American Society of Dental Surgeons.

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No. 6 is the part which passes beneath the posterior border of the mylo-
hyoid. The lobes numbered 1, 2, 9, 4 and 5, are nourished by a branch of
the facial artery, whilst lobe 6 receives a branch from the lingual.

Fig. d. The facial artery of natural size as it appears injected. The
branches go to the lobes with corresponding numbers.



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226 Levison on Anchylosis of the Jaws. [April,



ARTICLE VII.

Anchylosis of the Jaws from a Semi-Cartilaginous Band
Connecting the Upper and Lower Jaws. By Dr. J. L.
Levison, of London.

Some years since, during a hurried visit to Cheltenham,
I was asked by a relative of mine to see a friend of hers,
**who had some extraordinary growth in her mouth, which
eflTectually prevented her from opening her mouth."

On the following day the lady was introduced to me,
when I made a careful examination of her mouth, the par-
ticulars of which I shall now detail:

Mrs. A. J., a married woman, about forty, (without
any family,) and of a nervo-bilious temperament ; in her
appearance there was nothing to indicate any abnormal
tendency, and her particular annoyance was only manifested
when she attempted to answer some questions put to her.
I found on the left side of her mouth a strong semi-cartila-
ginous band, which seemed to originate in the upper jaw.
The situation of this band being about an inch from the cor-
ner of the mouth and the insertion of the buccinator muscle
near the dens molars, and probably also ititimately connect-
ed with the masset^r ; as the latter arises by strong tendi-
nous and fleshy fibres from the superior maxillary bone,
where it joins the os malsB, the whole length of the inner edge
of the zygomata. And the probable connection of the band
with the latter muscle may be fairly presumed, as the outer
part of the masseter stands backwards, and the inner part
forwards, and in some measure decussating each other. Tn
its descent it covers the coronoid process under the temporal
muscles to be inserted in the angle of the lower jaw, and •
from upwards to the outside of the coronoid process.

The probable origin of this pseudo-growth may be further
confirmed by the fact, that the action of the buccinator is
to draw the mouth backwards and outwards, and to con-



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I860.] Lwjsov on Anchylosis of tJie Jawa. 227

tract the cavity by pressing the cheeks inwards ; whilst the
action of the masseters is to raise the lower jaw, and pull
it backwards and forwards, according to the direction of
the fibres of these muscles.

We may now speak of this freak of nature and point out
the many annoying consequences it induced.

The poor creature's teeth approximated so closely that
she could neither cut, tear, or grind her food, and had to
live on slops ; besides this her pronunciation of words was
seriously defective.

The first defect was attempted to be obviated by the ex-
traction of an upper and a lower molar, on the opposite
side of the mouth at which the band was situated, for the
purpose of expediting, by means of a curved tube, her
capacity of receiving mucilaginous and other nutritious
fluids.

But little advantage actually resulted, and for this rea-
son: that it is essential, in order to produce a vacuum, for
the purpose of deglutition, the lips should be closed, and
the soft palate pressed up behind the nasal fosses, and then
both fluids and solids are propelled onwards and received
into the pharynx, and then the final act of swallowing
takes place by the action of the muscles of the latter organ.

The cause of her defective speaking is also worthy of a
passing notice. She spoke precisely like a person who has
a fissure in the palatial bones, as in congenital hare-lip;
in which case the bones are more or less separated, and the
pronunciation is more or less implicated.

In the normal state of the vocal organs, when the air
inspired by the lungs is used to form the vocal sounds —
during the act of expiration, the different organs of the
buccal cavity modify and individualize each kind — as the
teeth, lips, and the palate, producing dentals, labials, and
palatials, and these elementary sounds are combined, their
compounds are the dento-labial, dento-palatial, and so
forth.

But in the attempted speech of Mrs. A. J., the sounds



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228 Lbvison an Anchyloaia of the Jqaob. [Apul,

passed from the back of the mouth through the nostrils,
and these sounds were, consequently, as indistinct as if she
had had a congenital defect of the ossa-palati, to a consid-
erable degree.

