WITH THE COMPLIMENTS OF THE AUTHOR. 
& FRACTURE 
r p -v OFTHE 
INFERIOR MAXILLARY BONE, 
BY 
JOS. F. MONTGOMERY, Al. D., 
OF SACRAMENTO, CALIFORNIA. 
Extracted from the Transactions of the Medical Society of the State of 
California, for the year 1875. FRACTURE 
OF THE 
INFERIOR MAXILLARY BONE 
READ BEFORE 
|?wl» ? AWmk 
At the Annual Session, Held at Sacramento, April, 1875, 
By JOSEPH F. MONTGOMERY, M. D., of Sacramento, 
Member of the California State Board of Health, The American Medical 
Association, and the Medical Society of the State of California, 
Member and Ex-President of the Sacramento Society for 
Medical Improvement, Ex-President of the Sacramento 
City Board of Health, Etc., Etc. 
Extracted from the Transactions of the Medical Society of the State of 
California, for the year 1875. 
SACRAMENTO: 
H. S. CROCKER & CO., PRINTERS AND STATIONERS. 
1875. FRACTURE OF THE INFERIOR MAXILLARY 
BONE. 
JOS. F. MONTGOMERY, M. D., of Sacramento. 
Owing to the looseness of its articulation, its great freedom of 
motion, and the number and strength of the muscles attached to 
it, and which constantly tend, by their almost perpetual action, 
when it is broken, to draw its fragments asunder in different 
directions, the multiple or communicated fractures, at least, of 
the inferior maxillary bone, have puzzled surgeons more than 
the fractures of any other bone in the body-not, perhaps, 
excepting those of the clavicle-and they have, in consequence, 
at every period of the development of their art, exerted their 
ingenuity and skill to the utmost to devise contrivances to 
meet the indications so difficult to fulfill. These contrivances 
are numerous and diversified, and have been modified in a va- 
riety of ways, according to the fancy of each inventor, in his 
efforts to improve or perfect what his predecessors may have 
offered to the profession. 
I will not pretend to offer a detailed and descriptive account 
of these expedients, but they may be reduced to, and arranged 
in, four classes, viz: ligatures, slings, bandages and splints. In 
a few rare instances, the ligature may be employed with ad- 
vantage, either by bringing together overlapping fragments of 
the bone itself in oblique fractures, or* by being passed around 
the teeth on cither side of a transverse fracture, merely as an 
aid to the bandage or sling-never as the sole reliance. I 
have in several instances so employed them, or thin plates of 4 
silver or platinum, with much advantage. But this expedi- 
ent is usually objectionable because it is generally inefficient 
and unreliable, and often causes mischief by loosening even the 
firm teeth to which it may be attached, by the operation of the 
unsteady lateral force or dragging motion to which, through 
its agency, they are subjected. 
The treatment of fractures of this bone, by the single-headed 
bandage or roller, has had many distinguished advocates, par- 
ticularly among American surgeons; and in many cases of 
simple vertical or transverse fracture at a single point, or, 
perhaps, two points, where there is but little disposition to 
displacement, it answers very well. In this class, the bandages 
of Gibson & Barton are prominent. 
Other eminent surgeons, both in Europe and America, recom- 
mend the sling in some form, and use as materials therefor, 
leather, gutta percha, adhesive plaster, and gum elastic, and also 
cloth or muslin in the form of the four-tailed bandage or sling. 
Under this head must be placed the apparatus of Hamilton, 
composed of leather and firm linen cloth. I regard these as 
but little, if any, better than the bandage or roller, for the 
reason that they are, according to my experience, not suffi- 
ciently firm and unyielding to resist successfully the persistent 
disposition and effort on the part of the patient to open the 
mouth or move the jaw-sometimes involuntarily-and thus to 
favor displacement. I believe, indeed, that the roller, applied 
by turns sufficiently numerous to afford firm support, and to 
offer strong resistance to the action of the muscles, particu- 
larly when a sub-mental splint of leather or gutta percha, accu- 
rately moulded to the jaw, is first applied, is really preferable. 
