Chronic traumatic irritation is always attended by some degree of 
inflammation of tbe gingival tissues, thereby rendering these points vul- 
Fig. 46. Hypertrophy of the gums and periodontoclasia in which surgical inter- 
ference is indicated. 
nerable to the invasion of the microorganisms present. Hartzell believes 
that when this occurs the streptococcus forms the van of the bacterial 
invasion, causing deterioration of the tissues, which is followed by the 
staphylococcus and the host of other organisms which infest the oral 
cavity. 
The systemic conditions act more often as predisposing factors in the 
causation of the disease. Systemic disorders, which tend to lower the vital 
resistance of the patient, are often found to be associated with the disease. 
All debilitating diseases, therefore, such as syphilis, tuberculosis, diabetes, 108 
ORAL SURGERY 
anemia and gastro-intestinal disorders may be regarded as predisposing 
factors. That nutrition and diet play an important part in the maintenance 
of the condition of the teeth and their investing tissues is amply proven 
by scurvy, for example. Our knowledge regarding the influence which 
Fig. 47. A drawing after a clinical case. Note the marked recession and thickened 
condition of the gingiva. 
diet has upon diseases of the teeth and their investing tissues has been 
greatly augmented by researches of McCollum, Howe and others. On the 
other hand, we are often impressed with the fact that in some individuals, 
who are apparently in the best of health, presenting no symptoms of 
systemic disorders and whose mouths are kept scrupulously clean, with 
their occlusion normal, periodontoclasia nevertheless exists. Unquestion- 
ably senile atrophy, or sometimes precocious senile changes, play an im- 
portant part in these cases. PERIODONTOCLASIA 
109 
From a clinical standpoint, we may classify the 
cases in which surgical interference may be indicated 
into two general groups. One group is character- 
ized by more or less extensive atrophy of the affected 
tissues. The second group is marked by hypertrophy, which is accom- 
panied by a degree of breaking down and deterioration of the affected 
tissues. 
It may he here stated that success in the treatment of these conditions 
is always dependent, in the largest measure, upon thorough prophylaxis 
Conditions Where 
Surgical Interference 
Is Indicated. 
Fig. 48. The first step in the operation. Note the vertical incisions and the separa- 
tion of the gingival tissues. 
and the removal, correction and treatment of conditions recognized as local 
or systemic etiologic factors. Before undertaking any operative measures, 
therefore, the mouth in general should be scrupulously cleaned and the 
teeth freed from surface or subgingival deposits and then well polished. 
Considerable attention must be given to the elimination or correction of all 
systemic dyscrasia which may exist in the patient. 
As intimated, in the first group may be classed all those conditions in 
which there is extensive pathological destruction of the pericementum 
and a proportionate infection of the cementum, and infection and break- 
ing down of the alveolar process. As a result, deep pockets are formed 
about the affected tooth or teeth, in which any one surface, or all surfaces, 
may be involved. There may be frank, copious pus discharge upon pres- 
sure, or the pus may be so sparse that its presence cannot be clinically 
demonstrated. Black found that even in the absence of frank pus, pus 
cells were always present upon microscopic examination. When suppura- 110 
ORAL SURGERY 
tion exists, the pus discharged can often be eliminated, or checked with 
thorough prophylactic measures; scaling of the roots, in which all salivary 
and serumal deposits, infected portions of cementum, degenerated, or 
broken down, or infected pericementum and alveolar process are removed. 
Other etiologic factors, such as traumatic occlusion, or mechanical irritants 
must also be removed or corrected. 
Fig. 49. Shows the gum flap raised and the low grade of granulations Idling the 
interdental spaces exposed; also the denuded root surfaces. 
This treatment is often followed by a complete cessation of the pus 
discharge, or it may be only decreased. Invariably, however, there is a 
general clinical improvement of the affected tissues, a degree of tightening 
of the teeth when these are loose, and a closer adherence between the 
tooth root and the investing tissues. While this may be encouraging 
from a clinical standpoint, the deep pockets extending to the middle portion 
of the root, or sometimes beyond that, cannot become completely obliter- 
ated. The physiological coordination cannot be reestablished where, in 
the pathological process, a considerable part of the pericementum becomes 
destroyed and the cementum and the alveolar process become infected 
and broken down. The remaining pockets, therefore, predispose towards 
recurrence of the disease. These deep, infected pockets are also prone to 
act as foci of infection. 
The object of a surgical operation, in these cases, is to reduce, or 
entirely excise these tissues which form the pockets. The operation is 
not new and was advocated and practiced originally by Riggs. It consists 
of the removal of that part of the gingival and gum tissues which form the PERIODONTOCLASIA 
111 
pocket, and cover the denuded root surfaces. In doing this, care must 
he exercised to retain as much of the gum tissues as possible. The opera- 
tion leaves an unesthetic and very uncomfortable condition, so that, in my 
opinion, where this operation would need to he very extensive, the teeth 
should best be removed. Where a few isolated teeth are involved, the 
operation can be carried ov.t with success and much satisfaction. 
Fig. 50. The unhealthy gra ulations, in Acted and sharp portions of the alveolar 
process removed, and all surfaces smoothed. 
The second group is characterized by hypertrophy of the gingival 
issues. Fig. 46 is the case of a young woman 26 years of age. Note 
die blunted and irregular outline of the gum margins. The pockets are 
rather formed by the hypertrophied tissues than by destruction of the 
pericementum and alveolar process. 
The pockets in these cases are not, as a rule, quite so deep, and much 
of the involved tissues is damaged to such an extent onlv that repair is 
quite possible. The gingival tissues are discolored; they have a great 
tendency to bleed ; they may be somewhat ulcerated and there is, as a rule, 
a degree of suppuration. 1 here are other cases in which exuberant sickly 
granulations fill the pockets formed and the interproximal spaces, thus fill- 
ing in the points where the normal tissues have been destroyed. (Fig. 47.) 
There are still others, where the hypertrophied tissues cover a large part 
of the crown of the tooth. This last condit'on is more often observed in 
females than in males. It is quite frequent in women, during the period 
of pregnancy and lactation. Under the last stated circumstances operative 112 
ORAL SURGERY 
measures are decidedly contraindicated, as it will often be observed that 
at the cessation of this period, with the aid of prophylaxis, the tissues tend 
to return to normal. 
The object of an operation, in these cases, is to remove the excess of 
tissues and also all those sickly non-viable granulations which cover the 
under surface of the gingiva and fill the interproximal and alveolar spaces. 
Fig. 51. The gum margins trimmed and the flaps sutured into place. 
These tissues have a very low vitality and are subject to constant breaking- 
down and infection and thus prevent healthy granulation. The operation 
suggested by Ruhitzeck, and later modified by others, is well adapted to 
these cases. 
Where a larger number of teeth are involved, the case should be 
handled in several operations, four or five teeth being treated at one 
time. Severe reaction may follow in individuals whose vital resistance is 
below par, because of some constitutional, debilitating complication. The 
danger of excessive reaction is not caused by the removal of sepsis but 
rather by the opening up of larger surfaces for the absorption of the sepsis 
and toxins which are ever present in these regions. 
Two vertical incisions are made, parallel with 
the long axis of the tooth and so directed that they 
terminate in the interdental spaces, distal to the teeth 
to be operated upon. (Fig. 48.) The tissues are next reflected somewhat 
beyond the point of pathological detachment. In this way the operative 
field is clearly exposed to view. (Fig. 49.) It is often found that sickly 
Technique of 
Operation. PERIODONTOCLASIA 
113 
granulations cover the everted surface of the gums and they also fill the 
interdental spaces and frequently penetrate into the necrotic, semi-absorbed 
and deteriorated alveolar process. With fine curettes and scalers these 
tissues are carefully removed. Necrosed portions and sharp edges of the 
alveolar process are carefully scraped away. (Fig. 50.) Note next, where 
the healthy tissues terminate, and the gums are trimmed in accordance 
with their prospective reattachment. Considerable care must be exercised 
in this, as neither the removal of good tissues, nor the formation of pockets, 
is desirable. The tissues on the lingual aspect are not resected to the same 
extent, but they are raised sufficiently to expose the area of operation. 
Note where the denuded dentinal surface terminates and trim the gums 
in such a manner that when the flap is returned, it reaches slightly beyond 
this point. 
Both the lingual and labial or buccal flaps are brought into as close 
apposition as the intervention of the teeth permits. They are sutured 
through the interproximal spaces so that the gums rest snugly about the 
roots of the teeth. (Fig. 51.) 
When the flaps are closely approximated in this manner, packing is 
superfluous. The aim should be to insure primary union wherever this is 
possible, thus reducing the amount of cicatricial tissue. That this is de- 
sirable is obvious, as granulation tissues, because of their lower vital 
resistance, offer a vulnerable point and they are more prone to break 
down, thus presenting a fertile field for bacterial invasion and recrudescence 
of the disease. 
The postoperative treatment consists chiefly of thorough prophylactic 
measures and the sutures may be removed in four or five days. The gum 
margins appear highly inflamed at first, but these raw edges soon become 
covered with epithelium and, with cicatrization, a close adherence to the 
tooth surface is established. CHAPTER IX. 
Necrosis. 
Necrosis is death of tissue. In this chapter we shall use this term to 
mean death of bone en masse. Necrosis in this sense is analogous to 
gangrene of the soft tissues and is to he distinguished from other forms 
of bone destruction, such as caries or suppurating osteitis. In these latter 
conditions the bone is destroyed by a progressive unlimited cellular dis- 
integration, while in necrosis a portion of bone undergoes death in the 
aggregate without complete demolition of its inorganic matrix. In caries 
or in suppurating osteitis, the pathological process operates by extension 
from a primary focus (Fig. 52) ; in necrosis the death of a portion of 
hone is brought about rather by circulatory disturbances or the action of 
toxic substances. The former conditions must be regarded therefore as 
diseases, while the latter may truly he looked upon merely as a condition 
resulting from an injury or a disease. 
(1) Infections originating in dental lesions, such as 
alveolar abscesses, purulent percementitis or 
pyorrhea alveolaris. 
(2) Systemic infections, such as syphilis, tubercu- 
losis, scarlet and typhoid fevers, or any other disease which 
tends to undermine the vital resistance of the patient. 
(3) Inorganic poisons and drugs may act either by local application 
or by systemic absorption; as phosphorus, arsenic, mercury, 
hydrogen peroxid. 
(4) Traumatic injuries. 
(5) Sepsis introduced in local anesthesia in the solution or with the 
syringe or injecting it into a septic field. 
Necrosis of the jaws is usually preceded by osteitis, i.e., inflammation 
of the bone itself, osteoperiostitis and at times by osteomyelitis. The 
lesion may originate, however, at the mucoperiosteum and involve the 
bone subsequently. In the presence of infection which, we will presume, 
has originated with a diseased tooth, the inflammatory process spreads 
until a considerable area of the bone becomes involved. The circulation 
within the Haversian system may become impaired, or entirely obstructed 
Etiology of 
Necrosis of 
the Jaws. 
114 NECROSIS 
115 
Fig. 52. Chronic suppurative osteitis in a man 28 years of age. The infection fol- 
lowed a traumatic injury although there was no fracture. Wassermann test was 
negative and there were no symptoms of tuberculosis. Note the diffused bone de- 
struction and the subperiosteal enlargement of the bone at the point of lesion. 
Radiograph was taken when he was first seen, two months after the injury was 
sustained. 
by the pressure of the inflammatory exudates. The occlusion of the blood 
vessels may also be caused by bacterial thrombi, or emboli, or they may 
be severed by a direct traumatic injury. When the mucoperiosteum be- 
comes involved, the inflammatory exudates may collect underneath this 
tissue, and when it becomes separated from the bone, the second available 
channel of nutriment to the bone is cut off. 
It may here be stated that if the source of sepsis were removed 
promptly and the tension relieved by incising the mucoperiosteum to the 
bone and drainage were thus established, numerous cases of extensive 
necrosis could be aborted at this stage. In the shafts of long bones an 
inflammatory condition and infection often extends through the epiphysis 
to the medullary canal and the endosteum and true osteomyelitis develops. 
In the jaws, as they have no medullary canal, either one of the two first 116 
ORAL SURGERY 
Fig. S3. Necrosis of the mandible, following infection of temporary molar, in child 
7 years of age. There was a pathological fracture through the angle of the jaw. 
A part of the ramus and coronoid process became necrotic and the sequestrum can 
be seen anterior to and above the partly formed second molar. 
conditions may obtain, or both may exist simultaneously. Such fine lines 
of demarcation are merely hypothetical, however, and they cannot be de- 
termined nor demonstrated clinically, for, even under the microscope, dead 
cells appear for some time very much like the living ones. 
Briefly, then, a portion of bone in which the 
vascular mechanism has been impaired or entirely 
obstructed, may die because of lack of nutrition. A portion of dead bone, 
whether it is deprived of its nutrition by traumatic injury, a surgical 
operation, or an inflammatory process inaugurated by an infection, is called 
a sequestrum. A sequestrum, lodged within vital surroundings, acts as an 
infected foreign body and is not tolerated by the surrounding healthy 
tissue. With necrotization, a reaction takes place in which there is a 
softening of the adjacent healthy bone and a line of demarcation by 
granulation tissue is formed. The tendency is to dislodge the sequestrum, 
and this process is called “exfoliation.” 
Sequestrum. NECROSIS 
117 
Fig. 54. Necrosis of the mandible in a child 7 years of age. The radiograph of 
the case is shown in Fig. 53. The necrosis followed infection and abscess of a 
temporary molar. In cases of this type after drainage is established and main- 
tained for some time, the swelling, although marked, is free from all other inflam- 
matory symptoms. Upon retention of pus the symptoms become fulminating. 
These swellings often persist for years or even permanently after the condition 
has been cured. 118 
ORAL SURGERY 
Fig. 55. Extensive necrosis in a boy 11 years of age, following the removal of 
abscessed permanent first molar. Here the entire ramus and part of the body were 
lost. The case was treated conservatively and while the necrosed parts were being 
exfoliated new bone formed. Note the fracture anterior to the angle and the 
separation of the condyloid process which was later removed. The ramus is newly 
formed bone. NECROSIS 
119 
Fig. 56. Necrosis of the ramus and part of the mandible in a boy 11 years of age. 
The radiograph of the case is shown in Fig. 55. The ramus seen in the radiograph 
is newly formed bone. The condyle is in a state of exfoliation and was removed 
later. In cases of this nature, there is a tendency of displacement of the jaw, be- 
cause of lack of posterior support and the traction of the muscles which have lost 
their proper attachment. It is advisable therefore to provide an appliance to counter- 
act this tendency and to correct the acquired deformity where this is present. The 
position of the chin suggests the degree of displacement. 120 
ORAL SURGERY 
Exfoliation is usually accompanied by suppura- 
tion. There is a circumferential breaking down by 
osteoclasts and liquefaction of the sequestrum itself. When of long 
standing this presents, upon removal, an irregular, corroded, worm-eaten 
surface. Simultaneously, there occurs a receding absorption of the healthy 
bone beyond the granulation zone. This continues until the sequestrum 
becomes quite loose and can readily be removed. If it is not removed, 
suppuration will continue until the sequestrum is entirely broken down 
and liquefied or is extruded by the granulation process. This is true 
whether the sequestrum is a spicule or a larger section of bone. 
Inflammatory conditions of the bone, following 
dental infections, are quite common. Extensive 
necrosis occurs more frequently in the lower than 
in the upper jaw. These conditions are more prone to develop in children, 
prior to the eruption of the permanent teeth. It should be remembered 
that at this period of life both the upper and lower jaws are more readily 
invaded by infection because of the physiological absorption and rarefied 
condition of the cancellous bone which attends the formation and the 
eruption of the permanent teeth. Infection under these circumstances 
tends to spread more readily and the results are often deplorable and dis- 
astrous. This is particularly true of children who are ill-nourished or 
whose vital resistance has been undermined by the exanthematous dis- 
eases. Too much stress cannot be laid, therefore, upon the need for the 
very prompt and careful attention that must be exercised in the presence 
of infection in young subjects. In adults, all nutritional abnormalities 
or diseases, such as anemia, pernicious anemia, diabetes, syphilis and 
tuberculosis, may be looked upon as predisposing causes. The necrotic 
area is usually confined to the afifected side, though a number of cases have 
come under my observation, wherein both sides of the jaws became in- 
volved. This is more frequently true of the mandible. (See Figs. 53, 54, 
55 and 56.) 
Necrosis may follow almost spontaneously, an 
acute inflammation caused by any of the conditions 
described above. When this occurs, the area becomes 
largely swollen, with a deep throbbing pain and systemic symptoms of an 
acute infection. The bone itself becomes swollen, tender to the touch and 
when suppuration ensues the pus tends to point towards the external sur- 
faces. The bone enlargement often produces a marked asymmetry of the 
facial outlines which may become corrected in the course of time by resorp- 
tion. It is also to be noted that, in young children particularly, an increase 
in the overlying soft tissues occurs. This is quite marked in some. The 
Exfoliation. 
Occurrence of 
Necrosis. 
Symptoms 
of Necrosis. NECROSIS 
121 
Fig. 57. Asymmetry in facial outline following extensive necrosis of the body and 
part of the ramus of the right side of the mandible. This condition existed three 
years after the case was dismissed as cured. There were no signs whatever to 
indicate the presence of a pathological condition at this time. 122 
ORAL SURGERY 
I'lG. 58. Asymmetry of the mandible following necrosis of a section of the body 
of the bone in a woman 32 years of age. Necrosis followed the removal of a carious 
tooth. A cocain solution was used as the anesthetic and it was then suspected that 
the drug had something to do with the developing of necrosis. The photograph 
was taken six months after the case was cured. NECROSIS 
123 
Fjg. 59. Bilateral necrosis of the body of the lower jaw in a girl 14 years of age. 
The condition began with abscess of the right first molar, and necrosis extended 
to the molar region of the opposite side. All of the other teeth were in perfect 
condition but they were practically exfoliated with the necrosed bone. Note how 
the mucoperiosteum separated from the necrotic bone. 124 
ORAL SURGERY 
Fig. 6o. Same case as Fig. 59. Note the diffused ramifications of the necrosis 
through the entire body of the bone. This was taken soon after the onset of the 
infection. While the body of the bone was rebuilt the teeth and the alveolar process 
were lost. NECROSIS 
125 
Fig. 6i. Same case as Figs. 59-60, showing a thickening of the entire mandible. 
The photograph was taken sixteen months after cicatrization and dismissal of the 
patient. 126 
ORAL SURGERY 
swelling is entirely free from all inflammatory conditions, is not painful 
and there is no impaired function. (Fig. 57.) 
Where the enlargement is due to proliferative osteitis and hypertrophy 
of the bone, the deformity may he a permanent one. (Figs. 58, 59, 
60 and 61.) 
The pain caused by the inflammatory congestion can be relieved by a 
deep intra- or extra-oral incision carried through the overlying soft tissues 
to the bone. I11 the presence of suppuration, drainage and evacuation of 
the pus will promptly reduce all disturbing symptoms. If thorough drain- 
age is maintained, the condition often passes into a chronic state, and 
suppuration continues until all of the sequestrum is removed. 
From a clinical standpoint we may differentiate 
two types of necrosis, i.e., the circumscribed and the 
diffuse. The circumscribed type is often preceded 
by an inflammatory and suppurative condition which 
passes into a chronic state, or has a tendency to chronicity. The diffuse 
type more often is the spontaneous result of a severe infection and acute 
inflammatory condition, which may nevertheless pass into a chronic state. 
The radiograph presents variable pictures, de- 
pending upon the nature of the necrosis. The cir- 
cumscribed type appears as a portion of osseous 
tissue, definitely outlined by the surrounding granulation zone. (See 
Fig. 62.) In the diffuse type, the involved region or the entire thickness 
of the bone presents permeation of necrotic destruction with irregular 
ramifications. (Figs. 63, 64, 65, 66 and 67.) There are cases in which 
larger segments, involving a complete portion of bone, may become 
necrosed. A noteworthy case of this kind is presented in Fig. 68. This 
occurred in a girl 18 years of age. She had an upper molar removed, under 
local anesthesia, in which the tuberosity injection was used. Severe infec- 
tion followed, and the pus eventually localized on the inner surface of the 
ramus. Free drainage was maintained intra-orally and later extra-orally, 
but the entire ramus became necrosed and was removed. It is well to 
point out here, that, in the presence of necrosis of this extent, or where 
even a smaller portion involving the complete thickness of the bone is lost, 
an appliance should be prepared to maintain the correct position of the 
parts and to prevent deformity after the sequestrum has been removed. 
In this, such a result was not anticipated as she had a good occlusion of 
the teeth. About fourteen days after the removal of the sequestrum the 
entire mandible was shifted backward and to the left side, creating a dis- 
parity of more than half an inch in the occlusion. A11 orthodontic 
appliance was made and the mandible was brought into place by means 
of rubber bands. (See more detailed description in Chapter X.) 
Circumscribed 
and Diffuse 
Types of Necrosis 
Circumscribed 
Necrosis. NECROSIS 
127 
Fig. 62. Circumscribed necrosis of the lower jaw in a man 31 years of age. This 
followed the removal of an infected third molar. All examinations and history 
negative. The radiograph shows the condition three months after the onset of the 
disease. Note the zone of liquefaction about the sequestrum and also the limiting 
condensing osteitis beyond the area of liquefaction. 
Fig. 63. Unilateral diffuse necrosis of the lower jaw in a man 35 years of age. 
Note the isolated fragments of bone and the ramifications of the necrotic condition. 128 
ORAL SURGERY 
Figs. 64 and 65. Necrosis of the lower jaw in a young girl 16 years of age inci- 
dental to an abscessed lower first molar. This presents a typical picture of diffuse 
osteomyelitis, and necrosis. Note honeycombing of the bone by the necrotic 
process. The entire right side of the anterior portion to the bicuspid on the left 
side became involved. NECROSIS 
129 
Fig. 66. Necrosis of diffused type of the entire body of the mandible in a young 
man 23 years of age. All examinations, also Wassermann test, were negative. The 
condition started with an abscessed tooth bearing a bridge and soon spread to the 
opposite side. Note the honeycombed appearance of the entire bone. It is im- 
possible to determine which portions of the bone are necrosed and which are living 
and to be retained. The case must be conservatively treated and Nature relied upon 
to do the exfoliation. Curetting would simply aggravate the condition and cause 
the loss, probably, of the entire mandible. 130 
ORAL SURGERY 
The presence of necrosis may be established best by means of the 
radiograph. Where this is not available, or where its interpretation is 
obscure, probing through the sinus is a diagnostic aid. Necrosed bone 
usually presents to the steel probe as a gritty rasping solid, and upon con- 
tact we obtain a sharp metallic note. Living bone feels more like a smooth, 
elastic surface, and gives no clear metallic note on contact. 
Fig. 67. Spontaneous diffuse necrosis of the left side of the upper jaw in a woman 
32 years of age. Abscess formed upon the carious first molar. The pus diffusion 
spread very rapidly and osteomyelitis and necrosis developed in four days after the 
initial onset of the disease. The radiograph was taken on the fourth day after the 
onset of the acute symptoms and shows involvement of all of the teeth on the 
affected side. Except the first molar, all the teeth within the region were normal 
and contained no cavities nor fillings. Though the case was treated very conserva- 
tively all of these teeth were lost. 
The first step in the treatment is relieving by 
deep incision the inflammatory tension, evacuation 
of pus, and establishment of free drainage. Thor- 
ough drainage is imperative as this prevents the spreading of the infection 
and aids the exfoliation of the sequestrum. The statement that surgical 
interference should always be conservative cannot be over-emphasized. 
Despite the fact that some of these cases may be so prolonged as to become 
tiresome to both the surgeon and patient, a fine sense of discrimination 
must be exercised to determine the proper time for surgical steps to he 
taken and when this would be merely a meddlesome, aggravating procedure. 
With radical curettement, or an attempt to dislodge the as yet unsep- 
Treatment 
of Necrosis. NECROSIS 
131 
Fig. 68. Necrosis of the ramus due to sepsis following a tuberosity injection for 
the removal of an upper molar. 
arated sequestrum, the osteogenetic tissues are often traumatized. Such 
aggressive procedure only tends to cause spreading of the infection, de- 
layed repair of bone, and not infrequently an irreparable loss of large 
sections of bone and a permanent pathological fracture. 
In the circumscribed type of necrosis, the separation of the sequestrum 
is disclosed by the radiograph. Upon probing, the necrotic bone feels loose 
and it may be held down merely by the overlapping tissues. At this stage 
it is permissible to expose this region thoroughly, and the sequestrum 
can be removed. The bed of the sequestrum is lined with granulation 
tissue, which, on the surface, is poorly organized, soggy with pus, and 
shows clinical signs of degeneration. It is good practice to remove this 
non-viable tissue, but injury to the deeper strata of granulations which are 
closely adherent to the healthy bone should be avoided. The postoperative 
treatment consists of irrigation and light dressing with iodoform gauze 
until cicatrization ensues. 132 
ORAL SURGERY 
The diffuse type of cases, as a rule, are more 
troublesome and often more protracted. In their 
treatment the underlying principles of prompt drain- 
age and irrigation are equally important. In these we have a number of 
smaller and larger portions of necrotic bone undergoing exfoliation and 
the progress of this process must be carefully observed. The radiograph 
here is not quite so well defined and'does not show the clear-cut line of 
demarcation between healthy and necrotic bone structure. The entire 
involved part seems to be traversed by irregular penetrating lines and 
channels. It is impossible to discern which strip of bone is healthy, or in 
a state of repair, and which is dead and in a state of exfoliation. Frequent 
probing and the persistence of suppuration are helpful in determining when 
and where a sequestrum has formed. 
Suppuration will persist until all necrosed bone is removed or ex- 
foliated. Continued suppuration is a decided sign of the presence of a 
sequestrum. 
Prognosis is usually favorable. Care must be 
given to the patient’s general health. The vital 
resistance which is likely to be undermined by the 
lengthy suppurative condition, should be maintained 
with proper diet, careful elimination, rest and hygiene. The bone itself 
will repair and regenerate through the osteogenetic tissues. Often large 
hollowed-out regions will become spanned over and completely ossified. 
The new bone may be somewhat different in its structure from that which 
it replaces, but in accordance with Wolff’s law of bone regeneration, it 
will, in the course of time, be restored in external form, and internal 
structure by its functional requirements. 
Diffuse 
Necrosis. 
Prognosis 
in Cases of 
Necrosis. CHAPTER X. 
Infections and Complications Arising from Local 
Anesthesia. 
The question is frequently asked whether there is danger in the ad- 
ministration of local anesthetics. This query may be directly answered by 
stating that there is no danger whatever in the careful and discriminate 
use of the mildly toxic local anesthetics, such as are obtainable at the pres- 
ent time. 
To substantiate this statement we look back over a period of from ten 
to fifteen years, during which time many thousands of administrations 
have been performed without a single untoward complication, except some 
minor, transitory reactions, lasting but a few minutes. The statement 
cannot be made unqualifiedly, however, as we have had to treat cases of a 
serious and alarming nature on numerous occasions, and even fatalities 
have been reported which could be directly traced to a fault in some phase 
of the administration of the anesthetic. We must admit therefore that 
there is an element of danger in local anesthesia, if not properly per- 
formed. 
Up to this time many thousands of cases have been operated upon suc- 
cessfully, for almost every condition which might be encountered in the 
practice of oral surgery, from the removal of a tooth to the removal of 
growths and even the correction of cleft palates in adult patients. The 
patients have not always been the best kind of risks, as much of this work 
was done at clinics, amongst patients whose general health, nutrition, vital 
resistance and personal hygiene were practically at the lowest ebb. Their 
ages ranged from 6 years to 80 and 85. Many of these were suffering 
from graver maladies, such as diabetes, anemia, arteriosclerosis, leucemia, 
or affections of some of the vital organs, such as the heart, the kidneys, the 
liver, etc. 
It should be remembered that all anesthetics, even those of the least 
degree of toxicity, are protoplasmic poisons; that their toxicity, so far as 
local and general symptoms are concerned, is in direct ratio with the con- 
centration ; that a given quantity of the drug, in a more diluted solution, 
may be introduced without producing toxic symptoms, whereas the same 
dose in a more concentrated form may prove dangerous; that the injected 
133 134 
ORAL SURGERY 
tissues enter more readily into a loose chemical combination with weaker 
solutions; that the anesthesia may not be quite so lasting, but it is just 
as profound and will endure long enough for all practical purposes; that 
the injected tissues, inundated with this foreign substance, recover much 
more readily from the effects when used in lesser concentration; that for 
this reason, conduction anesthesia is rarely followed by excessive slough- 
ing of the tissues, such as we were wont to see when submucous injections 
of cocain were more generally used. The toxic action of the drug, 
superseded by the operative trauma, is often followed by necrosis of the 
soft and osseous tissues. 
The above statement is made simply as a matter 
of general information and as a matter of record. It 
should be of interest therefore to find the causes of 
the complications which often attend the use of local 
anesthesia in some men’s hands. Upon analyzing these, I find that the 
source of the trouble is not, as a rule, inherent in the case itself, but in 
almost every instance is traceable to some fault in the technique. Of these 
we may enumerate the following: (i) sepsis; (2) faulty solution; (3) 
faulty technique in the administration; (4) defective syringes or needles 
used. 
Sepsis is the source of the gravest complications 
and in some cases which have been brought to the 
writer’s attention, even fatalities have resulted: 
Sepsis may be introduced by three means: (1) septic syringes 01- 
needles; (2) the injection of a septic solution; (3) injecting into a septic 
area. 
The first two are the more common sources of danger. This is par- 
ticularly true in deep injections, such as the mandibular, tuberosity, or 
infra-orbital. The reactions caused are in some instances only very mild 
and may resolve; in others severe complications, such as deep-seated 
abscesses in the tonsillar, peritonsillar, sublingual, submaxillary, or tem- 
poral region may develop. 
While there is a degree of parallelism so far as the symptoms and re- 
action are concerned in most cases, there are phases of variation which 
are most likely dependent upon: (1) the type and number of microorgan- 
isms introduced: (2) the general health and the vital resistance of the 
patient. 
From my own observations I may state that more severe and more 
immediate reactions, both systemic and local, have followed where the 
injection was made into a septic area, than where extraneous sepsis is 
introduced. The injection necessarily produces a degree of tension of 
Causes of 
Complications in 
Local Anesthesia. 
Sepsis. COMPLICATIONS FROM LOCAL ANESTHESIA 
135 
the tissue and it is probable that through this pressure the microorganisms 
and their toxins are practically forced into the tissues and upon the 
system in overwhelming doses. 
The reaction is marked by immediate aggravation of the local symp- 
toms when this is present. The pain becomes more severe; the swelling 
becomes greater; the systemic symptoms also get to be more accentuated. 
In most cases there is a rise in temperature. There may be severe head- 
aches, chills and fever, pains and aches all over the body, and a marked 
leucocytosis. Treatment of the local conditions does little in the way 
of relieving and often has no influence whatever upon the systemic 
symptoms. Some cases terminate fatally and in those which recover there 
are usually local conditions in the way of extensive necrosis of the soft 
as well as of the hard tissues. 
The following history will illustrate a case of 
this type. Patient was a boy 12 years of age; 
applied at the clinic for treatment, reporting that 
three days before he had had a slight swelling on the left side of the upper 
molar region. He went to a dentist, who removed a carious and obviously 
abscessed temporary molar under local anesthesia. The face became con- 
siderably more swollen in a few hours after the removal of the tooth. He 
was now suffering excruciating pain and the physician found the tempera- 
ture to be 1020 F. Three days later he was admitted to the hospital. 
Upon examination, it was found that the pain had somewhat diminished; 
the cheek was considerably swollen ; the mucoperiosteum in the region 
of the extracted tooth socket was badly discolored; a considerable area 
was completely necrosed, leaving the bone denuded, and the breath was 
almost unbearably fetid. All other teeth in this region appeared normal 
and the entire mouth was in a generally clean condition. The sloughing 
of the soft tissues showed a tendency of spreading, and very soon the 
osseous tissues, which became denuded at first, showed signs of necrosis, 
the bone spaces being saturated with pus and other substances of decom- 
position. There was marked cervical adenopathy and an exceedingly high 
leucocytosis. Despite all care and treatment, the patient died ten days 
after the removal of the tooth. 
In observing a number of cases I have been impressed with the fact 
that where the septic agent was introduced into the deeper tissues with 
the syringe, or in the solution used, no immediate reaction occurred. The 
local as well as the systemic symptoms came into evidence only from five 
to eight days after the injection had been made. We may reason that this 
is probably the incubation period, during which the microorganisms change 
and multiply sufficiently to cause symptoms. To illustrate a condition in 
Case History of 
Death from Sepsis. 136 
ORAL SURGERY 
which the deduction can reasonably be made that the septic substances 
have been introduced upon a septic needle, in the solution, or both, the 
following case history may prove of interest: 
Mr. M. B., age 27. Date of first consultation, 
December 12, 1921. Had his lower left third molar 
extracted fourteen days before this date. All data 
prior to this and family history negative. The tooth 
was simply carious and was removed under conduction anesthesia (man- 
dibular injection). On the evening of the fourth day the face commenced 
to feel uncomfortable, and on the fifth day there was a degree of pain and 
slight difficulty in opening the mouth to the full extent. On the following 
day he returned to the oral surgeon, who washed out the tooth socket, and, 
as the radiographic examination was negative, stated that he could find 
nothing that should give him trouble. A sedative was prescribed, and the 
patient instructed to return if there was any further trouble. After two 
more days the face and the tissue on the inner surface of the ramus be- 
came swollen. He suffered intense pain, was unable to sleep, had general 
malaise, his temperature fluctuated between 101-103° F., and other signs 
of a severe infection presented. 
Upon examination I found that the face was considerably swollen 
from the temporal region down to the lower border of the mandible. The 
submaxillary area was not invaded, the outer skin surface presented no 
signs of the localization of the infection, neither by way of discoloration 
nor by fluctuation. The patient was unable to open his mouth more than 
about a quarter of an inch, was unable to swallow and had the sensation of 
choking. The soft palate and the peritonsillar tissues were swollen to 
such an extent that half of the oropharynx was obstructed. The pres- 
ence of pus was diagnosed immediately. A radiograph of the entire half 
of the jaw was taken and was negative; the parts from which the molar 
had been removed appeared decidedly normal and the tooth socket was 
practically closed. These two last points are rather significant in the 
case—the negative radiograph and the healthy normal state of the soft, 
as well as the osseous tissues in the region of the operation. 
The patient was given 10 gr. of triple bromid, and under nitrous oxid- 
oxygen anesthesia, the swelling was freely incised through the peritonsillar 
region. A large quantity of very foul-smelling pus was evacuated. The 
collapsed tissue bag was irrigated and dressed with iodoform gauze. As 
in all cases of this nature, evacuation and drainage gave immediate relief. 
Later, examination revealed that the entire ramus was stripped of most of 
its soft tissue covering on all surfaces. Pressure opposite the temporal 
region would force down some of the pus confined there and for the 
Sepsis Introduced 
on Needle or 
Otherwise. COMPLICATIONS FROM LOCAL ANESTHESIA 
137 
evacuation of the outer swelling an external incision had to be made just 
below the angle of the jaw, five days after the first operation. 
The localization and evacuation of the pus and the maintenance of free 
drainage are of paramount importance in the treatment of all of these 
cases. For some time it was feared that the entire ramus might become 
necrosed as we could reach the bone with a blunt probe on every surface, 
indicating that the entire ramus was completely denuded. The patient 
made an uneventful recovery, however, and was dismissed on January 30, 
1922. 
A case where extensive necrosis followed has 
been observed by the writer, and as this brings out 
a number of important points, the citation of the 
case may be of value. 
Miss R., 19 years of age, was first seen by the writer on August 15, 
1922. A carious upper first molar had been removed, under conduction 
anesthesia, nine days before this date. Tuberosity injection was used, and 
the tooth was successfully removed. Five days after the removal of the 
tooth the patient commenced to experience pain in the temporal region. 
Twenty-four hours later the pain became more intense, and a slight 
swelling appeared just above the zygomatic region. On the third day 
after the onset of the complaint the patient was suffering very intense 
pain, and her temperature fluctuated between 101-103° F. The attending 
physician prescribed coal tar sedatives, which were taken freely with but 
very little palliative effect. Upon examination, the patient was found to 
be quite exhausted from the prolonged fasting, sleeplessness and suffering. 
The skin was of a pale, grayish hue; the lips and the ear lobes appeared 
cyanotic from the large amount of the coal tar products taken. 
Upon external examination I found that the swelling was practically 
confined to the temporal region, commencing at the zygomatic arch, cover- 
ing the full extent of the temporal fossa. Upon palpation, a vague sense 
of deep fluctuation could be discerned. The patient could freely open her 
mouth, indicating that the ramus and the muscles of mastication were not 
in any way affected. The site from which the tooth had been removed 
appeared normal, there being no sign of laceration, discoloration or swell- 
ing in this region, and the tooth socket was fairly closed. 
The patient was to have been removed to a hospital, but, as arrange- 
ments could not be made the same day, cold applications were prescribed 
and the sedative was changed. The patient was much more restful during 
the night and she slept a few hours. The next morning the swelling 
seemed to localize on the inner surface of the remus. The temporal swell- 
ing became smaller and less tender. The patient was taken to the hospital, 
A Case History 
of Necrosis. 138 
ORAL SURGERY 
and, under ether anesthesia, an intra-oral incision was made into the 
sphenomaxillary fossa and the anterior pillars of the fauces, and free 
drainage secured. Despite the free drainage maintained, the entire ramus 
necrosed, as illustrated by the radiograph, Fig. 68. 
From these histories, the following conclusions 
may be made: That where an anesthetic solution is 
injected into a septic area, the local as well as the 
systemic reactions are more immediate and more severe; that there is a 
marked sloughing of the soft tissues and that necrosis of the osseous tis- 
sues may follow; that it is possible that, besides injecting into a septic area, 
sepsis may be introduced with the needle or in the solution or both; that 
while it may appear that conduction anesthesia is more dangerous than 
submucous injection, the contrary is true, provided that the injection is 
made carefully and aseptically; that the farther we inject from the area 
to be operated upon, the more the possibilities of infection are reduced; 
that the tissues operated upon recover more readily from the operative 
trauma if this is not superseded by the injection of an anesthetic, as, with- 
out exception, they are protoplasmic poisons, and it is only a question of 
degree. 
Where the sepsis is introduced upon the needle or in the solution, the 
first signs of reaction appear from four to eight or nine days after the 
injection has been made. The first sign of trouble is impaired function; 
thus we observe in mandibular injections that a degree of trismus precedes 
all other symptoms; that the reaction is more severe in some individuals 
than in others, and that other symptoms, indicating the presence of a deep- 
seated infection, may also be present; that this condition is not to be con- 
founded with the trismus which sometimes follows a mandibular injection, 
due probably to faulty technique, such as injecting into a muscle, the use 
of a hyper- or hypotonic solution, or postoperative trauma, as these forms 
of trismus occur almost immediately upon the wearing off of the anes- 
thetic ; that the tissues at the site of the operation usually show no signs of 
infection and seem to be doing well; that the radiograph is, as a rule, 
negative, as there is no alteration in the osseous tissues as yet, unless this 
has existed prior to the injection; that the prognosis in these cases is 
favorable, provided that timely, free evacuation is secured and thorough 
drainage maintained. 
As intimated before, sepsis in the solution is the 
most frequent cause for severe complications. Be- 
sides this, the admixture of some impurities may induce unexpected 
untoward reactions. Numerous cases of unduly prolonged anesthesia have 
been reported. This, in my estimation, is caused by the alcohol of the 
Conclusions 
Regarding Sepsis. 
Faulty Solutions. COMPLICATIONS FROM LOCAL ANESTHESIA 
139 
Fig. 69. 
Fig. 70. 140 
ORAL SURGERY 
Fig. 7i. 
Fig. 72. COMPLICATIONS FROM LOCAL ANESTHESIA 
141 
Fig. 73- 
Figs. 69, 70, 71, 72 and 73 illustrate the faulty positions in which needles are often 
inserted, indicating that poor technique has been used in these injections. 
alcohol and glycerin solution in which the syringes and dissolving cups 
are kept. This may he prevented hv submerging the syringes only to such 
an extent that the alcohol cannot gravitate into them. The small quantity 
which may pass up into the needle by capillary attraction can easily he 
removed with proper irrigation. The dissolving cups should be kept in 
the sterilizer, specially maintained with the anesthesia instrumentarium. 
Hyper- or hypotonic solutions are at times the cause of excessive post- 
injection pain; and, finally, high concentration or excessive dosage may 
cause local as well as systemic untoward complications. 
It cannot he left unmentioned that cases have come to our attention 
where formalin, tincture of aconite, or bichlorid of mercury had been 
injected instead of the anesthetic solution. This can only occur when 
stock solution is used, and bottles are mixed. These accidents can be 
prevented by: (i) keeping the local anesthesia instrumentarium separate 
and apart; (2) having a special sterilizer for the sterilization of the dis- 
solving cups and the syringes; (3) excluding alcohol and glycerin from 
the inside of the syringes; (4) preparing a fresh solution for each 
individual injection or for several injections performed in, say the same 142 
ORAL SURGERY 
Fig. 74. Lateral view of the mandible showing the anteroposterior position of the 
broken needle. 
hour; (5) preparing an isotonic vehicle and not altering its chemical com- 
position by too much boiling or by the admixture of extraneous substances. 
This consists chiefly in not observing the osseous 
anatomical landmarks as guides in injections; in- 
jecting too rapidly, thereby causing excessive dis- 
tension of the tissues and injury to the cells, or forcing a toxic dose upon 
the system. 
Since the more general use of conduction anes- 
thesia, needles have been broken during injection 
and lost in the tissues. This occurs more frequently in mandibular than 
in infra-orbital or tuberosity injections. It can be emphatically stated 
that the accident can be ascribed to no approved technique practiced, but 
rather to faulty technique. The fault may be in the manipulation of the 
syringe, but it is more often due to defective needles. (Figs. 69, 70, 71, 
72 and 73.) 
Of the forty-odd cases of broken needles which have been brought 
to my attention, every one was a steel needle, and upon removal I have 
found some of them to be unmistakably rusty. Undoubtedly, the iridio- 
platinum needles do also break, but they are more flexible and have to be 
bent several times before they are actually broken apart. Because of the 
Faulty 
Administration. 
Broken Needles. COMPLICATIONS FROM LOCAL ANESTHESIA 
143 
Fig. 75. Radiograph taken through the head of the same case as Fig. 74, showing 
that the needle is on the inner surface of the mandible and that the anterior part 
of the needle is towards the tongue and the posterior part dose to the bone. 
greater tenacity of iridio-platinum, a certain amount of warning is offered 
to the operator and he can guard against this accident. The steel needles, 
however, snap very readily; and when compression of the tissues, with the 
guiding and palpating finger, is released, or when there is a sudden move- 
ment of the patient, the needle is lost. 
It is impossible to state what the untoward results might be if one of 
these needles were left in the tissues, especially if it were sterile. I have 
seen no report, nor have I seen a case where complications resulted because 
of this. Still, it is rational to think that the needle will act as an irritating 
foreign body, and, whenever possible, it should be removed. 
The first case which came to my attention was brought to me by a 
colleague, in 1914. I was unable then to find the description of a technique 144 
ORAL SURGERY 
for its removal, and my first instinct was to he entirely guided by the 
radiograph. I his in itself I found to be misleading in many respects. 
Since then the following routine technique has been adopted in these 
Pig. 76. Illustrates the ILe cf inciT n to be made on the inner surface of the 
mandible. The soft tissues are carefully laid open until the needle is reached. 
cases: Two radiographic plates are taken. One 5 by 7 in. lateral exposure, 
Fig. 74. This shows the anteroposterior position of the needle. The 
second plate, 8 by 10 in., is taken with an anteroposterior exposure, the 
same as for the examination of the maxillary sinus, Fig. 75. This will de- 
termine three important points : (1) the more accurate vertical position 
or relationship of the needle; (2) whether the needle is located on the 
outer or inner surface of the ramus of the mandible; (3) and this is very 
important, whether the needle is close to the hone or buried in the over- 
lying soft tissues. 
At first glance, it would seem that the removal of a needle so lost 
should offer no difficulties whatever. In practice, however, it is a rather 
irksome, tedious, and often lengthy operation. In the hands of the 
experienced, the removal of a needle may take anywhere from a few 
minutes to an hour, or even longer. I have recently seen the case of a 
young man, 26 years of age, who was taken to a local hospital in one of 
the smaller towns. The patient was operated upon for the removal of 
a needle, under ether, on three different occasions within a week or ten COMPLICATIONS FROM LOCAL ANESTHESIA 
145 
days. In the first two operations, each lasting three hours, the removal 
of the needle was attempted intra-orally. In the third operation, an 
external incision, about three inches long, was made, and the entire cheek 
Fig. 77. Is a diagram of the relative position of the mandible and the broken 
needle. 
was laid back. This operation lasted over three hours, and the needle was 
not found. External incisions here are entirely uncalled for as well as 
impractical and should never be contemplated nor permitted. 
The operation is best performed under local 
anesthesia, and intra-orally. In the presence of 
severe swelling with the tissues displaced and false 
ankylosis, it is well to wait a few days until these 
conditions subside, and when the parts have returned to a state of nor- 
malcy the operation can be performed with greater ease. 
In studying the anatomical relationship of the parts we often find that 
a large part of the needle is anterior to the mandibular foramen. The 
only important structure which might be damaged at this point is the 
lingual nerve, and this is well below the surface of the needle, when it 
reaches a more anterior and superficial position. There are numerous 
muscle fibers of the soft palate and the pharynx, and of the muscles of 
mastication and their tendons. The glistening tendons are often mislead- 
ing, as they have almost a metallic sheen. Most of the structures encoun- 
Operative Procedure 
for Removing 
Broken Needle. 146 
ORAL SURGERY 
Fig. 78. Lateral view of a needle broken in the tuberosity area representing it rest- 
ing against the bone. 
terecl lie more or less in a vertical plane and at a right angle to the needle. 
Much palpation, in the hope of so discovering the needle, is of little avail, 
and only tends to displace it, or probably to force it more deeply into the 
tissues. The line of incision is made through the mucous membrane on 
the inner surface of the ramus and about a quarter or half an inch behind 
the anterior border of the bone. The tissues covering the inner surface 
of the bone are gradually incised and each layer retracted. (Figs. 76 and 
77.) The hemorrhage is usually not very severe and is easily controlled. 
I11 this manner the deeper parts are penetrated until the needle is reached. 
The region is very obscure and a good headlight is very helpful. 
A very fine, thin-bladed scalpel is used. The blade striking against COMPLICATIONS FROM LOCAL ANESTHESIA 
147 
Fig. 79. Anteroposterior radiograph of the same case as Fig. 78, showing that the 
needle is quite a distance away from the bone. 
the metal needle can be readily discerned. The tissues are retracted next 
at this depth and the needle may sometimes be disclosed to view. Very 
often, however, the operative field is obscured by the hemorrhage or the 
overlying tissues. In these instances we have to he dependent upon a fine 
and discerning touch for the localization of the needle. When this is 
definitely determined, the needle is grasped with a pair of artery or thumb 
forceps and gently pushed forward until it projects through the tissues 
and is removed. The retracted tissues are released next and the mucous 
membrane sutured. In the presence of hemorrhage, or where infection 
and suppuration are feared, the wound may he dressed with iodoform 
gauze between the sutures. A partial false ankylosis and considerable 148 
ORAL SURGERY 
swelling of the pharyngeal as well as the outer tissues may follow, which, 
however, gradually subsides in from one to two weeks. Suppuration rarely 
complicates the case. 
Needles lost in tuberosity injections are not quite so frequent as those 
lost in mandibular injections and are recovered more easily, in my experi- 
ence. Here, likewise, the radiograph is very important, but may prove 
quite misleading. An intra-oral film, obviously, represents the needle 
resting against the bone and the mucoperiosteum is simply stripped away, 
with the hope that the needle is imbedded between the periosteum and the 
bone. (Fig. 78.) This is found to be the case very frequently; but it 
is a surer plan to take at least two or three radiographs, one of which must 
be taken with an anteroposterior penetration through the head. (Fig. 79.) 
