THE FACE. 



55 



consequently become infected from the mouth and suppurate. This may cause 

 necrosis of the fragment, but the blood supply of the jaws is so good that death of 

 a fragment is rare, and it is not customary to remove fragments not completely 

 detached. The front wall is sometimes driven in. 



Fractures occasionally occur in which the line passes through one or both supe- 

 rior maxillary bones from below the malar bone into the nose. If this fracture passes 

 completely backward, it detaches the lower portion of the palate bone and pterygoid 

 processes of the sphenoid bone. The fragment in such cases has a tendency to slip 

 backward. It can be replaced by inserting a hook through the mouth and behind 

 the soft palate and pulling the fragment forward. This injury is produced by a blow 

 on the anterior portion of one or both bones, passing downward and backward. In 

 order to determine the existence of fracture, Guerin recommended inserting the finger 

 in the mouth and feeling for the pterygoid plates. The hamular process of the internal 

 pterygoid plate can readily be felt about 

 one centimetre above and behind the last 

 upper molar tooth. Fractures in the neigh- 

 borhood of the first and second molar teeth 

 are liable to open the antrum, as the roots 

 of these teeth project into it. 



Resection of Upper Jaw. Tumors 

 of the antrum may necessitate a resection 

 of the superior maxilla of one side. Hey- 

 felder was the first to remove both superior 

 maxillae, in 1844: this was before the dis- 

 covery of anaesthesia. In removing one 

 superior maxilla, the incision known as Fer- 

 gusson's is used. This is made through 

 the middle of the upper lip, around the ala 

 of the nose to the inner canthus of the eye, 

 thence outward along the lower border of 

 the orbit to the malar bone. The bleeding 

 from this incision is free. The coronary 

 arteries should be looked for near the 

 mucous surface of the lip toward its free 

 edge. Bleeding will also occur from the 

 lateralis nasi and the angular arteries. The 

 soft parts are raised from the bones as far 

 back as the masseter muscle. This is just 

 about level with the outer edge of the bony 

 orbit. In doing so the infra-orbital nerve and artery will be divided. The artery is 

 not large but may bleed freely. The fibrous floor of the orbit is raised and the attach- 

 ment of the inferior oblique muscle loosened. The malar bone is sawed downward 

 and outward opposite the sphenomaxillary fissure, and the division completed with 

 forceps. The nasal portion of the superior maxilla is sawed through from the orbit 

 into the nose. The soft parts of the roof of the mouth are divided in the median 

 line to the posterior edge of the hard palate, and thence along its edge to the last 

 molar tooth. The soft palate is firmly attached to the hard palate and has to be 

 detached with scissors. An incisor tooth is then drawn, and the bony palate sawed 

 through from the nose into the mouth. The bone with the tumor is wrenched loose 

 with lion-jawed forceps. The union between the posterior portion of the superior 

 maxilla and the pterygoid processes of the sphenoid is not bony, but fibrous, so that 

 the bone is torn away from the processes and the latter are left behind. As the bone 

 comes away, the maxillary nerve should be cut. The bleeding which follows is from 

 the infra-orbital, superior alveolar (posterior dental), and posterior palatine arteries, 

 branches of the internal maxillary. It is not so free as might be expected, provided 

 preliminary ligation of the external carotid has been performed. It will be observed 

 that the facial nerve is not touched nor is the parotid duct wounded. 



Neuralgia of the Maxillary Nerve. The pain involves the cheek from the 

 eye to the mouth and as far forward as the median line, also the upper gums and 



FIG. 64. Resection of the upper jaw. The curved 

 lines indicate the skin incision and the straight lines 

 where the bones are to be divided. 