The bandage or the sling will, in many simple cases as stated, be 
fully adequate to subserve the ends to be attained; but in another 
class of cases, the comminuted fractures, especially when oblique, 
nothing but the splint, in some form, will at all meet the indica- 
tions. Splints have been, from an early day, employed in various 
ways. First-simple interdental splints, to be placed along 
between the crowns of the teeth, and only sufficiently grooved 
to be retained in place. Second-clasps applied over the 
crowns and sides of the teeth, and retained either by lateral 
pressure or by screws. Third-splints moulded and applied to 
the outer and inferior margin of the jaw and retained by a' 5 
bandage passed over the head; and fourth, and lastly, inter- 
dental splints, combined with and attached by wings to outside 
or sub-mental splints, and so arranged that the two parallel 
or opposing surfaces can be drawn together and retained at 
will by and through the operation of a thumb-screw. The 
first variety is now generally discarded, except in some cases 
where many teeth are absent, and when gutta percha can be 
adopted as the material for their construction, instead of cork 
oi' wood, as formerly. The gutta percha may also be pressed 
down on the sides of the teeth, so as to operate as clasps 
When thus applied, and the jaw is, besides, properly supported 
by an external splint and bandage, the plan would in many 
instances be ample, doubtless, to fulfill every indication in the 
case. 
But within the last twenty-five years, during which period 
much advance has been made in dental surgery, and the dental 
surgeon has been frequently called to the aid of the surgeon in 
treating this class of cases, great improvement has been made 
in the construction of the interdental splint, the favorite form 
being that of the clasp, either fastened to the teeth by screws 
or not, as may be deemed necessary in each particular case, and 
extended sometimes to and embracing the upper jaw when cir- 
cumstances seem to require such extension or inclusion. In this 
manner a double splint is really constructed out of this material, 
gutta percha, so plastic when sufficiently warmed, and so firm and 
durable when cold, or at the natural temperature of the month. 
Some dental surgeons have, indeed, become noted specialists in 
treating these fractures, two of whom I will mention, viz: Gun- 
ning, of New York, and Beans, of Georgia. They employ 
gutta percha as the material for the interdental splint, and 
mould it to the form of the clasp; and after thus moulding it to 
fit the parts accurately, they vulcanize it so as to give it greater 
firmness and durability, and to admit of its being screwed to 
the teeth when found necessary. The former of these gentle- 
men reported in 1866 eight cases thus treated successfully, 
several of them being cases that had baffled, among others, 
several army and navy surgeons; and Dr. Beans treated for 
the Confederates, during the Civil War, upwards of forty such 
cases, with very satisfactory results, most of them, probably, 
being fractures caused by gun-shot. 6 
This plan is designed, or is applicable only, or chiefly at 
least, for such complicated cases or comminuted fractures as 
cannot be successfully managed by other means previously in 
use; but the use of gutta percha might be extended with 
advantage to some simpler cases, as it could be applied by any 
skillful surgeon directly to the teeth, properly moulded to tit 
them, and thus the treatment would be more certain to result 
satisfactorily. 
External splints applied along the base of the jaw were first 
recommeded by Pare, who constructed them of leather. They 
have been employed in some form by most surgeons, being 
composed of different flexible materials, as wetted pasteboard, 
felt, and linen saturated with whites of eggs, or paste, or dex- 
trine, or starch. Gutta percha has more recently been used for 
the same purpose, and it is probably bettei' than anything else 
of like character. 
The last form of splint mentioned is the combination of the 
interdental splint, with outside splints; and in some instances 
in which this is used it is proposed to dispense with all ban- 
dages or slings whatever, the mouth being allowed to open and 
shut at will during the treatment, in partaking of food and 
drink. This idea was originated as early as 1780, by Desault, 
who advised bands of iron or steel to be placed over the teeth 
upon the alveolar margin, covered with cork or plates of lead, 
and fastened by thumb-screws to a plate of sheet-iron, or some 
othei* material under the jaw. This principle has been carried 
out since by various surgeons in constructing an apparatus for 
the injury under consideration, and has been used with varying 
success in different hands. The most recent contrivance con- 
structed on this principle is an apparatus planned by Dr. Wales, 
surgeon United States Navy, and which is fully described in 
his work, entitled "Surgical Appliances and Operations." 
While this seems to me superior to any similar instrument 
previously in use, and approaches more nearly than any other 
the apparatus I propose to introduce, it appears manifestly de- 
fective on account of its lack of sufficient solidity and firmness 
to resist successfully the powerful muscular action to be en- 
countered and overcome. 