This will often show that the needle is about a quarter or half an inch 
away from the bone, buried in the soft tissues. The general plan for the 
removal is that followed in the mandibular area. Needles broken in 
submucous injections can be removed with facility in most instances. 
Regarding the breaking of needles, the following- 
deductions and suggestions may be made: very fine 
needles may be introduced less painfully and with less injury to the pene- 
trated tissues, but the danger of breakage is more imminent than when 
heavier needles are used. A not excessively heavy needle is quite per- 
missible, and with proper technique, by injecting a slight amount ahead 
of the needle, causes very little pain; breakage of needles is just as often 
due to improper technique as to defective needles; do not attempt to 
penetrate the bone with the needle—-it cannot be done; iridio-platinum 
needles are far safer than steel ones. These are more easily sterilized, as 
they can be flamed after every insertion into the tissues, and they do not 
break as easily as do the steel ones. 
Deductions. CHAPTER XI. 
Diseases of the Maxillary Sinus of Oral Origin. 
The maxillary sinus, or the antrum of Highmore, 
is a cavity which occupies the body of the superior 
maxillary bone. It is roughly pyramidal in shape, 
its base being its medial or nasal wall, and its apex 
corresponding to the zygomatic process of the bone. It has five walls, a 
superior, an anterior, an outer, a posterior and a medial. 
The superior wall is the orbital plate, a thin lamina of bone which 
separates the sinus from the orbital cavity above. This plate of bone is 
traversed by the infra-orbital nerve and vessels in the central portion of 
its inferior surface. These structures are lodged in a groove or canal 
and in many cases are in parts covered only by the lining membrane of the 
sinus. The anterior wall corresponds to the anterior surface of the maxil- 
lary bone; the outer wall to the malar process of the maxillary bone; the 
posterior wall corresponds to its infratemporal or zygomatic surface. The 
medial wall separates the sinus from the nasal cavity. This wall trans- 
mits the ostium maxillare, which is normally situated in its upper and 
anterior portion, and provides communication through the hiatus semi- 
lunaris, between the antrum and the middle meatus of the nose. This 
orifice is well above the floor of the cavity when the head is erect; there- 
fore gravity does not assist drainage through this channel when in an 
upright position. 
The lining membrane of the maxillary sinus is connected through the 
ostium maxillare and is continuous with the lining of the nasal cavity 
and the other accessory sinuses of the nose. This lining, the Schneiderian 
membrane, is a mucoperiosteum surmounted by ciliated columnar epi- 
thelium and may be absent in patches. Normally it is slightly moist. The 
ciliae aid in cleansing the cavity by beating towards the osteum which is 
the normal channel of drainage. 
The maxillary sinus is the largest of the air chambers accessory to the 
nasal cavity. It is comparatively smaller in youth, its walls being thick, 
accommodating the unerupted, developing teeth. It enlarges with age at 
the expense of its bony walls, so that in old age it is large, with compara- 
Anatomy 
of Maxillary 
Sinus. 
149 150 
ORAL SURGERY 
tively thin walls. One or both sinuses may be congenitally absent, or 
malformed. 
Infections of the Maxillary Sinus. 
It has been stated by men whose assertions may he considered authori- 
tative on the subject that 75 per cent of infections of the maxillary sinus 
are of dental origin. A more accurate judgment regarding this assertion 
could be obtained, if the data of the oral surgeons would be compared with 
those of the rhinologists. The treatment of diseases of the maxillary sinus 
of other than dental or oral origin, or those which are complicated with 
infections of some other of the accessory sinuses, belong to the province 
of the rhinologist and, despite the analogies and similarities which pre- 
vail in all cases, they shall not enter into our present consideration of the 
subject. 
Whatever the exact truth may be, it is an established fact that the 
oral cavity is a frequent source of infection of this sinus. The number 
of these cases is considerably swelled by the circumstance that through 
the now routine procedure of radiographic examinations, a great many 
infected, or diseased areas about the teeth approximating the maxillary 
sinus are discovered, and the too vehement or injudicious use of the 
curette or other instruments in their removal frequently lead to secondary 
infection of this cavity. 
Infection through the mouth is not limited to any age. Reviewing 
my cases for some years back I find that my youngest patient was five 
years old and the oldest seventy. The largest number, about 80 per cent, 
were between the ages of twenty-five and forty. 
Etiology of Maxillary Sinus Lesions. 
Dental lesions or anomalies, which are directly responsible or conducive 
to the involvement of the maxillary sinus may exist under two distinct 
and significant conditions, namely: (i) in the absence of disease of the 
surrounding soft or osseous tissues; (2) in the presence of disease of 
the surrounding tissues. 
As these circumstances have a decided bearing upon the general con- 
sideration and treatment of the case, it will be advantageous to view the 
etiological factors from this standpoint and accordingly classify them 
under these headings. In their respective consideration the treatment 
indicated will he pointed out. DISEASES OF THE MAXILLARY SINUS 
151 
(1) Traumatic injuries in the removal of, or in 
operating upon, or about the teeth. 
(2) Fracture of the maxilla, or other traumatic in- 
juries caused by external violence. 
(3) Forcing of foreign bodies into the maxillary sinus. 
Etiologic Factors 
in the Absence 
of Disease. 
Figs. 8o and 81. Show the proximity of the maxillary sinus to the apices of the 
root ends. 
(4) Impacted, malposecl or supernumerary teeth within or in the 
proximity of the sinus. 
(1) An infected tooth or a portion of a tooth pro- 
jecting through the floor into the maxillary 
sinus. 
(2) An alveolar abscess evacuating into the antrum 
through a sinus formed in the intervening tissues. 
(3) The extension of disease about a tooth, as a dental granuloma, 
suppurative osteitis, or periodontoclasia, may destroy the inter- 
vening bone until the sinus becomes involved. 
(4) Cysts—radicular or follicular (dentigerous). 
Other oral lesions which often involve the maxillary sinus are : 
(5) Necrosis of the bone. 
(6) Malignant growths. 
(7) Syphilitic gummata. 
Etiologic Factors 
in the Presence 
of Disease. 
Consideration of Accidental Openings Into the 
Maxillary Sinus. 
The upper molars and bicuspid teeth are in such close anatomical rela- 
tionship with the maxillary sinus that their roots form indentations into, 
or some even project through the floor of this cavity. (Figs. 80 and 81.) 152 
ORAL SURGERY 
Often they are separated only by a very fine lamella of bone or barely 
by the lining membrane of the sinus. The teeth which are so located 
are most frequently the second molar; next in order the first molar, the 
second bicuspid, the third molar, rarely the first bicuspid and still more 
rarely the cuspid. This proximity varies in extent as to Oe nu 'the 
Fig. 82. Case No. 1. Shows probe passed into the maxillary sinus through the 
socket of the extracted third molar. 
of teeth in different individuals. It is more marked in older than in 
young subjects. This, in a great measure, is due to the enlargement of 
the maxillary sinus, which, according to Cryer,* continues through life bv 
progressive absorption of the cancellated hone. 
In the removal of these teeth or in operating upon them, the maxillary 
sinus may be inadvertently opened, even where the laceration is not 
greater than is unavoidable in the operation. More often, however, the 
opening is caused by undue laceration or the unskillful or indiscreet use of 
instruments. 
An opening into the maxillary sinus, in a person whose vital resistance 
is normal, frequently heals without subsequent complications; in those 
whose vital resistance is below par, it may lead to severe acute infection. 
Here, as elsewhere in the body, when bacteria alone are introduced, they 
are relatively easily eliminated or destroyed. In the presence of foreign 
bodies or dead tissue, which may shelter them against disinfecting agents 
or the phagocytic defenses of the invaded tissue, or which may even act 
as satisfactory pabulum for their incubation and multiplication, the bac- 
teria may gain a dominating position. I have seen cases where such an 
opening cicatrized uneventfully with no treatment whatever. I have seen 
others where severe infection developed three or four days after the acci- 
*Cryer: Internal Anatomy of the Face, DISEASES OF THE MAXILLARY SINUS 
153 
Fig. 83. Disease of maxillary sinus due to infection following the removal of an 
impacted third molar. Fig. 82 shows the same case with a probe passed into the 
sinus through the socket of the extracted tooth. See case history No. I. 154 
ORAL SURGERY 
dent, and the loeal and general symptoms were those of an acute virulent 
infection. 
When a local anesthetic is used, and the field of operation is relatively 
bloodless, such opening may pass undetected by the patient or the operator. 
Frequently, however, the surgeon may perceive an unusual yield in the 
application of his instrument, when, with careful probing, the cause of 
this can be ascertained. There may be a slight frothing of the blood 
which fills the tooth socket, and blood may escape through the nostril of 
the affected side. The patient may notice that in talking, the air under 
compression escapes through the same channel, and the voice presents a 
hollow sound. 
Mrs. G., age 27, presented with a profuse pus 
discharge through the right nostril. The patient was 
a rather frail woman 5 feet 2 inches tall and weighed 
92 pounds. Her general health was poor and had been greatly impaired 
since the maxillary sinus became infected. The involvement of this fol- 
lowed the removal of an unerupted third molar. Fig. 82 shows a probe 
passing into the sinus through the third molar socket. Fig. 83 is an 
antero-posterior picture of the case and shows the diseased condition of 
the sinus. This patient was first seen by the author six weeks after the 
removal of the tooth. The pus discharge was preceded by no other symp- 
toms, but what might be expected as a postoperative discomfort following 
the removal of the tooth. The patient was dismissed after the operation, 
and about ten days later infection of the sinus became evident. A rhinolo- 
gist was consulted who established intranasal drainage and irrigation. 
This was kept up until the patient called on the writer. The third molar 
socket was freely opened and the soft as well as the osseous tissues show- 
ing pathological signs were removed. This wound was sutured and 
permanently closed. A new opening was made over the bicuspid region 
and the maxillary sinus was cleared of all degenerated and pathological 
tissues. Drainage was maintained through this opening for a week and 
irrigation for fifteen days. There was no further pus discharge, the 
opening was permitted to close and the patient was dismissed cured. 
Because of this possibility of infection when a healthy maxillary sinus 
is accidentally opened, the patient must not be negligently dismissed. 
Measures should be taken to prevent untoward complications. These 
consist of irrigation and prevention of the ingress, in so far as this is 
possible, of infecting or irritating substances from the oral cavity. The 
irrigating medium should not be irritating, corrosive nor escharotic. A 
tepid sterile saline, or boracic acid solution, 2 to 4 per cent, is used until the 
return is clear or nearly clear. Next, dress the tooth socket with a strip 
Case History 
No. 1. DISEASES OF THE MAXILLARY SINUS 
155 
of iodoform gauze, carrying this slightly into the maxillary sinus. Twenty- 
four hours later the irrigation is repeated, and if, two or three days later, 
no suppuration ensues, all subsequent dressing should be confined to the 
tooth socket. In this way the closing of the orifice nearest the sinus is 
favored and it soon becomes obliterated by cicatricial tissue. 
Fig. 84. The same case as Fig. 85, showing the portion of the root in the sinus. 
If suppuration ensues the opening must be kept open until the pus 
discharge is completely eliminated, and thereafter so treated that its closing 
is aided and not hindered. 
Foreign Bodies Forced Into the Sinus. 
Forcing of foreign bodies into the maxillary sinus in operating upon 
the maxillae or in the removal of teeth is not an uncommon occurrence. 
When a tooth, a portion of a tooth, or part of an instrument is forced 
into the maxillary sinus, the removal of this is imperative. If it is not 
removed, violent symptoms may develop within a very short time follow- 
ing the accident, or serious infection, or neuralgic disturbances may ensue 
later. To one who is not acquainted with the presence of such a foreign 
body, the treatment of the case may be perplexing, as the symptoms do 
not always indicate the presence of a foreign body and are therefore often 
misleading. 
Mr. G. S., age 39, applied for treatment on 
August 26, 1919, complaining of headache, a gen- 
eral indisposition, pain in the temporal region, a 
foul odor and periodical pus discharge from the left nostril. 
Case History 
No. 2. 156 
ORAL SURGERY 
Fig. 85. Case No. 2. Shows diseased condition of the maxillary sinus into which 
a tooth root was forced. DISEASES OF THE MAXILLARY SINUS 
157 
He had been suffering from pulpitis of the upper left first molar on 
July 23, 1919, and had had this removed on the 24th. The tooth was 
broken in extraction and the lingual root was forced into the maxillary 
sinus. The patient was dismissed, and two weeks later sinusitis developed, 
Fig. 86. Same case as Fig. 85. Showing the lining membrane of the maxillary 
sinus sagging through the socket of the first molar. 
for which he applied to another dentist for treatment. Radiographs were 
taken which showed the root in the sinus. The second dentist undertook 
the removal of this, and the operation was followed up with irrigation 
for ten days. The pus discharge ceased and the patient was dismissed as 
cured. About two weeks later the symptoms returned, when the patient 
applied to the writer for treatment. 
Further radiographic examination revealed the presence of a root in 
the diseased sinus. (Figs. 84 and 85.) As there was copious pus discharge 
the sinus was freely opened. The cavity was filled with coagulated masses 158 
ORAL SURGERY 
of pus and detritus. The sinus was thoroughly cleaned, the root removed 
and the lining membrane in the upper two-thirds of the cavity showing no 
clinical signs of degeneration, was left intact. Drainage was maintained 
through the tooth socket, and the patient was dismissed cured on Sep- 
tember 25, 1919. He has since been seen at intervals for six months, and 
there is no sign of recurrence. 
Figs. 87 and 88 show a small foreign body which proved to be a portion of a root 
over the apex of the suspected second molar before and after this tooth was 
removed. 
This case presented a condition which sometimes occurs in the more 
chronic cases. When a portion of the floor of the maxillary sinus is car- 
ried away in the removal of a tooth and shows no tendencies toward 
cicatrization, upon prolonged irritation, the lining membrane of the sinus 
may sag through this orifice almost like a hernia. (Fig. 86.) This tissue 
becomes greatly inflamed and thickened, and has a tendency to bleed. It 
may be dark red or cyanotic blue in tint. It often resembles, and may 
be mistaken for, an epulis. When the tissue is not badly degenerated 
nor infected, it can be pushed back and the oral orifice closed by means 
of a sliding flap operation. When the mass shows signs of degeneration 
it should be resected well into the maxillary sinus and the aperture closed. 
(See Chapter on “The Closing of Acquired Openings into the Maxillary 
Sinus.”) 
Mrs. A. J., age 44, Finnish, housewife, con- 
sulted the writer March 23, 1922. She had been 
complaining of neuralgic pain in the upper left maxil- 
lary, temporal and occipital region for four years. Lately her health had 
been rather poor and the vision of her left eye was becoming impaired. 
She applied for treatment to her dentist, who removed a bridge from that 
Case History 
No. 3. DISEASES OF THE MAXILLARY SINUS 
159 
Fig. 89 is the radiograph of the sinuses in which severe neural disturbances de- 
veloped some years after the removal of the upper left third molar. Note that 
there is an alteration in the texture of the lining membrane, although it is not 
decidedly diseased. 
side and also the second molar which supported this. There appears a 
small shadow over the apex of this tooth, which has the outline of a dis- 
tinct foreign body. (Fig. 87.) The trouble continued and the patient 
was referred to the writer for treatment, burther radiographic examma 
tion showed the presence of this foreign body even after the removal of 
the tooth. (Fig. 88.) Antero-posterior radiographs showed no marked 160 
ORAL SURGERY 
pathological conditions of the sinus, hut this also suggested the presence 
of the foreign body and obliteration of the right frontal sinus. (Fig. 89.) 
The sinus was opened by removing the outer plate of hone following the 
outline of the extracted second molar socket. The foreign body proved 
to be a portion of a tooth which was most likely a part of the third molar, 
which had been removed some years ago. It was lodged between the 
Schneiderian membrane and the bone. I11 this case the symptoms were 
Fig. 90. Shows portion of a tooth forced high up into the maxillary sinus. 
distinctly neuralgic in nature. The lining membrane was thickened but 
not degenerated and was left intact. Soon after the operation all neuralgic 
pain ceased and the patient was dismissed on April 14, 1922; on July 10 
the patient reported back and had had no recurrence. 
By means of radiographs, taken at different angles, the position and 
location of the foreign body can often be determined. At times our best 
efforts at radiographic examination will not localize it nor reveal its pres- 
ence. A negative radiograph in these cases is not to be looked upon as 
positively reassuring, and security against later complications lies in the 
actual removal of the foreign body. 
In the event of this accident it is advisable to 
leave the parts in as nearly an undisturbed condition 
as possible. It is but rational that we should attempt 
to recover the foreign body through the passage 
of entrance, although it may drift into such a position that a new opening 
must be made to reach it. (Fig. 90.) 
To remove foreign bodies from the sinus, expose carefully and enlarge 
Method of 
Removal of 
Foreign Bodies. DISEASES OF THE MAXILLARY SINUS 
161 
the original opening. It will often be found lying close to the orifice, 
or, if it is a portion of root, this may still be attached to a few shreds of 
tissue, when, with careful manipulation of a fine curette, or a hooked 
instrument, it can easily be recovered. When this is unsuccessful, a few 
syringefuls of saline solution may wash it to or through the orifice. 
In some instances all efforts at recovering the substance have proven 
Fig. 91. Shows fracture of the maxilla, the line of fracture traversing the 
maxillary sinus. 
fruitless and it was finally found to be lodged between the lining mem- 
brane and the bone. In the absence of infection the postoperative treat- 
ment is that indicated for accidental openings into the maxillary sinus. 
Traumatic injuries caused by external violence, such as gunshot, fall, 
crushing blows, not infrequently cause fracture of a wall of the maxillary 
sinus, and the inflicted injury may be compounded into this cavity. These 
cases must be treated in the same manner as other infected wounds. Re- 
move all foreign bodies, reduce the fracture, if fracture exists, and ap- 
proximate the displaced or severed parts into the most favorable position 
for cicatrization. When there is no pre-existing nor other complication 
within the maxillary sinus, this will clear up with the healing of the 
other wound. 
Miss E. J., age 23, applied for treatment on 
January 1, 1920. Said she had slipped and fallen 
on the pavement the day before and injured her left 
maxilla. Examination revealed the displacement of the teeth, posterior 
Traumatic Injuries to the Maxillary Sinus. 
Case History 
No. 4. 162 
ORAL SURGERY 
to and including the lateral incisor. The fractured portion of the bone 
and the contained teeth were projecting downward and toward the median 
line. The radiograph shows a complete separation of the bone which 
traverses the maxillary sinus. (Fig. 91.) There was considerable 
hemorrhage from the nostril of the injured side. The fracture was re- 
duced and immobilized with appliances constructed for the case, and the 
former alignment of the teeth restored. The patient was dismissed on 
February 16. No untoward complications developed. 
Fig. 92. Shows the way in which the maxillary sinus overshadows the roots of 
several teeth, and, when they are diseased, the difficulty offered in discerning the 
offending tooth. 
Malposed, Impacted or Supernumerary Teeth in Maxillary Sinus. 
Malposed, impacted or supernumerary teeth may develop in any wall 
of the maxillary sinus, where they may be placed in almost any position. 
The symptoms arising from these are at times of a distinctly neuralgic 
character, and the nervous reflexes may be so remote or complex that 
the association is difficult to explain. In others they may inaugurate a 
chronic and almost symptomless pathological condition which, by circum- 
ferential irritation, progresses until extensive tissue destruction has taken 
place and suppuration ensues. When such teeth are discovered, it is ad- 
visable to remove them upon reasonable provocation, to anticipate the 
development of graver conditions, for the exact extent of the pathological 
lesion cannot always be determined even by the closest scrutiny and 
thorough examination. Before undertaking the removal of the tooth the 
correlation of the anatomical structures should be studied, and after a 
close survey it should be approached from the most accessible point. In 
operating upon these cases one must be careful to avoid injuring the 
structures which are to be retained. 
In the presence of disease, the following conditions may prevail: An DISEASES OF THE MAXILLARY SINUS 
163 
infected tooth, or part of a tooth, in close proximity of, or projecting into 
the maxillary sinus may act as the irritant; when an infected tooth con- 
taining a gangrenous pulp is so located the bacterial or bacterio-chemical 
irritation issuing from this causes inflammation and suppuration in the 
surrounding tissues. Frequently a sinus forms in the infected area or 
Fig. 93. Shows the close proximity which often exists between a portion of a 
tooth root and the maxillary sinus and suggests the care essential in its removal 
to prevent forcing it, or carrying infection into this cavity. 
Fig. 94. Advanced absorption of the bone about the first molar, which involved the 
maxillary sinus and caused severe infection there in a woman 32 years of age. A 
radical operation was necessary. 
about the apex of an abscessed tooth, passes through the intervening bone 
and the pus evacuates into the antrum. (Figs. 92, 93 and 94.) These are 
the most frequent oral factors which cause involvement of the maxillary 
sinus. It is important, therefore, that in all cases of maxillary sinusitis, 
the teeth should be closely scrutinized and the condition of their pulps 
determined. The radiograph in itself cannot always be relied upon and 
other examinations, such as the faradic current, the thermal test, should 164 
ORAL SURGERY 
be applied. If a tooth is still doubtful, drilling into it will secure a 
positive diagnosis. 
In acute maxillary sinusitis, or upon an acute exacerbation of a chronic 
case, all of the teeth on the affected side may become sore and very tender 
to pressure. Judicious care must be exercised, therefore, in determining 
if the teeth are, and if so just which tooth is, responsible for the disease. 
In the radiographic examination the overshadowing of several teeth by 
the maxillary sinus often creates the impression that roots (of the molars 
particularly) are actually penetrating this cavity. Every irregularity in 
the outline of the maxillary sinus wall which conforms to the outline of 
the roots of the teeth should be carefully studied. Cryer points out the 
fact that the progressive enlargement of the maxillary sinus is interfered 
with at points where the roots of teeth are present. This is often veri- 
fied in close radiographic studies and in operations. 
Having concluded that a tooth is the original cause of the disease, 
for the guidance of our treatment we must extend our examination to 
the following consideration: the anamnesis; the symptoms and signs pres- 
ent ; the radiographic showing of all structures in this region; transillumina- 
tion ; the condition of the other accessory sinuses. From such an ex- 
amination we can more correctly prognosticate whether the case can be 
cured by the comparatively simple expedients of removing the cause and 
following this with drainage, irrigation and securing ventilation. The 
consideration of cases in which this form of treatment is inadequate will 
be presented later. 
Chronic Suppurative Osteitis. 
Chronic suppurative osteitis, originating about abscessed or pyorrhetic 
teeth, often involves the maxillary sinus. This pathological condition, in 
its pathogenesis, resembles caries of hone. It progresses by an unlimited, 
slow disintegration of the hone, and may extend from any tooth in the 
maxilla until the maxillary sinus is reached. Here it may set up a sup- 
purative inflammation, either by the continuity, or the contiguity of the 
disease, or through the blood current. The teeth within the diseased area 
must be carefully studied by other means besides the radiograph, as this 
in itself, in many cases, is misleading. 
When the diseased area is circumscribed and small, this can he curetted 
through the enlarged tooth socket. Whenever we have reason to suspect, 
however, the presence of rarefication not disclosed by the radiograph, or 
when we are in doubt about the extent of the involvement of the adjacent 
teeth, it is better practice to raise the mucoperiosteum from over the region 
and by cutting away part of the overlying external plate of bone, the DISEASES OF THE MAXILLARY SINUS 
165 
entire diseased area is exposed to view and can then be thoroughly studied. 
If the mucoperiosteum of the sinus is intact, and the history of the case, 
the prevailing symptoms, and other diagnostic signs indicate that it has 
not undergone septic nor polypoid degeneration, the maxillary sinus need 
not be radically treated. The buccal lesion is cleared, the parts are re- 
stored to their former anatomical relationship, and a drainage point is 
provided and treated as any other septic wound. 
J’lG. 95. A dentigerous cyst in a young man 23 years of age. The cyst was lodged 
in the maxillary sinus and was infected. 
Cysts in the superior maxillary region often encroach upon the maxil- 
lary sinus. They more often invaginate the contiguous wall than invade 
this cavity. (See chapter dealing with Cysts.) In this connection may 
be considered the dental pericementoma, as in its pathogenesis it closely 
resembles those growths and requires the same mode of treatment. 
Fig. 95 illustrates a dentigerous cyst which occurred in a young man 
twenty-three years of age. The cyst was infected, occupied practically 
the entire maxillary sinus and was associated with the malformed cuspid 
tooth. The curved root of this, shown in Fig. 96, was imbedded into the 
orbital plate. The patient was suffering for some three or four years from 
headaches, lack of appetite, insomnia, and chronic gastro-intestinal de- 
rangement. Very soon after the removal of the cyst and the tooth, his 
condition improved and his improvement kept pace with the cicatrization 
of the maxillary region. 
The operative procedure should be similar to that 
described for suppurative osteitis or cysts in general. 
(See chapter, “Cysts.”) When the maxillary sinus is not actually invaded, 
Radicular and Follicular Cysts. 
Operation. 166 
ORAL SURCRRY 
entering this cavity should be carefully avoided. There are cases, however, 
where the bone between the cyst and sinus becomes entirely destroyed and 
there is a close adherence, over an extensive area, between the cyst sac and 
the lining membrane of the maxillary sinus. Where this obtains, it is 
more expedient to remove the entire dividing bone septum and membranes, 
Fig. 96. Malformed tooth causing the cyst illustrated in Fig. 95. The curved 
portion of the tooth was imbedded into the orbital plate of the maxillary bone. 
and to transform the two compartments into one cavity. With this con- 
dition the cyst will not recur. If we deem it more expedient to obliterate 
the cyst cavity, the cyst sac should he carefully dissected from the lining 
membrane of the sinus, leaving the subepithelial connective tissue exposed. 
The wound is treated in accordance with the indication of the case. 
Necrosis of the Maxillary Bones. 
Necrosis of the maxillary bones may result from traumatic injuries, 
from infection, mercurial or phosphorus poisoning, or it may be sequen- 
tial to syphilis or tuberculosis. An infected maxillary sinus, complicated 
with the latter diseases, should receive the necessary systemic treatment. 
The local treatment consists of maintaining thorough drainage and irriga- 
tion and when a sequestrum forms this should be removed. Suppuration 
continues until all of the necrosed bone is removed or exfoliated. In 
many instances, the bed of the necrotic bone is filled with masses of DISEASES OF THE MAXILLARY SINUS 
167 
Fig. 97. Syphilitic necrosis of both sides of the maxilla. A large part of the body 
of the maxilla, the palate bone, the orbital plate, the nasal bones, the perpendicular 
portion of the vomer and also the left eye were destroyed. Note the first palate 
perforation, characteristic of this disease at the junction of the soft and hard 
palate. Patient was a man 56 years of age. He denied ever having had a venereal 
disease. The Wassermann test was 2 plus. 168 
ORAL SURGERY 
degenerated 11011-viable tissues which fall an easy prey to the infecting 
organisms present and suppuration continues until this is either removed 
by thorough and careful curetting, or is destroyed by liquefaction necrosis 
and replaced with healthy granulation tissue. There are cases where, either 
through necrosis, or through a slow disintegrating process of chronic 
suppuration, protracted over a period of years, large portions of the sinus 
walls become destroyed to such an extent that its integrity cannot be 
retained, or reconstructed. The utmost care must be exercised, therefore, 
in the preservation of all tissues which we hope to utilize to this end. 
When this becomes impossible, the only course left is to render the maxil- 
lary sinus accessory to the buccal cavity. The resulting deformity is cor- 
rected later by means of a suitable prosthetic appliance. 
Malignant Growths in the Maxillary Sinus. 
The principles governing the treatment of malignant growths in other 
parts of the body apply in these cases. The approved method in operable 
cases is thorough radical surgery, followed with radium or X-ray treat- 
ment. The prognosis is rarely favorable. The most frequent growths 
are the sarcoma and the epithelioma, the former predominating. They 
may develop in the buccal cavity and invade the maxillary sinus or they 
may originate within this cavity and grow outward. The utmost care 
should be exercised in recognizing them. 
Syphilitic Gumma in the Maxillary Sinus. 
A syphilitic gumma developing in the maxilla in most cases causes a 
perforation of the palate (Fig. 97) although any other part may be 
attacked or destroyed. As this destructive process is in a measure self- 
limiting, unless checked by systemic treatment, besides maintenance of 
hygiene very little can be done for it locally. When the destructive process 
has ceased the deformity, if not too bad, may be corrected with plastic 
surgery, where this is feasible, or with a prosthetic appliance. The lesion 
of the soft tissues often simulates, in its clinical appearance, a malignant 
growth and, when in doubt, serological examination should be made. 
Typical cases of maxillary sinusitis present unmistakable, characteristic 
symptoms from which a diagnosis can easily be made. There are other 
lesions, however, which in many respects closely resemble maxillary 
sinusitis: also, maxillary sinusitis often presents atypical features. The 
Diagnosis of Maxillary Sinusitis. DISEASES OF THE MAXILLARY SINUS 
169 
Fig. 98. Shows radiograph of healthy sinuses. Note the uniform penetration of 
the rays and the symmetrical formation and radiolucency of the two sides. 170 
ORAL SURGERY 
Fig. 99. Typical case of unilateral empyema of the maxillary sinus. The disease 
was caused by an abscessed third molar root in a woman 55 years of age. Note 
the contrast between the healthy and diseased sinus. DISEAS FS OF THE MAXILLARY SINUS 
171 
difficulty in diagnosing some cases is augmented by the consideration that, 
besides determining the presence of the disease, we must also ascertain 
the pathological stage of the tissues involved. A close, or nearly precise 
knowledge of this is essential, in deciding what treatment is needed for 
the case. In determining this, we must be guided by the anamnesis, the 
prevailing symptoms and signs, the etiology, the radiograph, transillumina- 
tion, and often the response to conservative treatment, such as irrigation, 
drainage and ventilation; in still others, an exploratory operation must be 
resorted to. 
Infection of the maxillary sinus is often secondary to diseases of 
the other accessory sinuses, or else some of the others may become infected 
from the maxillary sinus. It is not always a simple matter to determine 
which is the primary and which the secondarily infected diseased point. 
Because of their close anatomical relationship and the normally existing 
channels for their inter-communication, in the rational treatment of any 
one sinus it is important, therefore, that the condition of all of the others 
should be clearly understood. 
Radiographic Examination of Maxillary Sinus. 
Not unlike other diseases, in affections of the maxillary sinus, the radio- 
graph is of inestimable value and is indispensable in the examination of 
the teeth and their surrounding tissues. It is important that the quality 
of the radiograph should permit of no misinterpretation. The diagnostic 
sign is that the diseased sinus appears more opaque than the healthy one 
upon the X-ray plate. (Figs. 98 and 99.) In the absence of other symp- 
toms, the radiograph must not be looked upon as conclusive, and we must 
bear in mind that an anatomical anomaly, such as a difference in the size of 
the antra, or in the thickness of the bones, may produce similar differences 
in the radiograph. Dental radiographs in themselves are entirely inade- 
quate in sinus diagnosis. Large plates must be taken through the head in 
such a manner as will permit of a comparative study of all the cavities of 
the head. I usually take two exposures at two different angles: one with 
the patient’s nose and forehead resting upon the plate and the rays directed 
through the occipital protuberance at right angle to the plate. For the 
second, the patient’s nose and chin are rested upon the plate and the rays 
directed vertically at right angles to the plate. This last will show more 
clearly the frontal sinuses and the maxillary sinuses without the over- 
lapping of the malar bones. 
Care must be observed that in taking the radiograph the central rays 
have a rectangular postero-anterior penetration. A lateral exposure causes 
overlapping of the cranial bones which obscure the maxillary sinus and 172 
ORAL SURGERY 
Fig. ioo. Shows an alteration in the lower part only of a diseased sinus. The 
greater, upper part was clinically found to be normal as suggested by the radiograph. DISEASES OF TIIE MAXILLARY SINUS 
173 
Fig. ioi. Is the radiograph of a diseased sinus, six months after a radical opera- 
tion. There was no sign of recurrence. Note the alteration in the radiolucency, 
which most likely denotes the altered condition in the lining membrane. 174 
ORAL SURGERY 
Fig. 102. Case of a young woman 26 years of age. The primary focus in this case 
was the frontal sinus, which later involved the maxillary sinus and the ethmoid cells. DISEASES OF THE MAXILLARY SINUS 
175 
Fig. 103. Is the radiograph of a man 31 years of age. The condition originated 
with the removal of an upper, left, first molar. The maxillary sinus became involved 
and later all the other sinuses on that side. The entire course of the infective 
process occurred during three or four weeks. Neglect of caring for the primary 
infection was greatly responsible for its spreading. 176 
ORAL SURGERY 
may thus be misinterpreted. The error is often made by some radiog- 
raphers, that they base a diagnosis on the comparison of the radiographs 
of one patient with those of another. This procedure must lead into error, 
because the radiograph of one individual can be the facsimile of no other 
and each case must be regarded, in this respect, as original and unique. 
A close study of the radiograph should prove to be helpful in many 
other respects and may often serve as an index of the extent of the 
impairment of the parts. When the entire sinus appears opaque, this, 
with other clinical symptoms and signs, indicates that the sinus is diseased. 
In some cases, only the lower portion appears opaque while the upper 
part seems to be normal. (Fig. ioo.) From this latter radiographic 
indication, we may infer, in a suppurative case, that the mucoperiosteum 
is not badly, or only in part deteriorated, and we may anticipate that if 
the suppuration is eliminated this structure will return to normal and 
does not need to be entirely removed. In the absence of suppuration 
or inflammatory symptoms, the opacity indicates the probable presence of 
a cyst, a neoplasm or polypoid degeneration. If the opacity persists after 
the suppuration has ceased, where no radical curetting had been done, it 
is reasonable to assume that the mucoperiosteum has become altered to 
such extent that its return to normal is not likely to occur; as a result of in- 
flammation the lining membrane has been permanently changed in its histo- 
logical structure; this, however, does not essentially denote a pathological 
state (Fig. ioi) ; nor that there is a polypoid degeneration. When the 
etiologic factor has been removed and suppuration recurs with no 
apparent reason, following operation, and there is no change in the 
radiopacity, it is likely (i) that polypi are present, some of which are 
breaking down; (2) that the lining mucoperiosteum has degenerated to 
such an extent that it must be curetted out; (3) that the sinus is being- 
reinfected from some other source; (4) that some part of the sinus was 
not cleaned out or that an infected part may be walled off by a bony 
partition. Often, an abnormality within the nose, a deflected septum, 
hypertrophy of the turbinate bones, enlargement of the ethmoid cells, 
severe repeated coryza, may interfere with the drainage and ventilation of 
the sinus, thereby complicating the case. In this event the case should be 
treated in cooperation with, the rhinologist. (Figs. 102 and 103.) 
Transillumination, like the radiograph, is a help- 
ful diagnostic aid, but it is open to the errors 
enumerated under radiographic examination. When the sinuses are 
healthy, all parts of the maxillary area, including the inferior part of the 
orbit, appear a brilliant deep red with lighter and deeper shadings, de- 
fining the comparative bulk or density of the transilluminated tissues. 
Transillumination. DISEASES OF THE MAXILLARY SINUS 
177 
There is a sense of light in the eye on the healthy side when closed and 
the pupil appears red. This cannot always be demonstrated. In a dis- 
eased sinus the penetration of the light is obstructed. The two sides show 
uniform transillumination to the level of the allse of the nose, but above 
that the diseased sinus appears cloudy and almost opaque. The sense of 
light upon closing the eye, and red pupillary reflex are lacking. 
It is not always a simple matter to make an 
accurate differential diagnosis between cysts, neo- 
plasms, and polypoid growths in the maxillary sinus. 
These conditions have many features in common, which confuse the 
inexperienced, and often the experienced, careful diagnostician. Cysts or 
neoplasms may originate within, or invade from without, the maxillary 
sinus, without altering the appearance or the anatomical relationship of 
the structures of the oral cavity. With their growth, there may be a dis- 
tention of the maxillary sinus and with the turgescence there is absorp- 
tion of any one or all of the bony walls which eventually may become so 
attenuated that pressure will elicit an eggshell crepitation characteristic of 
thinned out bone. Doubtful cases must be closely scrutinized and aspira- 
tion will often give us the necessary information. In the presence of a 
cyst, a fluid which varies in color from a light, straw colored yellow to a 
lighter or darker green may be withdrawn. This may be mucilaginous, 
limpid, or turbid in consistency. In the case of a growth, a difference in 
the resistance offered to the penetration of the aspirating needle may be 
perceived and we may withdraw a scanty amount of frothy, bloody tissue 
juice. When a neoplasm reaches an advanced stage and begins to break 
down there is a fetid and penetrating odor which is characteristic of 
malignancy and is attended by constitutional symptoms. The odor of 
malignancy can often be differentiated from that of empyema. 
It is even more difficult at times to differentiate 
between polypi and malignant growths, and a close 
study of their clinical appearance is most helpful. Polypi appear as inde- 
pendent growths of varied size, or as growths of lobulated masses. They 
are somewhat sickly or dirty gray in appearance; they are pedunculated 
and seem to be studding the lining membrane of the maxillary sinus. Their 
gross histological appearance is that of a thick jelly-like material, confined 
within a very fine transparent membrane. In empyema many of these 
contain pus. They do not bleed as readily as malignant growths do. 
A malignant growth may appear as an individual 
mass or may be lobulated, but the tissues are more 
compact in texture than that of polypi. It springs 
more in homogeneous masses from an extensive base, and shows tendencies 
Differential 
Diagnosis. 
Polypi. 
Malignant 
Growths. 178 
ORAL SURGERY 
of invading the surrounding structures. The growth may penetrate the 
other accessory cavities of the nose and there is neuralgic pain when the 
surrounding structures are invaded and pressed upon. When the radio- 
graph shows a diffused invasion, accompanied with neuralgic pain and 
indications of malignancy in the patient’s general health, and there is no 
suppuration, one may feel fairly certain that a neoplasm is present. 
Inflammatory Affections of the Maxillary Sinus. 
Inflammatory affections of the maxillary sinus may be classified under 
two general headings: acute and chronic. 
Under these two headings several intermediate pathological states may 
exist, which may or may not be discernible. Although they are not marked 
by definite lines of demarcation it is well to comprehend these, as their 
recognition is helpful in the treatment of the case. 
Acute states are: (a) The mucoperiosteum of the maxillary sinus is 
highly inflamed, edematous, and there is a scanty or more or less abundant 
mucoserous discharge through the nostril of the affected side. The 
mucous membrane of the nose on the same side likewise becomes inflamed, 
and the symptoms resemble, in many respects, those of a severe case of 
coryza. 
(b) The inflammation of the mucoperiosteum reaches a more highly 
edematous state, becomes greatly engorged and thickened and there is a 
thick mucoserous or mucopurulent discharge through the nostril of the 
affected side. 
(c) The pathological state of the tissues may be as that last described, 
but now there is a copious discharge of pus. 
These successive pathological stages cannot always be traced, as, fre- 
quently, the first sign noted is a profuse pus discharge. 
Other symptoms are pain and tenderness over the outer plate of the 
maxillary bone. When osteitis or osteoperiostitis develops, the cheek 
becomes badly swollen, which when involving the eyelid, the eye becomes 
closed. The pus may burrow through any one of the bony walls, but 
more frequently escapes through the ostium maxillare into the middle 
meatus of the nose, the pain is of a deep throbbing and neuralgic nature. 
This may be confined to the infra-orbital region, but is often reflected to 
the supra-orbital area, to the ear, to the temporal and the occipital region, 
or over the entire half of the head of the affected side. Before drainage 
is secured, there is a sense of fulness in the maxillary region, pressure 
upon the floor of the orbit which is aggravated by stooping, by bending 
over, or the forceful expulsion of air through the air passages, as in sneez- DISEASES OE THE MAXILLARY SINUS 
179 
ing or coughing. The general symptoms are those observed in acute 
infections. 
The early inflammatory stages may terminate in resolution or suppura- 
tion. Suppuration usually follows upon prolonged irritation, or it may be 
determined by the ingress of an overwhelming number of bacteria, par- 
ticularly the staphylococcus or the streptococcus. Upon examination or 
transillumination the affected side appears cloudy. 
Treatment of Acute Maxillary Sinusitis and Empyema. 
Acute stages of maxillary sinusitis or empyema yield in many 
cases to the simple expedients of removing the cause, securing drainage, 
irrigation and ventilation. These measures will be of no avail, however, 
towards a permanent cure, where the etiologic factor remains undiscovered, 
or its removal is neglected. If this is a diseased tooth, the socket of this 
may be used for drainage; or, when there is an oral lesion through which 
a communication with the maxillary sinus already exists, this can be 
transformed into a favorable channel for the same purpose. In the absence 
of complication from infection of some other of the sinuses, the symptoms 
yield in most cases very speedily to this form of treatment. It may be 
well to remark that in some individuals, even though all etiologic factors 
are entirely eradicated and the parts have cicatrized, the once infected 
maxillary sinus permanently remains a “locus resistantice minoris” and 
there will be a degree of predilection for the recrudescence of the disease. 
In the event of repeated recurrences after all buccal lesions have been 
eliminated, the case should be handled in cooperation with the rhinologist. 
Chronic empyema of the maxillary sinus is 
always preceded by an acute stage. The chronic 
stage is frequently painless, particularly when there is free drainage. In 
some instances there is pain which is of neuralgic character; this may 
be periodical, intermittent or fairly constant. The inflammatory symptoms 
are mild but may become fulminating from time to time when there is 
no adequate drainage, when the drainage point becomes occluded or when 
the patient’s vital resistance is lowered for some reason. 
In chronic cases, the symptoms are pathogno- 
monic. There is a free and copious discharge of 
pus from the nostril of the affected side; when both 
antra are involved, which is a rare condition, there is a bilateral discharge. 
The odor of the discharge is offensive, resembling that of decomposing 
animal or organic matter and is perceptible, not only to the patient but 
also to those in their proximity, or even at a distance. The quantity, the 
frequency of accumulation, and evacuation of the pus varies in different 
Chronic Empyema. 
Symptoms of 
Chronic Empyema. 180 
ORAL SURGERY 
individuals. The patient usually has the troubled appearance of the 
sufferer, and a sallow, pasty, clammy complexion. He often complains 
of frontal headache, insomnia, attacks of vertigo, lack of appetite, nausea, 
vomiting and a general gastro-intestinal derangement. In the morning, 
or even during the night, he is obliged to rise to clear the nasal passages 
and pharynx from the coagulated accumulation of pus. 
In the chronic cases the lining membrane may reach the following- 
pathological states: 
(1) It may be so affected that upon the removal of the etiological 
factor, with drainage and irrigation, the tissues repair and may return to 
a healthy state. 
(2) It may undergo a liquefaction necrosis leaving the bony walls 
bare with smaller and larger patches of the membrane still adherent. 
(3) It may become greatly thickened, undergo fibroid degeneration 
and may or may not present polypoid growths. 
(4) In extreme stages, besides the soft tissues, the bony walls become 
necrosed or, to be precise, they are destroyed by suppurative osteitis and 
pressure necrosis. By this process any wall of the maxillary sinus may 
be perforated and permit of the escape of pus. The bone becomes highly 
attenuated, so that it yields to pressure, not unlike a crepitating cyst wall, 
and can easily be penetrated with a sharp instrument. The overlying 
mucous membrane most often appears normal; in some instances, however, 
there are marks of discoloration. 
With the exception of the first described condition, all of the others 
must be treated by radical surgical measures. 
The degree of the pathological state of the maxillary sinus is not always 
clearly defined, and at times cannot be satisfactorily determined without 
opening into it. Before resorting to this, however, all diagnostic data 
should be carefully weighed and deliberated upon. The onset of the active 
symptoms does not necessarily indicate the period during which the disease 
has existed. A dormant infection may be present for a long time without 
causing disturbing symptoms which can be activated by an injury, an 
admixture of different strains of microorganisms or by a change in the 
environment of the microorganisms. We must also bear in mind that 
the phase of virulence of the infecting microorganisms as well as the vital 
resistance of the patient are determining factors in this. 
Recently acquired acute cases will yield to the treatments described in 
connection with these conditions. In chronic cases, or acute exacerbations 
of these, however, we must often resort to radical surgical operations. 
It may be pertinent here to comment on some 
obsolete methods of treating these conditions, which 
are even today practiced by some men. 
Old Method 
of Treatment. DISEASES OF THE MAXILLARY SINUS 
181 
One of these methods depends upon a perpetual drainage point, secured 
through the socket of a tooth. The orifice is kept open by means of a 
hard rubber plug projected into the sinus, made part of a dental plate, 
or saddle, and is held in place by being attached to the adjacent teeth. The 
patient removes this twice, or more often, daily, and the pus, often in 
copious quantities, is permitted to escape. I have seen individuals who 
have worn such appliances from one to ten, or even twelve years. Another 
equally inefficient appliance is a metal tube constructed on the same 
principle. 
All methods which tend to perpetuate the disease by permanent drain- 
age must be disapproved, as they are wrong in principle as well as in 
practice. Even though the patient can often be kept in comparative 
comfort with one of these appliances, in our present light and under- 
standing of the baneful influence of infections upon the system, suppura- 
tive conditions should be eradicated. It cannot be too emphatically stated, 
therefore, that the treatment of these parts must be based on sound 
surgical principles; i.e., (i) remove the etiological factor, (2) remove 
the diseased parts, and (3) restore, as nearly as possible, the former 
anatomical relationship and the functional integrity of the remaining 
structures. 
Radical Operation Upon the Maxillary Sinus. 
A number of ingeniously devised intranasal, or intranasal combined 
with intrabuccal operations have been advocated by different authors. 
The virtue is claimed for each that it tends to minimize or to depart from 
excessive intranasal or maxillary mutilations caused by other operations. 
Some of these are performed with the object of securing a permanent, 
irreparable and unobstructable point of drainage. There are cases, un- 
doubtedly, where proper drainage and ventilation of the accessory sinuses 
and cells are obstructed, or entirely prevented by chronic inflammation, 
abnormal development, or hypertrophy of their walls, or an abnormal 
condition of the nasal septum, or of the turbinate bones, in which a 
partial removal of these structures is indicated. These are types of cases 
which belong to the domain of rhinology. But, where the etiologic factor 
is a buccal or dental lesion, which can be reached and eradicated without 
a permanent mutilation, such a method does not commend itself to our 
better judgment. 
Of the more often practiced radical operations, we may mention 
the alveolar or Cooper operation; the intranasal; the Kuster; the Caldwell- 
Luck; the Denker and the Canfiekf-Ballenger operations. One is tempted 
to enter into a detailed consideration of each one of these, but in accord- 182 
ORAL SURGERY 
ance with the general trend of this chapter, it shall he confined to those 
only which can he adapted to the needs of the oral cavity and which have 
given gratifying results in my hands. 
All operations upon the maxillary sinus, when executed from within 
the oral cavity, can he performed under nerve blocking anesthesia by 
Fig. 104. Note the distance which commonly exists between the canine fossa and 
the maxillary sinus. 
anesthetising the superior maxillary division of the fifth nerve in its pas- 
sage through the sphenomaxillary fossa, supplemented with injections of 
the infra-orbital, the anterior palatine and the posterior palatine nerves. 
Diseased Tooth as a Factor in Antral Disease. 
Let us consider the most common buccal etiologic factor, a diseased 
tooth which is to be extracted, or a tooth socket from which the diseased 
tooth has been removed but which remains patulous. When there is 
good reason to believe that drainage and irrigation will suffice to control 
and cure the case, the tooth socket can be enlarged by removing the bony 
septte dividing it, or by curetting away some of the bone. Care should 
he taken that the adjacent teeth are not mutilated, nor infringed upon. 
A healthy tooth, or a diseased one which can be restored by treatment, 
without jeopardizing later the condition of the maxillary sinus, should 
never be removed, merely to secure drainage. Where drainage alone 
is desired this can be secured more readily with an intranasal puncture. 
