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 Table of Contents  
REVIEW ARTICLE
Year : 2014  |  Volume : 1  |  Issue : 2  |  Page : 70-77

The story of mouth gags


1 Department of Plastic Surgery, Lala Lajpat Rai Memorial Medical College, Meerut, Uttar Pradesh, India
2 Department of Plastic Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
3 Director, All Indian Institute of Medical Sciences, Saket Nagar, Bhopal, Madhya Pradesh, India

Date of Web Publication2-Aug-2014

Correspondence Address:
Dr. Faisal Ameer
L-20, Lala Lajpat Rai Memorial Medical College Campus, Meerut - 250 004, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-2125.137893

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  Abstract 

Background: Intra-oral surgeries such as cleft palate repair essentially require holding of the jaws in the open position to facilitate access to the oral cavity, which is mostly achieved with the use of mouth gags. Materials and Methods: The objective of this article is to present an account of various types and modifications of gags as surgeons, anesthetists, and innovators attempt to make that ideal mouth gag. The authors present this compendium of development of mouth gags using articles sourced from Medline, surgical catalogs, museums, ancient manuscripts, original quotes, techniques, and illustrations. Results: This article describes notable types and variants of mouth gags with an attempt to classify them. Conclusions: The huge number of modifications done and reports of newer variants appearing at regular intervals goes to prove that we are still far from developing the ideal mouth gag.

Keywords: Cleft palate, instruments, mouth gags, palate repair


How to cite this article:
Ameer F, Singh AK, Kumar S. The story of mouth gags. J Cleft Lip Palate Craniofac Anomal 2014;1:70-7

How to cite this URL:
Ameer F, Singh AK, Kumar S. The story of mouth gags. J Cleft Lip Palate Craniofac Anomal [serial online] 2014 [cited 2019 Jan 19];1:70-7. Available from: http://www.jclpca.org/text.asp?2014/1/2/70/137893


  Introduction Top


Special instruments for holding the jaws apart while repairing a cleft palate and other intra-oral procedures made surgery easier and were initially "borrowed" from dentists. These were modified to allow easier access to the surgical site such as the cleft in the palate, keep other structures away like the tongue. Eventually, these important instruments were designed in several parts to allow the jaws to be "jacked" open and initially to allow the anesthetic tube to be held securely in the tongue depressor without kinking and compression. An ideal mouth gag should provide adequate exposure of all parts of the oral cavity to perform intra-oral surgery. It should be easy to apply, in all anatomical and disease variants and should facilitate safe anesthesia via an endotracheal tube without kinking or putting pressure on it.


  Mouth Gags without Tongue Blade Top


Mouth gags acting as mere mouth openers

Mouth gags were primarily designed to keep the mouth in the open position, improve exposure and later were to assist the anesthetist. Gags by Lane, Rose, French and Doyen-Jensen [Figure 1] and [Figure 2] simply held the mouth widely open, requiring a tongue stitch to maintain an airway and a view for the surgeon. [1]
Figure 1: First generation gags-without tongue blades. (a) Lane, (b) Rose, (c) French, (d) Doyen-Jensen. (With permission from the digitized version of Millard's Cleft Craft© University of Miami's Calder Memorial Library)

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Figure 2: Lane mouth gag (©British Association of Plastic, Reconstructive and Aesthetic Surgeons reproduced with permission from the Curator, Hunterian Museum, Royal College of Surgeons London)

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Mouth gags with anesthetic delivery tubes

Mason and Doyen, to assist the anesthetist, equipped their gags with thin metal tubes fixed to the gag blades through which the anesthetic vapors could be insufflated into the oropharynx. [1] Hewitt modified the Fergusson's gag (A5) and added two tubes to the gag to deliver chloroform vapor [Figure 3]. [2]
Figure 3: Hewitt's modifi cation of Fergusson's gag having two tubes to deliver chloroform vapor