Having presented the foregoing sketch of the history or 
literature of the subject under review, with comments on the 7 
plans of treatment suggested and pursued at different periods, 
and my personal experience with some of them, the object of 
such preliminary remarks being to render apparent the defects 
and inadequacy, in certain cases, of all the contrivances hith- 
erto devised, and to induce a more comprehensive and earnest 
consideration of the matter than mere reports alone would be 
likely to lead to, I will now report two cases of comminuted 
fracture of the bone whose injuries constitute our theme-the 
first treated with an interdental splint resting only upon the 
crowns of the teeth of the lower jaw and connected by wings 
to a sub-mental splint, the two, thus connected, being approx- 
imated by the action of thumb-screws extending on eithei* side 
through projections from each; and the other with interdental 
splints, one being severally adjusted and screwed to the teeth 
of each jaw, and the two being then firmly tied together with 
coarse silver wire. These cases will be presented in the order 
of then* occurrence, and the apparatus employed in each, 
though differing widely, will both be shown to embrace features 
or modifications never heretofore brought to the attention of 
the profession. 
Case 1.-Was called February 18, 1867, to see S. L., set. 32, a 
pilot. Four days previously, while on duty, a windy day, on 
board a heavily laden wood-barge, then descending the Sacra- 
mento Biver, one hundred and fifty miles above the city, the' 
boat, being unmanageable because of the strong current and 
high wind prevailing at the time, was swept undei* an over- 
hangingtree, the numerous strong boughs of which broke down 
the stanchions upon which the pilot-house rested, and precipi- 
tated him a distance of twenty-four feet, he alighting on the 
left side of his head and face, on the keelson in the bottom of 
the vessel, and sustaining a multiple or comminuted fracture of 
the inferior maxillary bone, two of the fractures being trans- 
verse, one directly through the symphisis, and the other be- 
tween the lateral incisor and the canine, and a third, an oblique 
fracture, through the angle and ascending ramus,- extending 
forward and slightly upwards through the socket of the third 
molar, separating it completely from its articulation, and ren- 
dering its removal necessary. The two last mentioned frac- 
tures were on the left side, the other being, as stated, exactlv 
through the symphisis-an accident, according to authorities, 8 
extremely rare in the case of a mature adult, Besides these 
fractures and severe contusions, the patient was so stunned by 
the fall as to be unconscious for five or six hours. It was four 
days before he reached the city, having had no treatment dur- 
ing the time, and having suffered much from pain and loss of 
sleep. 
When first seen, the soft parts were excessively inflamed and 
swollen, and there was a high grade of symptomatic fever, be- 
sides considerable pain. As there was too much inflammation 
and swelling to admit of any manipulation, I ordered an ano- 
dyne, to be repeated as needed, and warm poultices, to be kept 
constantly applied to the affected part. Also, gave a gentle 
cathartic, to be followed by fifteen or eighteen grains of qui- 
nine, in three or foui- grain portions, to be taken several suc- 
ceeding forenoons. 
February 21-Attempted to apply suitable apparatus, but 
found it impracticable, on account of the swollen and sensitive 
condition of the parts. Continued the poultice. 
February 26-Opened an abscess that had pointed an inch 
behind the angle. 
February 27-Opened anothei' abscess near the same point. 
February 28-Adjusted the fractures as well as practicable, 
and applied Hamilton's apparatus, besides several turns of the 
roller. 
March 4-Bemoved the apparatus, which failed to maintain 
the fragments in apposition, and applied, in stead, a gutta percha 
sub-mental splint, moulding the material, when warm, as well as 
could be, with the assistance of Dr. Nichols, to adapt it to the 
case in hand, aiming, at the same time, to adjust the fragments 
properly and then secure the splint by frequent turns of the 
roller under the jaw and over the head. But all these efforts 
failed to accomplish the purpose aimed at. 
Becoming convinced that nothing else would answer the 
case but interdental splints, properly made, after taking an 
accurate impression of the mouth, I applied to Dr. W. II. 