The Cooper or alveolar method has often been criticised, because of the 
probability of secondary infection from the oral cavity. The violent 
infections which often follow accidental openings into the maxillary sinus 
would rather bear out this contention. But here, as elsewhere, in cases 
of injury to the body, all factors controlling infection should be con- 
sidered. Frequently a chronic infection may have been existing at this DISEASES OF THE MAXILLARY SINUS 
183 
point which becomes activated by the injury itself, by admixture of extra- 
neous microorganisms, or by a change in the environment. On the other 
hand, we are impressed by the many cases in which these openings cicatrize 
rapidly with no signs of infection whatever. In still others, where infec- 
tion supervenes, recovery and cure follow with such readiness, that one is 
almost inclined to believe that the oral communication favors the case. 
When, contrary to expectations, the disease fails to yield to a conserva- 
tive treatment as suggested, or where, after a temporary remission, 
recrudescence of the disease occurs, we may conclude that an uncorrected 
condition exists which retards, or prevents the cure. The most frequent 
causes for this are: (i) a portion of sequestrum; (2) an infected com- 
partment within the maxillary sinus which has not been reached; (3) 
diseased and pus containing areas within the alveolus which have not 
been eradicated; (4) undiscovered infected tooth structures. Frequently 
a tooth, which is not directly responsible for the disease, becomes infected 
as a result of the degeneration, or destruction, of the surrounding tissues. 
The nerve trunk and blood vessels which supply the tooth cannot remain 
healthy in a diseased environment, and, as a result, it becomes a potent 
factor in the recurrence of the disease, wherefore it is best removed. 
Again, when we can ascertain that the tooth, though its root appears to 
project into the maxillary sinus, still retains its vitality, and is covered by 
normal mucoperiosteum of the maxillary sinus, through which the nerve 
and blood vessels supplying the tooth traverse, the utmost care must be 
exercised in the preservation of these tissues. Other conditions to be 
considered are the possible infection from some other accessory sinus, or 
an advanced stage of pathological or polypoid degeneration of the lining 
membrane. 
All tentative measures to avoid radical curetting and a complete re- 
moval of the lining membrane of the maxillary sinus are justified unless 
our diagnosis definitely indicates the need of a radical operation. Coakley 
states that a curetted maxillary sinus is eventually filled in with granula- 
tion tissue. Other authors believe that the sinus walls become covered 
with cicatricial tissue, which is different in its histological structure and 
thicker than the original mucoperiosteum. This is more in accord with 
our clinical findings. The new lining membrane may or may not be 
covered with epithelium and when epithelialization does occur, this, unlike 
the original, is not ciliated. Whichever the case may be, we are certain, 
however, that granulation tissues replace the removed membrane, and we 
know that repair tissue is always less resistant to infection than the original 
lining membrane was. Also the means of cleansing carried out by the 
ciliated epithelium is diminished. 184 
ORAL SURGERY 
Fig. 105. Shows the anterior view of 
the opening for radical operation upon 
the maxillary sinus. 
Fig. 106. Shows side view of 
opening for operation upon the 
maxillary sinus. DISEASES OF THE MAXILLARY SINUS 
185 
Fig. 107. Shows line of 
incision of the oral mu- 
cosa for operation upon 
the maxillary sinus. 
Fig. 108. Shows the bone 
exposed and portion of it 
removed, for opening into 
the maxillary sinus. 186 
ORAL SURGERY 
Fig. 109. Shows the method of opening, exposing the tooth socket where the bone 
area is necrotic or infected. 
Fig. 110. Shows the tooth socket cleared for drainage, where this is desired. 
In text books and current literature it is com- 
monly advised that oral openings into the maxillary 
sinus should be made through the canine fossa. In 
practice, this opening is not, in the average case, the point of vantage. 
Examination proves that in many instances, of all the walls of the maxil- 
lary sinus this is the thickest. (Fig. 104.) This point also forms the 
most anterior corner of the antrum and makes the inspection and accessi- 
bility of the more posterior portions, particularly the floor of this cavity, 
or the involutions formed by the turbinate bones, rather difficult, if not 
impossible. Another grave objection is that the root ends of the cuspid 
and bicuspid teeth are so close to this region that they are often injured 
in the operation. A number of cases have been brought to my attention 
in which, though the teeth themselves were not implicated, the nerve 
branches which supply the two incisors and cuspid teeth were severed. 
While this may appear negligible at the first glance, in practice it fre- 
quently creates conditions and complications which are not easy to cor- 
Radical Operation 
for Sinusitis. DISEASES OF THE MAXILLARY SINUS 
187 
Fig. iii. When drainage and irrigation is to be carried on through the tooth 
socket alone, the mucosa is sutured into place and the gauze is introduced between 
the sutures. 
rect. In these cases the injured teeth have to be subjected to complicated 
and unlooked for treatment and in some instances the neuralgias created 
could not be eradicated, neither by the treatment nor the removal of 
the teeth. I have found that opening through the base of the malar process 
and above the apices of the teeth offers several advantages: (i) The 
bone is much thinner here than at any other approachable point. (2) This 
opens into about the center and somewhat anterior portion of the cavity 
and renders inspection clearer and the surgical field more accessible. 
(3) The area can be reached without in any way infringing upon the 
teeth. (Figs. 105 and 106.) 
When it becomes necessary, for the above stated reasons, to resort 
to a radical operation, a free, crescent-shaped incision, about half an 
inch above the alveolar ridge, is made, extending from the first bicuspid 
to about the second molar tooth. (Fig. 107.) The mucoperiosteum is 
raised and the buccal aspect of the maxillary bone exposed. 1 he outer 
plate of bone is cut away with gouges and Rongeur forceps until the 
aperture permits of thorough inspection and exploration of the maxillary 
sinus. (Fig. 108.) When the parts are disclosed to view in this manner, 188 
ORAL SURGERY 
Fig. i 12. The mucoperiosteal flap is sutured into place over the tooth socket and 
also over the newly formed opening; drainage and dressing can be carried out at 
some point between the sutures. 
the condition of the bone and the adjacent teeth should be carefully 
observed. I have found in a number of cases that the floor of the sinus 
contained one or more smaller and larger walled off cavities containing 
pus, at the site from which a tooth had been removed years before, despite 
the fact that the buccal tissues appeared to be normal and the radiograph 
negative. Upon the removal of these, a rapid recovery followed in 
instances where several intranasal operations had proven to be futile. 
The bone septse of the alveolus proper are removed, with the lingual 
and buccal plates of bone left intact. (Figs. 109 and no.) After all the 
diseased tissues have been removed and the mucoperiosteum sutured into its 
former position the cavity is irrigated and packed through the anterior part 
of the incision and the enlarged socket of the tooth is permitted to close. 
(Figs, in and 112.) When cicatrization ensues, the only remaining de- 
formity is that produced by the removal of the tooth. The operation is in 
all its features similar to the Caldwell-Luck operation, except that the 
tooth socket is substituted for the nasal opening. This principle permits of DISEASES OE THE MAXILLARY SINUS 
189 
a very wide range of adaptation and can be modified to the needs of the 
case in hand. 
When the tooth socket is so situated that it does 
not offer a ready, nor available drainage point, a 
modified Kuster operation will prove to be expe- 
dient: for example, when an opening into and infection of the sinus is 
caused in the removal of an impacted third molar, or when a foreign body 
is so lodged that it cannot be reached with the operation described before. 
As in the Kuster operation, the sinus is opened on the outer surface of 
the maxillary bone and a portion of its outer wall is removed. As in the 
Caldwell-Luck operation the mucoperiosteum is carefully raised from the 
area and when the operation is completed this is restored and sutured into 
position. Drainage can be secured between the sutures at a convenient 
point. 
The cavity is dressed with iodoform gauze, which 
is removed no sooner than in forty-eight, and fre- 
quently not till after seventy-two hours. The 
removal of the dressing should be done with the utmost care to avoid 
secondary hemorrhage. While some surgeons do not renew the dressing, 
it will be found that iodoform gauze, if repeated for a week or ten days, 
has a most salutary influence upon cicatricial tissue formation. In irri- 
gating, irritating or escharotic drugs should not be used. A tepid normal 
saline, or mild boric acid solution will prove to be all that is desired. Re- 
cently I have been using one per cent, dichloramin T, in chlorcozene oil 
paraffin solution, which was incorporated into the gauze dressing or was 
introduced with a syringe. I have failed to observe any marked efficiency 
in aiding these cases. Unless there is hemorrhage after the first dressing, 
the cavity is not packed tightly again; just enough gauze is introduced to 
absorb and drain the inflammatory serumal exudates and the blood if there 
is any degree of hemorrhage. If all diseased tissues have been removed 
and there is no complication from any of the other accessory sinuses or 
the nose, there should be no suppuration following the operation. There 
is some doubt in the minds of a great many men regarding the advisability, 
or the need for dressing, or irrigation of the maxillary sinus following a 
radical operation. This operation is always followed by marked hemor- 
rhage in the first place and cicatricial serumal exudations which collect 
there and may readily break down and become infected. To avoid this it 
is advisable therefore to drain and irrigate following the operation until 
discontinuing this is indicated. 
I have omitted a detailed consideration of the anatomical relationship 
of the maxillary sinus to the other accessory sinuses and the nose; also, 
Modified Kuster 
Operation. 
Postoperative 
Treatment. 190 
ORAL SURGERY 
all such diseases of the antrum which have other than dental or oral origin; 
those intranasal examinations which are often helpful in making a diag- 
nosis, and other features which are strictly within the domain of the 
rhinologist. But it is well to bear in mind that, in the comprehensive 
study of the maxillary sinus and its diseases, it is essential to be thoroughly 
familiar with the internal anatomy of the head and the intricate relation- 
ship which exists between the various sinuses and cells of the facial and 
some of the cranial bones. (See Cryer’s Internal Anatomy of the Head.) 
Furthermore, we must not overlook the fact that there is a coordinate 
functional relationship between all of these structures and that the patho- 
logical state of one often complicates some one or all of the others. CHAPTER XII. 
The Closing of Acquired Oral Openings into the Maxillary 
Sinus. 
The closing of acquired openings, which lead from the oral cavity into 
the maxillary sinus, is not always a simple matter, from a technical stand- 
point ; and the attempt is not always followed by success. 
These openings occur, more often in the molar area, than in the anterior 
part of the mouth. 
The causes for their formation are: extensive tissue destruction, due 
to a pathological process, such as, necrosis, cysts, chronic suppurative con- 
ditions about the teeth; traumatic injuries; the removal of neoplasms; 
sloughing, due to undue surgical trauma, traction upon the tissues, or 
impaired blood supply; faulty approximation of the tissues in operations 
upon the maxillary sinus and faulty postoperative dressings. 
Success in their closing is dependent upon the observation of those 
principles which are essential in all types of plastic or corrective surgery. 
Of these we may mention: preservation of all available tissues; proper 
vivifying of the wound edges and the removal of scar tissue; correct 
approximation and suturing of the tissues; avoiding or minimizing surgical 
trauma; avoiding undue traction upon the approximated tissues; avoiding 
impairing the blood supply. 
The most frequent causes of failure are: excessive surgical trauma; 
impaired blood supply due to severing of, or pressure upon the nutrient 
vessel; undue traction upon the flaps of tissues; pressure of the underlying 
bone when the tissues are stretched too tautly over it; improper suturing. 
The case cited and illustrated below will bring 
out many of the essential features in a typical case. 
The patient, male, 29 years of age, had been suffering for a number of 
years from chronic recurrent abscesses in the upper left incisor region. 
A portion of bone which contained the three missing teeth was exfoliated 
and when cicatrization ensued, a considerable hole remained, which com- 
municated with the nose and the maxillary sinus. (Fig. 113.) 
The edges of the tissues were pared and the mucoperiosteum was freely 
detached from the bone. (Figs. 114 and 115.) The sharp edges of the bone 
Case History. 
191 192 
ORAL SURGERY 
Fig. i 13. This is a photograph of a large opening which communicated with the 
nasal cavity and the maxillary sinus. This was the result of necrosis, following 
abscess of the lateral incisor. The problem in this case was whether the opening 
should be simply covered with a prosthetic appliance, or closed first by surgical 
means. There are many advantages in closing these openings by surgical means 
first and to later covering the gap with a prosthetic appliance. This was done in 
this case, and the method used is shown in the following illustrations. CLOSING OPENINGS TO THE MAXILLARY SINUS 
193 
Fig. i 14. The first step in the operation is the removal of the scar tissue which 
attached the mucosa to the bone. Simultaneously the surfaces to be approximated 
are being pared. 194 
ORAL SURGERY 
Fig. i 15. The mucoperiosteum is freely undermined and raised on the palatal and 
on the labial surfaces. CLOSING OPENINGS TO THE MAXILLARY SINUS 
195 
Fig. 116. It is desirable to nearly evenly approximate the palatal and the labial 
flaps. As the palatal tissues are rather unyielding, an incision is made at some dis- 
tance from the edge, to compensate for this. 196 
ORAL SURGERY 
Fig. i 17. A diagram showing the successive steps in the operation. A indicates 
the amount of tissue to be removed; B the wound edges vivified and pared; C the 
flaps raised and the palatal tissue just slid forward and severed as the diagram 
suggests; D the tissues approximated and sutured into place. CLOSING OPENINGS TO THE MAXILLARY SINUS 
197 
Fig. i i 8. Photograph of the case after cicatrization has taken place. 198 
ORAL SURGERY 
Fig. 119. Incision of the mucosa on the palatal and buccal aspect for radical closing 
of opening into the maxillary sinus. 
were trimmed down to prevent pressure upon the overlying flaps; the 
palatal tissue flap was incised to render this more yielding in the approxi- 
mation and to reduce excessive tension. (Fig. 116.) Fig. 117 represents 
a cross-section of the various steps. The tissues were next brought into 
apposition and sutured with horse hair. Fig. 118, from a photograph, 
also shows the final result obtained in the case. 
It may be observed that the labial and buccal tissues, as a rule, are 
more elastic and more yielding than the palatal tissues. The palatal incision 
tends to overcome, or in a measure it compensates for this lack of elasticity. 
The incision should never be made too close to the edge of the wound and 
a strip of tissue as broad as possible, with a liberal blood supply, should 
be secured. Close attention should be paid to the nutrient vessels and 
their severing must be carefully avoided. The exposed area of bone will 
granulate and become covered with epithelium. Sharp edges of bone, 
which may cause angulation and pressure of the overlying tissues, should 
be smoothed, but no part of the bone should be unnecessarily removed. 
The resting of the soft tissues upon a healthy bone surface conduces to 
more prompt and favorable results. CLOSING OPENINGS TO THE MAXILLARY SINUS 
199 
Fig. 120. The palatal flap raised, 200 
ORAL SURGERY 
Fig. I2i. The buccal flap raised and deeply undermined. CLOSING OPENINGS TO THE MAXILLARY SINUS 
201 
Fig. 122. The palatal is tucked underneath the buccal flap and sutured into position. 
As stated before, this operation is not always followed by success. The 
chances of success in closing these openings decrease with the number of 
attempts made. This is largely due to the fact, that, with each attempt 
the opening tends to be larger and there is an increased amount of cica- 
tricial tissue which cannot be depended upon in plastic work. 
Where the opening is too large, where the available tissues are scant 
or where several less formidable sliding flap operations have failed, the 
operation described by Dr. H. S. Dunning * has been employed with very 
gratifying results. 
In this operation, the palatal mucoperiosteum is utilized principally. 
As illustrated in Fig. 119, an incision is made down to the periosteum, 
bisecting the opening to be closed, when this is upon the alveolar ridge. 
This incision is carried anteriorly towards the bicuspids, along the median 
line posteriorly to the vicinity of the junction of the soft and hard palate. 
This flap of tissue is raised from the bone, leaving the periosteum intact 
as far as this is possible. The flap thus secured is quite thick, is of 
considerable size and containing the anterior palatine artery, is abundantly 
supplied with blood. (Fig. 120.) 
* H. S. Dunning, Journal A. M. A., November 20, 1920. 202 
OR AT. SURGERY 
The area of the opening is cleared from all fragmentary soft tissues 
and the bone edges are smoothed. The buccal aspect is thoroughly under- 
mined next and a second flap is formed, carrying this considerably upon 
the outer surface of the maxillary bone. (Fig. 121.) The edges of the 
palatal flap are tucked underneath this tissue and sutured into place. 
(Fig. 122.) 
When the flaps are liberated to such an extent that they can be freely 
approximated to cover the gap, they are sutured with catgut, horse hair 
or silk. Horse hair is the most adaptable suturing material for the pur- 
pose, as it is more pliable than catgut is; though thin, it is strong enough, 
and it is not so likely to become infected as silk. CHAPTER XIII. 
Cysts of the Oral Cavity. 
A cyst is a circumscribed cavity with a well defined, organized, lining 
membrane containing a fluid or semi-fluid substance. This substance may 
be sterile or infected. 
The most common types of cyst formations found in the oral cavity 
and jaws are the radicular or root cysts, the follicular or dentigerous 
cysts, and the ranula, which is a form of retention cyst. The rarer types 
are the mucoid and multilocular cysts. 
Radicular cysts are invariably associated with 
devitalized or pulpless, infected teeth. Of the many 
theories as to their formation the following seem to be the most plausible 
and most in accord with our clinical findings. When a nidus of infection 
has been established in the apical region of a tooth, a reaction, with a 
tendency towards repair, takes place in the surrounding tissues. This 
may also serve as a barrier to the spreading of the infection. 
The very earliest pathological manifestations are changes in the peri- 
cemental membrane, which may lead to the formation of a pericementoma 
(dental granuloma). (Fig. 123.) These growths are the result of a 
productive inflammation induced by the irritation of pyogenic, or non- 
pyogenic organisms, such as the streptococci of the viridans group, and 
may or may not contain pus. 
A pericementoma, at some stage of its develop- 
ment, frequently undergoes central necrosis. This 
may be due to deficient nutrition, overwhelming 
activities, or the virulence of the microorganisms present and their 
toxins. A cavity is thus formed, containing pus or necrosed detrius, 
and becomes lined with epithelium thereby establishing a cyst. (Fig. 124.) 
The epithelial lining, according to Dependorf and also Black, is 
derived from the epithelial chain indigenous to the pericementum. 
Malassez believes that the epithelium is derived from stray epithelial rests, 
which are remnants of the enamel organ. This latter theory is opposed 
by Black and by Fisher. These investigators found that the epithelial 
cells lining such a cyst cavity, in their histological appearance, and in their 
Radicular Cysts. 
Etiology of 
Radicular Cysts. 
203 204 
ORAL SURGERY 
reactions to various dyes, are more analogous to the epithelial chains of 
the pericemental membrane. They maintain that the epithelial rests 
derived from the enamel organ are a decadent structure in all the higher 
Fig. 123. Pericementoma, or dental granuloma; believed to be the precursors of 
radicular cysts. 
Fig. 124. Common, smaller types of radicular cysts occurring about infected teeth. 
animals and in man, and that they become progressively absorbed. Black 
further holds that the epithelial cells derived from the enamel organ are 
merely accidental, whereas the epithelial chains of the pericemental mem- 
brane are always present and purposeful in function. 
Grawitz maintains that the epithelium may be just an ingrowth from 
the oral mucous membrane through a sinus which subsequently becomes CYSTS OF THE ORAL CAVITY 
205 
closed. Such a mechanism is comprehensible in those cases where there 
is a fistulous opening leading to the mucous membrane surface. We 
Fig. 125. Two retained radicular cysts disclosed in a radiographic survey, twelve 
years after the removal of the teeth. The cuspid between was a normal tooth. 
The patient was a man 38 years old. 
Fig. 126. Retained radicular cyst over lateral incisor, which became infected and 
began to discharge through the unclosed tooth socket six years after the removal 
of the tooth. 
know, however, that a cyst formation is not always preceded by sinus 
formation. Some investigators even go so far as to maintain that a cyst 206 
ORAL SURGERY 
cannot form where a sinus is present. I have found cysts of this nature 
in the presence of patulous sinuses and also where there was no evidence 
that a sinus had ever existed. 
Fig. 127. Radicular cyst in man 40 years of age. Note the dome-like invagination 
of the maxillary sinus. The cyst was removed without invading this cavity. 
That a connective tissue proliferation forms the initial and basic 
organization for these sacs is suggested by the fact that, almost invariably, 
their fibres seem to merge into the texture of the pericemental membrane. 
They frequently remain attached to the tooth which is removed, and 
nearly always so where the cyst is carefully dissected out. When a 
portion of the root which is devoid of cementum and pericemental mem- 
brane projects into the cyst cavity, this attachment is present where the 
denudation of the root terminates. 
Clinical findings seem to controvert the theory that pericementomas 
(granulomas) and their cystic degenerations partake of the nature of 
neoplasms. That this tissue is the result of productive inflammation and 
that its probable function is protective, is suggested by the fact that where, 
with proper treatment, the source of infection has been removed, retrograde 
changes are observed and in smaller cases even complete obliteration. It 
would seem that this tissue, having lost its function, is gradually resolved, CYSTS OF THE ORAL CAVITY 
207 
and with this progressive process of resorption there is a synchronous 
regeneration of bone until the entire cavity is filled in with repair tissue. 
Many become walled off and continue to exist, or even to grow long after 
Fig. 128. Radicular cyst in man 38 years of age. This originated with a central 
incisor which was abscessed some fifteen or sixteen years ago. The cyst was 
infected and invaginated the nasal cavity and also the maxillary sinus. 
Fig. 129. Same case as Fig. 128 from a different angle. 
the etiological tooth is removed. (Figs. 125 and 126.) This, however, 
should never be depended upon for the eradication of these pathological 
areas. In their clinical course and reaction to treatment, radicular cysts 208 
ORAL SURGERY 
behave as benign growths. They gradually increase in size by circum- 
ferential pressure absorption of the surrounding bone. 
I have studied some cases in which progressive growth could he 
observed by means of periodic radiographic examination. Their enlarge- 
Fig. 130. Radicular cyst in upper jaw of man 28 years of age, caused by broken 
down roots. The cyst sac was closely adherent to, and in parts blended into the 
lining membrane of the sinus, and was made continuous with that cavity in 
the operation. 
ment appears to be influenced in a measure by the nature of the surround- 
ing osseous structures. It seems that where cancellous bone is more 
abundant, their growth is more rapid and they attain a larger size. We 
observe that they are more common and generally attain larger dimensions 
in the upper jaw. In the proximity of the maxillary sinus they tend to 
invaginate the contiguous wall of this cavity. (Figs. 127, 128 and 129.) 
I have seen cases, however, where the cyst became continuous with the 
maxillary sinus, and the cyst sac was blended with the lining membrane of 
the antrum. (Figs. 130 and 131.) 
Radicular cysts in the mandible may also attain considerable size, and 
probably grow at first mainly at the expense of the cancellous tissue. The 
compact bone likewise may become involved and the entire body of the 
bone attenuated. When the mandibular canal is encroached upon, it is CYSTS OF THE ORAL CAVITY 
209 
Fig. 131. Large radicular cyst in a young man 21 years of age. The entire half 
of one maxilla was involved, and all the teeth posterior to the lateral incisor 
had to be removed, except the third molar. There was swelling of the face in 
the cuspid and infra-orbital region, due to the thinning out of the nasal process 
of the maxillary bone. The cyst must have originated with the first molar, 
which had a history of abscess and was removed some five or six years ago. 
The cyst practically occupied the entire maxillary sinus. 
Fig. 132. Radicular cyst in woman 35 years of age. The first molar, about which 
it most likely originated, was removed about fifteen years ago. 210 
ORAL SURGERY 
Fig. 133. Radicular cyst in a man 45 years of age, which most likely originated with 
the broken down root. The bicuspids and cuspid were vital teeth and were not 
involved in the cyst, as would appear from the radiograph. The growth was 
practically confined to the cancellous tissue and the compact bone appeared 
intact. The cyst was removed without injuring the teeth. 
Fig. 134. Radicular cyst in girl 15 years of age. The outline here is very charac- 
teristic and its growth must have been rapid. Note the compressed and deflected 
inferior dental canal. The inferior dental nerve was outside the cyst sac. CYSTS OF THE ORAL CAVITY 
211 
Fig. 135. Radicular cyst in a man aged 45. The part was edentulous for about 
twelve or fifteen years and the growth caused no disturbing symptoms. 212 
ORAL SURGERY 
Fig. 136. Dentigerous cyst in a man 25 years of age. This originated about an 
unerupted third molar and presented all the symptoms which characterize the 
tardy eruption of third molars. The tooth was removed, but the cyst was 
entirely overlooked by the oral surgeon who handled the case. As the condition 
would not heal, radiographs were taken, which disclosed a large cyst, occupying 
almost the entire ramus, the angle and part of the body of the mandible. CYSTS OF THE ORAL CAVITY 
213 
deflected in its course, or it becomes involved in the cyst. (Figs. 132, 133, 
134 and 135.) In either instance the inferior dental nerves and vessels 
are rarely destroyed and they retain their functional integrity. Even in 
cases where the mandibular canal is destroyed through bone absorption 
the contents of the same are often found to he outside the cyst sac and 
Fig. 137. Illustrates an upper cuspid, and shows the dental follicle surrounding 
the crown. 
if the sac is carefully removed these structures may remain unimpaired. 
The ramus and the angle of the jaw are also common sites for the forma- 
tion of cysts. (Fig. 136.) 
Clinical Signs and Symptoms of Radicular Cysts. 
The development of radicular cysts is invariably chronic and of a 
slowly progressive nature. As a rule, no disturbing symptoms arise until 
it becomes infected or some important structure is pressed upon. This 
in most cases occurs at a stage when the growth has attained consider- 
able size, a large amount of tissue has been destroyed and probably a 
number of teeth are involved. The bone is greatly thinned out and at 
these places pressure will elicit a crepitating egg-shell sound. In 
some instances, chiefly in the infected ones, there are mild periodical dis- 
turbing symptoms, with varying periods of remission, which are often 
misleading. 
The fluid contained in radicular cysts may or may not be infected. 
When not infected it is yellowish straw colored, mucilaginous in con- 
sistency and contains cholesterin crystals. The infected contents are more 
deeply colored, vary from a light amber yellow to a shade of lighter or 
deeper green, and may be cheesy in substance. This may sometimes 
appear as coagulated creamy white pus. When the infection is of long 214 
ORAL SURGERY 
standing, the contents are foul smelling, and if the cyst communicates 
with the oral cavity it imparts an offensive odor to the breath. 
The formation of radicular cysts is always preceded by chronic peri- 
Figs. 138 and 139. Impacted cuspid tooth, showing early tendencies of cystic 
degeneration. 
cemental infections. We find that both the fistulous and non-fistulous 
apical infections may undergo cystic degeneration. I have seen numerous 
cases which communicated with the oral cavity through two or more 
sinuses. Some of these were entirely invisible and could he discovered 
only when, upon pressure, the cyst contents would exude through them; 
others were larger and surrounded by exuberant granulation tissue rings. 
In many instances the overlying mucous membrane appears to he intact 
and is free from pathological signs, or there is a definite discoloration, 
varying from a red that is somewhat deeper than the normal shade, to a 
bluish cyanotic tint. In the examination of the oral cavity such dis- CYSTS OF TFIE ORAL CAVITY 
215 
colored areas, particularly in the vicinity of devitalized or pulpless teeth, 
should always be regarded with suspicion, and subjected to radiographic 
examination. 
Fig. 140. Impacted cuspid, showing early stage of a cystic degeneration in a young 
man 18 years of age. 
Fig. 141. Dentigerous cyst in a man 38 years of age. The transition of cyst 
development from conditions like those illustrated in the preceding cases seems 
quite logical. See Figs. 137, 138, 139 and 140. 
The radiograph, as a rule, defines a circum- 
scribed clear-cut cavity. With the growth of the 
cyst and the extension of bone absorption, some of 
the adjacent teeth may become involved. This tissue 
invasion is unlimited and progressive in its process. I have seen some 
cases where all of the teeth of the affected side were involved. While it 
tends to be confined to the originally affected side, sometimes both sides 
become involved. 
Follicular, or dentigerous, cysts develop about 
malposed, or impacted, or supernumerary teeth. 
They may grow without an apparent association with dental structures, 
Radiographic 
Examination of 
Cystic Areas. 
Dentigerous Cysts. 216 
ORAL SURGERY 
Fig. 142. Dentigerous cyst in woman 32 years of age. The cyst membrane was 
closely attached to the neck of the tooth, while the root was imbedded in the 
bone. See Fig. 143. 
Fig. 143. Photograph of the tooth and sac removed from case illustrated in Fig. 142. CYSTS OF THE ORAL CAVITY 
217 
I’IGS. 144 and 145. Dentigerous cyst in a child 10 years of age. The condition was 
not noticed until about three or four weeks prior to the consultation. As indi- 
cated by the radiograph, a large part of the mandible, extending from the first 
molar to the incisors of the opposite side, was involved. The cuspid root was 
partly imbedded in the lower border of the mandible. The cyst must have 
existed for some years, as the stunted roots of the two bicuspids bore marks 
of arrested development, rather than pathological absorption. All the teeth 
within the area were normal and free from disease. 218 
ORAL SURGERY 
often where all of the teeth are present, in normal position and normally 
developed. 
In the removal of impacted teeth we often find a definite membrane 
surrounding the crown of the tooth, which adheres to its neck. This 
membrane is most likely the remnant of the dental follicle and can nearly 
always be demonstrated by means of the radiograph and can be dissected 
Fig. 146. Dentigerous cyst in a young man 18 years of age. The growth was rather 
more perceptible on the palatal, than on the buccal surface. The patient was 
suffering from neuralgic pain in this region, which greatly interfered with con- 
centration upon his studies. In its removal, the cyst was found to contain very 
little fluid and the sac wall was unusually thick. This was closely adherent to 
the three fourths developed roots of the third molar. The posterior palatine 
artery, nerve and vein were merged into the texture of the cyst sac, and the bone 
was fairly hollowed out in this region. All symptoms disappeared after the 
removal of the cyst and tooth. 
out when the tooth is carefully exposed in the process of removal. 
Clinically, it is found to adhere to the neck of the tooth and presents as 
a tough connective tissue sac with its surface next to the crown, smooth 
and velvety. Histological examination shows it to consist of strong bands 
of fibrous connective tissue having an epithelial lining. A study of 
Figs. 137, 138, 139, 140 and 141 is very suggestive of the process of 
cystic degeneration. Fig. 142 gives the radiograph and Fig. 143 the 
photograph of a dentigerous cyst, which occurred in a woman 32 years of 
age. The cyst sac is closely attached about the neck of the impacted lower 
right bicuspid tooth and strongly suggests that its origin lay in the tissues 
which originally surrounded the crown. The root was found to be 
normally imbedded in the bone, while the cyst inclosing the crown of the 
tooth spread out mushroom fashion and was lodged in the surrounding 
bony cavity. This form of attachment is not always demonstrable. A 
further study of the cases represented in Figs. 144, 145, 146, 147, 148, 
149, 150, 151 and 152 will prove to be quite enlightening as they show 
the diverse manifestations of these growths and the varied ages at which CYSTS OF THE ORAL CAVITY 
219 
Fig. 147. Dentigerous cyst in a girl 14 years of age. The swelling was first noticed 
about three weeks before this radiograph was taken. The cyst was found to 
be attached to the misplaced second molar. The third molar was outside the 
cyst cavity, and the distal root of the first molar was partly absorbed. As the 
roots of the second molar penetrated through the lower border of the bone, it 
was feared that, with the removal of this tooth, the bone would collapse, thereby 
complicating the treatment and probably causing considerable disfigurement. 
The fine ledge of bone at the upper border was preserved to prevent this. I 
found later that this was the source of considerable osteogenesis, in the healing 
of the case. 220 
ORAL SURGERY 
Fig. 148. Dentigerous cyst in a young man 23 years of age. A rather thick cyst 
sac was attached to the neck of the malplaced third molar. Note the remark- 
able attenuation of the bone. In operating upon these cysts, it is desirable to 
leave as much as possible of this fine, scale-like bone, attached to periosteum, in 
an undisturbed state. This tissue contains considerable possibilities of bone 
regeneration, and it is obvious how desirable it is that a considerable amount of 
pew bone should form at this point. CYSTS OF THE ORAL CAVITY 
221 
Fig. 149. Dentigerous cyst in a man 34 years of age, caused by impacted cuspid 
imbedded in the lower border of the bone. All of the teeth, which appear 
crowned, were free from caries, but, as they were undermined by the cyst, they 
became loose, and they were erroneously crowned to overcome this. When the 
cyst was discovered, it had destroyed the entire anterior part of the bone. 222 
ORAL SURGERY 
Figs. 150 and 151 present an unusually large cystic condition involving both sides of 
the mandible. This occurred in a man about 34 years of age. All previous 
history was negative. Wassermann reaction was two plus. The only apparent 
etiological factor was the impacted cuspid shown in the radiograph. The other 
teeth present within the cystic area were normal and free from disease. Such 
extensive involvement of both sides of the mandible is unusual. CYSTS OF THE ORAL CAVITY 
223 
Fig. 152. Dentigerous cyst in a woman 55 years of age. The mouth was edentulous 
and not until about five years after she commenced to wear her artificial teeth, 
did symptoms arise. 224 
ORAL SURGERY 
Fig. 153. Dentigerous cysts in a young woman 24 years of age. The cyst, most 
likely, developed through aberration of the dentinal papilla of the second bicuspid, 
as the patient could not recall ever having this tooth extracted and all the other 
teeth on that side were normal. Note the manner in which the mandibular canal 
is destroyed throughout the cystic area. CYSTS OF THE ORAL CAVITY 
225 
they occur. In cases where there is no association between a tooth and 
the cyst, or where there is no tooth present, we may assume that they 
originate from misplaced and unabsorbed epithelial rests, probably rem- 
nants of a dental follicle, or an undeveloped supernumerary dental follicle. 
Fig. 154. Follicular cyst in young man 22 years of age, invaginating, but not invad- 
ing the maxillary sinus. All the teeth in this case were normal and entirely 
free from pathological lesions except the first molar, which was a carious but 
vital tooth. 
(Figs. 153, 154 and 155.) It is frequently observed that an aberration 
or abnormality in the tooth form or in its development is conducive to cyst 
formation. (Figs. 156, 157, 158 and 159.) 
Clinical Signs and Symptoms of Dentigerous Cysts. 
All clinical features of dentigerous cysts are very much like those of 
the radicular type in which no inflammatory conditions and no infection 
prevail. Dentigerous cysts are very rarely infected unless an external 
communication is created hy a progressive pathological process, or from 
adjacent infected structures. They contain usually the characteristic light 
straw or amber colored fluid, which can readily he withdrawn with an 
aspirating syringe. 226 
ORAL SURGERY 
Fig. 155. Dentigerous cyst in a young man 22 years of age. The teeth appeared 
normal, were free from caries and in normal occlusion. There were no disturb- 
ing symptoms until very recently, when a slight swelling appeared at the angle 
of the jaw, and the third molar became slightly sore upon pressure. It is rea- 
sonable to assume that when the third molar had reached this stage of its 
development, through some reason, there was an arrest of development and a 
cystic degeneration of the remaining portion of the dentinal papilla. The cyst 
sac was attached to the third molar, while the second molar roots, though out- 
side of the cyst sac, have undergone pressure absorption. CYSTS OF THE ORAL CAVITY 
227 
Figs. 156 and 157. Dentigerous cyst in a woman 45 years of age. The bridge was 
worn for about twelve years and the first sign of a swelling occurred about six 
months prior to applying for treatment. The cyst contained the malformed 
incisor tooth shown in Fig. 157. 228 
ORAL SURGERY 
Too much care cannot be exercised in the differential diagnosis between 
malignant growths and cysts. Sarcomatous growths of the jaws, in their 
clinical features often simulate cystic conditions. The overlying mucous 
membrane appears to he free from pathological signs and there is no 
Figs. 158 and 159. Dentigerous cyst in a man 28 years of age. There was no com- 
plaint until about three years prior to the operation, when swelling in the region 
appeared, with a slight amount of pain. An incision was made, to relieve the 
condition, which was repeated three times within this period, before he con- 
sulted me. The crown of the lateral incisor was normally shaped and of normal 
color, but, as indicated by the radiograph, it was twisted in its position. The 
radiograph showed the abnormal condition of the root surrounded by the cyst 
area. Upon removal, it was found that the cyst sac was attached to the lateral 
incisor. The root canal terminated in a funnel-shaped cavity, where the abnor- 
mal flattening of the tooth commenced, as shown in the enlarged photograph of 
the tooth in Fig. 159. The condition suggests a developmental aberration of the 
tooth which caused a cystic degeneration. All of the other teeth of this patient 
are faultless and he is a well-developed normal individual. 
palpable metastasis to suggest malignancy. When in doubt aspiration 
should be resorted to. This makes the diagnosis more definite but not 
always conclusive. Malignant growths may be known by the resistance 
offered to the penetration of the aspiratory needle and the withdrawal 
of a scant amount of frothy tissue juice, mixed or colored with blood. 
(See Malignant Growths.) 
In still other cases, an exploratory operation will be the deciding CYSTS OF THE ORAL CAVITY 
229 
measure. The overlying mucous membrane is carefully opened or 
reflected and in case of malignancy, tissues, characteristic of this growth 
will he disclosed. They appear as a conglomeration of irregularly formed 
masses showing no purposeful intent in their structural formation. The 
tissue usually occupies the entire cavity and has a decided tendency 
to bleed. 
Treatment of Radicular and Dentigerous Cysts. 
The treatment of cysts is always surgical. There are three different 
recognized operations that are practiced. 
The first consists of the following steps: incise 
and raise the mucoperiosteum removing a sufficient 
amount of the overlying bone to permit of the 
complete enucleation of the cyst sac. (Figs. 160, 161, 162, 163, 164 and 
165.) The mucoperiosteum is restored to its former relationship and 
sutured into position. Drainage is secured through a small aperture, or 
between the sutures. The cavity is subsequently dressed until it becomes 
entirely obliterated. This operation particularly commends itself to us 
for many reasons. First,, the principle of leaving the parts in a normal or 
nearly normal relationship can be best observed. Second, with the preser- 
vation of the mucoperiosteum a remarkable amount of osteogenesis will 
follow. That this is desirable, particularly in large cysts of the lower 
jaw, is quite evident. 
In the second operation, the outer wall of the 
cyst cavity is summarily removed and the mucous 
a™™™.™™, membrane may or may not be sutured to the 
adjacent margins of the cyst membrane, (bigs. 166, 167, 168, 169 and 
170.) In this way the cyst is made accessory to the oral cavity, and the 
cyst membrane and the oral mucosa become one continuous layer. Sub- 
sequently the cyst membrane undergoes a modification which renders it 
similar to that of the oral mucosa. The advantage of this operation is that 
the technique is simple; that cicatrization is more rapid and that there is no 
possibility of recurrence. The disadvantages, nevertheless, often out- 
balance these features. The hollow so created is often unsightly, par- 
ticularly in the anterior part of the mouth. Prosthetic restoration is 
difficult and, because of the bulk essential for the filling in of such a 
cavity, it is unesthetic in appearance. The hone—and this is especially 
true of the mandible—is left structurally in a weakened condition. 
Proper hygiene is difficult to maintain, as such a hollow favors the accumu- 
lation of food debris and oral exudates. 
Cyst Operation 
No. 1. 
Cyst Operation 
No. 2. 230 
ORAL SURGERY 
Fig. 160. Radicular cyst in man 65 years of age. There were no disturbing symp- 
toms but the bone presented a marked bulging in the area. The missing teeth 
were removed some twenty or twenty-five years ago. The cyst was infected. 
This case is used to illustrate cyst operation No. 1. CYSTS OF THE ORAL CAVITY 
231 
Fig. 161. Shows the line of incision of the mucoperiosteum. 232 
ORAL SURGERY 
Fig. 162. Shows the second step; the mucoperiosteum is reflected and the collapsed 
cyst sac is being detached from the bone by blunt dissection. CYSTS OF THE ORAL CAVITY 
233 
Fig. 163. Diagram showing the relationship of the tissues within the operative field. 234 
ORAL SURGERY 
Fig. 164. The third step; the cyst sac and the involved teeth are removed and the 
bone edges are trimmed. Note the bone ledge left to support the mucous 
membrane. CYSTS OF THE ORAL CAVITY 
235 
Fig. 165. The final step; the mucoperiosteum sutured into position and a point for 
irrigation and dressing secured at the anterior part of the wound. 236 
ORAL SURGERY 
Fig. 166. Drawing, after a practical case, representing a cyst in the bicuspid 
region; also showing the incision of the mucoperiosteum, in operation No. 2. CYSTS OF THE ORAL CAVITY 
237 
Fig. 167. The mucoperiostal flap raised and the bone exposed. 238 
ORAL SURGERY 
Fig. 168. The outer plate of bone and the outer part of the cyst sac removed, 
leaving the inner portion of the cyst sac adherent to the bone. CYSTS OF THE ORAL CAVITY 
239 
Fig. 169. The oral mucosa is sutured to the cyst, or the tissues forming the external 
part of the cyst are simply removed, and the cyst cavity is rendered continuous 
with the oral cavity. 
Fig. 170. Diagram of a cross section of the tissues after the operation. 240 
ORAL SURGERY 
In the third operation, the outer layer of 
mucoperiosteum is raised or reflected from the 
entire extent of the cyst cavity. The external bony 
plate is removed and trimmed to the outer edges so that the cavity is 
rendered comparatively shallow. The cyst sac is entirely enucleated and 
the mucoperiosteal flap is tucked down with gauze dressings to the inner 
remaining wall of the cyst cavity. (Figs. 171, 172, 173, 174 and 175.) 
The mucoperiosteum will unite with the bone surface and the bare bony 
areas eventually become covered with cicatricial tissue and epithelium. 
The advantage of this operation is that the cicatrization is comparatively 
rapid, the hollow is somewhat less deep than that left by the second 
operation, but, like the latter, it leaves the osseous structures in a com- 
paratively weakened condition, as very little bone regeneration can take 
place under these circumstances. 
As a result of experience, I advocate and practice the first operation, 
whenever it is possible. It is important in this operation that the cyst 
sac be removed in its entirety. To do this the cyst area must be well 
exposed to view. Blind curetting through a tooth socket, or through a 
small aperture, is not conducive to good results. Failure to remove all of 
the cyst sac may be followed by a recurrence or incomplete healing. While 
the postoperative treatment here is more protracted, the absence of 
deformity and the remarkable bone regeneration is a most gratifying 
compensation for the extra effort. 
The routine of diagnosis should include two or 
three radiographs taken from different angles, so 
that the extent of the involvement may be closely 
studied. The more obscure areas must later be observed in the operation. 
Particular attention should be given to the teeth within the area. 
Sometimes a tooth is just on the border line of a cystic area and, upon 
testing, it may give evidence of a vital pulp. This examination in itself 
is not sufficient, as we frequently find, upon exposing this point, that the 
apical portion of the tooth projects into the cyst cavity. The pulp, 
therefore, though not entirely devitalized, must be in a pathological state. 
Where one or more teeth involved are to be retained, the pulp should 
be extirpated and the pulp chamber and canals should be thoroughly 
cleansed and sealed prior to the operation. There are times when this is 
impossible, because the root canal communicates with the cyst cavity, and 
the contents of this will continually seep into or evacuate through this 
channel so that sterility and dryness of the root canal cannot be estab- 
lished. In this event a preliminary operation should be performed. This 
consists of incising the mucoperiosteum over the apical region of the 
Cyst Operation 
No. 3. 
General Technique 
of Cyst Operation. CYSTS OF THE ORAL CAVITY 
241 
Fro. 171. Shows the line of incision of the mucoperiosteum, in operation No. 3. 242 
ORAL SURGERY 
Fig. 172. Shows the second step; the mucoperiosteum raised and the bone exposed. CYSTS OF THE ORAL CAVITY 
243 
Fig. 173. Shows the third step; the cyst sac entirely enucleated and the bone edges 
trimmed down so as to render the cavity very shallow; also the teeth involved, 
removed. 244 
ORAL SURGERY 
Fig. 174. Shows the final step; the mucoperiosteal flap is held down with two 
sutures and tucked down into position with the bone surface. CYSTS OF THE ORAL CAVITY 
245 
teeth, and opening into the cyst through the bone by means of a chisel, 
curette, or a surgical bur. The cyst contents are evacuated through this 
opening and drained until the root canals have been properly taken care of. 
The majority of cysts of the oral cavity can he operated upon under 
local anesthesia and it is much to he preferred to a general anesthetic. 
The plan of operation upon cysts consists of the following steps : The 
oral cavity is swabbed and irrigated with an antiseptic solution, such as 
Fin. 175. Diagram showing the mucoperiosteal flap held down by sutures and a 
gauze pack. 
potassium permanganate, boric acid, or normal sterile saline. The area 
to be operated upon is painted with tincture of iodin. 
The line of incision is so planned that a thorough view of the cyst 
cavity is secured and in the restoration of the mucoperiosteal flap the 
approximated edges of the wound will rest upon a bone surface. 
The mucoperiosteum having been raised, a portion of the external 
bony wall is removed by means of gouges, chisels and rongeur forceps, 
until the cyst is rendered accessible and is exposed to view. The sac, if 
punctured, should he emptied of its contents with sterile swabs and 
sponges. It is next carefully detached from the bony walls with a blunt 
periosteotome. This dissection can he performed with facility as the 
membrane is not strongly adherent to the hone. The attachment is much 
closer about the teeth and where the sac is in contact with the muco- 
periosteum. 
Teeth which must he removed should he extracted at once. Of those 
teeth that have been prepared for retention, the portions of roots project- 246 
ORAL SURGERY 
ing into the cyst cavity should be amputated. The line of resection 
should be on a level with the surrounding bone. (See Chapter on root end 
amputation.) When the cavity has been cleared of all foreign substance 
and pathological tissue, the bone edges are smoothed by means of a 
curette; removal of any portion of bone beyond the cyst sac is contra- 
indicated. In the majority of larger cysts it will be found that, after 
the removal of the cyst sac, the thinned out portions of the bone still 
adhere to the mucoperiosteum. Where bone regeneration is desired this 
lamella of bone should be left intact, as it contains a prolific osteogenetic 
basis. The cavity is irrigated next, and the mucoperiosteal flap restored 
and sutured into its former position. Where a tooth is removed, the 
socket of this will prove to be a convenient point for dressing and 
irrigation, and in these cases the original incision can be sutured com- 
pletely and permitted to heal by primary union. Where a tooth socket is 
not available, a point for irrigation and for introduction of the dressing 
may be established between the sutures at the lowest point. The dressing 
of the cavity, which consists of iodoform gauze, is changed at intervals 
of from 48 to 72 hours, and continued until the cavity is almost entirely 
filled in. At the renewal of each dressing the cavity should be irrigated 
with a mild antiseptic solution. 
Multilocular Cysts. 
Multilocular cysts, or as they are sometimes termed, adamantinoma, 
or cystic adenoma, are cystic growths of the jaws containing numerous 
smaller and larger cystic crypts. 
These growths are rather uncommon as compared with other cystic 
degenerations found in the oral cavity or in the jaws. As a rule they 
are observed in young subjects, between the ages of twenty and forty. 
They occur more often in the lower than in the upper jaw and about twice 
as frequently in females as in males. 
They are believed to spring from the epithelial rest, or paradental 
epithelial debris to which Malassez first directed closer attention. He 
believed that these epithelial rests are derived during fetal life; (i) from 
the mucous membrane of the fetal jaw; (2) from the epithelial cord of 
the enamel organ; (3) from the epithelial membrane of the enamel organ. 
These tissues may also account for the development of some simpler types 
of cysts, in which no dental factor seems to be present. 
In their clinical course, these growths enlarge very slowly, sometimes 
during a period of years. They are painless unless some adjacent struc- 
tures such as the infra-orbital, or the inferior dental nerve is pressed CYSTS OF THE ORAL CAVITY 
247 
upon, or when they become infected. The cyst cavities may be individual, 
being divided by a connective tissue stroma or lamellae of bone, or they 
may communicate when, through infection, or through absorption the 
intervening structures are destroyed. Their contents are similar to that 
found in other cyst cavities. They may be discovered at an early stage 
of their development and may vary in size from a walnut to an orange, 
or even larger ones have been reported. 
Multilocular cysts are found to be the least malignant of epithelial 
growths in the jaws and ordinarily they do not metastasize. They are 
regarded as benign growths, but they have a tendency towards malignant 
degeneration. 