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Gags with additional light

Two major difficulties, which the surgeon faces when operating inside the mouth are the want of space and light. To overcome the second difficulty Cecil leaf fitted to Hewitt's gag a little battery operated electric light [Figure 4]. This is so arranged that it can be attached to either arm of the gag and turned to the right or left side as required and it enables the surgeon to get a good view of the whole of the inside of the mouth. [3] Later mouth gags were fitted with fiber-optic lighting system which have been described elsewhere in the paper.
Figure 4: Cecil's "light" modifi cation to Hewitt's gag, (reproduced with permission from BMJ Publishing Group Limited)

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Gags with spring catch

Coleman in 1861 developed a gag constructed upon the principle of a pair of forceps, with a difference, however that the handles do not cross each other at the hinge, so that, by pressing them together, the blades or short extremities are separated about the hinge [Figure 5]. Attached to one of the handles is a spring-catch, to keep the blades fixed at any required distance from each other. The extremities were covered on their outer surface with vulcanized India rubber. While using the instrument, the handles were opened and the blades brought together and introduced between the teeth at the back of the mouth. By compressing the handles, the patient's jaws could be separated from each other and by means of the catch, could be maintained in the required position at the will of the operator. [4]
Figure 5: Coleman mouth gag

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Gags with speed lock retention

Similar to the Coleman's gag, Sir William Fergusson, in 1876 described a gag with a speed-lock based retaining system [Figure 6]. [5] The grooved jaws designed to fit against the teeth of this mouth gag were added by William Robert Ackland, (1863-1949) a British dentist.
Figure 6: Fergusson mouth gag

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Gags with sheet spring and retention

Numerous forceps type gags were introduced with minor differences. Black in 1921 described a similar gag with sheet spring to keep its jaws closed while insertion and a ring type retention system [Figure 7]. [6]
Figure 7: Black's gag with sheet spring and a ring type retention system

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  Mouth Gags with Tongue Blade Top


Gags with tongue blade acting as only tongue retractor

Thomas Smith's gag (1868) incorporated a tongue depressor, as did gags designed by Whitehead, Collin, Geffer and Mahu [Figure 8] and [Figure 9]. Some of the gags began to get more complicated and incidentally, to look more like the gags of today [Figure 10], [Figure 11] and [Figure 12]. [1]
Figure 8: Second generation gags-with tongue blades. (a) Whitehead, (b) Collin, (c) Geffer, (d) Mahu. (With permission from the digitized version of Millard's Cleft Craft. ©University of Miami's Calder Memorial Library)

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Figure 9: Mouth gag, of a design known to Ambrose Paré in the 16th century. The lower blade was passed over the tongue and the wedge-shaped teeth kept the jaws apart. The frame formed a window through which the surgeon could operate on the palate or fauces. (©British Association of Plastic, Reconstructive and Aesthetic Surgeons Reproduced with permission from the Curator, Hunterian Museum, Royal College of Surgeons London)

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Figure 10: Whitehead's gag. (©British Association of Plastic, Reconstructive and Aesthetic Surgeons Reproduced with permission from the Curator, Hunterian Museum, Royal College of Surgeons London)

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Figure 11: Mouth gag with ratchet and pinion adjustment and ebony handle, made by Collin, France, 1868-1872. (©British Association of Plastic, Reconstructive and Aesthetic Surgeons Reproduced with permission from the Curator, Hunterian Museum, Royal College of Surgeons London)

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Figure 12: Thomas Smith mouth gag. Sir Thomas Smith, 1833-1909, 1st Baronet, surgeon. (©British Association of Plastic, Reconstructive and Aesthetic Surgeons Reproduced with permission from the Curator, Hunterian Museum, Royal College of Surgeons London)

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Gags with slotted tongue blade to prevent endotracheal tube compression