Thomas, an experienced and skillful surgeon dentist, to con- 
struct the apparatus contemplated. Upon calling on him I 
ascertained that some time previously he had constructed and 
used successfully, an apparatus for a simple fracture of the 
same bone, near the symphisis, in a case that some physician 9 
in the country had failed to treat with success. It consisted of 
an interdental splint, composed of silver obtained by melting 
coin, shaped so as to rest upon the crowns of the teeth on either 
side of the jaw, and to extend back sufficiently far to afford 
ample support to the fragments of the broken-bone, serving 
thus as one side of a clamp, while the mental splint, which was 
formed to accurately fit the under part of the jaw, operated as 
the other. On either side of the interdental splint, a smooth, 
flattened wing, made of iron, was blended or welded, which 
extended out horizontally between the lips-one neai* each 
commissure-and was connected by a hinge on each side 
respectively, an inch and a quarter in front of the mouth, with 
a perpendicular plate attached underneath to the mental splint. 
This plate projected horizontally an inch from its attachment, 
to the mental splint, and was then bent at right angles, or with 
a short curve, and extended up to unite, one on either side, by 
the hinge mentioned, to the wings projecting from the inter- 
dental splint. The plates connected with the mental splint 
were about five lines in width and two lines in thickness. In 
the horizontal portion below, there was a slit or opening, three 
fourths of an inch in length and the fourth of an inch in width, 
through each of which a small iron rod passed, and in which it 
had free play. This rod, which was more than two inches in 
length, besides the head, was at the upper end converted into 
a male screw, which worked in a female screw in the hori- 
zontal portion of the wing projecting from the mouth. The 
lower end of the rod had a flat head, by which to take hold in 
working what was really a thumb screw. The two splints, 
thus connected, being placed in position, the turning of the 
screws gradually brought them together until the requisite 
tightness was attained to hold the fragments securely, and yet 
not enough to interfere with the circulation or the nervous 
supply in the soft parts. The mental splint, besides being accu- 
rately adapted to the form of the chin and under surface of the 
jaw, was well padded and covered with buckskin, so as not to 
cause abrasion. 
This apparatus was, in the main, after the plan laid down 
long ago, but then rudely carried out, combining the inter- 
dental and the external sub-mental splint connected together, 
and so managed as to act as the opposing blades of a clamp - 
o applied to either surface of the jaw. 10 
Being satisfied that the principle of the contrivance was cor- 
rect, I determined to improve on the short splint, which had 
answered for a single fracture near the symphisis, and, to suit 
my case, have a mental splint constructed to extend on either 
sidc5 the full Jcngth of the jaw bone, passing along its sides 
and under surface to the angles, embracing them, and extend- 
ing up behind the rami more than an inch. My instructions 
were given to that effect, but the manufacturer made the 
mental splint sb short that it did not reach even to the angles 
of the jaw on either side. The apparatus was, however, ap- 
plied, to test its efficiency, and it at once became manifest, as I 
had been satisfied in advance would be the case, that it would 
exert no control over the rear and worst fracture through the 
angle and ramus. 
I then insisted that my original instructions should be car- 
ried out, and the splint was therefore spliced on either side, in 
the rear, so as to completely embrace, when applied, the angles 
and rami, as designed in the outset. 
The apparatus is here represented: 
March 9th.-Being finally in readiness, it was this day 
applied, and when screwed up, it became at once evident that 
all the fragments, four in number, would be held securely in 11 
place, and they were thus held, without the slighcst motion or 
disturbance, during the remainder of the treatment. It was 
somewhat irksome to the patient to wear the apparatus, and 
the contact of the swollen lips with the wings passing from-the 
mouth, as well as with the upright screws, caused some ulcera- 
tion upon their inner surfaces, although they were protected as 
well as could be, by lint, or strips of soft buckskin. But he 
was a man of real nerve, and bore his annoyance calmly, sleep- 
ing well the while, enjoying liquid aliments, and maintaining 
usually comparative cheerfulness. The apparatus was allowed 
to remain undisturbed until the 25th, sixteen days from its 
final application, and thirty-nine days from the time of the 
occurrence of the accident. 
While the instrument was being worn, the sub-mental splint 
was kept well supported by several turns of the roller under 
the jaw and over the head, in addition to such support as was 
afforded by the straps provided and attached by the manufac- 
turer. The patient was sustained, as already intimated, by 
soups, milk and gruels, and his mouth was cleansed by injecting 
water freely into it, from time to time, as well as a properly 
diluted solution of chlorinated soda or tincture of myrrh. 
When the apparatus was finally removed, it was ascertained 
that firm union had taken place at all the points of fracture. 