At some stages of their development it is impossible to differentiate 
clinically between a follicular cyst and an adamantinoma. Even the 
radiograph is not very definite as to the character of the inner structures. 
The possibility of sarcomatous growths should always be thought of in 
making the diagnosis. Some types of sarcomatous growths closely 
resemble cysts in their clinical and radiographic appearance. 
The prognosis, as a rule, is favorable as far as life is concerned. When 
they attain a large size, the operations are rather disfiguring. It is impor- 
tant that every locule and all parts of the cyst should be extirpated in 
the removal, as, when these are left in the jaws recurrence of the growth 
may result. 
It may not be out of place here to state that, as all cysts are small at 
first, they can often be discovered at a very early stage of their develop- 
ment. It should be a part of rational practice to advocate radiographing 
the jaws of all individuals in the presence of any abnormality about the 
teeth and jaws. 
Mucous Cysts. 
Mucous cysts may be considered to be retention cysts, caused by the 
obstruction of a mucous gland. They may be multiple, but are more often 
single. 
They may occur in almost any part of the oral cavity. The points 
where they develop most frequently, are the sublingual region, the inner 
surface of the lower lip, or opposite the bicuspid and molar teeth. 
It is very probable that irritation or trauma of the mucous membrane 
acts as an etiological factor in their formation. T have frequently found 
them to be associated with accidental, or deliberate external violence, or 
following biting of the lips or cheek. 
They usually appear as spherical bodies lodged in the submucous 
tissues. As a rule they are small and vary in size from that of a pea to 248 
ORAL SURGERY 
large bean. When the overlying mucous membrane becomes stretched it 
may appear slightly discolored. Their presence, however, causes con- 
siderable discomfort at times. They grow very slowly and are usually 
painless in their growth as well as to palpation. 
The. treatment consists in complete enucleation of the cyst sac. This 
at times offers a degree of difficulty, as the cyst sac proper is very thin 
and friable. Where the presence of some remnant of the cyst sac is 
suspected, it should be cauterized with pure carbolic acid. It is important 
that in those which occur upon the lip particularly, the mucous membrane 
should be closely approximated, to prevent an unyielding scar which is a 
source of discomfort. CHAPTER XIV. 
Ranula. 
Ranula is a retention cyst of the salivary glands in the sublingual 
region. Any one of the salivary glands located in this region, the sub- 
maxillary, the sublingual or the glands of Nuhn and Blendin may be 
afifected. 
Ranula has been considered as far back as medical knowledge reaches, 
and derives its name from its assumed resemblance to a frog’s belly. 
It occurs in both sexes and is not confined to any age. Cases have 
been reported by others and observed in personal experience in subjects 
between the ages of six and sixty. 
There is a diversity of opinion as to the etiology 
of this growth, even at the present time. Fleishmen 
claims that it is, commonly, a cystic degeneration of 
the sublingual bursa. Hanley suggests that it may be due to a congenital 
defect, or probably to the obstruction of a duct. This latter theory, 
although quite generally believed, is not truly substantiated by clinical 
findings. The obstruction of a duct, by mechanical means, is generally 
accompanied by inflammatory symptoms, whereas, the absence of inflam- 
matory symptoms is one of the characteristics of a ranula, unless it be- 
comes infected. Among the numerous cases which have come under my 
observation, I have failed to find a direct irritant or a palpable etiologic 
factor. , Lewis observes that the glaring fluid, usually found in a ranula, 
cannot be saliva. From its general behavior, its tendency to recurrence, 
its contents, and from the fact that no mechanical obstruction is ever 
discovered, the conclusion suggests itself that ranula is most likely a cystic 
degeneration of one or more lobes of the afifected gland. 
A ranula appears as a roundish, or slightly oval swelling, in the floor 
of the mouth. (Figs. 176 and 177.) It is usually unilateral and 
monolocular. In some instances, however, we find that it occupies both 
sides of the frenum, and that it consists of two or more lobes. The over- 
lying mucous membrane is free from inflammation, except that when large 
and the tissues become distended it may assume the bluish appearance of 
a stretched membrane. It is painless and not sensitive upon pressure. It 
often ruptures without any surgical interference, but usually recurs with 
Etiology 
of Ranula. 
249 250 
ORAL SURGERY 
Fig. 176. Schematic 
presentation of a 
typical ranula drawn 
after a practical case. 
Fig. 177. Same case as Fig. 
176 witli the tongue raised 
to the roof of the mouth. RANULA 
251 
Figs. 178 and 179. Ranula in a woman 34 years of age. This had been incised on 
several occasions and surface cicatrices prevented it, in some degree, from 
bulging in the mouth. Note the marked penetration into the sublingual region 
as indicated by the external swelling in Fig. 178. 
Fig. i8o. Ranula, with the overlying mucous membrane dissected away. Note the 
bulging through of the ranula. 252 
ORAL SURGERY 
Fig. 181. The 
exposed part 
of the ranula 
sac removed. 
Fig. 182. Suturing 
the pared edges of 
the sublingual mu- 
cous membrane to 
the lower part of 
the ranula sac. RANULA 
253 
the healing of the broken tissues. In some cases, the swelling becomes 
so large that it is apparent on the under surface of the submaxillary 
region. (Figs. 178 and 179.) The tongue is displaced to one side or 
upwards and backwards so that speech and deglutition are impeded. 
The treatment indicated is, in principle and detail, 
that required for other cystic conditions. Simple 
incision evacuates the contents and the condition 
will temporarily subside, only to recur again. Another mode of treatment 
used with indifferent success, consists of a seton in the form of a silk 
ligature, or a silver wire loop, passed through the growth. The fluid con- 
tents escape and the seton is left in position until the ranula shrinks and 
eventually disappears through retrogressive degeneration. This procedure 
is of somewhat doubtful value and can scarcely be considered as surgical. 
The following operation has afforded success in the author's hands: 
Local anesthesia is induced, care being taken 
that the hypodermic needle does not penetrate the 
ranula. The overlying mucous membrane is incised 
without carrying the incision into the cyst cavity. This can be avoided 
only with the greatest care, as the tissues are stretched and very thin. The 
cyst sac proper soon bulges through the incision and appears like a fine 
inflated membrane. (Fig. 180.) When a goodly portion of this is dis- 
sected out, the exposed part can be excised with a sharp knife or a pair 
of scissors. (Fig. 181.) The fluid contents, which is usually mucilag- 
inous, clear and ropy in consistency, is thoroughly sponged out. The 
mucous membrane flaps are inverted and sutured to the denuded sides of 
the cyst cavity. (Fig. 182.) The cicatrization is very rapid and in my 
experience there has been no recurrence following this operation. 
Treatment 
of Ranula. 
Operation 
for Ranula. CHAPTER XV. 
A Consideration of Bone Repair and Regeneration. 
A large proportion of the diseases and injuries of the face, teeth and 
jaws involve the bony framework of these regions. Consequently, most 
operations in this field complicate, to a greater or lesser degree, hone tissue. 
A clear understanding of the requirements of hone surgery, based upon 
bone pathology, repair and regeneration, should he a prerequisite therefore 
in the preparation for this work. A fairly thorough understanding of the 
processes, with which these problems are directly, or indirectly associated, 
are helpful in outlining the measures which are indicated in the treatment 
of the various conditions, as well as in formulating surgical procedures. 
The investigation of the complex processes of bone repair and repro- 
duction has occupied a host of brilliant minds during the past two centuries. 
Despite the extensive investigations, the problem is not as yet solved with 
any degree of finality and many of its phases are not clearly understood at 
the present time. 
It would be rather cumbersome to enter into a complete treatment of 
the subject in this book, but the presentation of an outline of the outstand- 
ing theories concerning the subject should be both helpful and of interest. 
Duhamel (1739), a French, nonprofessional in- 
vestigator, is generally credited with the discovery 
of the osteogenetic function of the periosteum. 
Keith states that these investigations were preceded by similar observations 
and findings made in 1730 by Belchier, an English surgeon. Haller 
opposed this view, his theory being that the periosteum is merely a limiting 
membrane, having some nutritional function, and that the bone is deposited 
by the blood vessels. John Hunter, a disciple of Haller, and an ardent 
advocate of Haller’s theory, discovered that bone growth entails a double 
process, i.e., bone deposition and bone absorption. Hunter also discovered 
that the long shafts of hone are produced at the epiphyses and that with 
this growth the diaphyses are moulded simultaneously. James Syme, a 
surgeon of Edinburgh, pointed out that scientific physiology and pathology 
must be combined with clinical observations and experimentation. He 
succeeded in determining the osteogenetic function of the periosteum by 
subperiosteal resection of the radius in dogs and the subsequent regenera- 
Theories on 
Osteogenesis. 
254 BONE REGENERATIONS 
255 
tion of these bones. Goodsir, assistant to Syme and a disciple of Hunter, 
though he witnessed the experiments of Syme, believed with Haller and 
Hunter, that bone is deposited by the blood vessels and resorbed by the 
lymphatics. Goodsir was also probably the first to determine, by means of 
Figs. 183 and 184. Marked bone regeneration following the removal of the sources 
of infection, a gangrenous pulp, from lower first molar. From the collections 
of Dr. Arthur W. Bark of New York. Fig. 184 shows the bone regeneration 
one year after treatment and filling of roots. 
microscopic examination, that only the cells in close contact with the 
bone—the osteoblasts—are concerned in bone formation, and that the same 
type of cells exist in the bone structure. In 1842 Flourens, a French 
investigator, proved that Duhamel was right, in that the periosteum con- 
stantly deposits hone; that Flunter was. right in that bone is constantly 
being absorbed and that hone subsance is therefore in a constant state of 
flux. Ollier wanted to settle this controversy for himself and concluded 
from a series of experiments upon rabbits the relative osteogenetic value 
of the different tissues composing the bone. It was his belief that the 
periosteum is the chief agent in producing hone; marrow takes a slight 
part and the bone itself the least share. Sir William Macewen (1877) of 
Glasgow conducted a series of experiments, principally upon dogs, and 
his conclusion was that the periosteum is merely a mould, or limiting 
membrane; that the osteogenetic function of the periosteum is dependent 
upon the proliferation of osteoblasts from the interior of the bone sub- 
stance, into the deeper meshes of the periosteum; that this outpouring of 
the osteoblasts can be induced by irritation, or by inflammatory conditions 
due to injury or infection. His view was that the principal osteogenetic 
function is lodged in the bone tissue itself. 
At present, despite these diverse opinions coming from these and other 
research workers in this field, the matter stands as Wetherhill states it: 256 
ORAL SURGERY 
“The embryologist, the anatomist, the physiologist, the surgeon, and the 
pathologist agree that the periosteum is not only a source of nutrition for 
the bone but that it also possesses definite osteogenetic function.” There is 
considerable divergence of opinion as to the exact processes of bone repair, 
or bone regeneration, but it is fairly agreed upon that it is accomplished 
by specialized cells, the osteoblasts. 
Fig. 185. Radicular cyst caused by infected central incisor in a man 41 years of 
age. Figs. 186 and 187 were taken six months and one year after the operation. 
The origin of the osteoblasts is likewise a sub- 
ject of controversy. Ribbert believes that the osteo- 
blasts are transported to the site of their activity by the blood. No cells 
which might undergo such a change have been isolated from the blood. 
In view of this fact Adami, while admitting the possibility of this, does 
not think it probable. 
A summary of the findings of later investigators in this field, such as 
Axhausen, Lewis, McWilliams, Pliemister, Albee and others, leads to the 
conclusion that all tissues comprising bone are capable of a varied degree 
of bone regeneration. Of these, Axhausen places the osteogenetic layer of 
the periosteum first; next in order are the endosteum, the marrow, and 
lastly the osteogenetic tissues in the bone proper. 
Osteoblasts. BONE REGENERATIONS 
257 
In its final analysis, bone reproduction is de- 
pendent upon the metaplasia of the young connective 
tissue cell into an osteofibroblast, which in turn be- 
comes the differentiated osteoblast. Paul divides this process into three 
stages: (i) decalcification and degeneration of the calcareous material; 
(2) irritation of some sort, leading to inflammatory proliferation; (3) 
Bone 
Regeneration. 
Fig. 186. Radiograph of case shown in Fig. 185, soon after the operation 
Fig. 187. Same case as Fig. 185, showing bone regeneration. 
ossification of the proliferated young connective tissue. Bunting believes 
that through metaplasia, the young connective tissue cells are transformed 
into osteoblasts. Under the influence of the osteoblasts the young con- 
nective tissue fibrils become impregnated with calcium salts, thus forming 
centers of ossification. Layer upon layer of calcium salts is deposited by 
the osteoblasts, and some of these become walled into the newly formed 
bone spaces and become bone cells. 
The readiness with which bone regeneration takes place after bone has 258 
ORAL SURGERY 
Fig. 188. Radicular cyst in a man 50 years of age. The molar teeth had been 
removed about fifteen years before the patient was first seen by me. The con- 
dition caused no disturbing symptoms and a small suppurating sinus was dis- 
covered by the dentist. 
become destroyed, as a result of disease or injury, is dependent upon the 
following factors: (i) the extent and the nature of the hone destruction; 
(2) the degree of surgical trauma; (3) the preservation and the treatment 
of the osteogenetic tissues; (4) the age and the general health of the 
patient. 
The process of hone absorption, or resorption, is 
accomplished by specialized multinucleated cells—the 
osteoclasts. The origin of these cells is still a matter of controversy. The 
Bone Absorption. BONE REGENERATIONS 
259 
Fig. 189 shows the same case as Fig. 188 two years later. The cavity is almost 
entirely filled in with new osseous tissue. Also note the reconstruction of the 
oblique ridges of the ramus. 
bone marrow contains two types of giant cells: the megakaryocites and 
the polikaryocites. It is the latter which are believed to he endowed with 
the specific power of causing osteoclasis. It is believed that these cells are 
derived from the fusion of the osteoblasts (Kolliker and Howell), the 
fusion of the matured hone cells (Bredichin), from the lymphoid marrow 
(Wegener), and the endothelium of the capillaries (Schaeffer). Phemister 
believes that there are no specific osteoclasts and that a variety of cells 
possess this absorptive power in common; that most of the hone absorption 260 
ORAL SURGERY 
Fig. 190. Radicular cyst in a young woman 26 years of age. The teeth of this 
region were removed some years before, and there were no disturbing symptoms 
until about three months before the cyst was discovered, when swelling of the 
face occurred. The cyst seems to have destroyed part of the body and the 
greater part of the angle and the ramus of the mandible. 
is done by the altered fibroblasts and endothelial cells, which, by alteration 
of function, give rise to giant cells—the osteoclasts. 
Alteration in the density of bone may be general, or regional, or local. 
In the first, there may be a normal absorption of bone, but owing to a 
perverted calcium metabolism the newly laid down connective tissue does 
not become calcified. This is seen in such diseases as rickets and osteo- 
malacia. In the second type, the bone absorption is purely local, and as 
seen about the teeth, or in the jaws, it is due to mechanical, chemical or 
septic irritation, or to perverted function. 
There are various theories, attempting to explain 
the actual method of the action of the osteoclasts, 
notably, that the osteoclasts resorb the matrix (Kol- 
liker) ; that the osteoclasts resorb the matrix and ingest the bone cells 
Action of 
Osteoclasts. BONE REGENERATIONS 
261 
Fig. 191 was taken eighteen months after the operation. Note the remarkable bone 
reconstruction, also the uniformity and normal appearance of the bone 
structure. 
(Prentis). Prentis also states that there is no evidence to prove how the 
bone is absorbed, but that, as the osteoclasts are in intimate contact with 
the bone, which is being resorbed, it may be assumed that they are active 
agents in this; also that it is probable that the bone is decalcified by an acid 
formed and digested by the action of an acid and a ferment. The ultimate 
fate of the osteoclasts is, that they become degenerated and completely 
destroyed. 
It should be a matter of interest to know just 
what becomes of the small and large bone cavities 
after a cyst has been enucleated and the etiological 
factor removed, or of some of the gaps resulting from the loss of bone due 
to necrosis or traumatic injuries. In attempting to determine this, we 
Bone Regeneration 
after Operations. 262 
ORAL SURGERY 
must depend in the greatest measure upon our clinical findings, as such 
facts cannot be disputed by mere theory or speculation. 
By following up some of my cases it has been gratifying to note to 
what extent bone regeneration occurs in the jaws. If we are to trust 
radiographic evidence, obtained by periodical examination, even extensive 
cyst cavities become obliterated, with what appears to be granulation tissue 
at first, which, in the course of time undergoes partial or complete ossifica- 
tion. (See Figs. 183, 184, 185, 186, 187, 188, 189, 190 and 191.) I 
have also often observed, especially in young children, that where larger 
segments of bone, as for example the entire ramus, become destroyed by 
necrosis resulting from infection, the entire part would he reconstructed. 
(See chapter on Necrosis.) In many instances, the original form of the 
hone is not reproduced and in still others the gap is only partly spanned 
over. This is very likely influenced by the violence of the destructive 
agents, the virulence of the infecting organisms and the recuperative 
powers of the host. 
It is commonly observed that the bone outside a cyst sac appears in the 
radiograph as well as clinically, to he more dense than the spongiose bone 
which is indigenous in the part. Our radiographic data suggest that repair 
here also, as in other processes concerning bone metabolism, is a double 
activity, that of construction and destruction taking place simultaneously. 
The apparently denser or so-called sclerotic bone is believed to be diseased 
by many. McCollum believes that in subacute, or chronic cases of infected 
hone lesions, the osteoblasts in the vicinity tend to cover up the bone 
lamellae to prevent the involving of the surrounding bone. The lamellae 
become thickened and the bone more compact, thus forming eburnation, 
or sclerosis. This tissue may be regarded therefore as a bone scar, or 
probably as a barrier, circumscribing a pathological area. Here again, if 
the radiograph can he taken as evidence, it can be demonstrated that with 
the removal of the irritating agents, this sclerotic bone which surrounds 
an infected area, becomes resorbed and is replaced with normal bone, 
which, in the course of time, blends into apparent uniformity with the 
continuous structures. 
It is exceedingly important in all bone operations in which bone 
regeneration is desired, that the tissues which are capable of osteogenesis 
should be preserved. This is particularly true of the periosteum, as I have 
frequently observed that where the pathological process involved the com- 
plete thickness of the bone, or, in the maxilla, when this extended from 
the buccal to the palatal surface, so that the periosteum was destroyed on 
both sides, complete ossification did not occur. It is also important that 
all bone operations should he performed with the utmost observation of BONE REGENERATIONS 
263 
surgical cleanliness. It has been found in bone graft operations, as well as 
in clinical experience, that acute primary infections are much more violent 
and destructive in their course than are chronic infections lodged in the 
bone. 
Some men depend upon the blood clot to fill in 
bone cavities, which is expected to metamorphose, 
in the course of time, into bone. Such osteoid trans- 
formation is observed and often depended upon, in aseptic fields of bone 
surgery or bone grafting. Complete reliance cannot be placed, however, 
upon such a process when operating in the oral cavity, as at best, the blood 
clot acts merely as temporary scaffolding for the young connective tissues 
and blood vessels. Even in an aseptic field, in numerous cases, the blood 
clot breaks down and becomes infected, so that suppuration follows. The 
oral cavity is constantly infected and with the greatest of care, aseptic 
operations cannot be carried out, either in the upper or in the lower jaw. 
Also, with the termination of the operation, the area is flooded with saliva 
which harbors numerous pathogenic organisms. 
I have been often convinced of the fallacy of this method by suturing 
and closely coaptating the mucosa over a cyst cavity, or over a bone cavity 
from which a tooth or a foreign body was removed. The lips of the 
wound were separated two or three days later, at some point between the 
sutures. Although there were no disturbing nor clinical symptoms, a 
copious pus discharge followed. When we consider how frequently 
suppurating conditions are retained in the jaws, often for long periods, or 
even years, without causing disturbing symptoms, such procedure does not 
inspire us with a sense of safety. 
I have found it to be better practice, therefore, to render these cavities 
as small and shallow as is consistent with esthetic appearances, and, in the 
mandible also, with strength desired for function. 
At times we observe that larger cavities become obliterated to a degree 
and at some stage, as though the regenerative powers of the tissues had 
become exhausted, the process stops. With the use of caustic irritants, or 
by curetting the superficial surfaces of the wound, proliferation may be 
again induced. This would argue against the above suggestion. My 
impression is that in these cases, through faulty approximation of the 
mucous membrane, through faulty postoperative dressings, or because of 
a prolific growth of the mucous membrane the wound surface becomes 
epithelialized. If this newly formed layer of epithelium is destroyed, or 
surgically removed, repair continues until it is complete. 
Blood Clot 
not Dependable. CHAPTER XVI. 
The Removal of Broken-Down and Buried Roots. 
Portions of teeth left in the alveolus may be classified as being septic 
or nonseptic. 
The septic ones are parts of diseased teeth and they may he broken 
down, either by a pathological process, or in the course of their removal. 
The nonseptic ones are parts of vital teeth and may be broken, either 
through traumatic injury or in the course of their removal. These also 
must essentially become infected in time. 
There are various views regarding portions of teeth, or roots left in 
the alveolus. Prior to the better understanding-of oral foci of infection 
it was common practice, especially in European countries, to leave all 
broken down roots in the jaws, unless they caused trouble, with the idea 
that the thus preserved alveolar ridges offer better retention for artificial 
dentures. These were often placed over the unhygienic and diseased con- 
ditions so created. Today, this practice has been entirely abandoned by 
all enlightened dentists and we shall therefore consider merely the isolated 
cases of roots deeply lodged in the alveolus. 
Regarding the fate of these, there are some who believe that smaller 
portions of roots will, in the course of time, become absorbed, or exfoli- 
ated. The first of these conditions does not occur, and the second is 
essentially accompanied by a pathological process in which a considerable 
portion of the surrounding hone is destroyed, while probably acting as a 
focus of infection. 
When isolated portions of broken teeth become infected they may act 
both as septic and as mechanical irritants. The reaction may he 
inflammatory or clearly neuralgic in nature. To retain any portion of a 
tooth on these suppositions cannot be considered good practice. The 
fallacy is even greater when an infected tooth is removed with the inten- 
tion of eradicating a focus of infection, as the part most frequently 
diseased is the apex and its surrounding tissue. 
The breaking of a tooth in extraction is a common accident and may 
occur in the hands of any one. The causes for this may be: a peculiar 
formation of the tooth root; brittleness due to disease, or to dental treat- 
264 REMOVAL OF BURIED ROOTS 
265 
ment; excementosis; excessive density of the surrounding bone; faulty 
technique or faulty manipulation in extraction; unsatisfactory anesthesia, 
preventing proper surgical procedure. 
A portion of a tooth broken off in extraction is often left in the 
alveolus, not so much because of lack of understanding, but rather because 
of lack of courage. It seems to be a tradition in the profession, as well 
Fig. 192. Portions of roots, such as shown in this radiograph, should never be left 
in the alveolus, in the hope that they will be absorbed, or exfoliated. They 
should be removed. 
as amongst the laity, that breaking a tooth is an unwarranted and dis- 
graceful accident. Yet we know that, in a percentage of cases, the 
occurrence is entirely beyond the control of the operator. For this reason 
a great many men try to conceal the accident by methods which rather 
aggravate than improve the situation. 
It is common practice that in hasty attempts they try to grasp the 
root by gnawing and tearing away the gum tissue and alveolar struc- 
ture with forceps. This often results in failure to remove the root; in 
laceration and mangling of the tissue, which may lead to necrosis; injury 
to the adjacent teeth; infection; and to intense and prolonged post- 
operative pain. 
A second method, often used, is drilling out the root by means of a 
surgical bur. The objection to this is, that it is a blind performance and 
may result either in the removal of too much of the surrounding bone 
tissue, or a portion of the tooth is left in position. 
It is often possible to remove a portion of a root with a curette or an 
elevator, as for example, when one of the roots of a lower molar remains 
imbedded in the bone. A Cryer, or a modified Cryer-Winter elevator may 
be inserted into the empty socket, and the alveolar septum and the root 
can be thus lifted out. 266 
ORAL SURGERY 
Fig. 193. Operation for removing broken-down root, such as shown in Fig. 192. 
The mucous membrane incised. REMOVAL OF BURIED ROOTS 
267 
Fig. KJ4- The mucoperiosteum is turned aside, exposing outer wall of alveolus, 
which wall is then broken away. 268 
ORAL SURGERY 
Fig. 195. The root is disclosed and removed with a chisel or elevator. REMOVAL OF BURIED ROOTS 
269 
Fig. 196. I he mucoperiosteum sutured back into position. 270 
ORAL SURGERY 
Whenever the root is so lodged that, because of 
its size, position or the nature of the surrounding 
hone considerable osseous tissue must be removed 
(Fig. 192), it is more correct to regard it as a 
foreign body and as such it should be removed by surgical dissection. The 
mucous membrane is incised anterior or posterior to the tooth socket 
(Fig. 193) and raised from over the area. (Fig. 194.) The outer wall 
of the tooth socket is removed next, following the alveolar ridge of the 
extracted tooth, until the portion of tooth is well exposed to view. This 
can be done with a surgical bur, or mallet and chisel. The root is dis- 
lodged next with a chisel or elevator. (Fig. 195.) The rough bone edges 
are smoothed off and spicules of bone removed. The wound surface is 
dusted with an anesthetic powder and the mucoperiosteum sutured into 
position. (Fig. 196.) 
The advantage of this is that the root is removed in its entirety with 
the least amount of laceration or traumatization of the involved and 
surrounding tissues. 
Operation for 
Removing Broken- 
down Roots. CHAPTER XVII. 
Alveolectomy. 
The operation of alveolectomy consists of the excision of a part of 
the alveolar process. The operation is more often indicated in the upper 
than in the lower jaw. 
The object of the operation is to correct abnormalities and deformities 
of the alveolar ridges which interfere with the proper adaptation of arti- 
ficial dentures, or other dental restorations; to remove sharp or projecting 
edges of the alveolar ridges, following the removal of teeth, which, 
through pressure and irritation of the overlying mucous membrane, are 
frequent sources of facial neuralgias, or localized inflammatory conditions 
and ulcerations; to expose infected areas lodged in the jaws, which may 
he associated with infected teeth, or which may exist as dififused latent 
infections; to remove excessive parts of the alveolar ridges which pro- 
long cicatrization and unduly prevent the placing of artificial dentures. 
The abnormalities which indicate the operation 
may be congenital or acquired. The congenital 
abnormalities occur, more often, in the upper than 
in the lower jaw. These are present as bulky masses 
of hone, most frequently in the molar, or in the condyloid region, and may 
project lingually, or bucally, or both. While the teeth are in position their 
presence has no pathological nor surgical significance. With the removal 
of the teeth, however, these parts rest upon, or are so close to the tissue 
surfaces of the opposing jaw, that there is no room for a denture; or the 
lingual or buccal mass of bone may be so large that a plate cannot be fitted 
over it. In tbe anterior part of the mouth, where the outline of the upper 
jaw is considerably larger than that of the lower, it is often helpful to 
trim the excess down, into better conformity with the lower. There are 
also cases where the alveolar ridge is too deep and considerably out of 
proportion with the lip line. 
Mention may be made at this point of the congenital osseous excres- 
cences which are not infrequently found to be situated at the median line 
of the palate. (Fig. 197.) This excrescence is found to be present in 
females as well as in males. It is sometimes mistaken for a new growth, 
Congenital 
Outgrowths 
Inviting Operation. 
271 272 
ORAL SURGERY 
or a cyst. The overlying mucous membrane is always normal, unless it is 
subjected to irritation as in the wearing of a denture. The hone, however, 
presents no pathological signs. This sometimes offers considerable im- 
pediment in the fitting of a denture. In this event the removal of the 
mass is permissible, but, otherwise, it presents no pathological features 
and causes no inconvenience to the patient. 
Fig. 197. Congenital palatal excrescence, which has no pathological significance, 
In the mandible these congenital excrescences more often exist in the 
internal surface of the hone clear of the median line in the region of the 
lateral incisors, the cuspids and bicuspids. They present, as unilateral or 
bilateral enlargements and give one the impression of an osteoma. The 
overlying mucous membrane is normal, except in the presence of the 
extension of disease from the gingival tissues. The radiograph taken 
through the bone is negative, and if one is taken from beneath the chin 
parallel with the long axis of the teeth the mass appears as a shelf of bone 
which is normal in its inner structure. Occasionally these growths are 
observed on the lingual aspect of the lower third, and very rarely the 
second molar teeth. ALVEOLECTOMY 
273 
Fig. 198. Drawing after a practical case, showing the incision of the gums for 
alveolectomy. 274 
ORAL SURGERY 
Fig. 199. The mucoperiosteum reflected and the superfluous alveolar process cut 
away with rongeur forceps. ALVEOLECTOMY 
275 
Fig. 200. The bone surfaces smoothed and the soft tissues sutured into position. 276 
ORAL SURGERY 
Fig. 20i. The correct apposition and suturing of the mucosa over the reduced 
alveolar ridge. ALVEOLECTOMY 
277 
The acquired conditions may exist prior to the 
removal of the teeth, or only after these have been 
removed. The removal of teeth at different periods 
often results in a marked irregularity in the outline of the alveolar ridges. 
The loss of antagonists after a longer period, may cause a tooth to ad- 
vance, and proportionate growth of the alveolar process often takes place. 
This is one of the most frequent acquired causes of irregularity in the 
outline of the alveolar ridges. Undue laceration in the removal of teeth, 
or necrosis, often causes irregularities which can be advantageously cor- 
rected by alveolectomy. The operation is often indicated, also, where a 
number of teeth are removed at one time. The ragged ridges can be 
excised and smoothed, to induce more rapid and more even cicatrization. 
With the discovery of some fallacies in the practice of some types of 
bridge work, there is a considerable tendency in favor of plate prosthesis. 
In this work many troublesome deformities and irregularities of the 
alveolar ridges demand correction. 
We cannot refrain from pointing out, however, that not unlike other 
recently popularized methods of practice, this operation has been often 
abused, or injudiciously performed. Numerous men, who specialize in 
plate prosthesis, aver that the alveolar ridges are often so mutilated and 
flattened, that it is impossible to secure retention for their dentures. The 
operation should be performed only in those cases where there is a decided 
indication for it, and in such a manner that, when cicatrization ensues, a 
useful and retentive alveolar ridge is the result. 
Prior to the operation the mouth is thoroughly 
irrigated; local anesthesia is induced, and the parts to 
be operated upon are painted with tincture of iodin. 
I f the part is an old deformity, an incision is carried over the center of the 
ridge and the mucous membrane is reflected, respectively, towards the 
palate and towards the buccal or labial surface. When the operation is 
performed at the time of the removal of the teeth, this incision is unneces- 
sary. The gum tissues which ordinarily fill the interdental spaces and 
hind the buccal and lingual mucosa are divided, or excised (Fig. 198), 
and the alveolar ridge thoroughly exposed to view. The superfluous por- 
tion of the alveolar bone is next cut away with rongeur or bone-cutting 
forceps (Fig. 199), and when a sufficient amount has been removed, the 
surface is smoothed with curettes and the soft tissues are brought hack 
into position. (Fig. 200.) The superfluous parts of mucous membrane 
are trimmed until the edges approximate, fitting snugly over the newly- 
formed alveolar ridge. These are sutured with horsehair or silk either 
by the interrupted or the continuous method. 
Acquired Conditions 
Inviting Operation. 
Technique for 
Alveolectomy. 278 
ORAL SURGERY 
The palatal mucous membrane is quite thick and, as a rule, unyielding; 
if in the approximation, the buccal flap has to be brought over considerably 
towards the palate this produces a slanting surface. The inclined plane 
which thus results makes the retention of a prosthetic appliance very 
difficult. This condition can be overcome by nicking the palatal mucous 
membrane on the surface next to the bone. Care must be taken that the 
edges of the mucous membrane flaps are so approximated that the pared 
edges are brought into direct apposition without undue pressure or trac- 
tion, so that they meet at the center of the ridge with no overlapping. 
(Fig. 201.) 
In the absence of infection or sloughing, these conditions heal by 
primary union and the sutures may be removed in four or five days. The 
postoperative treatment consists of thorough irrigation with a mild anti- 
septic and deodorizing solution, such as boric acid or normal saline, and 
the maintenance of cleanliness of the oral cavity. The application of 
irritants or escharotics to the wound edges is superfluous. CHAPTER XVIII. 
Impacted Teeth. 
Teeth which, in the aggregate, are designated as “impacted teeth,” can 
more properly be classified under three general headings: (i) impacted 
teeth; (2) malposed teeth; (3) unerupted teeth. 
Impacted teeth are those which, through an im- 
pediment in their eruption, fail to occupy their in- 
tended position in the alveolus and in the arch. Such impediment may 
lodge in some environmental obstacle, or in abnormal development and 
faulty eruption inherent in the impacted tooth itself. (Fig. 202.) 
Malposed teeth are those which, in the absence 
of an apparent obstacle, through some obscure 
ontogenetic abnormality in the individual, or an abnormality in the devel- 
opment of these teeth, assume a faulty position in the alveolus and in the 
arch. (Figs. 203, 204, 205 and 206.) 
Fig. 203 shows a malposed cuspid (commonly called impacted). 
Fig. 204 shows two malposed (impacted) cuspids and a second bicuspid 
in a young woman 25 years of age. Note the retained deciduous cuspids 
and the ample space which these teeth should have occupied. They could 
scarcely be called impacted in the true sense of the term. 
Fig. 205.—Complete and normal formation of upper and lower third 
molars in a young woman 21 years of age. The teeth are malposed and 
unerupted, though there does not seem to be outer cause to prevent their 
eruption. All of the other teeth were normal in their formation and are 
normally occluding. 
Fig. 206.—Malposed unerupted third molar in man 24 years of age. 
The tooth is not impacted, is fully formed and has sufficient space in the 
jaw. 
Unerupted teeth are those which are partly or 
fully formed, normally developed and normally 
placed, and, though there is no apparent environmental obstacle, they fail 
to advance through the mucosa and into occlusion. (Fig. 207 and 208.) 
Fig. 207.—Two unerupted third molars in a man 22 years of age. 
There was no discernible abnormality about his jaws or teeth to account 
Impacted Teeth. 
Malposed Teeth. 
Unerupted Teeth. 
279 280 
ORAL SURGERY 
Fig. 202. Impacted lower molars. 
Fig. 203. Malposed cuspid; commonly called impacted. 
Fig. 204. Malposed cuspids and second bicuspid in one mouth. IMPACTED TEETH 
281 
Fig. 205. Malposed, unerupted upper and lower third molars. No reason for 
non-eruption is evident. 
Fig. 206. Malposed, unerupted lower molar. Similar to Fig. 205. 
Figs. 207 and 208. Unerupted third molars. No cause apparent. ORAL SURGERY 
282 
for the condition. The lower one is not completely formed and is slightly 
impacted. 
Fig. 208.—Unerupted tooth in a woman 52 years of age. Some of the 
teeth in this case were missing, hut those present were in normal occlu- 
Fig. 209. Early stage of calcification of third molar; normal position. 
Fig. 210. Early stage of calcification of third molar; slightly crowded. 
sion. The third molar illustrated here can scarcely be called impacted. 
It is normally formed and in normal position. The occlusal surface was 
covered merely by the mucoperiosteum. 
These distinctions are helpful in the study of the nature and causes of 
impactions, but they are of small significance so far as symptomatology IMPACTED TEETH 
283 
and treatment are concerned. We shall, therefore, in this chapter designate 
all conditions described above merely as impaction. 
Fig. 211. Later stage of calcification of third molar; normal. 
Fig. 212. Similar to Fig. 211, But with mesiobuccal inclination. 
It is to be understood that almost any combination of these conditions 
may exist; for example: a tooth may be malposed and impacted; it may be 284 
ORAL SURGERY 
malposed, impacted, and unerupted; it may be impacted and unerupted; 
and other combinations may occur. 
Fig. 213. Early evidence of impaction of third molar. 
Fig. 214. Early evidence of impaction of third molar. Also malposition of bicuspid. 
Different theories have been advanced to ex- 
plain the abnormality of the impaction of teeth and 
their anomalies. AH of these, however, seem inade- 
quate to explain the varied conditions met and often 
fail to render more comprehensible our clinical findings. 
The most frequently advanced causes for impaction may be classified 
into local and general. 
The local causes are: (i) irregularity in the 
position and pressure of an adjacent tooth; (2) the 
density of the overlying or surrounding bone; 
(3) inflammation and density of the overlying mucous membrane; (4) 
Etiology of 
Impaction 
of Teeth. 
Local Causes 
of Impaction. IMPACTED TEETH 
285 
lack of space due to under-developed condition of jaws; (5) unduly long 
retention of the temporary teeth; (6) premature loss of the temporary 
Fig. 215. Early evidence of malposition of third molar. 
Fig. 216. Early evidence of malposition of third molar. 
teeth; (7) acquired diseases, such as necrosis due to infection or abscesses; 
(8) inflammatory changes in the bone due to exanthematous diseases in 
children. 286 
ORAL SURGERY 
We find, however, numerous impactions where none of these condi- 
tions appear to exist. While environmental influences may operate in a 
great measure in the causation of impactions, upon close study of the sub- 
Fig. 217. The case of a young man 26 years of age who had an impacted third 
molar removed, and its mesial root end was forced into the inferior dental canal. 
Fig. 218. Impacted lower third molar in a young woman 27 years of age. In the 
removal of this tooth the second molar must be undermined, or probably injured. 
Also, because of its deep-seated position, the bone would have to be greatly 
weakened if removal were attempted from the side, or from underneath. 
Fig. 219. Illustrates cases in which the second molars should be removed because 
of disease. 
ject we are forcibly impressed with the fact that there are other etiologic 
factors which must have an ontogenetic significance. 
In radiographing a number of young children between the ages of 6 
and 12, I observed that the lower third molars, which are the most fre- 
quently impacted, show rather early signs of a tendency to malposition. 
Radiographs show that, prior to calcification, there is variation in the posi- IMPACTED TEETH 
287 
tion of the dental follicles. Some are situated quite deep in the bone, 
while others, in children of the same age, are close to, or in contact with 
the mucoperiosteum. A variation in the two sides of the same child may 
also be observed. Again, where calcification of the cusps has just begun, 
even at this early stage, they show signs of a tendency towards malposi- 
tion. Some have their occlusal surfaces pointing upwards, some buccally 
Fig. 220. Impacted cuspid in which the removal of the first bicuspid is indicated 
because of disease. 
Fig. 221. Absorption of distal root of second molar in a man 29 years of age. 
Both teeth were necessarily removed. 
or lingually; others face directly towards the tboth in front of them or 
backward towards the ramus. These early manifestations may not be 
absolutely convincing, but they strongly suggest that the causes of impac- 
tion are more complex than we have suspected and that they must be 
sought in another direction. The subject would ofifer a very interesting 
field of research for men, particularly orthodontists, whose relations with 
children permit observation through a series of years, during the ages of 
the formation and eruption of the teeth until the period when this is com- 
pleted. See series of radiographs, Figs. 209 to 216, inclusive. 
Fig. 209.—Radiograph of a child about 8 or 9 years of age. Note the 
early stage of calcification of the cusps of the third molars and their posi- 
tion. This most likely will erupt normally. 
Fig. 210.—Radiograph of a child about 8 or 9 years of age. Note the 
similar degree of calcification of the third molar. There seems to be a 
slight crowding and a mesiobuccal inclination of the cusps. 
Fig. 211.—Radiograph of a child about 8 or 9 years of age. A some- 
what more advanced calcification of the tooth more deeply lodged in the 
bone. A normal eruption may be expected. Fig. 222. Impacted lower third molars having mesial inclination. 
288 Fig. 223. Impacted lower molars in upright position. 
289 290 
ORAL SURGERY 
Fig. 212.—About the same degree of calcification in a child about 8 
or 9 years of age. There is no impaction, but the tooth is covered with 
quite a thick layer of bone and has a slight mesiobuccal inclination. 
Fig. 213.—A somewhat more advanced calcification in a child of 9 or 
10. Note the fairly normal position of the cusps of the third molar, yet 
a tendency towards impaction. 
Fig. 214.—Radiograph of a boy about 10 years of age. Note the de- 
cided tendency toward malposition of the third molar; also torsion and 
malposition of the second bicuspid. 
Fig. 215.—Radiograph of a child about 11 years of age. There is no 
lack of space nor crowding of these teeth, all of which have erupted, but 
the third molar shows decided tendency towards malposition. 
Fig. 216.—Shows decided signs of impaction of the third molar and 
malposition (torsion) of the second bicuspid. 
The systemic causes of impaction may be pre- 
natal or postnatal. The prenatal causes are hered- 
ity, miscegenation, syphilis and tuberculosis, mal- 
nutrition, debilitating modes of living or diseases in the parent which may 
influence the development of the offspring. 
Postnatal influences, are all conditions which may interfere with the 
development of the child, such as malnutrition, rickets, anemia, heredi- 
tary syphilis, tuberculosis and the exanthematous diseases: diseases of 
the jaws and the surrounding tissues; the lack of space in under-developed, 
jaws. The impactions which might be attributed to the exanthemata can 
he explained by the generalized bony changes that occur. If an inflam- 
matory condensation osteitis should happen to localize in the jaw it is 
readily seen that impaction may result. 
Any tooth in the human mouth may be impacted in the terms of 
the above classification and examples of all are observed from time 
to time. Though I am unable to give accurate statistics, I shall venture 
to proffer my impressions as to the frequency of impaction of the vari- 
ous teeth. 
The most frequently impacted teeth are: (1) The lower third molars; 
(2) the upper third molars; (3) upper cuspids; (4) lower cuspids; (5) 
upper bicuspids; (6) lower bicuspids; (7) upper lateral incisors; and (8) 
upper centrals. I he upper and lower first and second molars are very 
rarely impacted. 
I he complications arising from impacted teeth 
may he classed under two general headings. First, 
conditions accompanied by palpable inflammatory reactions and tissue 
changes; second, neuralgias and neuroses, which may be reflected not only 
Systemic Causes 
of Impaction. 
Complications. IMPACTED TEETH 
291 
to the areas of distribution of the nerve involved and through the associ- 
ated nerve plexuses, but even to remote regions. 
The inflammatory conditions caused by impacted teeth may be acute 
or chronic. These are often accompanied by tissue deterioration or de- 
struction. The most common complications of the inflammatory type are: 
acute or chronic alveolar abscess; chronic suppurative osteitis; osteomy- 
Fig. 224. Impacted lower third molars having distal inclination. 
elitis; necrosis; cysts; pathologic absorption of the adjacent teeth. The 
tissue destruction in the above enumerated conditions may be slight, or 
so extensive that important structures in their region, as the maxillary 
sinus, the inferior dental canal, or the nasal cavities are infringed upon or 
actually invaded. 
In the second class are those in which the syndromes manifest as 
purely nervous disturbances, with no palpable inflammatory symptoms. 
The pain in these cases may be slight, or very severe and often excrucia- 
ting. This may be intermittent, periodical or constant. It may be local- 
ized, but is quite often reflected through the distribution of both dental 
branches of the trifacial nerve. 292 
ORAL SURGERY 
The citation of the following case in point will 
illustrate the complex neuralgic conditions which 
may arise as a result of impacted teeth. 
Miss C. M., 22 years of age; American; no 
occupation. Family history, physical examinations and laboratory tests 
negative. At the age of fourteen she developed neuralgic pains on both 
sides of her head. The pain was more severe on the right side and was 
referred to the ear and the mastoid region. Upon examination the ear 
was found to be normal and, except for the subjective symptoms, there was 
nothing to suggest mastoiditis. The right mastoid was opened and in the 
operation was found to he normal. This operation was performed at the 
age of sixteen, two years after the onset of the complaint. There was a 
mild but not complete remission following this, the pain being less intense 
and the aggravated attacks less frequent. At the age of about eighteen 
the pains became more intense and the patient commenced to suffer from 
severe headaches, spells of dizziness, and impaired vision. The exam- 
ination of the eyes proved negative, but glasses were prescribed. These 
did not seem to help the condition very much. At the age of twenty the 
left mastoid was opened and this was also found to be normal. This also 
failed to relieve the patient and she was treated with various sedatives 
and anodynes. 
In November, 1915, when the writer first saw the patient she was suf- 
fering with intense pain on both sides of the head. The pain was reflected 
to the ears, the temporal, the parietal, the occipital and the cervical regions. 
She was also suffering with intense, uncontrollable headaches, spells of 
vertigo, and blurred vision. She could not concentrate on anything, and 
was unable to turn her head, very much like those suffering from wry neck. 
Upon radiographic examination of the head and teeth three impacted third 
molars and two supernumerary teeth were found; two upper third molars 
and a supernumerary tooth on each side in this region and one lower right 
third molar, completely buried in the bone. The upper third molar on 
the left side was imbedded between the roots of the second molar and lay 
transversely in the maxilla with the roots pointing toward the palate and 
the crown buccally. As the muscles of the neck seemed more affected on 
the left side, the impacted third molar, the second molar and also the super- 
numerary tooth were removed. The almost immediate relief following 
this operation was truly remarkable. The pain seemed to have entirely 
abated on this side and within forty-eight hours, except the expected post- 
operative soreness at the site of operation, the patient was practically free 
from pain and could turn her head with perfect freedom. The other im- 
pacted teeth were subsequently removed and within three months she was 
Neuralgic 
Reflexes from 
Impacted Teeth. IMPACTED TEETH 
293 
entirely free from all complaints. There was at no time any inflammatory 
condition nor symptom in any one of these regions. 
The mechanism of these neuralgic phenomena is obscure. It is prob- 
able that, owing to its incorrect position, the nerve supply of the tooth 
proper is irritated; there may be pressure upon a nerve trunk in the area 
near the tooth; or the circumferential pressure in the hone surrounding 
the impacted tooth may cause the pain. 
Cases of insanity, blindness, tinnitis aurium, trifacial neuralgia, 
otitis and afifections of the eyes have been traced to impacted teeth. On 
the other hand, we see many cases which, even at the ages of 40, 50 or 60, 
have given no trouble whatever. Still this number is comparatively small, 
and, as the earliest disturbing manifestations are very often pathological 
conditions of the immediately surrounding tissues, or neuralgias, which, in 
their aggravated form, are difficult to correct, their early removal is indi- 
cated. Also, many severe cases of trifacial neuralgia could be traced to 
impacted teeth as their source of origin. 
Impacted teeth are often regarded and often re- 
ferred to as being harmless. Clinical experience, 
however, shows that they are not uncommonly the sources of serious 
and varied complications. It is my opinion that impacted teeth must be 
looked upon as misplaced bodies, and as such they are potential sources 
of trouble. Experience and many reports derived from different observers 
confirm the conclusion that they are best removed upon the slightest prov- 
ocation and often even in the absence of disturbing symptoms. When an 
impacted tooth is outside the possibility of usefulness, or when, in our 
judgment, it is likely to give trouble, it is best removed. 
T reatment. 
General Operative Principles in the Removal of Impacted Teeth. 
The primary principle underlying the removal of impacted teeth in 
general, may be stated as follows: We have an irregularly shaped solid 
body—the tooth—enclosed in an unyielding covering—the bone. In order 
that we may be able to remove the one, we must remove a sufficient amount 
of the enveloping substance to create an aperture which will permit of 
the dislodgment of the enclosed body. This procedure must be carried 
out on the plan of surgical dissection, rather than by brute force, which 
is often exercised in the removal of these teeth. Rapidity, consistent with 
clean surgery, is always desirable; but speed at the expense of good 
surgery is not conducive to best results. 
The accidents which sometimes follow the careless removal of these 
teeth are: fracture of the jaw; exposure of the inferior dental canal; 294 
ORAL SURGERY 
over-severe and often distressing trismus; fracturing of the roots and 
forcing these into the inferior dental canal (Fig. 217) ; traumatization or 
dislodgment of the adjacent teeth; opening into the maxillary sinus or 
forcing the tooth into this cavity; opening into the nasal cavity when cut- 
ting either from the palatal or the facial aspect; severing the lingual 
Fig, 225. Impacted lower third molar in the ramus, near and pointing towards the 
sigmoid notch. Patient aged 31. 
nerve; severing or injuring the nerve and blood supply of the adjacent 
teeth. 