With the advent of newer methods of anesthesia, the tongue blades became somewhat wider and underwent several minor alterations to allow various ways of delivering anesthetic. [7],[8],[9],[10],[11],[12] The blade with a slot engaging the tube as described by Davies should probably be mentioned as the most modern version in this series [13] to accommodate the endotracheal tube without compressing or kinking it. Rew, Wyly and Grant of Ochsner Foundation Hospital in New Orleans described a modification of the tongue blade for the Davis mouth gag [Figure 13]. A slot cut in the tongue blade, which extends approximately two-fifths the length of the blade. At the distal end of the blade, a short shallow trough was soldered to the prongs leaving approximately one-fourth inch of the blade protruding. [14] Similar modifications were described by Doughty in 1957. [7],[8]
Figure 13: Slotted tongue blade of Rew, Wyly and Grant

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Sommerlad and Mehendale in 2000, [15] described a number of modifications of the tongue blade of the Dott mouth gag to facilitate cleft palate surgery, especially on small infants and patients with micrognathia as well as surgery under the microscope. This also reduces the risk of compression of the endotracheal tube [Figure 14]. The highly reflective surface of the blade was replaced with a matt surface to eliminate glare. The two flanges at the base of the blade were removed, thereby eliminating a source of pressure on the lower lip and reducing the number of projections on which a suture can snag. Moreover, removal of the flanges and decreasing the width of the base of the tongue blade, allows the lower lip to ride over the proximal edge of the blade, so that the lips form a triangular shape when stretched instead of rectangular which reduces the stretch on the lips, particularly at the commissures and in patients with small mouths. The slot extends more proximally, toward the base of the blade. In the modified blade, the corner of this angle has been replaced with a gentler curve that allows a much better view of the anterior palate. For smaller babies and micrognathic jaws, two smaller (narrower and shorter) tongue blades were designed that could be positioned flush with the lower lip, without abutting against the posterior pharyngeal wall.
Figure 14: Sommerlad modifi cation of tongue blade

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Agrawal and Panda proposed a modification of the Dott's mouth gag that involves fixation of two parallel bars over the lingual surface of the tongue blades [Figure 15]. This simple modification successfully prevents compression of the endotracheal tube during cleft palate repair. [16]
Figure 15: Karoon-Panda modifi cation of tongue blade


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Gags with additional spring carrier

Kilner added a spring coil [Figure 16] around the top to hold sutures in perfect order prior to tying, in keeping with his tidy surgery. [1],[17],[18]
Figure 16: Kilner's spring coil as suture carrier. With permission from the digitized version of Millard's cleft craft. (©University of Miami's Calder Memorial Library)

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Gags with additional anesthetic tube

One version of the Dott gag incorporated an anesthetic tube in the tongue depressor. [1]

Gags with tongue blade requiring external support

The mouth gag employed in tonsillectomy by Professor Crowe in the Johns Hopkins Hospital, like the Davis mouth gag, required an assistant or a support. Thacker-Neville designed a suspension apparatus for the mouth gag in order to save an assistant's tiring task [Figure 17]a. [19] Draffin in 1951 devised a bipod for suspending the gag during oral procedures to maintain the airway [Figure 17]b. [20]
Figure 17: (a) Thacker-Neville suspension apparatus. (b) Draffi n's bipod

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  Mouth Gags with Different Design of Frames Top


Gags with open frame

An assistant of Harvey Cushing, named Crowe, noticed a mouth gag in an instrument maker's catalogue with a tongue depressor attached to it with a ratchet mechanism. [17] After minor changes, Davis, Cushing's anesthetist, started using it at The Johns Hopkins Hospital. It became known as the Crowe-Davis mouth gag [Figure 18]. Later, this instrument, with minor changes, was introduced in England by Boyle and from then on was known in Britain as the Boyle-Davis mouth gag.
Figure 18: Crowe-Davis; Boyle-Davis mouth gag

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Norman Dott of Edinburgh constructed a mouth gag that forms the basis of all gags popular today. It was "C" shaped, with one side open, consists of two parts: The upper part with the jaw hooks and the lower, sliding part with the tongue blade [Figure 19]. The advantages of this mouth gag are well established: It is easy to apply, adjust and to maintain. It had similarities to the Crowe-Boyle-Davis gag, but this was an independent development as Dott, a neurosurgeon, also spent some time with Cushing in Boston and took the Crowe-Davis mouth gag home to Edinburgh, himself, in 1924. [21]
Figure 19: Dott's mouth gag