I still maintained supervision over the case for a fortnight 
longer, when it was finally dismissed. The recovery was, in 
every respect, thorough and satisfactory, and no subsequent 
trouble arose. Not the slightest deformity remained, and the 
use of the jaw has been just as perfect as before the accident. 
The patient has pursued his special business ever since; and 
now, after the lapse of eight years, no one, not familiar with 
the history of the case, could detect the slightest trace of 
former injuries. 
I would, however, advise that, in the construction of this ap- 
paratus, the wings and rods be so shaped as not to interfere 
with, irritate or ulcerate the lips, or press into the angles of the 
mouth, and that they should be heavily plated with nickel, to 
prevent corrosion. With the care and precautions mentioned, 
1 regard this not only as a very valuable instrument, but as 
decidedly superior, in certain cases, to all others. I say this 
unhesitatingly, in face of the fact that this style of apparatus 
has been very extensively objected to, on account, as asserted, 12 
of the inflammation, swelling and suppuration, the pressure of 
the external splint is liable to cause. But by having it proper- 
ly padded, accurately fitted and adapted to the jaw, and by 
screwing it up only sufficiently to maintain the fragments of 
bone securely in apposition, the mischief apprehended may be, 
I am confident, very generally avoided. 
The originality in the instrument consists in the material of 
which it is composed-silver for the interdental, and sheet- 
iron oi' copper for the external splint-the manner of connect- 
ing and drawing together the inner and outer splint, and the 
extension of the latter around the angles, and up behind the 
rami, thus serving to hold all the fragments securely and steadi- 
ly in place until firmly united. In these respects it differs ma- 
terially from all other instruments designed for treating simi- 
lar injuries. The truth of all this, and the estimate to be 
placed upon the contrivance, are matters to be settled by a 
discriminating profession. 
Case 2.-Was called June 5, 1872, about 6 o'clock p. m., to see 
J. S., tet. 54, a farmer, a short, muscular man, who, at a point 
six miles from the city, while proceeding homewardin a wagon, 
had met with an accident, and received severe injuries. Upon 
arriving at the place indicated, I learned that he had been 
placed in his wagon on a mattrass, and conveyed to his res- 
idence, still five miles distant. I proceeded thence, and ascer- 
tained that while leisurely jourrftng on his way, in a two- 
horse farm wagon, laden with about a ton in weight of plank, 
he accidentally dropped the rein, and in leaning forward, in an 
effort to recover it, the small box upon which he was sitting 
and which rested loosely upon the plank, was toppled over, and 
he was precipitated head foremost to the ground, behind the heels 
of the horses. They being gentle, fortunately neither kicked 
nor became frightened, but proceeded on, and he was run over 
by both wheels on one side of the wagon, as he distinctly real- 
ized and noted, for they were five or six feet apart, the coupling 
having been extended to accommodate the long plank. The 
injuries consisted of the fracture of the sixth and seventh ribs, 
just in front of their angles; the oblique fracture of the cla- 
vicle near its sternal extremity, accompanied with the complete 
dislocation of that end of it; the fracture of the lower jaw at 13 
three points; the comminuted fracture of the nose, including 
the septum; an extensive irregular laceration of the scalp, ex- 
tending from the base of the tragus, in a zigzag direction, to a 
point about the junction of the sagittal with the lamdoidal su- 
ture, being altogether, following its irregularities, at least ten 
inches in length, the forward flap being torn from its connec- 
tions and dragged forward over the forehead-all these injuries 
being on the right side; and, finally, the severe contusion and 
extensive laceration of the left ear, including the cartilages, 
and nearly severing the entire appendage from the head. 
The patient being in great pain and scarcely recovered from 
the shock, although four hours had elapsed from the time of 
the accident, a full dose of morphine was administered, and all 
the injuries were attended to in detail and properly disposed of, 
except the multiple or comminuted fracture of the jaw. This 
consisted of a transverse or vertical fracture between the lateral 
incisor and the canine; an oblique fracture through the as- 
cending ramus, not far above the angle, and a transverse 
fracture through the neck of the condyle-all, as stated, on the 
right side. Finding it impracticable with the means at hand 
to manage this fracture properly, I advised the patient to go to 
the city, where he could, at less cost, receive all necessary at- 
tention, and a surgeon-dentist could be employed to construct 
suitable apparatus. I then left him at a very late hour at 
night. Visited him on the 7th and dressed his wounds, finding 
him comparatively comfortable. On the morning of the 9th he 
was removed to the city, where I visited him at his lodgings, 
dressed his wounds, and made arrangements with a skillful 
dentist, Dr. B. B. Brewer, to prepare suitable apparatus for the 
ease, embracing interdental splints. 