What tended to make her speech appear to be defective
from this cause simply, arose from the &ct, that in cases of
fissures of the palate there is observed a curious attempt to
compensate for the condition of the sounding board, as the
roof of the mouth has been called ; this compensation ena-
bles an individual so circumstanced to obtain a perfect vo-
lition over both nostrils, so that in the utterance of the
palatial or dental sounds — the nostrils are brought down
so forcibly as to prevent any escape of the expelled air.
This capability is another instance of the wisdom and good-
ness of God — ^that he has given a plasticity to different or-
gans under any abnormal condition, whether the result of
primary defectiveness, or from some casualty, so as to mod-
ify some of the ill consequences which otherwise would have
been greatly aggravated.

There was, therefore, a great difficulty to understand
Mrs. A. J., as she spoke with a constant snuffle, and with
the wings of the nose so compressed, as to impart an un-
pleasant appearance to one who had, otherwise, agreeable
features. Had it not been so, I should have made a
more searching examination in order to elicit some intbr-
mation from her as to what she attributed the original
cause of the formation of the band. But under the circum-
stance of her imperfect utterance, she either could not, or
would not assist me in forming anything like a correct
diagnosis.

Nevertheless, being satisfied that the band might be safely
separated, 1 proposed that she should visit me at Brighton,
(where I then resided,) when I proposed to operate on her
and remove the band without much pain or any danger.
And that to ensure both, I would place her under the med-
ical treatment of my friend. Dr. Peokford. And further
explained to her that my object would be, not only to re-
move the band, but to prevent its future growth.



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* >



I860.] Lbvison m Anchylosis of the Jaws. 229

She said, ''I have the greatest confidence in your judg-
ment^ for your opinion exactly coincides in every particu-
lar with the opinion given to me by the late Mr. Liston,
whom I consulted about a fortnight before his death. He
told me at the time, that being much engaged, he would
prefer seeing me on a future day, as a little delay would
not render the operation more difficult.

But it appeared that before the period he had appointed
to see her again, that gifted surgeon had paid the debt of
nature, and his death had caused her great sorrow ; for
she had to return to Cheltenham without the object of her
visit to the metropolis being efiFected.

If I could have operated at the time I first saw her, she
would have submitted most cheerfully, but my engage-
ments prevented my remaining a sufficient time either to
do her or myvelf justice: and I have since regretted that I
did not make some sacrifice, as the restilt would have proved
a great blessing to the sufferer.

However, prior to my leaving Cheltenham, she made a
definite engagement to pay me »ti8it..^Bttb#he did not
keep her word. And I was subsequently told that this
arose from her being influenced by the dentist who had
previously attended her, and that he had persuaded her to
see once more a resident surgeon. "*"

The gentleman she consulted had previously attended
her, and I am not aware whether he did or did not object
to an operation, but he did not seem much inclined to re-
move the band, probably because the patient herself was,
at the time, in a very highly nervous condition. So he
substituted a mechanical contrivance, but for what object I
cannot opine. As any force which could be applied with-
out immediate danger would not have prevented the anchy-
losis, so long as the resisting cartilaginous band remained.

This instrument I subsequently inspected. It was of a

«

^Tkifl gentleman's name was S., and he has since then departed from this
world, rather prematurely, for he was a young man.

VOL. X. — 16



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230 Levibon on Anchylosis of ihe Jaws. [April,

wedge form, being made of two Bteel portions, graduated,
80 as to be flat and thinnest at the edges. The flat ends
were perforated with holes, for the purpose of being covered
with white kid leather. A screw was placed through the
upper half of the wedge, to terminate into a cup-like female
screw, aflBLxed to the inner part of the lower half of it ; and
so contrived that the spaces between the edges of the wedge
could be enlarged at the will of the patient. The edges of
which were inserted or rather forced between front teeth.



The Instrument for forcing the Jaws asunder.



A The upper portion of the wedge, perforated with boles to enable the edge

to be covered with kid leather.
B The lower half of ditto.
C Movable screw to adjust the space.

D The female screw (cup-shaped) on the inner flat side of the lower half.
E The joint.