The history of the case illustrated in Fig. 217 is interesting. The pa- 
tient was a man 26 years of age, who had an impacted third molar re- 
moved. Unfortunately, during the procedure, the end of the mesial root 
was broken off and forced into the inferior dental canal. There was a 
partial anesthesia for a few weeks, most likely caused by the trauma to 
the inferior dental nerve. Recovering from this, severe neuralgic pain 
developed. Later inflammation and suppuration ensued. Radiograph 
showed the root forced into the inferior dental canal. Upon the removal 
of this, all symptoms soon ceased. 
Before describing the technique in detail, we may state that the opera- 
tion should be so planned and performed that no structures, nor organs IMPACTED TEETH 
295 
which have a functional value, are mutilated or sacrificed. Some men 
advocate the removal of a good second molar tooth to facilitate the dis- 
lodgment of an impacted third molar. Others advocate the removal of 
the second molar, with the illusory prospect that the third molar will 
then be able to erupt and will occupy the position of the extracted tooth. 
Except in rare cases, where a tooth, through disease, is so impaired that its 
removal is indicated, or its relative position is such that the removal of the 
impacted tooth necessarily entails its mutilation, such a procedure is not 
to be contemplated, nor countenanced. (Figs. 218, 219, 220 and 221.) 
From the preceding considerations the deduction may be made that the 
broader principles of surgical treatment as outlined, may well be observed 
in the majority of cases. However, a degree of variation will become 
requisite to meet the needs of individual conditions. These minor details 
are entirely dependent upon the exact nature of the impaction, or 
malposition. 
From this standpoint, we may classify impacted lower third molars 
into four general groups. 
1. In the first group we may place all of those teeth which have a 
mesial inclination, the occlusal surface of the crown pointing anteriorly, 
and the roots towards the ramus. Among these, there are numerous cases 
of what might be considered semi-impacted teeth, their crowns being 
completely above the surface of the bone and only in slight contact with 
the teeth in front of them. These often can be removed, in a fraction of 
a minute, with a single turn of a well applied lever. 
The mesial inclination may vary in degree and in some cases the tooth 
may be found lying in a completely horizontal position. There is also 
variation in the degree of impaction against the adjacent tooth. The area 
of contact may be very slight, or the entire occlusal surface of the crown 
may be in direct apposition with the adjacent tooth, at any point, from the 
crown down to the apical region. The overlying bone may also partly, 
or completely cover the impacted tooth and may vary in thickness. A 
number of these positions are shown in Fig. 222. 
2. In the second group we may include all impacted third molars 
which are in an upright position, their occlusal surfaces facing centrally, 
lingually or buceally. The occlusal surface of such a tooth, us a rule, is 
covered by the mucoperiosteum alone, but the rest of the crown may be 
nearly, or completely buried in the compact bone of this locality. There 
is little if any impaction against the adjacent tooth and the chief diffi- 
culty in its removal is due to the compact and heavy internal and external 
oblique ridges in which the bulky crown is found to be lodged. Examples 
of teeth in this position are shown in Fig. 223. 296 
ORAL SURGERY 
3. In the third group we may place those impacted third molars, the 
crowns of which are pointed towards, or which are, in varied degrees, 
impacted into the ramus. They also may be located centrally, buccally or 
lingually. A few examples are shown in Fig. 224. 
4. In the fourth group we may place those impacted third molars 
which are situated entirely out of relation with their true or normal loca- 
tion. These may be in almost any position and may be located in any 
part of the ramus, or the posterior part of the body of the mandible. 
The radiograph of a rare example of this kind (Fig. 225) I have obtained 
Fig. 226. Radiograph of type of third molar, the removal of which will be illus- 
trated in the following drawings. 
through the courtesy of Dr. R. Ottolengui, who m turn received it from 
Dr. C. S. Kramer, the resident dentist of the Modern Woodmen Sana- 
torium for Tuberculosis, in Colorado. 
Dr. Kramer writes as follows, in regard to this case: “There was no 
local nor referred pain from this tooth. It was not operated upon. The 
patient was unaware that he had it, but, it is our custom when teeth are 
missing and there is no history of extraction, to radiograph the region. 
The patient was 31 years of age.” 
The simplest complication arising from impacted 
ower third molars is inflammation of the overlying 
nucous membrane, caused either by the pressure 
md irritation of the opposing tooth from above, or 
Complications from 
Impacted Lower 
Third Molars. IMPACTED TEETH 
297 
the cusps of the impacted tooth from underneath. The mucous mem- 
brane becomes highly inflamed, greatly swollen, tender to the touch, and 
rather painful. From the tooth region the inflammation often extends to 
the pharyngeal tissues and interferes with deglutition. At the early stages 
we may or may not have a trismus of the jaws. When the tooth is so 
placed that its retention is possible or indicated, the overlying gum tissue 
can be dissected away until the entire crown of the tooth is well exposed. 
The edges of the severed tissues are packed tightly away from the tooth, 
so that their approximation and growing in over the tooth again is pre- 
vented. Where this measure is not feasible, the tooth should be removed, 
the overlying mucous membrane freely incised, and the wound dressed 
with iodoform gauze. 
A pocket often forms between the crown of the 
tooth and the overlying mucoperiosteum which, 
upon continued irritation, becomes infected through 
the microorganisms of the mouth. With infection, suppuration ensues 
and a pericoronal abscess is established. This may be acute or may pass 
into a subacute stage with periodical acute exacerbations, the pus escaping 
about the edges of the pocket. At this stage the condition is still amenable 
to the above described abscess treatment. 
When suppuration ensues, the pus does not always remain localized 
and may burrow into the submaxillary triangle. This often results in 
severe abscess, diffuse cellulitis, involving the entire angle of the jaw and 
the submaxillary regions; or it may point towards the pharynx, causing a 
peritonsilar abscess. At times, both regions become involved. When this 
occurs there is a partial or complete false ankylosis of the jaws, accom- 
panied by all the symptoms of an acute infection. 
There are two methods usually pursued in the 
treatment of this last described condition: In the 
first a general anesthetic is administered; drainage is secured by an intra- 
or extra-oral incision, according to the indications of the case; the mouth 
is pried open by means of a gag and the tooth is removed. This should 
be the method of choice, and whenever conditions permit, the tooth is 
removed in the same operation. In the second method, drainage is se- 
cured intra- or extra-orally, and when the inflammatory symptoms have 
subsided or abated, the tooth is removed under general or local anesthesia. 
This is particularly advantageous when the impaction is of such nature that 
a ccnsiderable portion of bone must be removed. In the presence of active 
suppuration it is not advisable to open up non-infected larger areas of 
bone, through which absorption or dissemination of the toxic substances 
may take place. 
Pericoronal 
Abscess. 
Treatment. 298 
ORAL SURGERY 
The mode of treatment of these cases is largely determined by the 
condition of the patient, by our facilities for anesthesia and for operation, 
and the nature of the impaction. 
In the presence of infection, especially when this is not accompanied 
Fig. 227. The line of incision of the mucoperiosteum for the removal of an im- 
pacted lower third molar. 
by pharyngeal complications, nitrous oxid and oxygen anesthesia is quite 
satisfactory, provided that the operation is not to be a prolonged one. 
When the tooth is so impacted that about fifteen minutes or more time will 
be required for its removal, ether should be used. When the trismus is 
severe and a general anesthetic is not available or feasible, extra-oral con- 
duction anesthesia may be used to advantage. Care must he taken, how- 
ever, that the injecting needle is not passed into infected tissues, or into an 
area where pus is present. 
Technique for the Removal of Impacted Lower Third Molars. 
Some lower third molars which appear to be impacted can easily be 
removed in a very short time. This may vary from a fraction of a minute IMPACTED TEETH 
299 
to a few minutes. Often these teeth are quite loose in their sockets 
in the presence of a severe inflammation. Truly impacted lower third 
molars, however, may consume from fifteen minutes to an hour, or even 
more time. 
Fig. 228. The mucoperiosteum raised and reflected. The bone and portion of the 
crown exposed. 
Prior to undertaking the removal of an impacted tooth, a thorough 
radiographic study of the case should he made. A radiographic exam- 
ination should determine not merely the presence of the impacted tooth, 
but also its location, the full size of the tooth, its form, and relationship to 
the adjacent structures. The degree of impaction, the amount of the 
overlying bone and the closeness of the adjacent tooth and inferior dental 
canal should be particularly noted. (Fig. 226.) 
The mucoperiosteum is incised; the incision commencing at the ante- 
rior border of the ascending ramus is brought forward along the median 
line, slightly nearer to the lingual aspect, until the alveolar ridge on the 300 
ORAL SURGERY 
distal aspect of the second molar is reached. Here the course of the in- 
cision is deflected towards the buccal side and brought forward well below 
the gingival margin of the second molar, to about the point of bifurcation 
of the second molar roots. This gives us practically a straight incision 
Fig. 229. Diagram showing the amount of bone removed posteriorly. 
instead of a pedicled flap. (Fig. 227.) The mucous membrane is raised 
from the bone towards the buccal surface, and when it is retracted, the 
field of operation is thoroughly and clearly exposed to view. (Fig. 228.) 
The bone overlying the tooth in the retromolar fossa, between the in- 
ternal and external oblique ridges, is, as a rule, spongy and easily removed. 
Greater difficulty is offered, however, by the compact external oblique 
ridge. With gouges and chisels or burs, a sufficient amount of the bone IMPACTED TEETH 
301 
is removed, to well expose the bulkiest part of the crown, and a con- 
siderable portion, about two-thirds, of the root of the tooth. When the 
tooth is not very deeply imbedded, it is well to cut a fairly deep groove 
alongside the tooth, with surgical burs, or suitable chisels. An elevator, 
Fig. 230. The bone overlying the tooth is removed with its crown clearly relieved. 
inserted into such a groove, which permits of a thorough and free leverage, 
will prove effective for the dislodgment of the tooth. Where the tooth 
is quite deeply imbedded in the compact bone, it is advisable to remove 
immediately, such portions of the bone as impede its removal. (Figs. 229 
and 230.) The amount of osseous tissue to be removed depends upon the 
size, the formation and the degree of impaction of the tooth. Temporizing 
and vain attempts to remove it through too small an aperture, only lead to 
undue traumatization and unnecessary delay. It is much more desirable to 
remove a section of bone, large enough to permit of the ready removal of 
the tooth, than to incur the danger of the accidents previously enumerated. 
(Fig. 231.) 302 
ORAL SURGERY 
The tooth removed, the entire cavity is sponged out and closely in- 
spected. Seek out all detached, or broken off fragments of bone. Note 
whether the bone which forms the roof of the inferior dental canal is 
displaced, depressed or fractured. Smooth the edges of the tooth socket 
Fig. 231. The tooth is lifted from its crypt by means of elevator. 
and the ragged bone surface by means of curettes; dust the entire cavity 
with an anesthetic powder, such as powdered procaine, orthoform, or 
novesthene, and dress the wound with iodoform gauze. 
If the above described incision is cleanly executed, no suturing will be 
necessary. The elasticity of the tissues themselves, aided by the pressure 
of the check, will hold the severed tissues in the proper position. IMPACTED TEETH 
303 
Where extensive bone cutting is necessary, a 
surgical bur, driven by a dental engine is of great 
practical value. Bone in these regions can be re- 
moved with a bur more rapidly, with less traumatization of the tissues 
and with less psychic trauma than with chisel and mallet. Though the 
use of the surgical bur is viewed with a certain amount of distrust 
and disdain by some operators, it is used by many, more advan- 
tageously than other bone cutting instruments. Those opposed to the 
Use of Burs. 
Fig. 232. Types of impacted upper third molars. 
use of the bur, in this work, maintain that it is a dangerous 
instrument and if not thoroughly controlled, the adjacent tissues may be 
injured. But this is true of any instrument not properly used. They 
also claim that owing to the overheating of the bone, caused by the fric- 
tion of the rapidly revolving bur, necrosis may follow, or, in milder in- 
stances, the postoperative pain may be more severe than where chisel and 
mallet are used. During these operations, however, the parts are con- 
stantly flooded with blood and saliva, whereby the bur is lubricated, so 
that overheating is not likely to occur. At any rate, clinical experience 
proves that these contentions are ill founded. 304 
ORAL SURGERY 
Drawing our analogies from other departments of bone surgery, we 
find that electrically propelled saws, trephines and drills are used for the 
removal, sectioning and shaping of bone. This is often done in operations 
of bone transplantation, in which particular care must be exercised not 
to undermine, nor impair the viability of the transplant. If the use of these 
instruments were grievously detrimental to the bone cells, this practice 
would be abandoned. In the choice of instruments we must be guided, 
however, also by experience and individual proclivities; only then can the 
operation be performed with celerity and simplicity. 
In the great majority of cases, it is better to approach an impacted 
lower third molar rather from the buccal than from the lingual aspect. 
Lacerations of the tissues on the lingual aspect often lead to troublesome 
inflammation of the pillars of the fauces and false ankylosis of the jaws. 
In some instances, sublingual infections occur. If the wound is too 
deeply extended towards the floor of the mouth, either through laceration, 
or through the necessary surgical procedure, the lingual nerve may be 
severed. The buccal aspect, on the other hand, is free from actively func- 
tioning tissues, and such complications are not likely to occur, although 
swellings and trismus of the jaws are not uncommon, even when this pro- 
cedure is followed. 
Impacted Upper Third Molars. 
Impacted upper third molars are rarely as troublesome as the lower 
ones. The symptoms here are more often of the neuralgic than of the 
inflammatory type. Cystic degenerations occur in a small percentage of 
cases. Acute inflammatory conditions and abscess formations are com- 
paratively rare. 
Their position may be an inclination of varied degrees mesially or 
distally, transverse, or they may point toward the palate, or posteriorly 
towards the tuberosity. (Fig. 232.) The chief danger in their removal 
is the possibility of their being forced into the maxillary sinus. Cases 
have been recorded where the tooth was forced into the sphenomaxillary 
fossa, causing serious complications and external incisions became neces- 
sary for its removal. 
The removal of impacted upper third molars can be accomplished much 
more easily than that of any other impacted tooth. The main difficulty 
lies in their inaccessibility. They are usually surrounded by very frail, 
thin bone, which yields readily to the force necessary for the dislodg- 
ment of the tooth. IMPACTED TEETH 
305 
Fig. 233. A typical case of impacted upper third molar, the removal of which is 
illustrated in the succeeding drawings. 
Fig. 234. Incision of the mucoperiosteum for the removal of an impacted upper 
third molar. 
Fig. 235. Lateral view of the incision shown in Fig. 234 and diagrammatic outline 
of the impacted tooth. 306 
ORAL SURGERY 
Fig. 236. Occlusal view of the mucoperiosteum pushed back over a shallow 
tuberosity. 
Fig. 237. Lateral view of the mucoperiosteum raised and pushed back over the 
tuberosity. 
Figs. 238 and 239. Triangular flaps formed by vertical incision, where the tuberosity 
is prominent. IMPACTED TEETH 
307 
Technique for Removal of Impacted Upper Third Molars. 
Let us suppose that we are operating on a case such as is shown in 
Fig. 233. The incision of the mucoperiosteum is carried on the lingual 
Fig. 240. Occlusal view of the tooth exposed, after the bone has been removed 
from about the crown. 
Fig. 241. Lateral view showing the crown exposed and ready for dislodgment. 
aspect, from a point somewhat anterior to where the apex of the normally 
erupted tooth would be, across the alveolar ridge, behind the second molar, 
to the corresponding point on the buccal aspect. (Figs. 234 and 235.) 
Where the tuberosity is shallow, the mucoperiosteum can be pushed back 308 
ORAL SURGERY 
next and the area exposed. (Figs. 236 and 237.) If the tuberosity is 
prominent, a second incision over the center of the alveolar ridge, per- 
pendicular to the first, is carried backwards, behind the tuberosity, thus 
making two triangular flaps. (Figs. 238 and 239.) 
The mucopericsteum having been raised, the occlusal surface of the 
Fig. 242. Impacted cuspids in buccolingual relation to the adjacent teeth. 
tooth is partly, or fully free from bony covering, and becomes exposed to 
view, in most instances. The mucoperiosteum is separated next, well 
over the crown of the tooth and the bone removed until the entire crown 
is well exposed. (Figs. 240 and 241.) We can now grasp the tooth with a 
pair of forceps and with a few loosening motions, lingually and buccally 
and somewhat posteriorly, the tooth can be dislodged. 
Where the grasp upon the tooth is uncertain the direction of the force 
should never be upward. Often an elevator can be used for the removal 
of an upper third molar. By inserting its blade on the mesial aspect 
of the impacted tooth it is forced backward and downward. Where the 
radiograph shows that the roots of the tooth are irregularly formed and 
their apices are close to, or indenting the maxillary sinus, the tooth should 
be slowly loosened in its socket so that the portion of bone forming the 
maxillary sinus wall is not carried away. The tooth removed, all bone IMPACTED TEETH 
309 
spicules or fractured and detached portions of the alveolus are removed, 
the hone edges are smoothed and the cavity dusted with one of the anes- 
Fig. 243. 
Fig- 244. 
Fig. 245. 
Fig. 246. 
Fig. 243. Impacted cuspid in buccal relation to adjacent teeth. This can best be 
removed from the labial aspect, as will be shown in succeeding drawings. 
Fig. 244. Impacted cuspid lodged over the incisors and bicuspid teeth and approxi- 
mating the median line, the nasal cavity and the maxillary sinus. 
Fig. 245. Impacted cuspid, same tooth as seen in Fig. 246, but the radiograph is 
taken vertically through the skull. 
Fig. 246. Impacted cuspid. Radiograph taken in a buccolingual plane. 
thetic powders. The mucoperiosteal flaps are approximated and sutured 
into position and the wound is dressed with iodoform gauze. 310 
ORAL SURGERY 
Impacted Cuspids. 
From a surgical standpoint impacted cuspids may be placed in three 
classes. This classification is based upon their anatomical relationship 
to the other teeth. First, those that are in buccolingual relationship to 
Fig. 247. Impacted cuspid which should be removed from the palatal aspect as is 
shown in the immediately succeeding illustrations. 
the adjacent teeth, the crown pointing lingually while the root points 
buccally (Fig. 242). Fig. 242-A shows bilateral impaction of upper cus- 
pids in young woman 21 years of age. Note the retained temporary cuspids 
and the displacement of the lateral incisors. The cuspids are lodged lin- 
gually of the adjacent teeth and should he removed from the palatal aspect. 
Fig. 242-B shows bilateral impacted cuspid teeth in woman 45 years of 
age. The fixed bridge had been worn for about twelve years when the 
radiograph was taken. The relationship of these teeth is very much like 
those in Fig. 242-A. Their position rather suggests that impacted teeth, 
when fully formed, do not migrate, even though the environmental 
obstacle has been removed, unless aided by orthodontic means, which 
is feasible in many instances. Second, those that are placed in buccal IMPACTED TEETH 
311 
relationship to the adjacent teeth. (Fig. 243.) Third, those which are 
placed directly over the adjacent teeth. (Fig. 244.) Besides this their 
position may vary from a slight anteroposterior inclination, to an almost 
horizontal one. 
Fig. 248. The line of the incision for the removal of the impacted cuspid from the 
palatal aspect. 
Before operative measures for the removal of an impacted cuspid tooth 
are undertaken, it should be closely studied and its position ascertained. 
A radiograph taken in a buccolingual plane will show the size, the forma- 
tion and the anteroposterior relationship of the tooth. (Fig. 245.) A 
second radiograph is taken vertically through the skull, from above down- 
ward, the rays being directed parallel, or nearly so, with the long axis of 
the teeth. This will show the buccolingual relationship of the tooth. 
(Fig. 246.) 
In the examination of the mouth, we often find that a slight elevation 
may be present, in the outline of the tissues overlying the crown of the 
impacted cuspid. The lateral incisor is often malposed through the pres- 
sure of the impacted cuspid and the nature of this malposition is deter- 
mined by the direction of the pressure of the impacted tooth. 312 
ORAL SURGERY 
Fig. 249. The mucoperiosteum raised and the bone exposed. Note the elevation of 
the bone over the crown and the application of the chisel. 
After a close clinical and radiographic study and orientation we are 
prepared to determine whether our avenue of approach is to be from the 
labial, or from the palatal aspect. 
When the impacted cuspid is pointing towards the palate, its crown is 
usually lodged just behind the lateral and central incisors, close to the 
gingival ridge and the incisal foramen. This proximity varies in different 
cases. The root points in the direction of the root apices of the adjacent 
bicuspid teeth, that is, towards the buccal aspect and is, in most instances, 
deeply imbedded in the maxillary bone. The crown is covered 
with a very thin layer of bone, which may be perforated at points, and 
the thickness of the osseous tissue increases as we approach the 
apex. The removal of this type of impacted cuspid teeth is probably 
more difficult than that of any other, from a technical standpoint, when our 
aim is that in the operation the integrity of the adjacent teeth be not en- 
croached upon. It should be remembered that while the impacted tooth IMPACTED TEETH 
313 
Fig. 250. The crown of the tooth exposed and the bone incised on both sides of 
the root alongside its broadest diameter. 
is thoroughly inclosed in an individual crypt, there is hut a very thin 
lamina of bone separating it from the neighboring teeth. The utmost 
care must be exercised that our surgical excursions do not pass these bony 
limitations. 
Technique for the Removal of Impacted Cuspids. 
Let us suppose that we are operating on a case, such as is shown in 
Fig. 247. The mucoperiosteum is incised and raised as illustrated in Figs. 
248 and 249. Note that the incision is carried somewhat beyond the 
gingival ridge and curved back along the median line. This form of 
incision permits a clearer view of the crown of the tooth, which is very 
important; also, in this way, the subsequent suture line will be supported 
upon an uninvaded surface of the bone. When the flap is raised the 
position of the crown of the tooth is marked by an elevation or ridge of 
the overlying bone. With gouges or chisels, this fine layer of bone, cover- 314 
ORAL SURGERY 
1'iG. 251. The bone overlying the tooth removed in smaller sections with the gouge. 
tiG. 252. The crown of the tooth and about two-thirds of the root exposed. IMPACTED TEETH 
315 
Fig. 253. The application of the elevator and the tooth being dislodged. 
Fig. 254. The mucoperiosteum replaced and sutured into position. 316 
ORAL SURGERY 
Fig. 255. Incision of the mucoperiosteum for the removal of impacted cuspid from 
the labial aspect. 
ing the crown of the tooth is removed, and the crown clearly freed from 
all overhanging bone tissue. It is essential that all bone which may impede 
the dislodgment of the crown should he removed, as this is the bulkiest 
portion of the tooth. (Figs. 250, 251 and 252.) 
At this stage we can discern the thickness, formation, and the direction 
of the root. With a sharp chisel the hone is deeply grooved, close to and 
on both sides of the root. The root outline is closely followed until the 
apical third is reached. To avoid unnecessary fragmentation of the bone, 
the bevelled side of the chisel is held toward the tooth and the flat side 
toward the outer boundaries. The chisel, used for this purpose, has a 
slanting edge, and should be had in pairs, so that this principle, as illustrated 
in Fig. 250, may be carried out. The lateral groovings are so directed that 
the broadest diameter of the tooth root is entirely freed from overlapping 
bone tissue. The section of bone may then be removed in successive cross 
cut segments with a gouge. (Fig. 251.) On the side nearest to the median 
‘.ine this lateral groove is deepened and somewhat enlarged to permit of IMPACTED TEETH 
317 
Fig. 256. The mucoperiosteum retracted and ridge of bone overlying the impacted 
tooth is shown. 
the application of the elevator. (Fig. 253.) This is the most favorable 
point for the application of our leverage. Force, applied from the 
tooth side, is likely to fracture the alveolar process, or traumatize the 
adjacent teeth. When the crown can be lifted out of its bed, in this 
manner, and the greater portion of the root is freed from the over- 
lapping bone, the dislodgment of the entire tooth will offer hut little 
difficulty. 
The wound is thoroughly inspected next. All detached fragments of 
bone, or spicules slightly adhering to the mucoperiosteum are removed; 
the uneven and coarse serrations of the bony edges are smoothed by 
means of curettes. The entire surface is sponged and dusted with an 
anesthetic powder; the mucoperiosteal flap is returned and sutured into 
position with horsehair or silk. (Fig. 254.) The needle used should con- 
form, in shape, to the domelike curvature of the palate. The wound is 
loosely packed between the sutures at the most anterior point of the in- 
cision with iodoform gauze tape. 318 
ORAL SURGERY 
Fig. 257. Shows the application of the chisel in removing the bone. 
Fig. 258. Shows the application of the elevator in dislodging the tooth. IMPACTED TEETH 
319 
In clean cut operations no suppuration should follow. If there is no 
excessive secondary hemorrhage when the gauze is removed after 48 
hours it need not be replaced. The line of the incision heals by pri- 
mary union and the sutures may be removed four or five days after the 
operation. 
Fig. 259. Supernumerary teeth at the median line causing separation and malposi- 
tion of the incisors. 
Fig. 260. Impacted upper central incisor. 
The operation for the removal of an impacted cuspid situated on the 
labial aspect (Fig. 243) of the teeth is, in principle, very much the same 
as the one described, but must be modified to conform with the require- 
ments of the existing anatomical relationships. On the labial aspect, a 320 
ORAL SURGERY 
semilunar incision is made, with a broad base and its convexity toward 
the crown of the teeth, extending from the mesial aspect of the first molar 
to the lateral incisor and about a quarter inch above the gingival margin 
of these teeth. (Fig. 255.) Semicircular flaps with narrow and thin pedicles 
are prone to slough because of insufficient blood supply. The bony layer 
Fig. 261. Impacted central incisor and cuspid 
covering the tooth on this surface is usually thin and elevated so that the 
outline of almost the entire tooth can he traced. We must he careful that 
the maxillary sinus, which, in many instances, is indented hy the root apex, 
is not invaded. The lateral deeper excavation for the application of the 
elevator should he made above, on the side furthest from the teeth. The 
technique is illustrated in Figs. 256, 257 and 258. 
In the third class the impacted cuspid lies directly above the apices of 
the teeth. Our technique of operation is complicated hy the necessary 
protection of the teeth which may be infringed upon in the operation, or if 
their nerve and blood supply is traumatized, or severed. It is to he under- 
stood that this infringement must never be a method of choice, yet it may 
he rendered unavoidable hy the anatomical correlation. Where this is 
anticipated, it is essential that, prior to the operation, the pulps of these 
teeth should he extirpated, and the root canals securely sealed with fillings. 
The impacted tooth in this position lies close to the apices of the teeth 
below, and close to the nasal cavity above. It is impossible to judge 
whether the nerves and blood vessels, supplying these teeth, are deflected IMPACTED TEETH 
321 
towards the lahial, or towards the palatal side. Whatever the condition 
may he, it is always more desirable that the removal of tissue should he 
close to the teeth, rather than that the nasal cavity he entered. In some 
biG. 262. Impacted central incisor with supernumerary teeth instead of lateral 
incisor and cuspid. 
Fig. 263. Impacted lower cuspid lying below the incisors. 
Fig. 264. Impacted lower cuspid at lower border of the mandible in a male aged 31 
rare cases, it is essential that the impeding root apices be amputated in 
the operation. Where the teeth have been priorly treated as stated above, 
this procedure is to be preferred to the invasion of the nasal cavity. 
These teeth, as a rule, are more readily reached from the labial than 322 
ORAL SURGERY 
Fig. 265. Impacted upper second bicuspids. 
Fig. 266. Impacted lower bicuspids. 
Fig. 267. Impacted lower bicuspid which caused neuralgia. IMPACTED TEETH 
323 
from the palatal aspect. They may be situated over the bicuspid teeth, or 
in any position closer to the median line. 
Fig. 268. Supernumerary tooth below the lower bicuspids. 
Other Impacted Teeth. 
It would be superfluous to enter into a detailed consideration of all 
other impacted teeth, as, in their malposition, in their anatomical relation- 
ship, in their pathological significance and in their treatment and removal, 
they all present phases and features which are in all respects analogous 
to those already described. Details in the surgical technique for their 
removal will have to be modified to meet the peculiarities of the individual 
cases. The broader outlines of the principles presented in the above 
descriptions can be well adapted to all cases, and alterations in detail are 
entirely dependent upon the experience and resourcefulness of the operator. 
Nevertheless a few instances of unusual impactions will be cited and 
illustrated, that the student may get a general idea of the possibilities. 
We will begin at the median line, where it is not unusual to find super- 
numerary teeth, one or more in number. In Fig. 259 we see two cases, one 
a boy of twelve and the other a girl of fourteen. The general results of 
the intrusion are closely similar. 
In Fig. 260 we see a very unusual condition, an impacted upper central 
incisor. One is apt to be deceived by the radiograph and might imagine 324 
ORAL SURGERY 
that this was but a small tooth, hut on removal it was found to possess a 
fully developed root. 
Fig. 261 shows an impacted upper right central and left cuspid in a girl 
14 years of age. Note also the malposed bicuspid. Other irregularities 
of the arches showed definite inherent tendencies towards abnormal 
dentition. 
Fig. 269. Impacted lower first molar. 
Fig. 270. Impacted lower first and third molars. 
Fig. 262.—The impacted central incisor here shown occurred in a hoy 
14 years of age. It may be assumed that the impaction was caused by the 
presence of the supernumerary teeth and this may be partly right. We 
note, however, that there is also, in this case, an aberration in dentition, 
as he never had a cuspid, nor a lateral incisor on this side. It is very 
likely that the supernumerary teeth developed from the dental follicles of 
the cuspid and the lateral incisor, both of which are missing. The lateral IMPACTED TEETH 
325 
incisor on the other side was also rudimentary. All of the other teeth were 
normal and in proper occlusion. 
Fig. 263 also shows a most unusual condition, an impacted lower cuspid, 
the tooth lying below the incisors. Fig. 264 is even more remarkable. 
Fig. 271. Impacted lower second molars. 
Here we see an impacted lower cuspid, at the lower border of the mandible, 
in a man of thirty-one. In this individual was observed decided signs of 
abnormal dentition. Note the formation of the teeth in the place of the 
second bicuspid. Similarly abnormally formed teeth were present on the 
opposite side and likewise in the upper jaw. 
In Fig. 265 we see two cases of impacted upper second bicuspids. In 
one the impacted tooth is in proper vertical position, hut there is no space 
for its eruption. In the other the impacted tooth lies horizontally in the 326 
ORAL SURGERY 
bone with the crown pointing distally. Note also a retained temporary 
tooth. This patient was a man 23 years of age, while the other was a 
man aged 21. 
Fig. 272. Impacted upper second and third molars, and lower third molar in same 
patient. 
Fig. 266 shows three examples of impacted lower bicuspids lying hori- 
zontally in the hone. 
Fig. 267 is somewhat similar. We see an impacted lower right first 
bicuspid, in a woman 28 years of age. She suffered with intense neuralgia 
on this side for five or six months, which terminated with the removal 
of the tooth. Note that the space intended for this tooth is partly bridged 
over by the inclination of the first molar. The tooth was lodged in the 
position of the mental foramen and caused a deflection of the inferior 
dental nerve at this point. Lack of space, or malposition of the adjacent 
teeth cannot account for this impaction. 
Fig. 268 shows a supernumerary tooth in a woman 32 years of age. She 
also had a small rudimentary supernumerary tooth in the upper left third 
molar region. The radiographic examination was made with the object IMPACTED TEETH 
327 
of finding the cause for the general nervous condition and severe head- 
aches, with which she had been suffering for the previous four years. 
Idle tooth was removed without infringing upon the two bicuspids and was 
followed by considerable decrease of her complaint. The patient was not 
seen again after three months following the operation. 
That impactions of molars are not limited to the third molars is well 
proven in the following illustrations. In Fig. 269 we see an impacted 
lower first molar. In Fig. 270 there is an impacted lower first molar, and 
also an impacted partly developed third molar. 
Fig. 271 shows two cases of impacted lower second molars, the upper 
being a man aged 38. And finally Fig. 272 shows an impacted upper second 
molar, and also an upper third molar, while in the lower jaw of the same 
patient there is an impacted third molar. CHAPTER XIX. 
Fractures of the Jaws, 
Fracture is a solution or a break in the continuity of bone. This 
chapter is confined, in the main, to the consideration of those types of 
fractures of the jaws which we are likely to meet in civil practice. The 
methods in their treatment, thus set forth, can be adapted with advantage, 
in all types of cases, as they are based upon fundamental principles under- 
lying the treatment of fractures throughout the body. All methods and 
appliances advocated are used therefore, because they are best fitted for 
the treatment of the parts concerned, and because inherently they are 
expressions of these principles. 
In civil life, amongst the bones of the face, the 
mandible is the third, and amongst those of the 
body, the tenth, most frequently fractured, ac- 
cording to statistics. After the nose, the mandible 
is tbe most prominent part of the face, and therefore most frequently 
exposed to external violence. Owing to its anatomical formation (being of 
a horseshoe shape), to the lodgment of the teeth therein, to the lack of 
that support which other facial bones obtain from the contiguous bones, 
it is more prone to fracture than the others. The articulation of the 
teeth aids greatly in withstanding the traumatic forces which may be 
brought to bear upon it. This is strongly suggested by the fact that the 
percentage of fractures in individuals who have a protruding lower jaw, 
or a poor complement of teeth, seems to exceed the proportionate ratio 
for similar accidents in more normal individuals. 
Fracture of the mandible may be: Single; frac- 
ture at one point only. Multiple; fracture at two or 
more points. 
Fracture may occur at any point between tbe condyle and symphysis, 
or at the symphysis. The point of fracture is not always determined by 
the thickness of the bone. I have found that the greatest percentage of 
fractures occur in the molar areas, where the bone is decidedly thickest 
and is reinforced by the heavy internal and external oblique ridges. The 
line of fracture, therefore, must be determined in a great measure by the 
direction and application of the force causing it. 
Proportionate 
Occurrence of 
Fractures. 
Fractures of 
the Mandible. 
328 biG. 273. Illustrates a single compound fracture, through the angle of the mandible, 
with a vertical displacement. 
Fig. 274. Fracture through the bicuspid region, with a lateral or transverse 
displacement. Note that while the posterior, shorter fragment is in proper 
occlusion with the upper teeth, the anterior fragment is badly displaced. 
329 Fig. 275. Fracture of an edentulous mandible, with the fractured ends overlapping. 
Cases of this type are somewhat difficult to reduce and to maintain in the 
corrected position. 
Fig. 276. f racture illustrating a lateral and overriding displacement. It is impos- 
sible, at times, to bring the fractured surfaces into apposition without surgical 
interference. The occlusion can be restored, however, and the overlapping 
reduced with mechanical appliances, and union will take place in this position. 
330 Fig. 277. Single, compound fracture in the molar region with an upward and lateral 
displacement. The proximal end of the shorter fragment was displaced buccally. 
Cases of this type offer considerable difficulty in their treatment. 
Fig. 278. Single, compound fracture, through the first molar region with no dis- 
placement of the parts. These cases can be well treated by the simplest form 
of fixation. 
331 Fig. 279. Single, compound, oblique fracture, with very slight displacement of 
the parts. 
Fig. 280. Fracture through the bicuspid region. Note that while the posterior, 
shorter fragment is in proper position, and the teeth in occlusion, the anterior 
fragment is badly displaced. 
332 Fig. 281. F'racture through the part anterior to the third molar. Note the tendency 
towards displacement of the shorter fragment. The third molar was loosened 
and therefore was inadequate to withstand the traction of the muscles. 
Fig. 282. Fracture through the angle of the mandible. This was caused in an 
attempt to remove the impacted third molar. 
333 334 
ORAL SURGERY 
The displacement of the parts may be vertical (Fig. 273), lateral (Fig. 
274) or overriding (Figs. 275, 276 and 277). In some instances the 
bone may be fractured without displacement of the parts (Figs. 278 and 
279). When the posterior or shorter fragment contains teeth which 
occlude with their opponents in the maxilla, this will most often be re- 
tained in its normal position (Fig. 280). Where such supporting medium 
Fig. 283. Pathological fracture, which occurred in a physician 45 years of age. 
He had a history of syphilis and a four plus Wassermann. There was what 
appeared to be an epithelioma of the soft tissues in this region, a marked 
adenopathy, and it was difficult to determine clinically, whether the growth was 
a specific gumma or an epithelioma. Note the marked alteration in the bone 
structure and its well-defined degeneration and breaking down, which is rather 
suggestive of malignancy. 
is lacking or inadequate this part will be displaced upward and backward 
by the traction of the muscles of mastication. (Fig. 281.) As a rule, 
the part to which the greater span of the hyoid muscles is attached 
will be displaced downward, and often backward and outward or inward. 
In fractures located in the anterior part of the mouth—in the incisor or 
cuspid area—displacement may be entirely absent, or it may be not so 
marked as in those occurring in the bicuspid or molar region. The dis- 
placement of the parts may be slight or quite marked; some of these can 
be readily corrected by mere finger manipulation; others, only with the 
exertion of considerable force. 
The outer, facial tissues, covering the injured area, are rarely lacer- 
ated, but are nearly always contused, bruised and ecchymosed. When the FRACTURES OF TFIE JAWS 
335 
fracture is located between the symphysis and the angle, i.e., in the 
body of the mandible, or at any point where teeth are in situ, the tnuco- 
periosteum, which is closely stretched over the hone, is usually broken, 
lacerated or it may be raised oft" the bone. The fractured ends sometimes 
project through the mucous membrane into the buccal cavity. 
Fig. 284. Pathological fracture, caused by an osteosarcoma, in a man 48 years of 
age. Note the character of the bone, which is very characteristic of malignancy. 
Etiology of Mandibular Fractures. 
The most frequent causes of fracture of the 
mandible are external violence, such as a blow, with 
the first, a club, sandbag, piece of lead pipe or a baseball bat; a fall; kicks; 
precipitation from some height; automobile accidents; a missile projected 
with considerable force, such as gunshots, shrapnel or portions of shell. 
The injudicious removal of teeth, particularly impacted third molars or 
other impacted teeth, occasionally result in fracture of the mandible. 
(Fig. 282.) 
Traumatism. 336 
ORAL SURGERY 
Fractures caused by gunshots, shrapnel or shell are, as a rule, more 
comminuted and the shattered fragments are driven into the surrounding 
tissues. The soft parts, within the trail of the projectile, are badly 
lacerated and bruised. These conditions complicate the treatment to a 
great extent and retard cicatrization. In these events the wound should he 
Fig. 285. Pathological fracture, caused by multiple cysts, in a sailor 28 years of age. 
Note that the retained coronoid process still contains two small cysts, while the 
missing portion of the bone was completely destroyed. 
thoroughly cleansed by removing and washing away all foreign bodies 
and substances. Fragments of bone which are entirely separated from 
the periosteum, or displaced, are best removed. Portions of bone or 
lacerated soft tissues, the viability of which is precarious because of 
lack of or impaired blood supply, will only give rise to later complications 
and are best removed. I do not recall instances where completely FRACTURES OF THE JAWS 
337 
separated and displaced portions of bone, even when large, have reunited 
and been retained. They became necrotic and were exfoliated. 
Where extensive injuries or mutilations are caused by infected 
shrapnel or shell, we may follow the method evolved and practiced 
during the late war. This consists of the thorough surgical cleansing 
of the wound, technically known as the “debridement,” in which not- 
merely every portion of infected necrosed or half-dead tissue or bone, 
Fig. 286. Fracture through the base of the condyle, also passing through the 
sigmoid notch. 
muscle or skin is removed, but an attempt is made to trim away all 
tissues which have been touched by the missile. This is done to prevent 
gangrene, gas gangrene or tetanus. The wound is left wide open and 
thorough irrigation, in most cases the Carrell-Dakin method, is instituted. 
Only when the infection is well under control are the tissues brought 338 
ORAL SURGERY 
together and the wound permitted to cicatrize. It must be obvious, 
however, that in the treatment of injuries about the face or jaws 
we must not be too lavish in the debridement and the utmost con- 
servation of tissue should be exercised, so that all tissues which may 
later be utilized in the reconstruction of the parts are carefully preserved. 
Fig. 287. Fracture through the base of the condyle in a negro 24 years of age. 
Note the manner of displacement of the condyloid process which is not very 
obvious in this picture, but it shows its displacement from the glenoid fossa. 
See also Fig. 288. 
The pathological conditions, which, most fre- 
quently, cause fractures of the mandible, are 
osteomyelitis and necrosis. These pathological con- 
ditions may he caused directly or indirectly hy infection about the teeth, 
Pathological 
Fractures. FRACTURES OF THE JAWS 
339 
Fig. 288. The same case as Fig. 287. Shows more correctly the displacement of the 
condyle. The fracture had to be newly reduced and the displacement corrected. 340 
ORAL SURGERY 
syphilis, tuberculosis, mercurialism, arsenical, lead or phosphorus poison- 
ing. Cryer reports cases in which the use of hydrogen peroxid, in 
suppurative sinuses, caused extensive necrosis by direct dissemination 
of the toxic substances through the structure of the bone, and fracture 
resulted. 
Malignant growths may cause a fracture either by direct invasion 
and absorption of the bone, or an ensuing localized embolism may so 
impair the nutrition of the bone that it undergoes gradual degeneration 
and destruction. (Fig. 283.) Fig. 284 shows a radiograph of an osteo- 
sarcoma which occurred in a male patient—age 48. He experienced 
no discomfort from the growth ancl sought no attention until the mandible 
was destroyed to this extent. By invading the surrounding tissues, the 
growth attained an inoperable stage. The radiograph shows the char- 
acteristic absorption and breaking down of the bone structures. 
Cysts occurring in the mandible also cause such extensive absorption, 
at times, that fracture of the bone results. (Fig. 285.) 
Surgical fractures are those produced by the sur- 
geon to render more accessible a subjacent or ad- 
jacent area to be operated upon particularly in cases of malignancy. 
Where this procedure is contemplated, it is important that provision for 
the treatment of the subsequent fracture be made prior to the operation. 
The necessity for this provision was recognized long ago, yet it is often 
overlooked, even today, by some surgeons. 
Surgical Fractures. 
Classification of Fractures of the Jaws. 
Fractures of the mandible permit of the same classification as those 
obtaining in other hones of the body. In this connection I shall confine 
myself to the consideration only of the type of fractures which do occur 
in the mandible, and a classification which is descriptive of the parts 
involved, and which may modify or influence the treatment of the case. 
Simple fractures are those where the severed os- 
seous tissues do not communicate with the external 
surfaces. Fractures located intermediately between the angle and the 
condyle, i.e., in the ramus, are usually, or nearly always, simple. This 
may be accounted for by the character and the amount of the tissues 
surrounding this part of the bone. The ramus is covered, on its external 
surface, by the masseter muscle, the parotid gland, the masseteric facia 
and the integument. On its inner surface, it is covered by the internal* 
pterygoid, some fibres of the palatine and pharyngeal muscles, and the 
mucous membrane. 
Simple Fractures. FRACTURES OF THE JAWS 
341 
Fractures through the body of the bone are rarely simple, except 
when they are located in an edentulous part, of long standing. 
Compound fractures are those in which the 
severed bone communicates with the atmosphere. 
Fractures occurring at the angle or between the symphysis and the angle 
of the jaw, i.e., the body of the bone, are almost invariably compound. 
The line of cleavage is often through the socket of a tooth, or through a 
tooth, and tends to be in the direction of the roots of the teeth in situ. 
The mucoperiosteum, which is closely adherent and almost stretched over 
the bone, is readily broken or lacerated, and through this the fracture 
is compounded into the buccal cavity. When the fracture is through 
a long standing edentulous part of the hone, the mucoperiosteum may 
at times remain intact. 
Comminuted fractures are those where the bone 
is shattered or the broken ends of the bone are 
splintered, or some of its portions are broken off 
and separated. The alveolar process is frequently thus comminuted. 
Extensive splintering of the body proper occurs when the fracture is 
caused by gunshot, shell or shrapnel, or some other forcefully projected 
missile. 
Complicated fractures are those where an im- 
portant structure, such as a blood-vessel, nerve 
trunk, muscle or tendon is severed or badly lacerated. 
The inferior dental artery, vein, and nerve, which structures are con- 
tained in a common sheath in the mandibular canal may he stretched, 
lacerated or entirely severed. It is noteworthy, that, except for hemor- 
rhage, which is readily controlled, injury to these structures rarely gives 
rise to any immediate complication. In some cases there is a partial 
anesthesia of the part innervated by the mental nerve of the affected 
side, but this usually becomes corrected after three or four months. In 
two cases which came under my care the facial artery was severed and 
had to he exposed and ligated. 
When the fracture is through the sigmoid notch, through the coronoid 
process, or through the base or neck of the condyle, the extension of the 
inflammation may cause a temporary, partial, or complete ankylosis. 
These fractures, however, are comparatively rare, and the patient does 
not always survive the injury. The force causing this type of fracture 
is usually of a crushing nature, and the injury may be accompanied by 
rupturing of the thin plate of hone separating the glenoid fossa from the 
cranial cavity. The patient dies as a result of the shock sustained, or from 
subsequent meningeal or cerebral complications. 
Compound Fractures. 
Comminuted 
Fractures. 
Complicated 
Fractures. 342 
ORAL SURGERY 
I have seen but few cases of this type two of 
which are cited herewith. In one case, there were 
some interesting atypical symptoms. The patient, 
male, age 35, fell in a collapsing building, from the sixth door to the 
ground. Several of his ribs were broken. The line of his mandibular 
fracture penetrated through the sigmoid notch, the base of the neck 
of the condyle to the posterior border of the ramus. (big- 286,) 
A11 almost complete ankylosis lasted for over four months, which was 
gradually and ultimately entirely corrected. Partial anesthesia of both 
the upper and lower maxillary area prevailed for over nine months. 
The second case (Fig. 287 and 288) occurred in a negro 24 years of 
age and was caused by a blow of the fist. When first seen, he was 
unable to close his mouth and moving the mandible caused considerable 
pain. The radiograph was taken with a lateral exposure. Fig. 287 does 
not show the exact displacement of the bone. Fig. 288 shows that the 
condyloid part was displaced towards and digging into the masseter 
muscle. By depressing the mandible the shorter fragment was forced 
into position at a second immobilization, and union, in the corrected 
position, followed. 
Case Histories 
Nos. 1 and 2. 
Symptomatology in Fractures of the Mandible. 
The pathognomonic symptoms of fractures of the mandible are: (i) 
Deformity: this may present as asymmetry in the facial outline, of 
the bone and overlying soft tissues and a drooping of the lip on the 
injured side. (2) Faulty articulation, or faulty alignment of the teeth. 
(3) Crepitation: the grating sound produced by the friction of the broken 
ends of the bone. As this entails considerable pain, it should not be 
sought. (4) False point of motion: this is decidedly the most reliable 
and descriptive symptom. It at once indicates the presence, the location 
and type of fracture. (5) Impaired function: this is evidenced by the 
patient's inability to bite or masticate food. (6) Tenderness and pain 
on point of pressure. 
Other concomitant diagnostic signs are: the history of the injury, pain, 
excessive salivation, hemorrhage at the point of fracture, the protrusion 
of a tooth, or its loosening in its socket, laceration of the mucous mem- 
brane and discoloration or contusion of the surrounding and overlying 
tissues. 
I11 most cases the symptoms are marked and so obvious that the 
diagnosis is very readily made. In others, they are slight, obscure, 
elusive or entirely absent. The radiograph is one of the most helpful Figs. 289 and 290 illustrate a double fracture of the mandible, in which the removal 
of the impacted bicuspid, or the second molar within the line of fracture, would 
have greatly complicated the treatment of the case. 
Fig. 290. The same case as Fig. 289. 
343 344 
ORAL SURGERY 
means of diagnosis, and should be taken to determine more precisely the 
character of the injury. 
In diagnosing a fractured jaw, we must deter- 
mine: (i) the number of fractures; (2) the location 
of the fracture; (3) the type of fracture; (4) the 
extent of the injury to the tissues within the line of fracture and to 
the adjacent tissues; (5) the nature of the deformity produced; (6) the 
condition, the number and distribution of the teeth present; (7) the 
condition of all tissues within the buccal cavity; (8) and the general 
health of the patient. 