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Gags with closed frame

In 1962, Dingman and Grabb modified the open, C-shaped frame Dott-Kilner gag modified into a rectangular, closed frame. The tongue blade supported the gag inferiorly and held an endotracheal tube over the tongue. To this had been added bilateral side retractors mounted on universal joints, which hooked the lips near the commissures to pull the cheeks laterally out of the way [Figure 20]. [22] It was this mouth gag that became more popular in the United States. [23] The major problem of this gag being the lack of adaptability of the rigid rectangle to fit the irregular alveolus. [1]
Figure 20: Dingman mouth gag

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Gags with split alveolar bar

The frame was opened up again, (Lewis Thompson) by removing the central segment on the cephalad side of the rectangular frame [Figure 21]. This allowed more space to work on the anterior central third of the palate and the alveolar ridge. [24]
Figure 21: Thompson's open frame Dingman gag

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Gag with adjustable split alveolar bar

The majority of severe cleft palate patients have abnormal spacing between the maxillary alveolar arches. When there is maxillary retrusion, collapse or a protruding premaxilla, it is difficult to fit both alveolar hook retractors on the irregular alveolae when these retractors are attached to a rigid rectangular frame. To overcome this, Millard and Slepyan came up with the Miami device. It had an open frame on the cephalad side, to make the jaw hooks more independent for maximum adaptability. They divided the anterior bar to admit any projecting premaxilla. For more mobility, the anterior segments were constructed to slide sideways through the lateral barrels and these sliding anterior arms were capped with swivel-hook retractors, which could be set at any angle to clasp the alveolae. The swivel-hook retractors were made interchangeable-one for infants, one for adults, for total adaptability for any irregularity of the alveolar arch in patients of any age. The Dingman side cheek retractors were omitted in this modification [Figure 22]. [1],[25]
Figure 22: Miami modifi cation (Millard)

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Gag with long hooks to improve intra-oral visibility

Rao and Peter, [26] suggested a modified Dingman mouth gag to improve access to and visibility of the anterior palate. The length of the hooks that fit around the alveolus or on teeth was increased, which would displace the superior horizontal bar more superiorly, thus improving access to the anterior palate. The entire frame assembly was more curved than the original, which allows the sliding and fitting of the hooks on more distal teeth or palate from the sides, rather than from the front as in the original gag. This modification also included a more curved frame and minor modifications of tongue blade.


  Self Illuminated Mouth Gag Top


Dott's bearing lamps were already available in the early years. [27] Later, a fiberoptic light was attached to the Dingman-Millard variation [Figure 23] as well as to the original Dott. The use of fibreoptic lights for surgical retractors has been an accepted technique for improved visualization for some time. It makes sense then to incorporate fibreoptics when working in small, dark areas, like the oropharynx. In order to improve the lighting when using the Dingman Millard mouth gag, a fiberoptic modification previously used on the Dott retractor was devised for the blades. [28]
Figure 23: Lighted Dingman (on Millard's modifi cation)

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  Mouth Gag with Sliding Stem for Surgery on Tongue Top


Gags with tongue blades have one major disadvantage: They do not allow surgery involving the tongue. For this reason, yet another variation was proposed [Figure 24]. Instead of the standard tongue blade, a lower part consisting of the sliding stem combined with the same adjustable jaw-holding device as in the upper part. The tongue blade itself was omitted. [19]
Figure 24: Gag for surgery over tongue (Bloem and Hage)

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  Other Modifications Top


It is necessary to visualize the posterior pharyngeal wall deeply when constructing a long, superiorly based pharyngeal flap. The base of the tongue must be brought forward to see far down on the posterior pharyngeal wall (for cutting the tip of the flap). The blade of the Dingman mouth gag has a 90° angle; if one uses it, the distal portion of the handle of the tongue retractor must be lifted to visualize the flap tip. When this is done, the tongue retractor often bends (straightens slightly) at the junction of the blade and handle allowing the posterior part of the tongue to fall back and obstruct the view. The 90° angle may be reestablished by manual manipulation, but the retractor soon re-bends and eventually breaks. To avoid this a tongue blade with a metal-reinforced, nonadjustable angle was introduced. [29] Furthermore, noteworthy is another modification of the tongue blade with an adjustable angle, to facilitate visualization of pharyngeal wall. [30]