Mrs. A. J. persevered for two months in using this
instrument, until she experienced great agony, and not
finding the slightest improvement, she abandoned its use
altogether. And when the nature of the strong resisting
band is taken into consideration, and that it utterly pre-
vented the action of the temporales and masseters, no other
result could have beon anticipated.



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I860.] liwns/oi^ on AnchyUma of the Jav78. 231

Soon after this experiment, I received from my corres-
pondent a reply to certain queries of mine, and among
others the following:

•'Mrs. A. J. has been very ill this winter from an en-
larged lung on one side^ and under the slightest cold she is
incapacitated to speak, even in her usually imperfect man-
ner. She is now suflfering from bronchitis, and looks very
ill and much emaciated."

It seems to me not improbable that the wedge was in-
tended to gradually separate the jaws, being forced between
the teeth ; and it may be presumed that the pain she com-
plained of whilst wearing the instrument, had induced a
chronic inflammation of the integuments and muscles of the
buccal cavity, causing both the latter to become thickened,
so far as may be judged of from her subsequent symptoms,
and the results.

I saw her again, about two years after the wedge exper-
iment, and my own first examination, (now about six years
since,) and found the band, instead of being separated from
the inner portion of the cheek, so to admit the finger pass-
ing freely between it and the band, the latter had become
so perfectly united with the cheek, that it would now be
impossible to do any good by any attempt to separate it ;
and it could only be removed by dissecting it away from
the cheek to which it is incorporated, and in so doing, as
it is merely covered with the integument, any operation
might tend to induce another very unpleasant deformity.

The last spring, having had occasion to visit Cheltenham
again, on a melancholy bereavement of one of my family, I
took the opportunity of once more examining the patient,
and now feel assured that any operation would be attended
with some danger.

The jaws are perfectly immovable, and the anchylosis is
complete. And although she lives altogether on suction,
yet she looked better in health than I had anticipated.
There is, however, every probability that she may ultimate-
ly die from actual inanition.



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232 Lbvison on Anchylosis of the Jaws. [April,

As my object in giving publicity to this unique case is
for the purpose of obtaining some information on its prob-
able origin, I shall conclude, therefore, this brief paper
with a summary of an article on anchylosis of the alveo-
lar arch, in Oppenheim's Zeitschrift Band, 44, page 375,
as given in the xviith number of the Medico-Chirurgical
Review, for January, 1852.

The writer says, * 'anchylosis of the lower jaw may occur
in three localities. Ist. The head of the condyle may be-
come fix6d in the glenoid cavity. This form is the most
frequent, examples of which are recorded by Sandifort,
Blandon, Cruvelhier, Howship, Holcher, Hyrtle, and
others.

''2d. The coronoid process may become attached to the
zygomatic arch, of this two cases are recorded.

"3d. The alveolar process may become conjoined.* Of
this form there are examples besides the one recorded by
Dr. Werner, which is now cited. "S. R., at twenty-three;
when three years old he underwent severe salivation, after
which his jaw remained in a fixed state. Notwithstanding
the absence of masticatory powers, he was well nourished.
The jaw was quite immovable, firm pressure or traction
exerting no effect on the condition of the teeth. The t»-
cisores and molares were indeed for the most part wanting,
the roots of which did exist, projecting beyond the alveoli
of the diminutive jaw bone. The jaws were so far separa-
ted, that with some trouble, a little finger could be intro-
duced in front, but from the anterior on each side back-
wards, bony arches connected the upper and lower jaws.
The buccal mucous membrane was attached to the gums at
the edges of these arches, but the temporal and masseter
muscles remained free.

''Speech much resembled that which takes place with the



*I haye seen. a preternatural growth of guros, which gums have completely
hidden the teeth, falling down over them like a curtain. In this disease of the
alveoli, they seem to suffer also from an abnormal growth.



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I860.] Lbvison on Anchylosis of the Jaws. 233

mouth closed ; and food which did not require masticiatioQ
was introduced between the defective teeth.