Given a fractured jaw case, grasp the anterior part of the mandible 
with two or three fingers and pull it gently forward. By so doing the 
broken surfaces are separated and with a gentle up and down motion, 
the point of fracture is disclosed. 
We next proceed to place the entire buccal cavity into as hygienic a 
condition as circumstances permit. It is important that all active sup- 
purative processes, and all dormant or chronic foci, or potential sources 
of infection, should be eradicated. Broken down or infected roots, or 
teeth which are of no functional value are best removed. 
Occasions present, where such teeth or roots should be temporarily 
retained or even restored, for purposes of immobilization, or for the 
preservation of the correct relative position of the parts. Figs. 289 
and 290 illustrate a double fracture sustained by a young man, aged 19, 
caused by a blow of the fist. One fracture is through the socket of an 
unerupted bicuspid and the second through the mesial root of the second 
molar. The removal of these teeth would have made the correct 
reduction of the fracture very difficult if not impossible; therefore they 
were retained until complete union had taken place. Teeth within the 
line of fracture, and which we know will have to be removed, are often 
retained to prevent cicatricial contraction of the parts (Figs. 291 and 
292), or to prevent a faulty correlation of the fragments which could 
not be corrected otherwise. (Fig. 293.) There are others wdiich im- 
pede the reducing of the fracture and which therefore should be re- 
moved (Fig. 294). 
Diagnosis. 
Treatment of Fractures of the Mandible. 
Much has been written, within recent years, on treatment of fractured 
jaws, as a result of experiences gathered during the late war. A good part 
of this came from the hands of some very ingenious and brilliant men, 
who undoubtedly were very fortunate in the expressions of their in- Fig. 291. There was considerable loss of osseous tissue in this case. With the 
removal of the teeth, a gap would have been created and further loss of bone, 
as well as of osteogenetic tissue. The teeth became abscessed, and were removed 
after cicatrization of the fracture ensued. 
Fie. 292. There was considerable deformity and loss of bone in this case, and 
with the removal of the molar within the line fracture the condition would 
have been greatly complicated. The tooth was removed after union of the 
bone occurred. 
345 Fig. 293. The third molar in the line of fracture, in a case such as this, should be 
retained until some degree of union has taken place. With its removal the 
posterior fragment would be displaced by the muscles attached to the bone. 
Fig. 294. Fracture through the cuspid region. The cuspid tooth within the line 
of fracture protrudes from its socket and should be removed to facilitate the 
reducing of the fracture. 
346 FRACTURES OF THE JAWS 
347 
genuity, and therefore in the results which they have obtained. Never- 
theless, one can trace throughout their activities in this work, as th< 
dominating factor, the application of the principles which have sub- 
served in the treatment of fractures of the jaws in the past. These 
principles they have most ably combined with appropriate prosthesis, 
to meet the needs and peculiarities of individual cases. 
Having made our diagnosis and having accomplished these primary 
steps, we are now ready for the treatment of the fracture proper. 
As suggested before, principles, which subserve the treatment of 
fractures of bone in general, must be observed in the treatment of 
fracture of the mandible, with such modifications as are compatible with 
the peculiarities, the functional requirements, the anatomical formation 
and location, and the behavior of this bone under treatment. 
In the treatment proper, we recognize two important steps, i.e., First: 
reducing the fracture. Second : immobilization or fixation. 
Reducing a fracture, is the restoration of the 
fractured parts to their former relationship. In 
doing this, our best guide is the occlusion of the 
teeth. As the principal functions of the mandible are secured chiefly 
through the correct occlusion of the teeth, the restoration of this is of 
paramount importance, and when this is successfully accomplished, we 
may prognosticate a good result. Those cases where the attending 
surgeon overlooks the importance of, and fails to achieve, such restora- 
tion must he considered as failures. A good union at the point of fracture 
notwithstanding, jaws reduced in a faulty position, often need to be re- 
fractured. A correct occlusion of the teeth may be obtained without 
absolute coaptation of the broken surfaces of the bone, as evidenced by 
the radiograph. This is often inconsequential, as in many cases it does 
not alter, nor mar the facial outline, nor impair the function of the 
mandible and its component structures. (Fig. 295.) The gap so created 
is soon spanned by fibrous repair tissue which, even in somewhat extensive 
cases, may, in the course of time, undergo ossification. I have seen cases, 
where the broken surfaces were coaptated with a great deal of care and an 
absolutely firm union has taken place; yet the result was a failure, because 
the occlusion of the teeth was not restored. 
This principle must be observed, even in those cases where there 
is considerable loss of bone. Whether the loss of bone is due to 
necrosis; to extensive comminution; or when a portion of the bone is 
carried away by a missile, such as bullet, shrapnel or shell; or when 
it is removed by the surgeon in the case of a malignant growth, the re- 
maining parts should always be restored to their former relative position 
Reducing the 
Fracture. Fig. 295. Fracture through the bicuspid region with considerable fragmentation 
and loss of bone and a marked gap between the fractured surfaces. These can 
often be reduced without absolute coaptation, and the gap becomes spanned 
over by repair bone. 
Fig. 296. Fracture of the mandible due to extensive necrosis following dental 
infection and osteomyelitis extending from the bicuspids to the ramus. 
348 Fig. 297. The same case as Fig. 296, showing the adaptation of the bone after 
cicatrization occurred. 
Fig. 298. The same case as Fig. 296, shows the occlusion of the teeth on the 
opposite side, despite the unossified condition at the point of fracture. 350 
ORAL SURGERY 
and maintained there, until some form of union has taken place. When 
this relative position of the parts is preserved, the defects and abnormalities 
can be so much more readily corrected later by means of appropriate 
prosthetic appliances, or by means of plastic or hone surgery. 
Fig. 296 shows the radiograph of the right side 
of the mandible. Mr. A. G., age 45, cloak operator 
by trade. Patient gave a negative history, and was 
in good health prior to the onset of the disease. Blood examination: 
Wassermann, negative. FTe suffered from an acute abscess of a lower 
right molar in February, 1916. This tooth was removed before I had 
occasion to see the patient, and when I saw him, about four weeks 
after the onset of the first lesion, he had an area of necrosis, with a 
copious and foul smelling pus discharge through several sinuses. The 
necrotic area extended from the third molar to the second bicuspid, and 
through the entire thickness, to the lower border of the hone. The 
region was thoroughly irrigated and the necrosed portions of bone re- 
moved as they were being exfoliated. In the latter part of August, 
1916, a large portion of bone, comprising the entire angle and part of 
the ramus, was removed. This created a gap about two inches long, 
and the left and anterior part of the mandible was displaced towards 
the right side. The teeth were nearly three-quarters of an inch out of 
alignment. The occlusion of the teeth was restored by means of wiring. 
A retaining appliance permitting of a limited degree of motion was 
worn by him for five months, after the last portion of necrosed hone 
was removed. The patient was discharged in January, 1917. The 
radiograph (Fig. 297) was taken in March, 1918, and shows that the 
ends of the bone had been considerably approximated through regen- 
eration and muscular action, and the present gap is only about one-quarter 
of an inch. The patient has normal motion of the temporomandibular 
articulation, and a slightly movable false joint at the site of the injury. 
He enjoys a perfect occlusion of his remaining teeth, and a normal 
function of his mandible. (Fig. 298.) 
In the treatment of comminuted fractures, uni- 
form results or response to treatment, should not 
be anticipated. From a clinical aspect we may 
classify comminuted fractures into two arbitrary groups: First; those 
in which the shattered fragments are retained in their normal relative 
position and are not detached from the periosteum. The surrounding 
soft tissues are only slightly injured, and the fracture may or may not 
be compounded into the oral cavity. If the nmcoperiosteum is not badly 
lacerated or traumatized these tissues will unite by first intention and 
Case History 
No. 3. 
Treatment of 
Comminuted Fractures. Fig. 299. Comminuted fracture, in which the bone is shattered into several frag- 
ments. The fragments were not detached from the periosteum and they 
retained their vitality and reunited without infection. 
Fig. 300. A case in which a portion of the bone and the second molar is circum- 
scribed by the line of fracture. The bone was not detached from the periosteum 
and reunited without infection. 
351 352 
ORAL SURGERY 
infection may not follow. In the second group, we may include those 
cases where the fragments of hone are entirely displaced and detached 
from the periosteum. The surrounding soft tissues are badly contused 
and lacerated, and the fracture is compounded intrabuccally or both intra- 
and extrabuccally. These conditions are, as a rule, attended by severe 
abscess formations, copious suppuration and necrosis of the shattered 
fragments. From time to time we meet with the suggestion that if 
these shattered fragments are restored to their former relationship, 
and so maintained through surgical fixation, they will reunite. My 
observation, however, in numerous cases has been that this rarely takes 
place in cases of the second group, even under the most favorable 
circumstances. 
Whatever the ultimate fate of these fragments of bone may be, 
more gratifying results are obtained by conservative procedure. Ac- 
cording to Duhamel, Ollier, Axhousen, and others, the osteoblastic layer 
of the periosteum is of special importance in osteogenesis, and, therefore 
we must not subject these tissues to immediate and undue trauma. It 
may be assumed that although such portion of bone may be ultimately 
exfoliated, if restored to its normal position, it may exert an osteogenetic 
or osteoconductive influence, analogous to that of an autogenous bone 
graft, as is believed by MacEwen, McWilliams, Albee and others. My 
clinical observation, in the treatment of extensive cases of necrosis of the 
jaws, where, as a result the bone is in a rather weakened condition, is, 
that it is best not to disturb the sequestrum until it is exfoliated. This 
procedure may he carried out with equally beneficial results in extensive 
comminutions of the mandible. The following cases are illustrative of 
the text of the above paragraph: 
Fig. 299 shows the radiograph, disclosing a 
marked comminution of the left side of the mandible. 
The fracture was sustained by a man, age 29, and 
was caused by the blow of a baseball. The fragments are retained in 
their correct relative position. The mucous membrane over the area 
was broken, but this united by primary union. The fracture united 
uneventfully within four weeks following the injury. There was no 
sign nor symptom of any abnormality or necrosis five months later, 
when he was last seen by me. 
Fig. 300 shows the radiograph of the lower jaw 
of a young woman of 26. She sustained a double 
fracture of the mandible in an automobile accident. 
On the left side, the line of fracture passes through at the mesial side 
of the second molar, to the lower border of the bone and up through 
Case History 
No. 4. 
Case History 
No. 5. FRACTURES OF THE JAWS 
353 
where the distal root of the third molar would be. The fracture was 
compounded into the buccal cavity. Although the tooth, which was 
likely an infected one, was directly in the line of fracture, contrary to my 
anticipation, the bone was retained because it was not dislodged and 
detached from the periosteum. 
Fig. 301. Fracture of the lower border of the mandible. This was not compounded 
into the oral cavity nor upon the external surface, still the portion of bone 
necrosed and had to be removed. 
Fig. 301 shows the radiograph disclosing the frac- 
ture of the right side of the lower border of the 
mandible. This was sustained by a young man of 
24, in rather robust health. He was working in a brewery and was hit 
by a fellow-worker with a beer bottle. A portion of the lower border 
of the bone was chipped out, and, although the overlying tissues were 
contused, the fracture was a simple one. This portion of bone was 
but slightly displaced, and decidedly in a most favorable condition to 
unite, but suppuration ensued, it necrosed and had to be removed. 
The fracture illustrated by the radiograph (Fig. 
302) was sustained by a sailor (shipwright), age 31. 
He was hit by an implement during his work 
aboard ship. The fracture was badly comminuted and compounded into 
Case History 
No. 6. 
Case History 
No. 7. 354 
ORAL SURGERY 
the buccal cavity. The posterior fragment held only the third molar, the 
mesial root of which was within the line of fracture. This tooth was 
temporarily retained, and in reducing the fracture it was antagonized 
with its opponent in the maxilla, to prevent the displacement of the 
containing fragment. (Fig. 303.) Tn the hope that the large triangular 
portion of bone would reunite, this was forced into its nearly normal 
Fig. 302. Compound comminuted fracture in which the portions of bone were 
detached from the periosteum. The fragments of bone were forced into close 
apposition and the jaw thus immobilized. (Fig. 303.) The bone fragments 
necrosed and had to be removed. (Fig. 304.) 
relative position. Suppuration and necrosis followed, and it was later 
exfoliated. (Fig. 304.) After five months, there was a quite firm fibrous 
union. Although the patient had but a very few, badly neglected and 
malposed teeth, they were restored and maintained in their normal relative 
position. The patient was retired and pensioned because of other physical 
infirmities, and left the city before prosthetic restorations could he 
undertaken. 
Figs. 305 and 306 further illustrate that the 
viability of these detached, even larger fragments 
of bone, is rather precarious. This fracture was 
caused in a fist fight, and was sustained by a young man, age 24. The 
Case History 
No. 8. FRACTURES OF THE JAWS 
355 
Ftg. 303. The same case as Fig. 302. 
Fig. 304. The same case as Fig. 302. 356 
ORAL SURGERY 
Fig. 305. Compound, comminuted fracture, through the bicuspid region. Both the 
upper fragments containing four anterior teeth, and the lower triangular part, 
were detached from the periosteum and were exfoliated. 
Fig. 306. The same case as Fig. 305. FRACTURES OF THE JAWS 
357 
Fig. 307. The same case as Fig. 306, showing the external wound. 358 
ORAL SURGERY 
fracture was compounded into the oral cavity and upon the chin. (Fig. 
307.) In the radiograph (Fig. 306) we can see two large fragments of 
bone. The alveolar or upper portion contains four anterior teeth, all of 
Fu;. 308. Fracture, in which immobilization was attempted by drilling holes into 
the bone and securing the parts with silver wire. Note the extensive necrosis 
which followed, and the fragment of bone within the wire loop. 
which had to be removed en masse. The large triangular segment consti- 
tuting a portion of the body and the lower border was likewise exfoliated. 
The lateral parts of the mandible were restored to and maintained in their 
proper relative positions until union had taken place. This prevented their 
sagging together and thus creating an abnormality which would he 
difficult to correct. The defect was later corrected and the teeth FRACTURES OF THE JAWS 
359 
supplied with a prosthetic appliance, and the patient enjoys a normally 
functioning mandible. 
Experience has proven that fractures of the man- 
dible are not amenable to surgical methods of 
fixation such as are often successfully employed, 
particularly in the long bones. The use of Lane plates, metal screws 
or nailing together the fragments with bronze nails as practiced by the 
late Murphy, of Chicago, or securing them with silver wire or kangaroo 
gut, result almost invariably in extensive necrosis so that the sequel of 
the treatment is much more serious than the initial injury was. 
Even in other departments of bone surgery, these methods are 
rapidly being supplanted by autoplastic bone transplantations. Metallic 
foreign bodies introduced into living tissues always cause a degree of 
irritation which may result in absorption, degeneration, and necrosis. 
This establishes a point of lesser resistance which further predisposes 
the parts to infection. 
Fig. 308 shows a radiograph illustrating such a case. The fracture 
was sustained by a young man, age 26, through the left bicuspid region. 
The mandible was exposed by an external incision. Holes were drilled 
through the substance of the bone on both sides of the line of fracture 
and the parts fastened with a silver wire. Observe the isolated, necrosed 
portion of the bone within the wire loop. Unfortunately for this 
patient, the necrosis extended posteriorly, and, ultimately, the entire 
left half of the mandible was lost. 
The best, and uniformly good results, are obtained by the judicious 
construction and application of mechanical appliances which are par- 
ticularly designed for the correction of the deformity existing, and 
to maintain the disrupted parts in their normal relationship. 
The requirements of a method or appliance to be employed are: (1) 
efficiency; (2) expedience; (3) adaptability to fit the needs of the par- 
ticular case; and (4) convenience in construction and application. The 
construction of some appliances requires a deal of ingenuity and skill. 
Some operators fall into the error that they advocate and adhere 
to the use of a single favored appliance in the treatment of all cases 
and conditions. We may state positively that a certain type of appli- 
ance is best indicated for groups of fractures of a certain class, or 
those presenting certain characteristics. But much more favorable results 
can be obtained if every case is individualized, and studied from all 
angles, as suggested above. These are important enough to bear reitera- 
tion: (1) The number of fractures; (2) the location of the fracture or 
fractures; (3) the type of fracture; (4) the extent of the injury of the 
Fixation in 
Fractured Mandibles. 360 
ORAL SURGERY 
Fig. 309. Double fracture, caused by a blow. One fracture is through the left 
cuspid and the second through the right second molar region. Note the 
deformity. The displacement of the parts was of such nature, that anterior 
and lateral traction had to be applied, and the anterior teeth had to be wired. FRACTURES OF THE JAWS 
361 
Fig. 310. Radiograph of the same case as Fig. 309. 362 
ORAL SURGERY 
Fig. 31 i. The same case as Fig. 309 reduced and immobilized. Note the absolute 
restoration of the occlusion of the teeth. FRACTURES OF THE JAWS 
363 
tissues involved; (5) the displacement of the parts; (6) the nature of 
the deformity produced; (7) the condition, number and distribution 
of the teeth present; (8) the condition of the entire buccal cavity; (9) 
and the general health of the patient. From such a study of the case, 
we can more rationally determine what forces must be applied and how 
these forces are to he exerted to attain the desired result. In deciding 
upon an appliance for a particular case, we must be guided by these 
considerations. 
Whenever a method, or appliance, meets with the above stated re- 
quirements, we have attained all that is desired. It is rarely essential 
that an appliance should be excessively complicated, or superfluously 
elaborate. Unless some elaborate feature of an appliance offers ad- 
vantages towards greater efficiency in the treatment of a case, such 
construction is not to he advocated, since its utility is but temporary. 
In a healthy individual, the average fracture unites within four to six 
weeks. The formation of abscesses, age, systemic complications such 
as syphilis, tuberculosis, anemia, diabetes, poor general health, will in 
a measure antagonize cicatrization and due allowance must be made 
for such existing conditions. 
The method first advocated by Dr. Gilmer, of 
Chicago, that of securing the mandible by wiring the 
teeth to their antagonists in the maxilla and so restor- 
ing their former occlusion, may be used to the best advantage in the major- 
ity of cases. The Angle brass ligature wire, as manufactured by the S. S. 
White Dental Manufacturing Co., serves this purpose most admirably. It 
is more tenacious than silver or iron wire. It does not oxidize and is not 
acted upon by the fluids of the mouth. A double strand, of the 
medium or heavy wire, is passed through the interdental spaces and 
fastened about the neck of the tooth, just beneath the free margin of the 
gum. All wires should be twisted in one direction to prevent their un- 
winding later. Wherever conditions permit, it is best to select opposing 
teeth, or else to plan the wiring so that when the jaws are brought 
together the traction upon the wires will tend to correct the deformity 
caused by the displacement of the parts. The bicuspids and first molars 
are best suited for this purpose. These teeth are accessible, more or 
less bell-shaped and are more strongly rooted than the anterior teeth, 
and consequently better able to withstand the stress which will be brought 
to bear upon them. 
The anterior teeth, particularly the lower ones, are not quite so 
favorable. In some cases, however, the displacement of the parts is 
of such nature that only anteroposterior traction will bring about the 
Dr. Gilmer’s Method 
of Fixation. 364 
ORAL SURGERY 
Fig. 312. Double fracture of the mandible, one through the second molar and the 
second through the bicuspid region. Note the deformity created. FRACTURES OF THE JAWS 
365 
Fig. 313. The same case as Fig. 312, with the fracture reduced and immobilized. 
Note the absolute restoration of the occlusion of the teeth. 366 
ORAL SURGERY 
desired result. When the anterior teeth must be utilized for immobiliza- 
tion, two of the lower ones should be included within one wire loop, 
and this is to be secured to one of the upper teeth. (Figs. 309, 310 and 
311.) Because of their conical shape, wire loops cannot be retained 
or only with difficulty, upon the cuspid teeth. Where compelled to use 
such a tooth, an Angle band or one made of German silver with a lug 
on its labial aspect, may be cemented on the tooth. 
It is advisable to wire as many teeth as we conveniently can. The 
considerable tension or traction produced by the attempt or act of 
deglutition, sneezing, yawning, coughing or speaking, is thereby distributed, 
l he wiring of teeth within the line of fracture must be avoided wher- 
ever possible. Those who have judiciously tried this method will agree 
with me that it offers several decided and distinct advantages over other 
methods of fixation. It is efficient, expedient and convenient. 
A unique advantage of wiring is that we can always see the relation- 
ship of the parts. Should there be a displacement, due to sagging or 
breaking of the wires, this can readily be detected and corrected. 1 
know of no method whereby the occlusion of the teeth can be restored 
with equal precision. (Figs. 312 and 313.) For these reasons, and 
because of the uniformly good results obtained, I employ wiring as a 
method of preference. 
That the interposition of an appliance between the teeth tends to 
disturb the absolute correlation, must be quite obvious. Even when 
a well-constructed splint is used, there is always a possibility that, 
owing to either uncorrected angulation of the bone at the point of frac- 
ture, or an adaptive modification of the temporomandibular articula- 
tion, malocclusion may result. Even these deformities can often be 
corrected, in their early stages, by means of wiring. The tension 
exerted by the wires causes a gradual yielding of the newly formed 
callus, which as yet has not undergone complete ossification, and in a 
similar way, may correct the deformity produced at the temporo- 
mandibular articulation. 
One of the objections raised against wiring is that the gums about 
the wired teeth may be unduly injured, or that the teeth may be dis- 
lodged from their sockets by the traction upon them. If carefully 
done, the placing of the wires entails no greater and probably less in- 
jury to the soft tissues than the cementing of a splint or the adjustment 
of Angle bands would. Nor have I observed the dislodgment of teeth 
when a sufficient number of teeth were properly wired, even under very 
unfavorable conditions. Another objection raised is, that the patient is 
unable to open his mouth and masticate his food. This, however, must FRACTURES OF TFIE JAWS 
* J 
367 
Fig. 314. The single arch, or cap splint 
be looked upon as a necessary part of the treatment, just as in other 
fractures surgical rest is secured by absolute immobilization by means 
of plaster casts, extension contrivances and confinement of the patient 
to bed from four to five weeks or longer. I prefer subjecting the 
patient to a temporary inconvenience rather than to obtain a result which 
leaves him in a crippled condition for life. 
All forms of splints must be so constructed that 
they permit the application of the principles which 
accord with the rational treatment of fractured 
jaws as set forth above. Those to be described in the following pages 
permit of a wide range of modification and this renders them adaptable 
for most cases. They may be made of precious or base metal, and 
may be cast or swedged. They serve to equal and frequently to better 
advantage if made of vulcanized hard rubber. When made of this 
material, they can be more readily constructed, adapted and placed, or 
removed with greater facility. 
The single arch, or cap splint, is about the most 
satisfactory means for immobilization, (big. 314.) 
The advantage which this appliance offers is that it 
Splints. 
Single Arch 
Splint. 368 
ORAL SURGERY 
secures a complete fixation of the fractured bone, without immobilization 
of the temporomandibular articulation. This makes mastication and all 
other functions possible during treatment. The utility of this splint is 
limited, however, to certain types of cases only. It is best indicated for 
conditions where the deformity is not very marked and in which the dis- 
placement of the parts can readily be corrected by mere finger manipula- 
tion. The fracture must be essentially so located that there are two or 
three well-rooted teeth on either side of it. The splint is cemented onto 
these teeth and the fragments are thus held in their intended relative 
position. When a fracture is so located that were it not for the marked 
displacement and the force required in its reduction, a cap splint could be 
used, the fracture may be reduced by means of wiring first, and ten days or 
two weeks later, when the fragments tend to stay in their corrected 
position, the wires may be replaced with a splint. When the fracture is at 
the angle, behind the third molar, between the second and third molars, 
or at some point where the teeth do not other adequate anchorage for 
the retention of the containing fragment, this splint is contra-indicated. 
The method of construction of a cap splint is as 
follows: An impression is taken, preferably in 
modeling compound, of both the upper and lower 
jaws. From these, plaster casts are made, which will be accurate models 
of the existing conditions of the jaws, reproducing also the deformity 
of the fractured mandible. The disarrangement of the parts is corrected 
by dividing the plaster model of the mandible at the point of fracture 
and these segments are articulated with the cast of the maxilla. The 
plaster segments are assembled in this corrected position and united with a 
fresh layer of plaster. A heavy sheet of tinfoil is burnished over the 
lower teeth, covering them to the gum margin. The tinfoil is covered 
with a single layer of red or pink base plate wax. The occlusal sur- 
face of the wax splint is conformed to the indentations of the cusps 
of the upper teeth. The pattern so formed is reproduced in black or 
red vulcanized rubber with the tin lining in position. The tin lining 
prevents the vulcanite from entering undercuts and the interdental spaces 
and when removed provides a space for the cement and facilitates the 
setting of the splint. 
Before cementing the splint in position, it is well to permit the patient 
to wear it loose for one or two days. By so doing, we give an opportunity 
for the adaptation of the displaced parts to the splint, and we also de- 
termine points of irritation of the gums that may be caused by it. Such 
points of chafing can he readily corrected by removing the encroaching 
rubber. 
Technique for 
Making Splints. FRACTURES OF THE JAWS 
369 
Fig. 315. The double arch, or Gunning splint. 
In cementing the splint, we pack off the salivary 
secretions first, by means of gauze—sponges or 
cotton rolls. The tooth surfaces are dried with 
absorbent cotton or bibulous paper. The black oxyphosphate of copper is 
the best cement as it is hygroscopic and adheres more tenaciously to the 
teeth. The cement is mixed to a creamy consistency and introduced into 
the splint, covering the entire inner surface. The splint is placed over 
the teeth and the fractured parts are forced home into the splint. This 
must be held firmly as when the yielding of the fingers permits a dis- 
placement of the parts, union will take place in this shifted position. 
It sometimes occurs, that, owing to such shifting, upon the removal even of 
a well-constructed splint, the parts will have united in a faulty align- 
ment. This is one of the disadvantages of the cap splint, that, when 
it is once set, we are unable to observe or ascertain the relationship 
of the parts. It has been suggested by some, that perforations be 
made into the occlusal surfaces of the splint through which we might 
see when the teeth have reached their intended position. This is good 
practice in some cases, and particularly where thin swedged metal splints 
are used. 
Technique for 
Cementing Splint. 370 
ORAL SURGERY 
Fig. 316. Splint constructed for the treatment of fracture of both jaws. Each jaw 
is reduced individually and immobilized through the wire loops. FRACTURES OF THE JAWS 
371 
Fig. 317. Appliance provided with a jack-screw to correct an acquired deformity, 
following loss of bone. 
The intermaxillary, or interdental “Gunning’’ 
splint (Fig. 315) in some cases is very helpful, 
and in some instances is the only appliance which 
can be utilized to good advantage. Modified forms of this appliance are 
used by some men, almost exclusively, in the treatment in all types of 
cases and conditions. In my hands its practical use is confined to such 
cases only where the condition, position, or lack of teeth, or the location 
of the fracture does not permit of more reliable fixation. With this 
splint absolute fixation cannot be secured. It must be used in con- 
junction with bandages and we depend chiefly upon these for immobiliza- 
tion. For example, in a case of an edentulous mouth, an edentulous 
upper or lower jaw, or where the teeth present are so distributed that 
they cannot be approximated. Where plates are worn by the patient, 
the splint is constructed to be applied over the dentures. It is particularly 
useful in young children during the period of dentition, when the 
permanent teeth have as yet not erupted. In all such cases the splint 
The “Gunning” 
Splint. 372 
ORAL SURGERY 
acts partly as a guide in the restoration of the correlation of the parts 
and as a means of fixation. After the fractured parts have been assembled 
and maintained in the splint for a few days, there is usually no difficulty 
in retaining them there. 
This splint is constructed much in the same manner as the single arch 
splint, but the upper surface is molded against the model of the upper 
jaw, so that an occluding surface is made for the reception of the 
maxillary teeth. 
The splint illustrated in Fig. 316 may he utilized in cases where 
both the upper and lower maxillae are fractured. These fractures, as 
a rule, are accompanied by extensive comminutions. It is best to reduce 
the fracture of each maxilla and the mandible independently and com- 
plete immobilization may be secured by wiring through the loops imbedded 
into the vulcanite. The double arch metal splint advocated by Dr. 
Cryer can he used to distinct advantage in a great many cases of this 
type. 
Fig. 317 illustrates a type of appliance which I have used in several 
cases with very satisfactory results, where the fragments were permitted to 
sag together and to partly close a gap created through an extensive 
loss of osseous tissue. The appliance is provided with a jack-screw. 
By the gradual extension of this the parts were restored to their normal 
position. 
The complication which often attends fractures 
of the mandible is the formation of abscesses. It 
is my impression that this occurs in sixty to sixty- 
five per cent of cases. 
The most prolific causes of abscess formations are: First; as most 
fractures are compounded into the oral cavity, we may have a direct 
infection of the wound by the organisms of the buccal cavity. Second; 
fragments of necrosed bone, or foreign bodies, will exert irritation which 
often leads to suppuration. Third; fragments of teeth, or traumatised 
teeth within, or in the proximity of the line of fracture. As fragments 
of hone, or traumatised teeth containing gangrenous pulps are the most 
prolific causes of abscess formations here, their presence should be deter- 
mined by means of the radiograph, and whenever conditions permit, they 
should he removed prior to reducing the fracture. When suppuration 
ensues, the abscess should be treated independently of the fracture 
proper, by securing thorough drainage intrabuccally. Quite frequently, 
however, external incision must be resorted to. Suppuration will con- 
tinue until all irritating factors are removed, or exfoliated. Often, small 
spiculse of bone, which are not disclosed by the radiograph, become en- 
Abscesses 
in Fractured Jaw 
Cases. FRACTURES OF THE JAWS 
373 
tangled in the meshes of the soft tissues and prolong suppuration. These 
can be detected best by gently probing the abscess tract, and when found 
are removed. 
Fig. 318. Complete ossification of fracture reduced in false position. Note the 
fine osseous formation. The case had to be refractured to restore function. 
During the period of immobilization, the patient 
must subsist on liquid and semi-solid food. This 
can be taken through a tube or sipped through the 
interdental spaces, or passed through a space where some of the teeth 
have been removed. The removal of good teeth, for this purpose, is not 
to be tolerated. The diet must be of high nutritional value, so that the 
patient's health is not undermined. Milk, soft boiled eggs, broth, chowder, 
beef-extract, chopped meat and other similar food substances will 
keep the patient in comfort and maintain his weight to a large degree. 
With the proper regulation of the diet, the bowels should be kept 
open and the patient advised not to do any unduly strenuous manual 
work. 
The oral cavity must be frequently and thoroughly irrigated with 
mild antiseptic and deodorant solutions. A solution of potassium per- 
manganate, or boric acid, will serve well in most cases. The use of 
Feeding in 
Fractured Jaw Cases. 374 
ORAL SURGERY 
Fig. 319. A case in which a double fracture was not reduced, and the parts united 
in false position, with resulting facial deformity. FRACTURES OF TFIE JAWS 
375 
Fig. 320. The same case as Fig. 319. Showing the unsatisfactory correction of 
the lip. This represents the best effort at closing the mouth. 376 
ORAL SURGERY 
hydrogen peroxid is to be discouraged and in my estimation has no plaee 
in bone lesions within the buccal cavity. When the teeth are wired, or 
when the splint is cemented in position, the patient should he instructed 
to brush all accessible surfaces with a tooth-brush and dentifrice. When 
a removable appliance is used, this should be immersed in permanganate 
solution, or in a dilute solution of hydrogen peroxid and thoroughly 
scoured and brushed with soap and water every twenty-four hours. If 
strict hygiene is not observed, the appliance and the breath become fetid 
and very offensive. 
When a fractured mandible is reduced in a 
faulty position, the deformity produced and the 
consequent impaired functions are so irksome, that the patient prefers 
to go through a corrective operation rather than to endure these through 
life. Such deformities result in alteration of the facial outline and ex- 
pression, the impairment of speech, vocalization, and the primal function 
of mastication. It would be hard to estimate just how far-reaching the 
ill effects of this deformation may be upon the mental processes of the 
patient. Among psychopathologists there is a decided and increasing 
appreciation of the subtle relationship existing between mind and body, 
and the detrimental influences that may be exercised by acquired or con- 
genital physical defects. 
In the recent stages, prior to the complete ossification of the callus, 
this operation is a comparatively simple one. Under anesthesia, the 
mucoperiosteum is raised from over the point of fracture, the fibrous 
primary callus severed and the fragments separated. The case is treated 
as a recent fracture of a similar character. 
When ossification is complete, the operation is more difficult and com- 
plicated. Whenever conditions and the position of the fracture permit, 
the operation should be performed intrabuccallv. The mucoperiosteum 
is raised off the bone on its entire circumference and by means of a Gigli 
saw or surgical burs, the bone is separated at the point of fracture. 
This can sometimes be accomplished with chisel and mallet. It is best 
to divide the bone at this point, as it is here where the angulation caus- 
ing the deformity exists. The complexity of reducing these fractures 
is greatly augmented by the need of correcting the adaptive modification 
which invariably obtains in the temporomandibular joint after it has 
functioned in the false position for some length of time. 
Fig. 318 shows the fracture united in a false position. Note marked 
bone formation and the interlacing of bone trabeculae at the line of 
fracture. This case was refractured with a good result. 
Figs. 319 and 320 present a case in which a very poor, or no 
Refracturing. FRACTURES OF THE JAWS 
377 
attempt, was made to reduce a double fracture, and the parts united 
in this false position. This patient sustained a double fracture of the 
mandible, one being through the right molar and the other through the 
left bicuspid region. Note the abrupt V-shaped position of the jaws. 
Fig. 321. Fracture through the angle of the mandible, the ramus being retained in 
a practically normal position by the juxtaposition of the broken surfaces. 
After this union had occurred, an attempt was made to correct the 
deformity hy resecting a part of the ramus at the base of the condyle, 
through an external incision. Naturally, this also failed, as the angula- 
tion causing the deformity was in the molar and bicuspid region. Note 
also the poor correction of the lip, big. 320, this being a photograph 
with the lips and mouth closed. 
Fractures through the angle of the mandible, through the third molar 
socket, or sometimes even more anteriorly when lodged behind the last 
tooth on the injured side, offer special problems in their treatment, 
and therefore must be specially considered. The ramus in these cases 
may be retained in its proper position by the juxtaposition of the broken 
surfaces. (Fig. 321.) In a considerable number of cases it is displaced 
by the muscles of mastication. The displacement may he upward and 
forward, or tilted inward or outward. The displacement may be so 
marked that the anterior surface of the ramus presses against the upper 378 
ORAL SURGERY 
teeth, and this becomes a constant source of irritation, ulceration, and 
discomfort, or may even interfere with function. The displacement is 
nearly always determined, or caused, by the lack of teeth in this posterior 
fragment to counterbalance the traction of the muscles, or because of 
loss of a portion of hone. 
Fig. 322. Shows fracture with considerable loss of bone in a young man age 20. 
The ramus is drawn forward by the muscles because of loss of support. 
In the early stages, these displacements are amenable to finger 
manipulation, and the problem lodges rather in maintaining this pos- 
terior fragment in its reduced position. This can be accomplished, very 
frequently, with the double arch splint, as well as with the cap splint. 
The splint is extended to cover the anterior part of the ramus without 
causing too much pressure. It is not always a simple matter to deter- 
mine beforehand, just how deeply this should be extended. 1 prefer to 
have this posterior extension to fit the ramus as far from the bone as 
the occlusion of the teeth permits. When the pressure is inadequate, 
this can always be modified by placing a portion of modeling compound 
over the surface next to the bone. This method can also be used where 
a gradual depressing force is desired. 
In the later stages, if a part of the fractured surfaces have remained 
in apposition despite the displacement, satisfactory osseous union may FRACTURES OF THE JAWS 
379 
occur. There may or may not be a flattening of the facial outline to a 
varying degree, but function is good. In some cases I have found that 
such a case was complicated merely by the pressure against the upper 
jaw. The anterior part of the ramus was exposed intrabuccally, and 
a moiety of the bone was removed. 
If the displaced position is permitted to persist for some time, imme- 
diate reduction becomes impossible. The ramus practically becomes 
fixed, through a modification of the masseter, pterygoid, and temporal 
muscles, or there may be a callus or fibrous union. An attempt at gradu- 
ally correcting the displacement in these cases is more apt to bring 
satisfactory results. For this purpose, it is best to utilize the upper 
jaw as the point d’appui. An appliance in the form of a splint may be 
constructed which is fixed to the upper teeth. A small saddle is con- 
structed of metal or vulcanized rubber to fit over the anterior surface 
of the displaced ramus. This is attached to the upper appliance with a 
solid metallic bar, in such a manner that it can be extended by operating 
a jack screw. This is gradually extended without causing too much 
pressure, and the slowly acting force may also stimulate a corrective 
change in the tissues acted upon. If too aggressive, or too sudden 
pressure is used, the process becomes unbearably painful and the soft 
tissues ulcerate. 
Where there is a considerable loss of bone, as a rule, two things 
may happen. The ramus is drawn forward, or forward and upward, 
and although there is no bony union, the bone surfaces are quite closely 
approximated and held in place by a firm fibrous union. The balance of 
the mandible is maintained in its normal position, the teeth contained 
therein articulate, and function is good. Such a case is illustrated in 
Fig. 322. This occurred in a young man 21 years of age and was caused 
by a gunshot. The radiograph was taken about eight months after the 
injury was sustained. His chief complaint was the facial asymmetry. 
Note to what extent the ramus was drawn forward to meet the anterior 
fragment and the new bone being laid down at the ends of both stumps. 
There are other cases which are not quite so fortunate. The ramus 
is tilted forward and upward, and outward or inward. The gap may 
be considerably larger. The balance of the mandible is drawn over to 
the injured side; there is a marked facial deformity; the teeth are out 
of occlusion and function is impossible. In these cases it is good prac- 
tice to maintain the disrupted parts by means of wiring, or splints in 
their proper relative position, until all surface wounds have healed and 
infections, or infecting factors, have been eliminated. When this occurs, 
autogenous bone grafting may be resorted to, 380 
ORAL SURGERY 
Fractures of the Maxillae. 
Fractures of the maxillae are comparatively rare and for all purposes 
they may be classified in the same manner as those of the mandible. 
In some cases, both the upper and lower jaws are fractured simul- 
taneously in the same individual. 
The etiology is always a forceful traumatic injury, caused by some 
Fig. 323. Fracture of the maxillary bone caused in the removal of a bicuspid 
tooth. The line of fracture communicated with the maxillary sinus. No 
appliance was necessary in this case. The fragment of bone was forced into 
position and held there by the overlying mucosa. Union followed in about 
fourteen days without complications. 
external violence such as a fall, a kick, a blow with an implement, auto- 
mobile and railroad accidents, gunshots, and even by extracting a tooth. 
(Fig. 325.) 
Fractures of the upper jaw may be unilateral or bilateral and the 
different types may be arbitrarily grouped into four general classes. 
(1) In the first group we may place all of those which involve a portion of 
the alveolar process only; (2) those which penetrate beyond the alveolar 
process and involve a part of the maxillary bone proper, often complicating 
the maxillary sinus; (3) those in which there is fracture of some of the 
facial bones. The most frequently fractured are the malar, the nasal, the 
palate bones and the zygoma; (4) those in which some of the cranial 
bones are likewise disrupted or fractured. 
All fractures of the maxillae are caused by some external violence of FRACTURES OF THE JAWS 
381 
considerable force and the majority are therefore compound and com- 
minuted. This circumstance often complicates their treatment. Other 
complications which may be present are: invasion (Fig. 323) and infection 
of the maxillary sinus; invasion of the nasal cavity; injury to the teeth 
and their investing tissues; injury to the infraorbital nerve; injury to the 
lachrymal gland; severe hemorrhage which is not always easy to control. 
When the point of hemorrhage cannot be discovered, or stopped by 
tamponing the bleeding surface or by compression, or the severed vessel 
cannot be reached it may become essential to ligate the internal maxillary, 
or the external carotid artery. 
Because of the violence causing these fractures, severe shock is not 
uncommon, particularly in those cases which are complicated with fracture 
of the cranial bones. There is generally, also, considerable contusion 
and laceration of the facial tissues. 
Diagnosis can be made with comparative ease in 
all those cases in which only the alveolar process, or 
the maxillary bones are involved. There are con- 
ditions, however, in which the diagnosis is obscured by swelling, contusion 
and lacerations of the face and the tissues of the oral cavity. The 
radiograph is helpful in all cases, but not always clear cut, because of the 
overlapping of the cranial bones. 
A free diagnostic manipulation of the parts is at times contraindicated 
because of traumatic shock or other complications. It is important, how- 
ever, that an accurate diagnosis be made just as soon as possible and it is 
essential that provision should be made for the early treatment of the 
fracture. Prompt measures in these cases are even more important than 
in the treatment of fractures of the mandible. It has been my experience, 
that where delay was inevitable because of the complications present, the 
disrupted parts which were easily moved and replaced at first, even after 
five or six days could not be restored completely, or only with the exertion 
of considerable force. The broken surfaces may also become altered to 
such an extent that their absolute coaptation becomes impossible. 
This was well illustrated in the treatment of a 
man, 38 years of age, who sustained a double frac- 
ture of the mandible and fracture of the right 
maxilla, in a railroad accident. He was taken to a near-by hospital and 
was brought on to New York about fourteen days later, when he was 
placed in my care. Upon examination I found that the fractures of the 
mandible could be freely moved and manipulated but the fracture of the 
maxilla seemed to have completely solidified, and it was impossible to 
move or displace the parts with forceful hand or finger manipulation. 
Diagnosis of 
Maxillary Fracture. 
Case History 
No. 9. 382 
ORAL SURGERY 
He also had a fracture through the left infra-orbital ridge, the outer 
wall of his left maxilla was caved in and there was fracture of a nasal 
bone. Although the contusion and lacerations of the soft tissues were not 
completely healed, except for the deformity of the facial bones there was 
no sign of fracture, or mobility. The fractures of the mandible and that 
of the maxilla were reduced independently and immobilized. It was 
impossible, however, to completely correct the maxillary deformity. 
The tendency towards rapid healing of injuries 
in the maxillae was also observed in the case of a 
child five years of age. He fell into an elevator 
shaft and his head was pinned between the elevator and the wall. Besides 
other injuries, he sustained a fracture of the left maxilla. The fracture 
penetrated through the socket of the lateral incisor, through the median 
line of the palate and diagonally through the region of the maxillary 
sinus, well into the malar bone. Upon examination, I found that the 
hard palate was completely separated at the median line; the overlying 
soft tissues were severed and the fractured part of the maxilla was dis- 
placed outward and upward. The part was freely movable and could be 
forced into position with very little finger pressure. Because of the grave 
traumatic shock all interference was contraindicated and treatment had to 
be deferred for ten days. At this time the patient was put under ether 
and I found it impossible to restore the disrupted parts with finger 
manipulation or even with considerable force exerted with the palms of 
the hands. Fearing that the shock might be too severe, separation of 
these partly united parts with a wedging force was not deemed advisable. 
A wire arch, such as is used in orthodontia, was securely ligated to his 
teeth. Other, fairly heavy brass wires were attached to these and passed 
across the palate to the opposite side. By twisting these, pressure was 
exerted on both sides of the maxilla, with a tendency to approximate the 
disrupted parts. The wires crossing the palate were tightened each day 
and the direct pressure thus exerted was also aided by the pressure of 
the tongue. In less than ten days the disrupted parts were restored to 
their former position and the teeth were in normal occlusion, except the 
lateral incisor, which had to be removed. The gradual pressure acted more 
favorably and more effectively than forceful surgical measures would have. 
In the treatment of fractures of the maxillae, the same primary meas- 
ures must be carried out which are essential in the treatment of all infected 
wounds and fractures regardless of the part of the body involved, 
(i) Arrest hemorrhage; (2) remove foreign bodies; (3) remove frac- 
tured or fragments of teeth, also all completely detached and infected 
portions of bone; (4) antisepticise the wound with a mild germicidal 
Case History 
No. 10. FRACTURES OF THE JAWS 
383 
solution; (5) restore the soft as well as the osseous tissues into the most 
favorable position for repair; (6) immobilize and secure surgical rest. 
If infection and suppuration supervene the cause 
of this is not always easily detected. In this it is 
advisable to investigate and radiograph all of the 
teeth in the injured region. The radiographic examination should include 
more than the structures investing or immediately surrounding the teeth. 
In some cases portions of teeth or fragments of bone are driven to con- 
siderable depth within the line of fracture. 
If the fracture traverses the maxillary sinus, this cavity may, or may 
not become infected. Where the outer wall of the sinus is caved in to 
such an extent that it seriously encroaches upon this cavity and causes 
considerable facial deformity, this should be corrected. In the absence 
of external laceration it is more advisable to approach the bone lesion 
from the oral cavity than to expose it through an external incision. 
Where external incisions are made, the scar becomes attached to the bone 
so that it is often more disfiguring than the original deformity was. In 
the absence of a complicating factor the sinus should be treated the same 
as the other infected parts. In most cases where there has been no prior 
disease in the maxillary sinus, this will clear up with the cicatrization of 
the other injuries. 
Whatever the nature of the fracture may be, when immediate com- 
plete treatment is not permissible because of complications as above stated, 
it is advisable to restore the parts as closely as possible to their intended 
position and to maintain them there with temporary silk, or wire figure 
of eight ligatures applied about the teeth. This can be accomplished with 
very little disturbance. The occlusion of the teeth and the pressure of 
the mandible, reinforced with a Barton bandage, aid considerably in this 
temporary fixation. The disrupted parts in the maxillae are not so prone 
to be displaced as they do not move in function and are not acted upon 
bv the traction of the muscles as is the case in the mandible. 
The simplest types of fractures are those in 
which a portion of the alveolar process with the 
teeth contained therein is broken off. This is not an uncommon accident 
in the removal of teeth. The fracture may include one or more teeth. 
Sometimes the tuberosity is broken off in the removal of an impacted 
third molar, or deeply imbedded roots. The broken off fragment remains 
attached to the mucoperiosteum alone. Repair of these broken off frag- 
ments occurs much more readily in the maxillae than in the mandible. 
When there are a sufficient number of firm teeth on both sides of the 
fragment, this can often be securely immobilized with a simple orthodontic 
Infection of the 
Maxillary Fracture. 
Simple Fractures. 384 
ORAL SURGERY 
appliance, or with a stout wire bent to the shape of the arch. When the 
fracture includes the last tooth postei'iorly, a single arch splint is the most 
effective appliance for the case. If the use of a splint is decided upon, 
it is good practice to adapt this to all of the teeth, covering them to the 
gingival margin. The occlusal plane of the splint should be made in con- 
formity with the occlusal surfaces of the opposing teeth. In these simpler 
cases, the palate does not have to be covered. The splint should be 
cemented into place or the pressure of the lower teeth supplemented with 
a bandage may give sufficient retention. 
When the tuberosity becomes fractured, in a considerable number of 
cases, the maxillary sinus is exposed, or clearly opened. In this event it is 
best to restore the bone fragment into its proper position and hold it in 
place by suturing the mucosa with a few silk or catgut ligatures. The 
disrupted parts should be compressed as closely as possible, because the 
approximation, or the apposition of the tissues, aid cicatrization consider- 
ably and thereby the possibilities of infection are reduced. The restora- 
tion of the normal outline at this point is unimportant. 
In fractures of the second group the outer wall 
of the maxillary bone is fractured to a variable 
degree and the palate may be split at the median line, 
or at some other point. The degree and the direction of the displacement 
is dependent entirely upon the nature and direction of the force causing the 
fracture. The displacement may be upward and outward, or downward 
and towards the median line. In still other cases, the entire lowTer part of 
the maxillary bone is broken from all its osseous attachments, the line of 
cleavage being well above the teeth, parallel with the palatal process, carry- 
ing this and the floor of the maxillary sinus with it. If the separation upon 
the palate is not too large, and the fracture can be readily reduced, a cap 
splint fitted over the teeth of the complete arch, secures a very satisfactory 
fixation. If the palatal gap is considerable, and there are not sufficient 
teeth on the opposite side to offer adequate anchorage, the splint should 
be constructed as an ordinary dental plate, covering the entire palate. 