Although I had employed the apparatus described in Case 
No. 1, with such satisfactory results, yet, to avoid the annoy- 
ance caused by the wings of the interdental splint as they pass 
out between the lips, as well as the firm pressure of the sub- 
mental splint, I suggested to him to construct an interdental 
splint or splints to be secured to the teeth by screws, as had been 
particularly recommended and practiced by Gunning & Beans. 
His partner being absent at the time in the East, and he being 
very busy, Dr. J. A. Woodward, a very ingenious and skillful 
young dentist, then at work in the office, undertook the job, 
after consulting with his principal, Dr. Brewer. He proceeded 14 
according to the plan laid down in the books, taking first a wax 
impression of the teeth of either jaw separately, and then form- 
ing casts of plaster of Paris, answering accurately to both the 
upper and lower jaw within, and of the face or lower jaw with- 
out. To those made after the model of the teeth he fashioned, 
out of silver plates made from melted silver coin, an interdental 
splint for each jaw, fitting it respectively over the crowns of 
the teeth above or below, and extending it up or down in either 
case, on both the outer and inner aspect, to the edges of the 
gums, thus encasing the rows of teeth completely in the accu- 
rately fitting splint. To each of these on either side he 
soldered eyelets or loops, through which to pass strong coarse 
silver wire to tie' the splints together after they had been con- 
fined, each to its proper jaw, by screws let into the teeth. To 
prevent the lower jaw from slipping backward, which was 
its tendency, ingenious devices were resorted to that I have 
not seen mentioned elsewhere. The first bicuspid in the 
upper jaw on the right side being gone, a stout flat pro- 
jection or protuberance of the same metal was soldered to the 
lower splint at the proper point for it to pass up into the open 
space when the jaws were brought together, the posterior sur- 
face of it being adapted to fit accurately and firmly against the 
forward surface of the second bicuspid, thereby preventing the 
possible backward slipping of the lower jaw when pressing 
against the upper. And to prevent as certainly the slipping 
back of the same jaw on the other side, a projecting point was 
soldered on the outer side of the upper splint opposite the 
space between the two bicuspids, the point being directed 
downward perpendicularly, and a hole, suitable for its recep- 
tion, was drilled through the outer edge of the upper aspect of 
the lower splint at a position to correspond to or to be exactly 
opposite to the descending point, and into which it could bo 
readily made to pass. Everything being in readiness, the next 
step was to drill, with a patent drill, worked by a lathe moved 
with the foot, a sufficient number of holes through the splints 
and into the teeth to receive the screws designed to fasten the 
former firmly to the latter. For this purpose a screw was put 
into the canine, the second bicuspid and the first and third 
molars in the upper jaw on the right side, and into the canine, 
the first bicuspid and the first and second molars on the left 
side of the same jaw, the third molar being absent. On the 15 
lower jaw a screw was inserted into the second bicuspid and 
the first and second molars on the right side, and into the 
canine, the first bicuspid and the first and second molars on the 
left side. Thus, altogether, fifteen screws were inserted and 
screwed up until all were firm and solid. Wherever a point 
was chosen in advance on the splint for a screw to be passed 
through, an additional quantity of metal was soldered on, the 
purpose being, by making the splint thicker thus at those 
chosen points, to hold the screws the more firmly. The splints 
having been fastened as described to the teeth of each jaw re- 
spectively, the lower jaw was properly and firmly brought 
forward, the projecting points were passed into their respective 
openings, the coarse silver wire, drawn specially for the pur- 
pose by a jeweller at hand, was passed through the eyelets 
or loops, and the jaws were tied firmly together. All this being 
done, it was manifest that every fragment of the fractured bone 
was accurately adjusted, and the apparatus was firm and 
seemed fully to accomplish its purpose. 
The splints for the upper and 
lower jaw, respectively, are here 
first represented separately, and 
then as united, after having been 
brought together and tied se- 
curely, the front view being pre- 
sented. 