''To remedy this state of things, the gums were separa-
ted by an incision from the cheeks to the lips, and a broad
portion of the connecting arch on either side removed by a
small saw. The jaws could not be expanded by the aid of
a mouth speculum, to the extent of half an inch, some
painful stretching of the muscles being induced. The pa-
tient was, however, enabled to voluntarily close the mouth
again — proving that more than twenty years' inactivity
had not destroyed the functions of the joints and muscles.
After several weeks perseverance in gradual dilation, a still
wider expansion was obtained, enabling the patient to chew
food that was not too hard^ which indeed the loose state of
his teeth prevented from biting."

[Vide Medical and Chirurgical Review.]

Mrs. A. J. was, in all probability, more than thirty be-
fore the band was formed, and now, after the lapse of so
many years, there is every probability that both the mus-
cles and joints in her case are implicated.

As, therefore, anchyloses of the jaws are rare, even when
dependent on morbid growth of the alveoli, or the union of
the coronoid process in the glenoid cavity, little can be
known of their special pathology, and in the case of Mrs.
A. J., (now first reported,) it being altogether an isolated
one, the difficulty is still greater. 1st. As to origin of the
band, and what predisposed its peculiar formation. But we
have data to indicate the cause which aggravated the in-
convenience and destroyed all chances of cure ; namely, the
pressure and force of the machine, and the consequential
adhesion of the band to the cheek itself, from which it had
been previously separated. Those who are acquainted with
theorgansof the buccal cavity, and particularly those who
supply artificial teeth, know that often, in narrow jaws,
(commonly spoken of as rabbit mouthed,) that elastic
springs will often excoriate the inner surfaces of the cheeks,
and that an inflammatory condition thus set up will afiect



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234 A New Method of Making Dies. [April,

the temporaleSj &c., by sympathy, causing much pain to
the patient. Hence the mechanical force induced by the
wedge instrument, not only caused inflammation of the
muscles and the integuments of the cheek, and by thus
thickening them, point out with Certainty why now the
band and cheek are so intimately united. And that though
when not so connected, there would not have been any
danger to operate, that now it would be dangerous to at-
tempt any.



ARTICLE VIII.



A New Method of Making Dies. By F. Y. Clark, of
Savannah, Ga.

To view comparatively the process for obtaining metallic
dies, which we now offer the profession, we might speak at
some length of the many objectionable features in connec-
tion with the various plans now in use ; but, as we are
addressing the experienced practitioner more than the stu-
dent, we trust that these features are sufficiently familiar
and understood to need no more than a mere allusion.

We believe there are very few, if any, who have not felt
the want of a less tedious, rapre accurate, and simple pro-
cess, while going through the disagreeable list of difficul-
ties and manipulations, such as varnishing and oiling
impressions, taking and trimming casts, varnishing again^
and moulding in sand, using flasks and similar auxiliaries.
If an irregular, prominent, or diverging alveolus is pre-
sented, a little skill and the yielding nature of the mem-
brane will always enable us to secure a good impression ;
but, by our usual mode of procedure, a perfect metallic die
of that impression is impossible. We may consume time,
weary our heads and hands with flasks, pour the metal on
our cast, or dip the cast in the metal, yet withal, as the
principle is incorrect, the result must be the same.



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I860.] A New Method of Making Dies. 236

We are coDfident that the most experienced portion of
the profession will fully coincide with us in saying that
what is wanted is some simple method by which the metallic
die can be taken directly from the impression. Plaster comes
nearer to what is wanted in this respect than any thing
else in use , but were we to pour metal into a plaster im-
pression, wo know that the moisture would destroy the die :
and to attempt to drive off this moisture by heat, would
prove equally fatal to the impression. To accomplish our
end, then, we found it necessary to forsake the beaten path
pursued for years, and start anew, to seek some material,
or combination of materials, by ^hich we could secure a
perfect impression, and which would resist the amount of
heat necessary for obtaining a metallic die.

During the last three or four years our experiments to
this end have been numerous. After testing from time to
tim'o, with more or less success, one material after another,
and finally securing a copibination that met our most san-
guine expectations, we then found it necessary to construct
a cup and flask, or set of flasks, by which tbis could be
conveniently and successfully used for the end in view. In
doing the latter^ we have had much trouble, and spent
much more time and money than many would suppose.
We have gone from sheet iron, forced in shape by wooden
forms, to copper struck up by iron dies, and then to various
kinds of castings, until we arrived at that which we now
offer, and which we believe, after being once fairly used,
will never be thrown aside for any other method now in .
vogue.