Whenever the anchorage offered by the teeth and the alveolar ridges 
seems insufficient, the retention of the splint may be aided by the pressure 
of the mandible and bandages. 
I have seen but a few cases in which the fracture 
was bilateral. In one case, both maxilire were torn 
from their bony attachments and there was a complete separation of the 
palate at the median line. In all bilateral fractures, a complete double 
arch splint can be used to the best advantage. In their construction, the 
two arches are coordinated with the original occlusion of the teeth. The 
Complicated 
Fractures. 
Bilateral Fractures. FRACTURES OF THE JAWS 
385 
disrupted parts are assembled into this appliance and held securely by 
the pressure of the mandible, aided with a stiff bandage. Where the 
cooperation of the patient cannot be depended upon, a plaster bandage may 
be used. This is applied as the Barton bandage, but the bandage roll is 
saturated, before it is put on, with a very thin watery mixture of plaster 
of Paris. When the plaster sets, the bandage is completely unyielding. 
Care should be exercised that the bandage be so placed that it does not 
extend much beyond the point of the chin, posteriorly. When it is placed 
too deeply, it causes considerable chafing of the tissues and may also inter- 
fere with deglutition. 
It may be well here to mention the several 
ingenious appliances invented for the treatment of 
fractures of the mandible and the maxillae, which 
depend upon external anchorage for immobilization. Many of these 
were conceived and constructed, before our present better understanding 
of and better facilities for oral prosthesis. Of these we may mention 
the Kingsley splint and the appliances devised by Martin, Beltramy, and 
others. They are used in combination with external bandages and straps, 
attached to metal or leather chin and skull caps, and are dependent upon 
the chin and skull for the point d’appui. Most of these are obsolete, as 
they are complicated, cumbersome and not efficient. 
In the very few cases in which I have attempted to utilize the prin- 
ciple upon which they are based, I have found that the immobilization was 
inadequate and that the absolute coordination of the upper and lower 
teeth, which is so important in the treatment of fractures of the jaws was 
entirely uncertain. I have therefore abandoned their use completely. Still, 
there may occur some few very exceptional cases in which some of them 
may be used with advantage. 
The prognosis of fractures of the maxillse is nearly always favorable. 
Where no complications set in, the fractured parts unite more rapidly than 
do fractures of the mandible. Even smaller fragments of bone reunite 
with greater frequency than in the mandible. When a deformity of the 
maxillary arch results, this can be corrected with prosthesis, much more 
easily than similar deformities occurring in the mandible. 
Appliances for 
Treating Fractures. 
Bandages. 
Bandages are made of muslin, gauze, linen, or some other fibrous 
material. The fabric is rolled up and cut in widths and lengths, in accord- 
ance with the needs of the parts to which they are to be applied. 
Bandages are used to hold in apposition, broken or severed tissues, to 386 
ORAL SURGERY 
Fig. 324. Barton’s Bandage. FRACTURES OF THE JAWS 
387 
Fig. 325. Gibson’s Bandage. 388 
ORAL SURGERY 
Fig. 326. The four-tailed bandage. FRACTURES OF THE JAWS 
389 
protect body surfaces, to produce pressure, and to hold a dressing or 
medicament in position. 
They are frequently used in surgery and in the treatment of injuries 
about the head, face and jaws. They can be used with advantage in the 
treatment of fractures of the mandible and the maxillse as a temporary, 
or supplementory means of immobilization. With a well applied bandage, 
considerable pain and discomfort may be prevented in the early treatment 
of a fractured jaw. In these injuries, prior to fixation of the parts, every 
movement, walking, talking, deglutition, causes a degree of motion of the 
broken parts and the friction of the broken surfaces causes, in some cases, 
excruciating pain, especially when the inferior dental nerve has been 
injured, severed or exposed. 
Bandages can be used as the sole means of fixation in the treatment 
of the very simplest types of fractures, when there is no displacement, 
nor tendency towards displacement of the disrupted parts, or when these 
are held in their normal relative position by the juxtaposition of the broken 
surfaces. They are indispensable in the treatment of all those cases where 
the appliance used cannot be relied upon for absolute fixation. 
The bandages which are best suited for the treat- 
ment of fractures of the jaws are, the Barton, the 
Gibson and the four-tail bandage. All of these are 
very simple to apply after a little practice. In the application of all roller 
bandages, the outer surface of the bandage should be placed next to the 
skin so that, as the bandage is being applied, it rolls away from the body. 
If the inner surface is applied to the skin, there is a tendency to pull the 
bandage out of the hands of the bandager. 
I have found the Barton bandage (Fig. 324-A, 
B and C) to be very satisfactory in the treatment of 
fractures and other injuries about the face and jaws. 
A two-inch, ten-yard bandage is used. The bandager stands on the right 
side of the patient; the roll of bandage is held in the right hand and the 
free end is grasped with the left. The initial end is placed just behind 
the right ear over the mastoid process (Fig. 324-A) ; from here the 
bandage is carried across the vertex of the skull, down the left side of 
the face just in front of the ear, underneath the chin, up on the right side 
of the face, across the first layer of bandage upon the vertex, and over 
the left mastoid process; next, the bandage is carried underneath the 
occipital protuberance, over the nape of the neck, across the chin and 
back to the starting point (Fig. 324-B). These turns are repeated five 
or six times to give stability to the bandage. Pins are inserted to secure 
all crossings, or adhesive tape may be used for the purpose (Fig. 324-C). 
Application of 
Bandages. 
Barton’s 
Bandage. 390 
ORAL SURGERY 
For the Gibson bandage (Fig. 325-A and B) a 
two-inch, ten-yard bandage is used. The bandager 
stands on the right side of the patient and the roller 
bandage is held in the right hand with the free end grasped with the left. 
The outer surface of the initial end is placed upon the vertex, and from 
here the bandage is carried down the left side of the face, underneath the 
chin, up on the right side of the face just in front of the ear, making 
three turns in this manner. The fourth turn is carried to the temporal 
region and here the bandage is inverted (Fig. 325-A), making three turns 
around the forehead and the occiput; at the fourth turn, the bandage is 
carried over the occiput to the nape of the neck and three turns are made 
across the chin; at the fourth turn the bandage is reversed again and 
carried over the vertex to the forehead (Fig. 325-B). The bandage is 
pinned at all crossings. 
The four-tail bandage (Fig. 326) is the simplest 
of the head bandages and like the Barton’s bandage 
it is used to support the mandible and to exert 
pressure upward and backward. A fairly heavy strip of muslin or linen 
one yard long and three inches wide is used. The two ends of the muslin 
are split in the middle to about three or four inches from the center. A 
slit is made in the center part which is placed over the point of the chin. 
The lower two tails are carried over the sides of the face and firmly tied 
over the vertex; the upper two tails are tied over the nape of the neck; the 
free ends are tied next to the corresponding ones upon the vertex. 
Gibson’s 
Bandage. 
The Four-Tail 
Bandage. CHAPTER XX. 
Dislocation and Luxation of the Temporomandibular 
Articulation. 
Dislocation is the partial or complete separation or displacement of 
two articular surfaces. This may be: (i) traumatic; (2) congenital; 
(3) pathological. 
Traumatic dislocations of the mandible are not uncommon. They 
may be partial, or complete; unilateral, or bilateral; simple, where there is 
no external wound; compound, where there is a surface wound communi- 
cating with the injured joint; complicated, where some of the structures, 
such as muscles, ligaments, or blood vessels are severed, or the bone is 
fractured. 
Dislocation of the mandible consists of the dislodgment of the condy- 
loid processes from the glenoid fossa of the temporal bone. The displace- 
ment may be forward, or upward and backward. 
When speaking of dislocations of the mandible, we usually mean the 
bilateral, forward, complete, simple dislocation. This is the one which we 
commonly meet: the others do not occur in the mandible, or are very rare. 
(Fig. 327.) 
The etiology of these dislocations are: forceful or excessive opening of 
the mouth, as in the act of yawning, laughing, vomiting, or the attempt to 
open the mouth beyond its normal capacity; dental operations, such as the 
taking of impressions; the insertion of a mouth gag under anesthesia, or 
the removal of lower teeth. A blow or external violence rarely causes 
dislocation, except a blow upon the chin while the mouth is open. 
The symptoms of bilateral dislocation are as follows : the mouth is ajar 
and fixed, the masseter muscle giving the impression of tension; the con- 
dyles slide from the glenoid fossa over the eminentia articularis where it 
becomes fixed by the muscles and ligaments; the patient is unable to close 
the mouth, although a slight opening movement may be possible; speech 
and deglutition are difficult; the saliva is dribbling from the mouth; there 
is a marked depression in front of the external ear and an elevation over 
the displaced condyle; there may be pain of varying degree, or the con- 
dition may be entirely painless. 
391 392 
ORAL SURGERY 
Fig. 327. Dislocation of the mandible in a woman 32 years of age. Note the 
outline of the ramus of the mandible, suggesting that the coronoid process is butting 
against posterior surface of the maxilla. This dislocation was of two days’ standing. DISLOCATION 
393 
When the dislocation is once reduced, in most cases there is no further 
trouble. From the complete absence of disturbing symptoms following 
reduction, we may conclude that the dislocation is not essentially attended 
with rupture of the capsular ligament, or injury to the articular disk, and 
that, in the painful cases, such injuries are likely to exist. There may be 
a tendency towards recurrence, and some individuals, after they have had 
the mandible dislocated once, must guard against forceful opening of 
the mouth. I have seen a young woman, twenty-one years of age, who 
could dislocate and replace her mandible with voluntary muscle manipu- 
lation. Sometimes the action of the muscles had to be assisted with 
pressure of the palm of the hand. 
Treatment of Dislocation of the Mandible. 
In the early stages, reducing a dislocated mandible offers very little 
difficulty. In doing this, I have found that a comprehensive manipulation 
is more effective than sheer force. The operator may assume two different 
positions: (i) The operator stands in front of the patient who is so seated 
that the head is not above the operator’s waist line. The thumbs are rested 
upon the molar region on both sides and the ramus depressed, while the 
chin is elevated from underneath with the other fingers. In this way the 
depressing thumbs act as the fulcrum for the leverage, the condyles are 
raised to the summit, or over the eminentia articularis, and with a slight 
backward thrust they glide back into position. (2) Where more force is 
necessary than can be exerted in this manner, the operator may stand 
behind and overhanging the patient, so that the pressure of the thumbs is 
aided by the bearing down of the weight of the body, while the other fingers 
elevate the anterior part of the mandible. In most literature the suggestion 
is made that the thumbs should be protected against biting by winding 
towels about them. I have never found this necessary, as the bone glides 
rather than snaps into place. 
The mandible is not infrequently dislocated during the administration 
of nitrous oxid. This is done either by excessive manipulation of the 
mouth gag, or by the force used in the removal of lower teeth. Whenever 
this is suspected or noticed, the dislocation should be immediately reduced, 
while the patient is still under the influence of the anesthetic, as it is much 
more easily done then than after the patient has recovered. 
In these immediately reduced cases, there is scarcely any trauma, post- 
operative pain or discomfort, in which event no treatment is necessary. 
When the patient experiences pain, rest should be secured by means of a 
Barton bandage and the patient is instructed to refrain from chewing hard 394 
ORAL SURGERY 
food for at least ten days or two weeks. Function should be resumed 
guardedly and gradually. 
Old dislocations, even after one or two weeks, are not quite so easily 
reduced, as the muscles and ligaments become fixed and rigid. In this 
event the patient should be put under a general anesthetic, preferably ether, 
and when the muscles relax, there is little difficulty in reducing the dis- 
location. Cutting down upon the joint is very rarely, if ever, necessary. 
Dislocations backward are very rare and are always attended with 
fracture of the anterior portion of the glenoid fossa of the temporal 
bone, or the tympanic plate. The external auditory canal, or the middle 
ear, may be infringed upon, and blood may escape from the external ear. 
There is no evidence that the articular disk is injured. These injuries are 
nearly always attended by concussion and severe shock. Because of the 
injury and inflammation of the joint proper, true ankylosis may follow. 
When intra-articular ankylosis results and movement of the joint cannot 
be restored, osteotomy of the neck of the condyle becomes necessary. 
Pathological dislocation is caused by the alteration or distention of the 
tissues comprising the joint, by sepsis or by inflammatory exudates result- 
ing from diseases, such as infectious arthritis, the febrile diseases, pneu- 
monia and others. This is rarely, if ever/observed in the mandible. 
Congenital dislocation is dependent upon a congenital deformity of the 
joint, which makes it impossible to retain the articular surfaces in their 
proper relative position. These types of cases have not been reported 
as occurring in the mandible. CHAPTER XXI. 
Ankylosis of the Temporomandibular Articulation. 
Ankylosis is the partial or complete fixation of a joint, clue to intra- or 
extra-articular alteration of tissues, resulting from injury or disease. 
Ankylosis has been classified in different manner by different authors, 
according to the peculiarities which they present in different parts of the 
body. The following classification is not in any way original, but an 
attempt is made to include only those types of conditions which are in 
accord with the clinical and pathological findings in this joint. 
(i) True or intra-articular ankylosis: In this there is an alteration of 
the tissues within the joint proper; the alteration may be fibrous but is 
more frequently osseous. (Fig. 328.) (2) False, or extra-articular anky- 
losis : In this the tissues external to the joint are altered or replaced by 
cicatricial tissue as a result of injury or disease. (Figs. 329 and 330.) 
The term “false ankylosis” is sometimes also applied to those cases of 
trismus or temporary partial fixation of the jaws, which are so frequently 
met in acute inflammatory conditions caused by abscess due to infected or 
erupting third molars; or, to parotitis, tonsillar and peritonsillar abscesses. 
Furthermore, ankylosis is not to be confounded with other conditions in 
which the jaws are spasmodically closed, as in tetanus ; or their movements 
limited as in hysteria, or by neurologic reflexes. 
The etiology of true or intra-articular ankylosis 
are: (1) Traumatic injuries of the mandible, trans- 
mitted to the glenoid fossa; (2) Extension of sup- 
puration from the middle ear ; (3) Mandibular osteitis extending to and 
involving the glenoid fossa; (4) Fracture of the condyle or the neck of 
the condyle from an external injury, as in posterior dislocation, which is 
followed by extensive callus formation; (5) Arthritis, as a part of involve- 
ment in a generalized arthritis, or this may be caused by metastasis from 
distant foci of infection. 
In true bony ankylosis the condyle and the glenoid fossa become solidi- 
fied by bony tissue formations. The ossification may also extend to the 
lower border of the zygomatic arch, and the coronoid process and the sig- 
moid fossa become welded to the zygoma. 
Etiology of 
Ankylosis. 
395 396 
ORAL SURGERY 
Fig. 328. Intra-articular partial ankylosis which commenced at an early age. Note 
the underdeveloped mandible, the receding chin, and the tension of the hyoid muscles 
caused by the attempt to open the mouth. (From the collection of the Oral Surgery 
Department, Vanderbilt Clinic.) ANKYLOSIS 
397 
An accurate diagnosis is important in the treatment of these cases and 
to obtain this is not always a simple matter. Attentive and detailed clinical 
examination and close inquiry into the past history should be supplemented 
with good radiographs. 
Fig. 329. Cicatricial ankylosis in a woman about 50 years of age. This resulted 
from ulcerations following scarlet fever at an early age. The ankylosis was more 
caused by the fibrous bands which tied the upper and lower jaws together than by 
the facial scar. 
There are some fairly definite diagnostic signs, which, if understood, 
aid materially in arriving at a diagnosis. In early cases, this is even more 
difficult as there is no, or but very slight, deformity; and the alteration of 
the tissues may be such that it cannot be demonstrated with radiographs, 
nor by clinical discernment. In those which occur in early childhood, 
there is usually a history of trauma sustained upon the chin, caused by a 
fall or a blow, and sometimes many months pass before the ankylosis 
becomes perceptible or complete and is discovered by the parents. As a 
result of such an injury, the capsular ligament becomes distended by the 
hemorrhage, or by inflammatory exudates, which may be followed by 
ossification. 398 
ORAL SURGERY 
When the ankylosis occurs in early life, the clinical appearance is of 
great diagnostic value: (1) There is a characteristic, conspicuous de- 
formity of the face, marked by a receding chin and underdeveloped man- 
dible. This underdevelopment, or aplasia, can he readily explained if we 
Fig. 330. The same case as Fig. 329, showing the intra-oral cicatricial bands. 
recall that the mandible grows in length from the epiphysis of the condyle 
and that the other four centers of ossification are united with bone before 
birth. Growth, therefore, is retarded or completely arrested by injury to, 
or ossification of the epiphysial line. Some authorities believe that this 
lack of development is due to atrophy because of lack of function. If 
atrophy is considered as a retrograde wasting or diminution of a part, 
this theory must give precedence to the former supposition. A lack of 
development is observed in all early cases. (2) For the same reason the 
ramus of the affected side may he slightly shorter and the angle of the 
mandible describes a rather obtuse angle. (3) The face on the affected 
side is full, rounded and appears to he normal. (4) The unaffected side 
appears flat and is of abnormal appearance, the flattening being most 
marked at the chin, and the chin may be slightly drawn over to the un- ANKYLOSIS 
399 
affected side. (5) There is no movement whatever on attempting to open 
the mouth, in bilateral bony ankylosis. (6) In unilateral bony ankylosis, 
upon attempting to open the mouth there may he a slight separation of the 
teeth and a deviation towards the affected side. (7) Forced effort may 
bring the mandible slightly forward through the action of the muscles 
of the neck and upon this sliding motion the palpating finger may discern 
a slight movement of the condyle on the unaffected side. (8) Upon 
attempting to open the mouth the muscular activity is greater on the 
unaffected side. (9) The muscles on the affected side are more atrophied. 
The treatment of true ankylosis, whether of 
fibrous or osseous nature, is essentially surgical. 
The attempt to establish motion by trying to change 
these altered conditions by means of wedging, forced movement, or thera- 
peutic measures, avails little more than the loss of effort and time. Simple 
osteotomy is nearly always followed by bony union. More satisfactory 
results can be obtained by arthroplasty. 
Of the various methods which have been used in the past for re- 
establishing motion in ankylosed or diseased joints, I shall mention those 
only which have been successfully used in the mandible and which find 
ready application in the treatment of this joint. These are: (1) Restora- 
tion of the mobility of a joint by the interposition of muscle or fibrous 
tissue between the separated surfaces; this was originally practiced by 
Helferich in 1893 ; (2) Transplantation of pedicled flaps or fascia and fat, 
establishing thereby a sliding movable joint. This was originally intro- 
duced by John B. Murphy, of Chicago,* with very gratifying results, in 
the treatment of the mandible, the hip, knee and elbow. This operation is 
the one which is in vogue at the present time; (3) Transplantation of free 
fat and fascia taken from distant parts of the body. This method is par- 
ticularly indicated in those cases where a pedicled flap is not available, 
because of the pathological conditions preceding, or associated with the 
formation of the ankylosis; (4) The interposition of metallic substitutes 
or the transplantation of heterovisceral absorbable membranes, as practiced 
by Roser and Baer. Murphy states that any method which depends upon 
the insertion of heteroplastic foreign bodies must perish from this field of 
work and is foredoomed to failure. These substances, even when aseptic, 
must be supplanted with fibrous connective tissue, which may permit of 
some degree of motion, hut will not provide a sliding movable joint, such 
as can he obtained with the use of an autoplastic pedicled flap. 
Treatment of 
True Ankylosis. 
* Murphy, John B.. Jour. A. M. A., June 6, 1914. 400 
ORAL SURGERY 
Technique of Operation for Ankylosis. 
Briefly stated, the technique of the operation consists of the following 
steps: The temporal area of the affected side is shaved and the entire 
region is prepared, as any field of operation would be. An L-shaped skin 
incision is made, with its vertical limb in the hair line and about a quarter 
of an inch anteriorly of the external ear; the horizontal limb is made 
parallel with the upper border, or over the zygomatic arch. The tissues 
are freely retracted next and the joint and the upper part of the ramus 
are exposed through the subzygomatic region. Care should be exercised 
that the temporal artery, or the seventh or facial nerve, which makes its 
exit from the skull through the stylomastoid foramen and traverses the 
lower portion of the parotid gland, are not severed. This accident is some- 
times inevitable, and when some of the fibers are divided, paralysis of the 
respective muscles of expression of the face follow. This may be only 
temporary, however. After the bone and the joint are clearly exposed, 
the neck of the condyle is divided by means of a Gigli saw, a bur, or chisel 
and mallet. In doing this, there is a danger of severing the internal 
maxillary artery, which is situated very close to the inner surface of the 
neck of the condyle. A portion of bone, one-half to five-eighths of an 
inch, is removed with its complete periosteum. Clearing out the glenoid 
fossa is not essential, and where this is attempted, there is a possibility 
of entering the base of the skull. A flap of the temporal fascia, fat and 
aponeurosis is raised next from over the temporal muscle. This is brought 
over the zygoma and tucked into the cavity created by the removal of the 
segment of bone, and is attached to the tissue laterally by means of two 
sutures. The final step is closure of the surface wound, dusting the line 
of incision with a dusting powder and applying a dressing. 
After the operation, a wooden block is introduced between the molar 
teeth on the operated side, which Murphy advises to keep in place day 
and night for two weeks. This will prevent shifting of the mandible and 
pressure upon the flap of fat and fascia interposed between the separated 
bone surfaces. Mastication, or opening the mouth, is not attempted for 
at least two weeks. 
The operation is not always followed by success. Frequent causes of 
failure are: (i) A part of the periosteum left in place, causing regenera- 
tion of bone. (2) The flap becomes necrosed because of pressure, exces- 
sive trauma, or because of infection, and the repair connective tissue be- 
comes ossified. (3) The transplanted fat or fascia becomes absorbed and 
replaced by connective tissue which becomes ossified. (4) The after care 
is not carried out according to instructions. ANKYLOSIS 
401 
It may be quite in place here to mention the 
operation devised by Brophy,* for which he claims 
very good results. The angle of the mandible is 
exposed through an external opening, the line of incision being in the 
shadow line of the jaw. The mandible is divided next with a bur, by 
making a crescent shaped incision, which is carried from the posterior 
aspect of the third molar, through the angle of the jaw. The convexity of 
the crescent is towards the ramus; this to prevent displacement of the 
parts. A sheet of gutta-percha, 2 mm. thick, is interposed between the 
divided surfaces of bone to prevent their reuniting and the external wound 
is closed, leaving a small opening for drainage. The wound is kept clean 
and the gutta-percha is left in place for six weeks. After this time the raw 
bone surfaces become covered with connective tissue. The original incision 
is reopened, the gutta-percha is removed and the wound is closed. This 
operation commends itself because of its comparative simplicity, its free- 
dom from complications and accidents. It must be evident, however, that 
a closer approximation to the original joint and a more normal function 
of the muscles can be obtained with arthroplasty. 
False or extra-articular or, as it is sometimes 
very appropriately called, interalveolar ankylosis, is 
established by the formation of cicatricial bands 
which may be lodged at any point between the symphysis and the posterior 
part of the oral cavity. They are more common in the molar and bicuspid 
regions and result from extensive ulcerations of the oral mucous membrane 
following typhoid and scarlet fever, measles, infections and extensive 
denudation of the alveolar processes; subzygomatic infections which may 
extend from the mouth, from the temporal fascia or from the scalp; also 
extensive destruction of tissue in cases of malignant growths or syphilitic 
gumma. The cicatrix is not always confined to the tissue of the oral cavity. 
In many instances the destruction of the oral mucosa extends to the 
surfaces of the face. 
In the treatment of cicatricial ankylosis, favorable results cannot be 
obtained by merely severing the tissue bands which cause fixation of the 
jaws. With successive incisions, there is an increase of cicatricial tissue 
which rather tends to aggravate than to improve the condition. The re- 
uniting of the severed bands or the denuded surfaces whence the cicatricial 
tissue has been removed, can best be prevented by covering these raw areas 
with mucous membrane or epithelial tissue. This can be secured by 
pedicled mucous membrane flaps as originally practiced by Murphy.** 
Brophy 
Operation. 
False 
Ankylosis. 
* Brophy, Oral Surgery. 
** Murphy, John B., Jour. A. M. A., June 6, 1914. 402 
ORAL SURGERY 
The pedicled flaps are taken from the soft and hard palate or from the 
floor of the mouth and are secured by means of ligatures. The apposition 
of the tissue may be assisted by the pressure of sponges, or by fitting a 
portion of wax to conform with the vestibule of the mouth. Wolff grafts, 
taken from the thigh, or from the outer surface of the arm, have likewise 
been successfully used for the purpose. In these cases the transplanted 
tissue is sutured on to the denuded surface and held in close apposition 
by means of a portion of wax, moulded into conformity with the normal 
anatomical outline of the parts. The transplant soon takes on the charac- 
teristics of the oral mucosa. CHAPTER XXII. 
Ludwig’s Angina. 
Ludwig’s angina is a severe, acute septic infection, characterized by a 
rapidly spreading edema, which involves the floor of the mouth, the sub- 
maxillary regions and the upper part of the neck. 
The disease was first described by Ludwig of Stuttgart, whence it 
derives its name. 
The etiological factor is a very virulent streptococcic infection which 
may be derived from a carious or infected tooth. The invasion may take 
place through a very slight abrasion or break in the continuity of the 
mucous membrane surface. 
The bacteria reach the submaxillary regions probably through the 
lymph channels, and the glands usually become enlarged or even destroyed, 
after which the infection spreads along the connective tissue planes. The 
first points of induration are, as a rule, the regions of the submaxillary and 
sublingual glands. The disease usually runs a very rapid and violent 
course. In a variable time, within one or two days, the entire floor of 
the mouth becomes involved, and the edema spreads to the glottis, causing 
dyspnea, and when this occurs trachiotomy must be performed to save the 
patient from suffocation. Very frequently the induration and the edema 
become so extensive that the whole neck presents a hard, boardlike, browny, 
discolored swelling, and this may spread to the lower parts of the neck 
or even to the mediosternum. There may or may not be some ill-defined 
points of fluctuation. There is a marked or only a moderate rise of 
temperature. 
The prognosis is not always favorable and there is high rate of mor- 
tality. When death occurs, this is not always due to septicemia but more 
frequently to edema of the glottis and bronchopneumonia. 
The treatment consists of prompt operative meas- 
ures. The edematous areas are freely incised, both 
intra- and extra-orally. The incisions should be made judiciously to avoid 
severing some of the larger blood vessels which traverse these regions. 
The incisions are so communicated that thorough drainage is established, 
which is maintained with rubber drainage tubes. Antiseptic fomentations 
may be beneficial. Stimulants should be freely used when indicated. 
Treatment. 
403 CHAPTER XXIII. 
Salivary Calculus. (Sialolithiasis.) 
Salivary calculus as used here designates the formation of calcific con- 
cretions within the substance, or within the duct of a salivary gland. 
The affection is comparatively rare but not quite so much so as the 
paucity of the reports of cases would indicate. My records show that 
during the past ten years I have seen and treated eight cases. None of 
these has been reported, principally because, despite the complications 
arising from them, they seemed to be of rather minor surgical or patho- 
logical interest. 
The affection may occur at any age. Some few cases have been 
reported as early as five or six years of age, and also some as late as the 
ages between sixty and seventy. They may occur in any one of the sali- 
vary glands; the most frequently affected is the submaxillary; next, the 
sublingual, and finally the parotid gland. 
The etiology of the formation of these calcific 
deposits is rather obscure and beyond plausible sur- 
mises nothing really definite is known. The follow- 
ing theories have been advanced: (i) A foreign body such as a fishbone, a 
fragment of calculus from the teeth, a piece of straw or toothpick, may find 
entrance into the duct and form a nidus for the deposition of calcific salts. 
(2) Inflammation of the duct causes retention of the saliva and through 
some unknown chemical change, brought about by the inflammatory con- 
dition, some of the calcium salts are precipitated. (3) Clumps or aggrega- 
tion of microorganism may find their entrance into the duct and form the 
nidus for the deposition of the calcific salts. (4) Retention of the saliva 
causes a chemical change and precipitation of some of the calcific salts, 
which may be retained in the inflamed and constricted lumen of the duct. 
The external form of these concretions suggests that they may develop 
in a portion of the gland proper, in which event they are irregular in 
outline and not easily dislodged. Others are cylindrical and ovoid in form, 
indicating that they were deposited in the duct. Those which are deposited 
in the duct are as a rule cylindrical in shape, more or less ovoid in outline, 
and vary in length and thickness. The substance consists chiefly of in- 
Etiology of 
Salivary Calculus. 
404 SALIVARY CALCULUS 
405 
organic salts, calcium phosphate and carbonate, and may also contain 
numerous organisms and some organic matter. 
The symptoms usually vary to a degree with the 
nature of the obstruction of the gland and with the 
gland involved. 
They may be divided into two stages. In the first stage, when the 
calculus is very likely small, there may be periodical irritation, inflam- 
mation, and an ill-defined sense of discomfort in the region of the 
affected gland. There may also be a degree of periodical swelling in 
the sublingual and the submaxillary regions. The swelling usually in- 
creases when eating, or when the sight of food induces a freer flow of 
saliva. This simply indicates that saliva cannot escape through the 
obstructed duct, is dammed back, and the gland becomes distended. These 
symptoms persist often for many months before the patient may become 
discommoded to such an extent that medical advice is sought. 
The second stage is marked with somewhat more disturbing symptoms. 
The swelling, though fluctuating in size, is fairly constant. Suppuration 
ensues. There is, as a rule, a marked inflammation, and the tissues under- 
neath the tongue become indurated, presenting a ridge over the direct 
region of the calculus. The calculus may be felt by manual palpation. 
Suppuration of a varying degree may likewise ensue, which may discharge 
freely from the orifice of the inflamed duct. There may be considerable 
swelling and induration of the base of the tongue, and also a swelling 
which may be seen in the submaxillary region. Often retention of the 
pus may take place; the pressure causes considerable pain and there are 
toxic symptoms and rise of temperature. 
In diagnosing, the case may be mistaken for a sublingual abscess, for 
lymphadenitis, tuberculosis, syphilis, or malignancy of the affected gland. 
It may sometimes be mistaken for a ranula. The absence of inflammation 
and disturbing symptoms easily differentiates it from the latter disease. 
In the parotid gland there is considerable swelling of the face because of 
the distention of the gland, and pain due to the unyielding, tense capsule 
enveloping this gland. Here it may be mistaken for mumps, cystic de- 
generation, syphilis or malignancy. 
That the diagnosis is not always easily made, is indicated by the fact 
that numerous cases reported, and some treated by me, were under medical 
care for some time before the true cause of the disturbance was discovered. 
One of the cases illustrates this well. A boy nine years of age had been 
complaining for about six months of periodical pain and swelling in the 
right submaxillary and sublingual region. After about three months, a 
filled first molar was removed as the suspected source of the complaint, 
Symptoms. 406 
ORAL SURGERY 
and because the now chronic abscess was evacuating through this point. 
The removal of the tooth did not seem to influence the symptoms. Upon 
examination I found that the tissues in the sublingual region of the affected 
side were considerably indurated, and that pus escaped upon pressure 
Fig. 331. Radiographic expression of salivary calculus. The film is on the occlusal 
plane, and the rays are directed from below the chin, upward. 
through a small orifice. A blunt silver probe was introduced through the 
point where the pus escaped, and very soon a solid, gritty mass was 
encountered within the duct. Probing through the duct is a very good 
means of ascertaining the presence of a calculus, but care must be taken 
that it is not pushed into the interior of the gland. 
The radiograph is also an unmistakable guide, when the obstructing 
body is large enough to be demonstrated by this means. A lateral exposure 
is not always satisfactory as the calculus is not more radiopaque than the 
bone and it may be thus overshadowed. A better method is to introduce 
one of the larger films as far back as the posterior part of the mouth per- 
mits. The patient is made to bite upon this, the head is thrown back as 
far as possible and the exposure is made from underneath the chin, the 
rays being directed parallel or nearly parallel with the long axis of the 
teeth. (Fig. 331.) This secures a well-defined picture of the floor of 
the mouth and the presence of a calculus is disclosed. SALIVARY CALCULUS 
407 
The treatment consists in the main in the removal 
of the calculus, which usually terminates all symp- 
toms. Upon the removal, considerable pus and thick, ropy saliva may 
be evacuated. Smaller stones may be passed through with finger manipu- 
lation by merely distending the orifice of the duct with a probe. In 
larger ones, or when the calculus is within the gland, the overlying tissue 
must be slit. Whenever possible this should be avoided, to prevent com- 
plete or partial cicatricial stenosis. It should be observed whether there 
are multiple stones, or, when one is broken, all particles should be carefully 
removed. In almost all adult cases this can be done under local anesthesia. 
In young or intractable children a general anesthetic must be used. 
The postoperative treatment consists of a general hygiene of the mouth 
by means of a mild antiseptic mouthwash. As a rule there are no 
complications. 
Treatment. CHAPTER XXIV. 
Leucoplakia Buccalis. 
Leucoplakia may be regarded as keratosis of epithelial tissue which 
may affect almost any part of the oral mucosa. It is most frequently 
observed upon the dorsum, spreading in some cases to the sides but very 
rarely to the under surface of the tongue. Other parts which are some- 
times affected are the buccal parietes, the inner surfaces of the lips, and 
even the pharynx is not immune. 
The keratosis usually appears in the form of smaller and larger, well 
circumscribed or irregularly outlined, milkish white, or grayish, glistening 
patches. Those occurring upon the mucosa of the cheeks are prone to 
appear raised, while those occurring upon the dorsum of the tongue often 
appear as depressed and desquamated surfaces. There are other cases 
which, in outline or in general appearance, do not correspond to the classical 
descriptions given in most text books. 
The case presented in Fig. 332 is atypical in many respects. This 
occurred in an Italian laborer, sixty-five years of age. He was a moderate 
smoker and a moderate drinker of light wines. I here was no luetic his- 
tory, and the Wassermann test was negative, even after provocative treat- 
ment. His mouth was generally in a neglected state and had only a few 
broken down and diseased teeth. The condition was noticed for some 
years, but, as there were no disturbing symptoms, very little attention was 
given to it. About six months before this, a degree of glositis developed, 
so that pain was experienced upon moving the tongue and food of every 
kind caused a degree of irritation. 
Upon examination, I found that the entire dorsum, back to the circum- 
vallate papillae, and the sides of the tongue, were covered with thick, fuzzy 
keratosis. It seemed as though the papillae had become elongated and 
hornified. He was unable to project, or turn his tongue, up to the roof 
of his mouth. There were no fissures, cracks, nor signs of any kind to 
indicate malignant degeneration. The condition was treated with radium, 
through which the keratosis was removed so completely, that the tongue 
was entirely devoid of papillae, and the mucous membrane appeared to be 
highly colored, very thin, glistening, and was exceedingly sensitive. There 
408 LEUCOPLAKIA 
409 
Fig. 332. Leucoplakia of the tongue in a man 65 years of age. Note to what extent 
the tongue is involved, the keratosis penetrating even to the under surface of the 
tongue. 410 
ORAL SURGERY 
were no fissures, ulcerations, nor breaks in the continuity of the surface, 
nor other signs of degeneration. This condition persisted for six months, 
after which the patient was lost track of. 
The etiology of leucoplakia is obscure. The 
popular belief is that it is caused by some kind of 
chronic irritation, such as the use of tobacco, of alco- 
hol or highly spiced foods. This assumption was largely founded upon the 
observations that they more frequently occurred in heavy smokers and very 
few cases in women have been reported. For some time it was believed to 
be the product of a syphilitic soil. This theory has been abandoned, as in 
the largest per cent of cases, the presence of syphilis could not be proven. 
The seriousness of leucoplakia lies in the fact that it is recognized to 
be a precancerous condition. Especially those of the tongue have the tend- 
ency to form fissures, or they may ulcerate and undergo malignant 
degeneration. It is advisable to instruct these patients to return for 
observation at stated intervals. Upon the first sign of degeneration, the 
part of the tongue bearing the patch should be excised, before a positive 
cancerous condition develops. To treat with caustics or silver nitrate, at 
any stage, is just courting trouble. When there is reason to believe that 
malignancy has developed, the operation must be more radical. 
The treatment should be principally preventive. The patient is in- 
structed to abstain from smoking, the use of alcoholic drinks, and all spicy 
and irritating food substances. 
The prognosis is not essentially alarming. About twenty to thirty per 
cent of the reported cases have been found to undergo malignant degenera- 
tion. When epithelioma develops the chances of recovery is in a ratio with 
other cases of malignancy of the tongue. 
Etiology of 
Leucoplakia. CHAPTER XXV. 
Neoplasms of the Oral Cavity. 
The subject of neoplastic diseases in general is so broad in its scope, 
and so overwhelmingly important, that it is my opinion that whoever 
assumes the responsibility for their diagnosis, or undertakes their treat- 
ment surgically, or by therapeutic means, must have more than a mere 
passing knowledge of the subject. 
With this view in mind, it is beyond the scope of this book to deal with 
the topic in this broader and comprehensive manner. To do justice to 
the subject, it is essential that one should acquaint himself, as far as 
possible, with the pertinent literature extant in the text books, and also 
the individual contributions published in different periodicals. I should 
like to point out in this connection that reading knowledge alone is entirely 
inadequate to a clearer comprehension of the different phases and often 
confusing clinical aspects which individual cases may present. Nor are 
laboratory findings, even in the hands of expert pathologists, always 
reliable. On more than one occasion it has been my experience, as well 
as that of others, that specimens deliberately taken from a neoplasm were 
returned with the diagnosis, “inflammatory tissue.” A reliable diagnosis 
and treatment must be based upon prolonged and close clinical observa- 
tions and study of individual cases. This should be combined with a 
comparison of the laboratory findings, observations and well-kept data 
followed up for a period of years, after treatment has terminated. 
A neoplasm may be defined as the proliferation 
of new tissue which is autonomous in its growth and 
which shows no purpose in structure nor of function. 
The etiology of neoplasms is, today, nearly as 
much of an enigma as it has been in the past. A 
number of old theories have become obsolete and 
been discarded. A number which still survive are the subject of contro- 
versy and are partly retained, because they contain some elements which 
provide a workable hypothesis. Through the extensive experimental re- 
search and the investigations by specifically endowed institutions for can- 
cer research, also because of the more accurately kept data and the statistics 
based thereon, we learn more and more definite facts about the etiological 
Definition 
of Neoplasms. 
Etiology of 
Neoplasms. 
411 412 
ORAL SURGERY 
factors, and these scientifically conducted observations will bring us, in the 
course of time let us hope, nearer to the solution of the subject. 
Of the prevailing theories regarding the etiology we may mention the 
following: Misplaced embryonal cells which begin to develop, as with 
advanced age the physiological restraint normally controlling tissue growth 
is released; the inciting of dormant embryonal cells to greater activity; 
aberration of function with a concomitant power for greater prolif- 
eration.* 
The most widely known hypothesis for the etiology is generally credited 
to Cohnheim. This assumes the existence of embryonic groups of cells 
in the body, which, under some unknown circumstances, are propelled to 
over-active proliferation. This theory was formulated upon Virchow’s 
law that “every cell comes from a pre-existing cell.” Cohnheim failed to 
point out just what these activating forces are and his hypothesis was 
further elaborated by Ribbert. Ribbert holds that the process can be 
explained best by the assumption that in the formation of an epithelioma 
the epithelial cells prepare the soil into which they later penetrate. Hauser 
believes that an epithelioma or carcinoma can originate only through a 
fundamental change in the biological properties of the implicated cells. 
From these, and numerous other propounded theories, it is clear that 
the true etiological factor still remains undiscovered. We do have, how- 
ever, some very definite information as to specific conditions with which 
neoplasms are found to be associated. F.wing points out, in this connec- 
tion, that heredity may be one of the predisposing factors.** Also, types 
of growths have been noted to be prevalent in certain occupations or under 
circumstances where habits produced points of irritation. Ewing also 
states that, notwithstanding the generally observed cell autonomy, “it may 
be almost said that the etiology of each form of tumor is specific, and that 
a practical knowledge of tumor etiology requires a minute analysis of all 
the factors in each case.” 
It is probable that it is with this view in mind 
that, at a recent meeting, Bloodgood made the sweep- 
ing statement that cancer of the mouth is a prevent- 
able disease. On this occasion he pointed out, also, that people who keep 
their teeth well attended rarely develop cancer, but that it is almost in- 
variably observed in filthy mouths, or in patients who wear ill-fitting 
dentures. Those people whose teeth are kept in a healthy, clean 
and smooth condition are comparatively immune. Unquestionably, 
there are exceptions to this rule. My own recollection, of the numerous 
Relation of 
Teeth to Cancer. 
* Delafield and Prudden, F. C. Wood, Text Book of Pathology. 
** Ewing, Neoplastic Diseases. NEOPLASMS 
413 
cases which I have seen, is that in almost every instance of malignancy, 
the teeth were in a very dilapidated, and mouth in a generally filthy, 
condition. 
In neoplastic growths about the oral cavity we recognize therefore that 
the specific etiological factors are trauma, and some form of constant or 
repeated irritation. Judd * states,—“An old, broken or roughened tooth, 
in constant contact with the border of the tongue, may result in ulcer 
formation and later epithelioma.” Broders (quoted by Judd) is inclined, 
to believe that smoking, as an etiological factor in the production of a 
lesion upon lip or tongue, is considerably overestimated. 
In the February, 1923, issue of Surgery, Gyne- 
cology and Obstetrics, there appears a symposium on 
carcinoma of the jaws, tongue, cheek and lips. The 
contributions come from some of the most noted surgeons, with many 
years of experience in this field:—Crile, Judd, New, Brewer, Ochsner, and 
Blair. The compilations presented contain, besides personal experiences, 
statistics derived from other creditable sources here and abroad. From the 
perusal of this article one is impressed with the gravity of the malady, and 
that although numerous cures are reported, the prognosis at best offers a 
rather dismal outlook. 
There seems to be a concurrence of opinion that the malady can often 
be prevented if recognized in the precancerous stage, as an ulcer upon the 
tongue, a fissure or point of irritation upon the lip, leucoplakia in its early 
stages of degeneration, etc. In the early stages of cancerous degeneration 
a cure may be definitely expected. It is very unfortunate that those who 
are afflicted with the malady, often through sheer negligence, through 
ignorance, or because of the absence of disturbing symptoms, apply for 
treatment only when the growth has attained an advanced or inoperable 
stage. That professional meddling is often the cause of delay is not in- 
frequently observed. Blair, in the above cited article, makes the following 
statement: “Fifty per cent of all carcinoma of the mouth could be elim- 
inated in the precancerous stage.” 
Further quotations from the above stated article 
are of more than passing interest from a surgical 
standpoint. “It is the duty of every physician and dentist who is con- 
sulted with regard to an apparently insignificant lesion, completely to 
remove the lesion and to determine its exact character as early as possible. 
If the ulcer has been treated locally, a report of inflammatory tissue from 
the pathologist should not be considered absolute.” 
Symposium 
on Carcinoma. 
E. S-. Judd. 
♦Judd, Surgery, Gynecology and Obstetrics, February, 1923. 414 
ORAL SURGERY 
“I agree with Judd’s objection to temporising 
A. J. Ochsner. anc[ local treatment with silver nitrate, iodin or other 
remedies until secondary involvement of the lymph nodes has occurred. 
Early diagnosis and radical operation with the cautery should be insisted 
upon.” Ochsner further makes the following conclusions:— 
(1) “Cancer of the jaw is usually preceded by some form of irritation 
(mechanical) or trauma, caused by decayed teeth, ill-fitting plates, 
etc. 
(2) “Inflammation due to unclean or infected conditions usually precedes 
the cancer formation. 
(3) “The growths are characterized by slowness in invading the sur- 
rounding tissues. 
(4) “They fail to produce metastasis in remote organs. 
(5) “Incomplete operations are followed by immediate recurrence and 
rapid increase of growth, regardless of secondary operations and 
X-ray or radium treatment. 
(6) “Insufficient radiation seems to have the same harmful effect. 
(7) “The best results are obtained from very thorough, early operation 
with the cautery iron, destroying at least one centimeter of ap- 
parently healthy tissue of the surrounding area. The rule is, 
destroy as much tissue in the primary operation as we would 
naturally expect to destroy after the first recurrence.” 
“When death occurs from cancer of the head and 
George W. Crile. llecft; ft ft because of local and regional development 
of the disease and not because of distant invasion. The collar of lym- 
phatics about the neck forms an almost impassable barrier through which 
cancer rarely penetrates. Every portion of this barrier is accessible to 
the surgeon. In 4500 reported cases of autopsy, in only one per cent 
were there secondary foci in distant organs.” His conclusions are in 
part 
(1) “The primary focus may be destroyed by cautery or removed by 
excision. 
(2) “Local excision of only the primary focus of the tongue, lip and the 
floor of the mouth, leaving regional lymphatic glands, is as ineffec- 
tual as excision of the breast without removal of the regional glands. 
(3) “Excision of individual lymphatic glands not only does not afford 
permanent cure, but is usually followed by greater dissemination 
and more rapid growth. NEOPLASMS 
415 
(4) “The logical technique is a complete block excision of the regional 
lymphatic system, together with a wide excision of the primary 
focus. 
(5) “A single treatment with deep, accurately measured X-ray or radium 
dosage is employed after operation.” 
Whatever their location or their point of origin may he, tumors may he 
loosely classified as being,— (1) benign, (2) malignant. 
Benign tumors are characterized as follows:— 
(1) They proliferate slowly, although there may be periods in their life 
history during which they increase very rapidly after considerable 
seeming inactivity. Some may attain so large a size that they 
infringe upon the surrounding tissues or structures. 
(2) They enlarge through a multiplication of their own cells rather than 
by the invasion of the adjacent and subjacent tissues. 
(3) They do not metastasize. 
(4) They do not recur if thoroughly removed. 
Malignant growths are characterized as follows:— 
(1) They show rapid growth. 
(2) They infiltrate the surrounding tissues and the invasion may progress 
without limitation until the patient dies. 
(3) They metastasize; the secondary growths may appear in the vicinity 
of the original growth, or at some remote point. 
(4) They tend to recur after removal. 
In the clinical study and diagnosis of a neoplasm 
observe :—the anatomical location; the clinical ap- 
pearance ; the relation to adjacent tissues; the histo- 
logical structure, or better, the apparent texture. Determine the tissues 
from which it springs; the period of growth, or the life history; the pres- 
ence of involvement of the glands when this can be determined by gentle 
palpation; the possible reaction upon the entire organism. 
Other diagnostic considerations are : Age : Sarcoma of the jaws is more 
commonly found in younger patients, before thirty-five or forty, though 
some authorities place this at fifty. Carcinoma of the jaws is more fre- 
quent between the ages of fifty and seventy. Adamantinoma is usually 
observed between the ages of twenty and forty. Sex: Epuloid growths 
are more frequently observed in women while carcinoma of the oral cavity 
is more common in men. 
In the examination of neoplasms, it is very strongly advised not to 
subject the tumor to palpation when this can be avoided. Palpation may 
Diagnosis of 
Neoplasms. 416 
ORAL SURGERY 
disengage some of the neoplastic cells, which may be carried to remoter 
areas through the channels of communication (Tizzer). It is equally ill 
advised to cut into a tumor, or to remove a portion of it for examination. 
It has been pointed out that even the finest blade of a knife may detach a 
few neoplastic cells, which may be transported to distant parts through 
Fig. 333. Inflammatory hyperplasia caused by an ill-fitting plate. The patient was 
56 years old and had worn her first plate for the past twenty or thirty years. 
Note the numerous invaginations which may give the impression of malignancy. 
There was no complication after removal. 
the severed blood and lymph vessels. If a tumor gives a history of having 
existed for several years, it is probable that it was not malignant at its 
origin or that it is not malignant. But when there is a sudden propulsion 
of rapid growth it is probable that there is a malignant degeneration. 
The classification of tumors is largely dependent upon their resemblance 
to certain types of tissue with which they are not entirely identical. How- 
ever, other classifications are regional and etiological. This vague classi- 
fication is not always applicable, as there are tumors of the malignant type 
which do not resemble any normal tissue (Ewing). 