For greater security, the den- 
tist also moulded a gutta percha 
sub-mental splint (not here rep- 
resented, because deemed unnec- 
essary), to fit accurately the 
lowei* jaw, with wings to ex- 
tend a short distance up behind 
each ramus. Across the chin 
portion of this splint a small 
stick was let in, the projecting 
ends of which were designed the 
better to secure the roller or 
bandage that would be passed over the head to maintain it in 
place as a support. This was applied, as designed, after being 
well padded with cotton wadding, and was secured by numer- 16 
ous turns of the roller, under the splint and over the head. 
This was on the twenty-first day of June, sixteen days after 
the accident, the inflammation and swelling in the soft parts 
having forbidden an earlier application. 
The patient was very comfortable after the adjustment of the 
fractures and the application of the apparatus, and we hoped 
that no furthei* difficulty would arise, and that an easy and 
satisfactory cure would result. 
Nothing very special occurred for several weeks, the roller 
in the meantime having been re-applied occasionally to main- 
tain ample support to the sub-mental splint, and prevent motion 
of the injured parts. Beside, the screws were inclined to 
loosen, rendering it necessary to tighten them from time to 
time. It was also discovered that the canine tooth became and 
continued loose, and that at the point of fracture, through its 
socket, there was some motion, and of course want of union. 
So, on the seventeenth of July, twenty-six days after applying 
the apparatus, and forty-two from the time of accident, it was 
determined to remove the dressings and examine into the cause 
of the unsatisfactory progress. Accordingly, that day, the 
apparatus was removed, and the mouth thoroughly cleansed. 
It was then ascertained that firm union had taken place at two 
of the points of fracture, that is, those through the ascending 
ramus, and the neck of the condyle. At the other point of 
fracture, that is between the lateral incisor and the canine, 
and which extended through the socket of the latter, there was 
no disposition to union. The canine tooth, being quite loose, 
was removed, as also several loose spiculae of bone that had 
separated from about its socket. The apparatus was then re- 
applied, in every respect as before, and thoroughly secured in 
every particular. Thus re-applied, it seemed, as before, to ful- 
fill perfectly every indication, and the case needed no further 
attention, except in the matter of tightening the screws every 
four or five days, when they seemed inclined to become loose, 
and in keeping the sub-mental splint properly secured. 
The case was kept under necessary observation, and was 
examined from time to time to ascertain whether union had 
become perfect. All through the month of August and the 
greater portion of September, it was clear, whenever this inves- 
tigation was made, by having the patient very cautiously move 17 
the lower jaw, that there was some motion at the point of 
fracture. This unsatisfactory state of things continued until 
towards the last of September, when there seemed to be union, 
and by the 7th of October, thinking it safe so to do, we re- 
moved the splints and dressings generally. It was then found 
that firm, bony union had taken place at the gap made by the 
loss of the canine tooth, as well as of a considerable portion of 
the bone adjoining its socket, and which had evidently been 
shattered at the time of the accident. 
Thus four months elapsed from the time of receiving the 
injury until the final and complete cure was effected; but then, 
at last, we were gratified to learn that it was surely complete 
and perfectly satisfactory in every respect. Not the slightest 
trouble has appeared since, and the patient is in all respects 
as sound as before the accident, except that he lost one tooth, 
and his left ear is a little contracted from loss of substance, 
though not sufficiently so to attract notice. 
And now, with these cases before us, so similar in character, 
and both resulting so satisfactorily, the question arises as to 
the relative merits of the two widely differing styles of appa- 
ratus employed in their treatment. With the limited experi- 
ence I have had, I am decidedly inclined to favor more the 
instrument used in the first of the two cases reported, while I 
admit that authorities are just as decidedly in favor of the 
other. 
The first mentioned certainly fulfills as completely every 
indication, and it is preferable because of its comparative cheap- 
ness, its simplicity, its unyielding firmness, and its less liability 
in consequence to become deranged. The chief objections to it 
I have endeavored to answer, and I think they may be obvi- 
ated or easily guarded against. 
The most noticeable objections to the other are the necessity 
of drilling into the teeth, which must injure them; the greater 
expense attending its construction and application, as well as 
of plugging the cavities made by the drill; and the great lia- 
bility to the loosening of the screws, and the consequent neces- 
sity, trouble and expense of watching it when applied, and 
correcting its derangements.