With those prefatory remarks, we submit the following
process, which we hope will be found as successful in the
hands of others as it has been in our own :

To commence, it is necessary to have an impression-cup
made from brass, German silver, copper, or any other
metal that will stand the necessary amount of heat for ob-
taining a metallic die without change : we prefer one made
from copper, because this metal is more malleable and



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236 A New Method of Making Dies. [April,

easilj cleaDed after using, than any other that we have
tried. It should differ in no other respect from the ones
in general use, except in the perforation of holes all over
its surface, about one-fourth of an inch apart, and one-
eighth of an inch in circumference. These holes are very
essential, for they not only prevent the material from leav-
ing the cup in removing it from the mouth, but greatly
facilitate the escape of moisture in drying or on receiving
the metal for the die. With a cup as described, we use a
batter composed of equal parts of clear, white spar and the
best calcined plaster ^f paris. The manner of taking an
impression with this batter is nearly the same as with
plaster alone. It should be mixed somewhat thicker at
first than plaster-batter used for the same purpose, and
should be kept in constaut motion with a spoon, or any
thing that will answer, until there are unmistakable signs
of its setting, and then it should be emptied into the cup
and conveyed to the mouth as quickly as possible. As we
said before, the plaster used for this purpose should be of
the very best quality and freshly calcined, for it will not
do to add salt to it to quicken its hardening, as is custom-
ary in the use of plaster alone. In very difficult cases,
where the gums have receded, thereby exposing the necks
of the teeth, it is best to have more spar than plaster in
the batter used, for then the giving will be more apt to
take place at the very point of difficulty. In such cases
we know it is out of the question to get a perfect impres-
sion with anything ; but we are confident this will be
found more practicable than either wax or plaster, for it
being harder than one and not as hard as the other, and
somewhat brittle, is thereby more liable to give where it
should — at the very point of trouble. We think a little
experience is all that is necessary to convince any one that
there are few cases, if any, where a better impression can-
not be taken with this mixture than with either plaster or
wax ; for about the last two years we have used nothing else.
The impression, when taken, and as represented in letter



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I860.] A New Method of Making Dies. 237

A, should next be placed in flask No. 1, as represented in
the following cut. This flask is cast from gray iron^ and

No. 1 . A



has a large open space in the bottom, leaving only a rim
on the inside large enough for the impression-cup to rest
on. This open space is for the escape of moisture coming
from the holes in the cup, as before described. The space
between the impression and the flask should now be seamed
up with batter a little thicker than that used for the impres-
sion ; it should be spread with a knife or spatula, so as to
prevent it running down much between the cup and the
rim of the flask. It is not best to use much batter for this
purpose, just enough to hold the cup in place, and to give
a smooth, continuous surface to the parts. When this is
properly done it will present the appearance of the annexed
representation^ marked B. This flask and impression,
thus prepared, is now ready for flask No. 2, which, when
placed around the first, will present the following appear-
ance. The whole should now be placed in an oven or on
a stove^ or any place where it will dry ; this can be done
either rapidly or gradually ; when we are in a hurry we
generally have it dry by the time the metal is melted, but
it may be better to give it more time. It is not my wish
to say anything here about metal ; almost every dentist
has some peculiar favorite of his own ; of course it is im-



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238 A New Method of Making Dies. [April,

material what kind i» used in this process. We generally
construct our dies from zinc. Some time after the metal
has been poured in the flask, a red hot iron shbuld be
B No. 2



placed in its center, and held there until it begins to sety
then the iron should be withdrawn and more metal poured
in. This is done to command the shrinkage, making it
take place where it will do no harm ; in other words, the
metal should always be made to congeal last at the top of
the flask : an iron, shaped like a tinner's soldering iron,
is about the kind necessary for this purpose. When the
die has become sufficiently cold, it should next be removed
from the impression, etc., and flask No. 2 placed around
it as before, then inverted, and the counter-cast taken.

In conclusion, we would remark, that all improvements



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