For our purposes it will be the simplest and most satisfactory method, 
therefore, to classify the tumors of the oral cavity on a histological basis: NEOPLASMS 
417 
Fig. 334. Inflammatory hyperplasia in a woman 45 years of age. Note here also 
the number of folds of tissue indicating the progressive absorption of the alveolar 
bone and the compensating tissue formation. 418 
ORAL SURGERY 
Fig. 335- Inflammatory hyperplasia of the lower jaw in a woman 46 years of age. 
The growth was continuous with a fibrous tissue band posteriorly, which likewise 
had to be removed to make it possible for her to wear a plate. She had worn 
her first plate for over twenty years. NEOPLASMS 
419 
(1) The connective tissue type:—Fibroma; epuloids; osteoma; angioma; 
sarcoma; chondroma; lipoma; odontoma. 
(2) Of the epithelial tissue types there are: Epithelioma; carcinoma; 
adamantine epithelioma. (This probably is a mixed tumor.) 
Inflammatory Hyperplasia of the Oral Mucosa. 
Inflammatory hyperplasia of the oral mucosa, as illustrated in the 
figures 333, 334 and 335, are comparatively rare conditions. They spring 
from the labial and buccal mucosa and the alveolar mucoperiosteum, as 
the result of irritation caused by an ill-fitting plate. While their appear- 
ance rather suggests that of a new growth, they are not neoplasms in the 
true sense of this term, and are always benign in character. I present 
these in this chapter because of their appearance, as they may be mistaken 
for a neoplastic growth. 
The clinical appearance and the history of these cases suggests the 
following cause for and course of their development. The removal of 
teeth is always followed by shrinkage and absorption of the alveolar 
process and the overlying mucous membrane. The degree of shrinkage 
and the period through which this takes place varies in different individuals. 
When an artificial denture is inserted soon after the removal of the teeth, 
with this shrinkage of the tissues a space is formed between the alveolar 
ridge and the plate. At this period, it is desirable to modify the denture 
to meet the existing conditions, or to replace it with a new one. Where 
this is neglected a point of irritation is established which, though not 
intense enough to cause actual discomfort, may in some individuals incite 
tissue proliferation. Under these conditions the overhanging tissues sag 
into and conform to the space. With further shrinkage a second lobe may 
form, accommodating itself to the existing conditions, and in this way I 
have seen cases in which one, two, three, and even four layers or folds of 
tissues have formed and the plate while containing this exuberant tissue 
was but insecurely retained. In some cases this proliferation is limited to 
smaller areas. There are others, however, where the entire alveolar ridge 
becomes involved and sometimes even mars and displaces the lips. 
The mass of new tissue is always covered with normal mucous mem- 
brane, and, beyond the invaginations of the different lobes, presents no 
signs of inflammation and there is no tendency towards hemorrhage. The 
patient is eventually disconcerted by the insecure retention of the artificial 
denture, and the condition is discovered by the dentist. In some cases the 
condition is discovered and relief is sought ten, fifteen, or even twenty 
years after the insertion of the artificial denture. This implies that the 420 
ORAL SURGERY 
irritation must have existed through a period of years with no sign of ma- 
lignancy, nor tendency towards a malignant degeneration. Tt is impossible 
to state whether such degeneration would occur in the course of time. 
The condition is corrected by the removal of the hypertrophied tissues 
in conformity with the normal alveolar ridge. In this, care must he taken 
Fig. 336. Shows the incision to dissect away the lowest and the uppermost surface 
of the mucosa, for the removal of hypertrophied tissue. 
so that the resulting cicatrix is reduced to the minimum. Extensive, tough, 
cicatricial tissue bands render the lips inflexible, and materially interfere 
with the retention of the artificial denture later. 
Simple excision of the mass of tissue often 
creates this condition. Better results are obtained by 
the following method: The mucous membrane is 
dissected down from the upper and lower surface of the growth close to 
the hone (Fig. 336) and the bulk of the growth which is now lodged 
between the two flaps of mucous membrane is removed (Fig. 337 a. b. c.). 
It will be found that it consists mainly of connective tissue bands which 
may run parallel or may be interlacing, and are abundantly interspersed 
Operative 
Treatment. NEOPLASMS 
421 
Fig. 337. A, B and C are diagrams showing the successive steps in the operation. 422 
ORAL SURGERY 
with adipose tissue. The blood supply is frequently quite rich, especially 
in the anterior part of the mouth. The severed blood vessels should be 
secured with catgut ligatures, to avoid undue ecchymosis or other com- 
plications. The hypertrophied tissue is completely dissected away, close 
Fig. 338. Shows the mucous membrane flaps trimmed and sutured into place, 
to the bone, and the mucous membrane flaps approximated. The surplus 
of mucous membrane is trimmed away and, whenever conditions permit, 
the flap nearest to the alveolar ridge is carried about two thirds over the 
area to be covered. By so doing a higher alveolar ridge is produced and 
the too low attachment of the labial and buccal tissues prevented. The 
flaps are sutured with fine catgut or horse-hair, with interrupted sutures. 
(Fig. 338.) 
Where the condition is such that the labial or buccal flap of mucous 
membrane must be utilized, to prevent the formation of too short a ridge, 
it can be depressed with modelling compound adapted to the denture or 
may he held in place by the approximation of the jaws. 
After forty-eight hours this appliance may be discarded, and the 
sutures are removed four or five days after the operation as these condi- 
tions usually heal by first intention. NEOPLASMS 
423 
Epulis. 
Epulis is ci benign growth which, as the term implies, appears on the 
gums about the teeth, or upon the alveolar ridges. Epulides more fre- 
quently spring, however, from the peridental membrane of a tooth to which 
they seem to be often attached. In many instances they are observed in 
parts which ha\e been edentulous for a number of years. 
Xot unlike other neoplasms about the oral cavity, their formation can 
almost invariably be traced to some prolonged and constant irritation. 
The most frequent, apparent, etiological factors are: Calcific deposits 
about the teeth ; broken-down teeth and the jagged edges of carious teeth 
dipping down into the gum tissues; ill-fitting dentures, clasps, bridges; 
overhanging fillings; and sharp portions of the alveolar process following 
the removal of teeth. I have seen numerous cases of epuloid growths 
where there was no apparent irritating factor which appeared upon the 
labial surfaces of the anterior sound and clean teeth in young subjects 
339)’ I he most frequent site for their occurrence is the anterior 
part of the upper jaw, the incisor and the bicuspid regions. They occur 
more often in women than in men. Women, during the period of preg- 
nancy or lactation, are particularly prone to develop these growths, and I 
have seen a number of cases which markedly decreased in size, or entirely 
disappeared, upon the termination of this period. 
Epuloid growths vary in size, the average size being from three to 
four centimeters in diameter. There are many which are considerably 
smaller, and again some very much larger ones have been reported. 
While epulides are usually regarded to be distinctly benign growths, 
there are some which manifest malignant characteristics, and they may 
undergo a malignant degeneration. 
Epuloid growths are generally grouped into two classes : (1) The fibro- 
matous, (2) the sarcomatous. This differentiation is based upon the dis- 
tinctiveness of their clinical appearance, their tendency towards recurrence 
aftei removal and the histological structure;* The sarcomatous types are 
also known as giant cell sarcomas. 
Fibromatous epulis is more frequently observed 
to grow upon the buccal or labial aspect of the teeth. 
Some seem to grow from the periosteum within the 
interdental spaces, and, separating the teeth, they straddle the alveolar 
ridge. Still others seem to be confined to the palatal aspect. They almost 
invariably appear to spring from a constricted base, and spread out in a 
mushroom-like fashion; i. e., they are pedunculated. (Figs. 340. 341 and 
342.) They are covered with what appears to be a continuation of the 
Fibromatous 
Epulides. 424 
ORAL SURGERY 
Fig. 339. Fibromatous epulis in a young woman 19 years of age. It originated 
from the mucoperiosteum and peridental membrane of the bicuspid teeth. The 
second bicuspid was entirely and the first bicuspid was but partly covered by the 
growth. Both of these teeth were free from pathological lesions. The source of 
irritation could not be determined as the entire mouth was well cared for and clean. NEOPLASMS 
425 
Fig. 340. Fibromatous epulis in a woman 40 years of age. The growth was not 
observed until about 3 or 4 weeks prior to the consultation. It arose from the 
alveolus of the crowned cuspid tooth. The irritation of the crown most likely 
induced the growth. Note the smooth surface of the growth. Fig. 341. Fibromatous epulis in a woman 20 years of age. The growth was first 
noticed about three months ago. It arose from about the roots of a broken down 
bicuspid tooth which it covers. It straddled the alveolar hone and the mass of the 
growth was fairly uniformly divided on the lingual and buccal aspect. 
Fic,. 342. Fibromatous epulis in a woman 42 years of age. This was growing about 
an ill-fitting crown bearing a bridge, 
426 NEOPLASMS 
427 
normal mucous membrane and do not have a tendency to bleed, except in 
those cases where they extend over the biting surface of the teeth, and the 
irritation of the cusps beneath, or those of the opposing teeth, causes 
laceration of the surface of the growth. 
Fig. 343. Sarcomatous epulis in a woman 35 years of age. The two bicuspids, the 
cuspid and the first molar were involved. Note the lobulated and pitted surface of 
the growth. It was of a deep red color and bled readily. The pathological report 
was that of giant cell sarcoma. 
The sarcomatous types are very similar in their 
behavior and in their etiology, but they present a 
somewhat different clinical picture and prognosis. 
These growths usually spring from a broader base; there may he a slight 
degree of infiltration and destruction of the subjacent structure. The outer 
layer of tissue presents numerous furrows and invaginations, and the 
surface appearance is granular or like that of a strawberry. They vary in 
color from a bright inflammatory red to a deep cyanotic hue. They have 
a great tendency to bleed and to recur if not thoroughly extirpated. (Figs. 
343 ancl 344-) 
Sarcomatous 
Epulides. 428 
ORAL SURGERY 
Fig. 344. Sarcomatous epulis in the lower right bicuspid region in a woman 45 years 
of age. The neoplasm grew over the jagged edges of the alveolus where the teeth 
had been extracted several years ago. The growth was deep red and in some parts 
cyanotic blue in color. Note the lobulations and the broad base from which it 
springs. NEOPLASMS 
429 
The treatment of epulis consists of the complete 
surgical extirpation of the growth. It is probable 
that some men are driven to pessimism by the insidi- 
ousness of neoplasms in general, and therefore they advocate and practice 
what, in my estimation, are ultra-radical measures in many instances. They 
advocate the removal of a number of teeth in all cases, and also a goodly 
portion of alveolar bone, to prevent recurrence. I have found that when 
the diagnosis is definitely that of fibromatous epulis, these aggressive meas- 
ures are not always necessary. I have removed numbers of smaller and 
larger epuloid growths, leaving all good teeth within the region intact. 
Many of these cases were followed up for five years and even longer, and 
there was no recurrence. When the teeth are not diseased and the peri- 
cementum and the alveolar process present no clinical or radiographic- 
signs of infiltration or deterioration, they can often be safely retained. 
It is essential, however, that all the tissues which appear to form the bed 
of the growth should be eradicated. Where the teeth are diseased, de- 
vitalized, crowned, or contain larger fillings, they should be removed 
together with the larger part of the alveolus. 
With a sharp knife or cautery the growth is circumscribed, the incision 
being carried well beyond what appears to be the base of the growth and 
down to the bone. This incision is carried through on both the labial and 
the palatal surfaces. All tissues thus circumscribed are raised from the 
bone, together with the periosteum. When the bone is exposed, every 
vestige of the periosteum and sharp or deteriorated portions of bone at the 
site of the growth are removed. 
In the sarcomatous types, our measures must be considerably more 
radical. The removal of the growth should include also a goodly portion 
of the underlying bone; also the teeth which are implicated in the growth. 
Within the past number of years I have been using the actual cautery 
in the removal of all benign neoplasms about the oral cavity, although, I 
must admit, that for a number of years I used the knife and blunt dis- 
section in most cases with excellent results. I have adopted the use of 
the cautery because in a way it is often simpler to use, and also because 
of the degree of safety which it offers. 
Treatment 
of Epulis. 
Fibroma. 
Fibroma is a benign growth and consists chiefly of dense and some- 
times lobulated masses of connective tissue. 
Fibroma of the jaw, which is comparatively rare, may occur in the 
upper as well as in the lower jaw. It may originate in the periosteum of 
the bone, on the alveolar ridges, or may spring from the inner substance 430 
ORAL SURGERY 
1'IG. 345. Fibroma of the lower jaw which occurred in a young woman 23 years 
of age. There was the history of having had two loose teeth removed two years 
prior to the time when this radiograph was taken. The first sign of swelling 
appeared about three months before. The growth was diagnosed to be a cyst, as 
it presented clinically, in its life history and in the radiograph, the characteristics 
of this growth. The growth was completely incapsulated, dense and hard in sub- 
stance and the pathological report was that of fibroma. NEOPLASMS 
431 
Fig. 346. Small growth such as is sometimes seen in different parts of the vesti- 
bule of the mouth, or near the lips. 432 
ORAL SURGERY 
of the bone. It may reach quite a large size and some cases that have 
been reported have attained such dimensions that they caused a marked 
destruction of the invaded region and distorted facial symmetry, causing 
deformity. Nasal polypi and also those frequently found in chronic affec- 
tions of the maxillary sinuses are classed as fibromatous growths. 
When developing in the maxillae or in the mandible the bone becomes 
distended and thinned out at the point of the growth. In this they often 
resemble cysts. As a rule they are painless unless some nerve trunk is 
pressed upon. In the diagnosis we must differentiate them from cysts and 
sarcoma. 
The one case which came under my observation occurred in a young 
woman twenty-three years of age. (Fig. 345.) The two missing molars 
had been removed about two years before this radiograph was taken. 
There were no disturbing symptoms then, except that the teeth were loose. 
At this time, there was a marked non-inflammatory swelling of the 
mandible, and the bone crepitated at some points upon pressure. The pain 
was negligible and periodical. The growth presented all the clinical, his- 
torical and radiographic characteristics of a cyst. The first information 
of the neoplastic nature of the growth was obtained upon aspiration. In 
operating, it was found that the growth was completely incapsulated and 
could be practically shelled out like a cyst sac. 
The gross appearance of the tissue upon section was that of closely 
packed, gritty masses of fibrous tissue. The pathological report confirmed 
this diagnosis and it was reported to be a fibroma. In the operation, no 
invasion beyond the capsule was discerned, although a large part of the 
body of the mandible had been destroyed. The case was operated on 
seven years ago. The patient was last seen five years after the operation, 
at which time there was no sign of recurrence, and the patient was well. 
Smaller and larger growths such as illustrated in Fig. 346 are some- 
times observed in different parts of the vestibule of the mouth, or near 
the lips. They are not inflamed and present no disturbing symptoms ex- 
cept when they are traumatized in chewing. The mucous membrane is 
intact and the growth is freely movable within the tissues. It is roundish 
in outline and hard and painless upon palpation. When the overlying 
mucosa is split it can be readily separated from the surrounding tissues. 
Macroscopically it appears as a white fibrous tissue mass and pathological 
examination shows that it consists of fibrous tissue. 
Other Benign Growths. 
Osteoma is a benign growth which consists most often of compact bone 
tissue. These tumors occur very rarely about the jaws, and they are to NEOPLASMS 
433 
be differentiated from other hyperplastic conditions, such as we often find 
following inflammatory conditions about the jaws. They are also to be 
differentiated from those congenital exostoses which appear as excrescences 
in the maxilla at the tuberosity and upon the palate, or upon the inner 
surfaces of the mandible. 
True osteoma may develop in the upper or in the lower jaw, in the 
maxillary sinus, and in some instances they attain considerable size in- 
fringing upon important structures in their region, or they may spread 
and involve a complete surface of the bone. 
Lipoma is a benign growth consisting chiefly of fat and connective 
tissue. Lipomas usually occur in the submucosa of the sublingual region, 
upon the tongue or at some other point of the oral cavity. They grow 
very slowly but may attain considerable size, so that they may interfere 
with function, when removal becomes necessary. They occur but very 
rarely in the oral cavity. Only a very few cases have been reported. 
Angioma is a tumor consisting of vessels. Two different types are 
known : the hemangioma and the lymphangioma. 
Hemangioma is made up of newly formed blood vessels. Of these two 
types are differentiated: (i) the simple or capillary (tellengiactasis), (2) 
cavernous angioma. 
Sarcoma. 
Sarcoma is a malignant neoplasm composed chiefly of connective tissue 
type of cells. 
Sarcomatous growths may occur in any part of the mandible, in the 
maxillae, upon the alveolar ridges, in the maxillary sinus, in the salivary 
glands, and some few cases have been reported which developed upon the 
tongue. Sarcomas are generally observed to grow in younger patients, but, 
in the jaws, they occur comparatively rarely in young children. I have 
seen some cases in children between the ages of seven and ten or twelve 
and also some at the ages of fifty and fifty-five. 
Sarcomas may develop from the periosteum, from the bone substance, 
from the medulla, and from the blood and lymph vessels. 
In pathological examination, three varieties are differentiated based 
upon the histological cell forms of the tissues; the giant cell; the spindle- 
shaped ; and the round-cell sarcoma. The spindle-shaped and the round- 
cell types are classed amongst the most malignant tumors known. These 
develop and metastasize very rapidly; often with fatal termination. 
Sarcomatous growths in general are also classified in keeping with the 
tissues from which they appear to spring, as—osteosarcoma, fibrosarcoma, 
chondrosarcoma, lymphosarcoma, etc. 434 
ORAL SURGERY 
Fig. 347. Sarcoma in the region of the lower left bicuspids in a child 7 years 
of age. The overlying mucosa appeared to be normal, and the only symptom was 
a slight swelling discovered by the dentist. Note how the partly developed bicuspids 
are displaced and also the apparently circumscribed invasion of the bone. Compare 
this with the radiograph of the opposite side. Fig. 348. 
Fig. 348. The same case as Fig. 347, showing the well side of the same patient. NEOPLASMS 
435 
No satisfactory classification has as yet been offered whereby all sar- 
comatous growths could he distinctively classified from a pathological 
standpoint. Our present classification is largely based upon their clinical 
and histological appearances and the tissues from which they appear to he 
Fig. 349. Sarcoma of the mandible in a boy 11 years of age. Note the circum- 
scribed bone destruction resembling a cyst. Note also that the teeth which are 
normally erupted and free from disease are displaced. I he apparent space was not 
caused by the loss of teeth but was created by displacement of the growth. 
derived. Even those occurring in identical localities may present distinc- 
tive characteristics, so that it is more advisable to study each individual 
case. 
They all seem to have the ability to widely infiltrate the surrounding 
tissues. After the immediately invaded tissues become broken down, they 
have a great tendency to spread along the fascia, along the sheaths of 
vessels, the nerves, and through the invaded bone and other tissues. They 
are exceedingly vascular, grow rapidly, and often attain very large size. 
They are generally very susceptible to traumatic injuries and to parasitic 
infection. Those occurring in the oral cavity often present breaking-down 
or ulcerative areas, due to inherent sloughing, to trauma caused by oppos- 
ing teeth, and other irritating factors prevalent in the oral cavity. 436 
ORAL SURGERY 
From a clinical standpoint, sarcomatous growths 
of the oral cavity present widely diverse variations. 
Of those which occur on the surface and appear to 
spring from the periosteum, or from the peridental membrane of a tooth, 
i.e., periosteal sarcomas, two different types are observed. In these the 
Periosteal 
Sarcomas. 
Fig. 350. The growth presented here occurred in a woman 28 years of age. The 
surface appearance of all the tissues and the outline of the bone as well as the face 
was normal. The only symptom was neuralgic pain for three months which seemed 
to increase progressively. The radiograph shows a destructive alteration in the bone 
substance, although all of the teeth were firm and those within the area proper were 
free from disease. It was rather difficult to determine the exact nature of the lesion, 
which in operation proved to be a sarcoma. 
tissues of the sarcoma are clearly exposed upon the surface, and present 
as highly vascular, lobulated, soft masses of tissue, somewhat loose in 
structure and with a great tendency to bleed. The second type is likewise 
a surface growth, and present as a firm, irregularly formed tumor mass, 
which springs from a broad base with very little invasion of the subjacent 
structures. These are not quite so vascular as those first described, and 
their texture suggests that they are composed of fibrous tissue. NEOPLASMS 
437 
In the second group, the sarcomatous growth 
does not appear upon the mucous membrane surface 
but may occur as an ill-defined swelling in any part 
of the mandible or the maxillae. There are no disturbing symptoms except 
that, in the more advanced cases, a nerve trunk may be pressed upon, when 
vague, neuralgic pains of variable degree are experienced. The covering 
oral mucosa in itself presents no pathological signs except the swelling 
caused by the distention of the growth underneath. The teeth in the area 
usually become loosened and often completely dislodged from their normal 
position or even become exfoliated. The tissue may become so displaced 
that biting down of the opposing teeth causes ulceration. 
The clinical manifestations of central sarcomas, which develop from 
the substance of the bone, are often confusing as they do not always 
present distinct characteristics of sarcomatous growths. The outer sur- 
faces may appear entirely intact and the only sign may be indefinite neu- 
ralgic pain, probably caused by pressure upon a nerve trunk within the 
region. The radiographs indicate that the affected area is completely cir- 
cumscribed, although upon exposure the growth is not found to be in- 
capsulated. (Figs. 347 and 348.) They often resemble in many respects 
a cyst, and a differential diagnosis can often be made only by aspiration, 
or by reflecting at a convenient point the overlying mucous membrane. 
There are others in which the affected area is not so circumscribed, but 
there are indications that the bone destruction is still confined to a definable 
area. (Figs. 349, 350, 351, 352, and 353.) 
In the third group, which probably originates in 
the periosteum, the involvement of the tissues is so 
advanced that it is hard to determine their point of 
origin by clinical or radiographic examination. There is a breaking down 
of the surface tissues, considerable infiltration, and the bone seems to be 
completely decalcified at some central portion, and from here evidences of 
the alteration in the bone structure (including the cortical portion), is 
observed to penetrate in all directions. These often cause destruction of 
the complete thickness of the bone and fracture. (See pathological 
fractures.) 
Sarcomatous growths occurring in the maxillary sinus cause no dis- 
turbing symptoms in the early stages of their development. Their greater 
insidiousness lies often in the fact that they develop painlessly until they 
have attained a large size and considerable infiltration has taken place. 
Slight neuralgic pain may be the first sign noted, which is prone to increase 
with the pressure upon the infraorbital nerve. With the enlargement of 
the growth there may be, in the course of time, a thinning out and bulging 
Central 
Sarcomas. 
Third 
Group. 438 
ORAL SURGERY 
of any or all of the walls of the maxillary bone. Crepitation may be dis- 
cerned upon pressure at points, and there is hemorrhage from the nostril 
of the affected side. There may be a degree of exophthalmus as the orbital 
plate is being pressed upon. The degree of facial deformity increases with 
Fig. 351. This growth occurred in a man 35 years of age. He complained of very 
slight pain in the bicuspid region some six months before, and was told to let “sleep- 
ing dogs lie.” The growth has proven to be a sarcoma. Note the peculiar alteration 
in the bone structure, the circumscribed character of the lesion and the separation of 
the teeth. The overlying mucosa, though apparently normal, was slightly swollen. 
Four years after operation the patient is well. 
the expansion of the tumor. The alveolar wall and the teeth contained 
therein are often displaced downward and outward, and the biting of the 
opposing teeth may cause irritation or ulceration of the gum tissues. 
The oral mucosa appears to be intact in many even advanced cases. 
This, considered with their apparently slow and painless development, the 
crepitant bony walls and also the radiograph, may lead one to believe that 
the condition is a cyst. In all cases of swellings about tbe jaws and teeth, 
in which the teeth appear to have erupted and seem normal and have 
become loose and dislodged, the possibility of malignancy should be 
considered. The vague neurologic pains which I have come to regard as NEOPLASMS 
439 
almost pathognomonic of malignancy in the presence of tumors, rarely 
exist in cysts. Aspiration is one of the surest means of diagnosis. In the 
presence of a cyst the fluid contents of this growth are withdrawn. When 
a growth is present there is a degree of resistance offered to the penetrating 
needle and a scant amount of frothy tissue juice is withdrawn. In some 
1*IG- 352- 1 he same case as Fig. 351 four years after the operation. There is no 
local sign of recurrence and the patient appears to be well. 
very obscure cases it may be necessary to split the overlying mucosa so as 
to expose the contents at a small point. The growth will he indicated by 
the presence of lobulated masses of tissue which are characteristic of 
sarcomatous growths in these regions. 
It is rather difficult to prescribe or even to outline 
a definite treatment for sarcomatous growths. It 
may he stated, however, that the location, the extent 
of infiltration so far as this can be determined by 
the methods of examination at our command, the degree of malignancy as 
determined by the histological structures, the age of the patient, the history 
of the growth, and the extent of bone destruction, should be the guiding 
factors. Numerous cases metastasize very rapidly and are highly malig- 
nant regardless of size. Quite often the extent of invasion can be guessed 
Treatment 
and Prognosis 
of Sarcoma. 440 
ORAL SURGERY 
Fig. 353. Sarcoma of the maxilla in a young man 20 years of age. The growth 
most likely originated in the maxillary sinus, as all the bone tissues in the region 
appeared to be destroyed. The oral mucosa presented no break excepting the in- 
vagination caused by the lower teeth and ulceration at this point. The growth was 
noticed some six months before, but the patient applied for treatment only three 
weeks before this picture was taken. It was considered then an inoperable condition. NEOPLASMS 
441 
at only during the progress of the operation. Those who undertake to 
operate upon these cases must be prepared to meet all emergencies. To 
the experienced, the gross texture of the tissues may indicate the presence 
of infiltration. Conservative operations are permissible only in sarcomas 
of the giant cell type or in those where the tumor appears to be well 
circumscribed. In others the resection must be more radical and an entire 
maxillary bone or half of the mandible must be removed. The prognosis 
is rarely favorable. Some are fatally malignant from the beginning. A 
number of five-, seven-, and even fifteen-year cures have been reported. 
Epithelioma is a malignant neoplasm which grows from epithelial 
tissue. 
Epithelioma occurs more frequently in the oral cavity and the asso- 
ciated structures than sarcoma. Statistics show that they more often 
occur in men than in women, although the contrary is true in other regions 
of the body. They are more frequently observed in the upper than in the 
lower jaw. No part of the oral mucosa is immune and they may occur 
upon the inner surface of the cheeks, upon the alveolar ridges, upon the 
palate, in the floor of the mouth, and upon the pillars of the fauces. The 
tongue and the lips are frequently the sites for the development of cancer, 
the lower lip more frequently than the upper. They also occur in the 
maxillary sinus and the pharynx. 
As sarcoma is regarded to be a neoplasm of youth, so epithelioma is a 
growth of later life. Though cases are seen at earlier ages, they occur 
more frequently after fifty, the highest per cent being between the ages 
of sixty and seventy. 
The tumor usually originates in some part of the oral mucosa, and, 
through a process of destructive proliferation, the surrounding tissues and 
also the bone may become involved. Ewing differentiates two groups of 
growths according to their derivation:— 
(1) Those which are derived from mature normal epithelial cells and 
through irritation, or through some other unknown factor undergo 
malignant degeneration. 
(2) Those which, according to Cohnheim’s theory, are derived from mis- 
placed embryonic cells. 
Little is known about the true etiological factors which induce malig- 
nant degeneration even after the intensive research work in this field. It 
is very significant, however, that the pathologist and also the surgeon recog- 
Epithelioma. 442 
ORAL SURGERY 
nizes a precancerous stage. Ribbert believes that epithelial surface tumors 
are always preceded hy some kind of irritation, caused by chemical, 
mechanical, or radiating agencies. It is not possible, at the present time, 
to definitely determine in all cases just where this dividing zone lies, but 
Fig. 354. Epithelioma in the upper jaw of a man 55 years of age. The growth 
extended from the tuberosity to the cuspid region, and to a considerable distance 
upon the palatal and buccal surfaces. 
in many instances there are very early clinical signs and histological 
changes which definitely mark malignancy. It is probable that in view of 
the graveness of malignant conditions it is at times more advisable, in 
doubtful cases, to he inclined towards a radical diagnosis, although Ewing 
states that numerous reported cured epitheliomas of the tongue were benign 
papillomas. 
Epithelioma of the oral cavity is very frequently associated with some 
form of trauma or chronic irritation. The most frequently identified are: 
Irritation of sharp, broken-down or diseased teeth; use of tobacco and 
snuff; alcohol; the habit of eating too hot or spicy food; other irritating 
factors such as calcific deposits or ill-fitting dentures, fillings, etc., which 
are prevalent in the oral cavity. It is often cited that amongst Indians who 
habitually chew betel nuts cancerous degenerations occur frequently at the NEOPLASMS 
443 
point of irritation. In the face of this we frequently see epithelioma 
develop at points which are not exposed to direct mechanical irritation and 
are out of the range of the teeth, as, for instance, the soft palate. Syphilis 
and leucoplakia are regarded as precancerous or predisposing factors in 
malignancy. 
Fig. 355. Carcinoma of the lower jaw in a man 65 years of age. The growth 
extended deep down into the sublingual regions of the pharynx. There was marked 
adenopathy and it was considered to be an inoperable case. 
Epithelioma of the tongue is frequently traced to some traumatic in- 
jury or chronic irritation producing an ulcer which may later degenerate 
into a malignant growth. 
Epithelioma of the lips is almost invariably ascribed to the irritation 
caused by the use of a pipe, and it is also often observed in cigarette 
smokers. Cases have been reported in which an apparently single trau- 
matic injury was followed by malignant degeneration. 
Although it is generally recognized that epithelioma does not essentially 
begin as a malignant growth, it is rather unfortunate that the condition is 
not always recognized in the precancerous stage. In fact, most cases apply 
for treatment when the growth has attained an advanced or inoperable 444 
ORAL SURGERY 
stage. This is frequently due to the patient’s negligence and just as fre- 
quently to meddlesome treatment by the physician or the dentist. 
Epithelioma extends locally by the continuous invasion of the cancerous 
growth into the surrounding tissues. There may be considerable induration 
and inflammation. The inflammatory condition may act either as a barrier 
to further infiltration, or may just favor the extension of the growth. 
There may be considerable hyperplasia due to the active proliferation of 
the cancerous tissue. In the more advanced stages they generally break 
down, forming an extensive sloughing surface, deep induration and de- 
struction of the subjacent tissues. Epitheliomas may metastasize through 
the blood and lymph channels but they more frequently do so through the 
lymphatics. Cervical lymphadenitis is observed in early stages, after 
metastasis has taken place. Metastasis is very often embolic and all lym- 
phatic and lymph-bearing tissues are regarded with suspicion, even in the 
absence of palpable glands. It is maintained and was first suggested by 
Crile that the metastasis rarely penetrates beyond the lymphatics of the 
neck. 
The treatment as advocated at the present time consists of radical sur- 
gery combined with radium or deep X-ray therapy. In the operation the 
complete growth and a considerable zone of what appears to be healthy 
tissue, as well as all the lymphatic and lymph-bearing tissues of the neck, 
are removed. 
Fig. 354 is an example of a case of epithelioma of the upper jaw which 
occurred in a man fifty-five years of age. He went to a dentist (about 
three months before I first saw the case) with the complaint that for some 
few weeks the second molar had been annoying him. The dentist found 
that the tooth proper was free from disease but that it was loose in its 
socket and was surrounded by what appeared to be granulation tissue. 
This was confined to the immediate surroundings of the tooth and he 
curetted it away, down to the bone. The condition would not heal, and 
about three weeks later he curetted again. He soon noticed that the con- 
dition was spreading. When I first saw him, the growth extended as 
shown in the photograph, from the tuberosity to the cuspid region and to 
considerable distance upon the palatal and buccal surfaces. There were 
several palpable glands on the affected side at that time. 
Fig. 355 is a carcinoma of the lower jaw in a man sixty-five years of 
age. Though he experienced a degree of discomfort, he never applied for 
medical aid until this advanced condition developed. The growth extended 
deep down into the sublingual regions to the pharynx; there was a marked 
adenopathy, and it was considered to be an inoperable case. INDEX 
Abscess, 59 
Acute alveolar, 65 
surgical treatment of, 68 
Chronic dento-alveolar, 76 
Curetting in acute alveolar, 70 
Fistulous type, 76 
Fractured jaw cases, 372 
From septic injections, 104 
treatment of, 105 
Mandibular, 70 
Maxillary, 69 
Non-fistulous, 77 
Pericoronal, 297 
treatment of, 297 
Pointing of, 66 
Radical treatment of chronic, 78 
Sublingual, 104 
Acute, 
Alveolar abscess, 65 
Curetting, 70 
Surgical treatment of, 68 
Exacerbation, chronic cases, 63 
Inflammatory conditions, 61 
Suppurative conditions, 61 
Alcohol, 5 
Alveolar abscess, acute, 65 
Curetting in, 70 
Surgical treatment of, 68 
Alveolar process, 39 
Alveolectomy, 271 
Acquired conditions inviting opera- 
tion, 277 
Congenital outgrowths inviting opera- 
tion, 271 
Technique for, 277 
Amputation, 
Root End, 
Causes of failure, 95 
Contraindications for, 93 
Indications and technique, 86 
Technique for, 97 
Treatment when tooth is retained, 86 
Anesthesia, local, 18 
Broken needles, 142 
Complications in, 134 
Deductions in regard to, 148 
Faulty administration, 142 
Faulty solutions, 138 
Sepsis after, 134 
Anesthetics, choice of, 17 
Consideration of, 16 
Anesthetics, Precautions with local, 17 
Technique with inhalation, 16 
Angioma, benign growths, 433 
Ankylosis, 
Brophy operation, 401 
Etiology of, 395 
False, 401 
Murphy operation, 400 
Technique of operation for, 400 
Treatment of true, 399 
Antiseptic method in surgery, 3 
Antiseptics, 2 
Antral disease, diseased tooth as a 
factor in, 182 
Apical, 
Inflammatory conditions, 61 
Pericementitis, septic, 62 
treatment of, 64 
Apicoectomy, 87 
Causes of failure, 95 
Contraindications for, 93 
Technique for, 97 
Articulation, temporomandibular, 43 
Asepsis, 2 
Aseptic method in surgery, 3 
Bandages, 385 
Application of, 389 
Barton’s, 389 
Four-tail, 390 
Gibson’s, 390 
Barton’s bandage, 389 
Benign growths, 
Angioma, 433 
Lipoma, 433 
Osteoma, 432 
Bichlorid of mercury, 4 
Uses and actions, 4 
Bleeding vessels in soft tissues, 52 
Blood clot, not dependable, 262 
Blood vessels, treatment of severed, 51 
Bone absorption, 358 
Regeneration, 257 
after operation, 261 
Boric acid, 6 
Action and uses, 6 
Breath, offensive, 44 
Broken down and buried roots, 
Operation for removal, 270 
Removal of, 263 
Brophy operation for ankylosis, 401 
445 446 
INDEX 
Calculus, salivary, 
Etiology of, 404 
Symptoms of, 405 
Treatment of, 407 
Capillary ooze, 52 
Carcinoma, symposium on, 413 
Quotations on, from 
George W. Crile, 414 
E. S. Judd, 413 
A. J. Ochsner, 414 
Case histories, 
Apicoectomy, 
Case 1, 101 
Case 2, 102 
Death from sepsis, 135 
Fractures of the jaws, 
Case 1, 342 
Case 2, 342 
Case 3, 350 
Case 4, 352 
Case s, 352 
Case 6, 353 
Case 7, 353 
Case 8, 354 
Case 9, 381 
Case 10, 382 
Hemorrhage, successful treatment of, 
5° 
Maxillary sinus, 
Case 1, 154 
Case 2, 155 
Case 3, 158 
Case 4, 161 
Case 5, 191 
Necrosis, 137 
Causes of impaction of teeth, 
Local, 284 
Systemic, 290 
Cementum, 39 
Chloroform, 20 
Chronic, 
Abscesses, radical treatment of, 78 
Dento-alveolar abscess, 76 
Inflammatory conditions, 75 
Suppurative conditions, 75 
Suppurative osteitis, 164 
Cleanliness, surgical, 1 
Contraindications for nitrous oxid- 
oxygen, 20 
Cystic areas, 
Radiographic examination of, 215 
Cysts, 
Clinical signs and symptoms of den- 
tigerous, 225 
Clinical signs and symptoms of radic- 
ular, 213 
Dentigerous, 215 
Etiology of radicular, 203 
Follicular, 165 
Mucous, 247 
Cysts—continued 
Multilocular, 246 
Operation No. 1, 229 
Operation No. 2, 229 
Operation No. 3, 240 
Radicular, 165, 203 
Technique for operation, 240 
Treatment of dentigerous, 229 
radicular, 229 
Death, following hemorrhage, 47 
Dentigerous cysts, 215 
Clinical signs and symptoms of, 225 
Treatment of, 229 
Diagnosis, 28 
Dichloramin T, 7 
Dislocation of mandible, treatment of, 
393 
Drainage, 26 
Dressings and sponges, 12 
Dressing wounds, 24 
Drugs used in surgical practice, 4 
Empyema, 
Acute, maxillary, 179 
Chronic, maxillary, 179 
old treatment method, 180 
symptoms of, 179 
Epithelioma, 441 
Epulis, 423 
Fibromatous, 423 
Sarcomatous, 427 
Treatment of, 429 
Ether, 20 
Exacerbation, acute, 62 
Chronic cases, 62 
Examination, 28 
Radiographic, 38 
Cystic areas, 215 
Maxillary sinus, 171 
Oral cavity and associated parts, 30 
Exfoliation necrosis, 120 
False ankylosis, 401 
Fear, 15 
Feeding in fractured jaw cases, 373 
Fibroma, 429 
Fistulous type of abscess, 76 
Follicular cysts, 165 
Fractures, 
Mandibular, etiology of, 335 
traumatism, 335 
Maxillary, appliances for treating, 385 
bilateral, 384 
complicated, 384 
diagnosis of, 381 
infection of, 383 
simple, 383 
Occurrence of, 328 INDEX 
447 
F ractures—continued 
Of the jaw, abscesses, 372 
classification, 430 
comminuted, 341 
treatment of, 350 
complicated, 341 
compound, 340 
simple, 340 
Feeding. 373 
Of the mandible, 328 
diagnosis, 344 
splints for, 367 
symptomatology, 342 
treatment of, 347 
Of the maxillae, 380 
Pathological, 338 
Reducing, 347 
Surgical, 340 
Fractured mandibles, fixation in, 359 
Gilmer’s method, 363 
Germicides, 2 
Gibson’s bandage, 390 
Gilmer’s method, Dr. 
Fixation in fractured mandibles, 363 
Gingiva, 36 
Gloves, rubber, 10 
Sterilization of, 10 
Gums, 37 
Gunning splint, 371 
Heat, 7 
Hemorrhage, 46 
Causes of death following, 47 
Effects of, 47 
Treatment of, 49 
Hemophilia, 53 
Causes of, 53 
Symptoms of, 53 
Treatment of, 54 
Hydrogen peroxid, 5 
Hyperemia, 57 
Hyperplasia, of the oral mucosa, 419 
Operative treatment, 420 
Impacted, 
Cuspids, 310 
removal of, 313 
Lower third molars, 297 
removal of, 299 
Teeth, 279, 323 
In maxillary sinus, 162 
Neuralgic reflexes from, 292 
Removal of, 293 
Upper third molars, 304 
Removal of, 307 
Impaction, of teeth, 
Etiology of, 284 
Local causes of, 284 
Impaction of teeth—continued 
Systemic causes of, 290 
Incisions, technique for external, 71 
Infection, 3 
Circumscribed areas of, 83 
Limited to teeth and pericementum, 82 
Of maxillary fractures, 383 
Of maxillary sinus, 130 
Uncircumscribed areas of, 83 
Inflammation, 56 
Chronicity of, 59 
Inflammatory, 
Conditions, acute, 61 
apical, 61 
chronic, 75 
Hyperplasia of the oral mucosa, 419 
Instruments, 10 
Iodin, 5 
Action and uses, 5 
Iodoform, 6 
Jaws, fractures of, abscesses, 372 
Classification, 430 
comminuted, 341 
treatment of, 350 
complicated, 341 
compound, 340 
simple, 340 
Feeding, 373 
Leucoplakia, etiology of, 410 
Linen, 12 
Lipoma, 433 
Benign growths, 433 
Lips, 35 
Local anesthesia, 18 
Broken needles, 142 
Complications in, 143 
Deductions in regard to, 148 
Faulty administration, 143 
Faulty solutions, 138 
Sepsis after, 134 
Ludwig’s angina, treatment of, 403 
Lymphadenitis, cervical, 32 
Lysol, 6 
Action and uses, 6 
Malignant growths, 
Maxillary sinus, 168, 177 
Malposed teeth, 279 
In maxillary sinus, 162 
Mandible, fractures of, 328 
Diagnosis, 344 
Fixation in, 359 
Gilmer’s method, 363 
Splints for, 367 
Symptomatology, 342 
Treatment of, 347 
Treatment of dislocation of, 393 448 
INDEX 
Mandibular abscesses, 70 
Fractures, etiology of, 335 
traumatism, 335 
Maxillae, fractures of, 380 
Maxillary abscess, 69 
Maxillary bones, necrosis of, 166 
Maxillary fractures, appliances for 
treating, 385 
Bilateral, 384 
Complicated, 384 
Diagnosis of, 381 
Infection of, 383 
Simple, 383 
Maxillary sinus, 
Accidental openings into, 151 
Anatomy of, 149 
Differential diagnosis, 177 
Etiologic factors in the absence of 
disease, 151 
Etiologic factors in the presence of 
disease, 151 
Foreign bodies forced into, 155 
Impacted teeth, 162 
Infections of, 150 
Inflammatory affections of, 178 
Lesions, etiology of, 150 
Malignant growths in, 168, 177 
Malposed teeth, 162 
Method of removal of foreign bodies, 
160 
Modified Kuster operation, 189 
Oral openings into, case history, 
191 
Polypi, 177 
Postoperative treatment, 189 
Radical operation upon, 181, 186 
Radiographic examination of, 171 
Supernumerary teeth, 162 
Syphilitic gumma in, 168 
Transillumination, 176 
Traumatic injuries, 161 
Maxillary sinusitis, 
Diagnosis of, 168 
Radical operation on, 186 
Treatment of acute, 179 
Medication, preliminary, 15 
Mercury, bichlorid, 4 
Uses and actions, 4 
Mouth, the floor of, 42 
Mucous cysts, 247 
Multilocular cysts, 246 
Necrosis, 114 
Circumscribed, 126 
Diffuse, 126, 132 
Exfoliation, 120 
Occurrence of, 120 
Of maxillary bones, 166 
Of the jaws, etiology, 114 
Necrosis, Prognosis in, 132 
Sequestrum, 116 
Symptoms of, 120 
Needle, broken, 143 
Operation for removing, 145 
Neoplasms, definition of, 411 
Diagnosis of, 415 
Etiology of, 411 
Neuralgic reflexes from impacted teeth, 
292 
Treatment of, 293 
Nitrous oxid and oxygen, 18 
Nitrous oxid-oxygen, contraindication 
for, 20 
Non-fistulous abscesses, 77 
Offensive breath, 44 
Operating room, 8 
Operation, 22 
Conduct of, 21 
Field of, 12 
Preparation for, 8, 21 
Operator’s hands, 9 
Oral cavity, examination of, 30 
Oral mucosa, inflammatory hyperplasia 
of, 419 
Osteitis, chronic suppurative, 164 
Osteoblasts, 256 
Osteoclasts, action of, 260 
Osteogenesis, theories on, 254 
Osteoma, benign growths, 432 
Oxygen and nitrous oxid, 19 
Pain, 30 
Topography of, 31 
Pathological fractures, 338 
Patient, preparation of, 13 
Pericementitis, septic apical, 62 
Treatment of, 64 
Pericementum, infections limited to, 82 
Peridental membrane, 40 
Periodontoclasia, 106 
Conditions indicating surgical inter- 
ference, 109 
Etiology of, 106 
Surgery in, 106 
Technique of operation, 112 
Peroxid of hydrogen, 5 
Phenol, 4 
Action and uses, 4 
Polypi, 177 
Postoperative treatment, 24, 73, 189 
Potassium permanganate, 6 
Uses and actions, 7 
Preparation for an operation, 8 
Of the patient, 13 
Pulpless teeth, possible retention of, 
102 INDEX 
449 
Radical treatment of chronic abscesses, 
. 78 
Radicular cysts, 165, 203 
Clinical signs and symptoms of, 213 
Etiology of, 203 
Treatment of, 229 
Radiographic examination, 38 
Of cystic areas, 215 
Of maxillary sinus, 171 
Ranula, 251 
Etiology of, 251 
Operation for, 253 
Treatment of, 253 
Refracturing, 375 
Resolution, 58 
Root end amputation, 87 
Causes of failure, 95 
Contraindications for, 93 
Indications and technique of, 86 
Technique for, 97 
Treatment when tooth is retained, 86 
Roots, operation for removal of broken 
down, 270 
Root sockets, treatment after extraction, 
52 
Rubber gloves, 10 
Sterilization of, 10 
Saline solution, 7 
Salivary calculus, etiology of, 404 
Symptoms of, 405 
Treatment, 407 
Sarcoma, 433 
Central, 437 
Periosteal, 436 
Prognosis of, 439 
Treatment of, 439 
Sepsis, 2 
After local anesthesia, 134 
Conclusions regarding, 138 
Death from, 125 
Introduced on needle, 136 
Septic apical pericementitis, 62 
Sequestrum, necrosis, 114 
Splints, 
For fractured mandibles, 367 
Gunning, 371 
Single arch, 367 
Technique for cementing, 369 
Technique for making, 368 
Sponges and dressings, 12 
Sterilization, rubber gloves, xo 
Sublingual abscesses, 104 
Treatment, 105 
Supernumerary teeth in maxillary sinus, 
162 
Suppuration, 58 
Suppurative conditions, acute, 61 
Chronic, 75 
Suppurative osteitis, chronic, 164 
Surgeon, attitude and appearance of, 
14 
Surgery, antiseptic method in, 3 
Aseptic method in, 3 
Surgical, cleanliness, 1 
Practice, drugs used in, 4 
Technique, x, 8 
Surgical fractures, 340 
Suturing, 24 
Syphilitic gumma in maxillary sinus, 
168 
Technique, alveolectomy, 277 
Cementing splints, 368 
Cyst operation, 240 
External incisions, 71 
Making splints, 368 
Operation for ankylosis, 400 
Operation for periodontoclasia, 112 
Removal of impacted cuspids, 313 
Removal ©f impacted lower third 
molars, 299 
Removal of impacted upper third 
molars, 307 
Root end amputation, 86, 97 
Teeth, 37 
Impacted, 279, 323 
In maxillary sinus, 162 
Removal of, 293 
Impaction of, etiology of, 284 
Infections limited, 82 
In maxillary sinus, 162 
Malposed, 279 
Neuralgic reflexes from impacted, 292 
Possible retention for pulpless, 102 
Relation of to cancer, 412 
Supernumerary in maxillary sinus, 
162 
Unerupted, 279 
Temporomandibular articulation, 43 
Tongue, 40 
Transillumination of maxillary sinus, 
176 
Trauma, to be avoided, 23 
Treatment, 
Acute alveolar abscess, 68 
Acute maxillary sinusitis, 179 
Ankylosis, 399 
Comminuted fractures, 350 
Dentigerous cysts, 229 
Dislocation of mandible, 393 
Epulis, 429 
Fractures of the mandible, 347 
Hemorrhage, 49 
Hemophilia, 54 
Hyperplasia, operative, 420 
Impacted molars, use of burs, 303 
Ludwig’s angina, 403 450 
INDEX 
Treatment—continued 
Necrosis, 130 
Neuralgic reflexes from impacted, 293 
Old method of empyema, 180 
Pericoronal abscess, 297 
Postoperative, 24, 73, 189 
Radical, of chronic abscesses, 78 
Radicular cysts, 229 
Ranula, 253 
Root sockets after extraction, 52 
T reatment—continued 
Salivary calculus, 407 
Sarcoma, 439 
Severed blood vessels, 51 
Sublingual abscesses, 105 
Unerupted teeth, 279 
Wounds, dressing, 25 
Ziratol, 5