Humby and Hawksley, [9] added a chin piece that fitted snugly to the gag to prevent the tube from rotating. More protection to the extra-oral part of the endotracheal tube is given by the modification that was described by Murakami, [31] in 1970, at the same time providing better exposure of the surgical field. Better exposure and better access to the posterior pharyngeal wall was accomplished by Laitung, [32] by retracting and holding the soft palate with an extra blade fixed to the superior bar of the frame.


  Conclusion Top


Mouth gags have developed from simple retractors to complex multifunctional instruments that assist exposure during surgery and at the same time facilitating anesthesia delivery. Lack of adequate exposure, difficulty if application, bulky hardware interfering with surgery, anesthetist complaining of resistance in airway ventilation is all commonly encountered during palatal and other oral surgeries. No single gag has all the attributes of and ideal mouth gag and the fact that the huge number of modifications has been done and reports of newer modifications appearing at regular intervals goes to prove that we are still far from developing the ideal mouth gag.

 
  References Top

1.Millard DR. Anesthesia in Clefts (Gas, Tubes and Gags). Cleft Craft. Boston: Little Brown; 1980. p. 147-8.  Back to cited text no. 1
    
2.Hewitt FW. Anesthetics and their Administration: A Textbook for Medical and Dental Practitioners and Students. London: Macmillan and Co. Limited; 1907.  Back to cited text no. 2
    
3.Medicinal and dietetic preparations. Br Med J 1910;1:760.  Back to cited text no. 3
    
4.Coleman A. An instrument for keeping the mouth open in operations under chloroform. London: Medical Times and Gazette; 1861. p. 105-6.  Back to cited text no. 4
    
5.Fergusson W. Further observations on hare-lip and cleft palate. Br Med J 1876;1:3-4.  Back to cited text no. 5
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6.Appliances and preparations. Br Med J 1921;1:127.  Back to cited text no. 6
    
7.Doughty A. A modification of the tongue-plate of the Boyle-Davis gag. Lancet 1957;272:1074.  Back to cited text no. 7
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8.Doughty A. Anaesthesia for adenotonsillectomy; a critical approach. Br J Anaesth 1957;29:407-14.  Back to cited text no. 8
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9.Humby G, Hawksley M. Apparatus for peroral intratracheal anaesthesia. Br Med J 1943;1:317-8.  Back to cited text no. 9
[PUBMED]    
10.Magill J. Oral intubation and the Davis gag. Br Med J 1948;1:417.  Back to cited text no. 10
    
11.Monro JS. A modification of the Boyle-Davis gag for oral intubation. Br Med J 1948;1:267.  Back to cited text no. 11
[PUBMED]    
12.Barton RT. Instrument for endotracheal anesthesia during oropharyngeal surgery. J Am Med Assoc 1953;153:1017.  Back to cited text no. 12
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13.Davies RM. A modification of the Dott gag. Lancet 1954;267:635.  Back to cited text no. 13
    
14.Ring WH. Modification of Crowe-Davis mouth gag. Anesthesiol 1961;22:494.  Back to cited text no. 14
    
15.Sommerlad BC, Mehendale FV. A modified gag for cleft palate repair. Br J Plast Surg 2000;53:63-4.  Back to cited text no. 15
    
16.Agrawal K, Panda KN. Modified palate mouth gag tongue blade to prevent endotracheal tube compression. Plast Reconstr Surg 2005;116:857-9.  Back to cited text no. 16
    
17.Bodley P. Development of anaesthesia for plastic surgery. J R Soc Med 1978;71:839-43.  Back to cited text no. 17
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18.Holdsworth W. Cleft Lip and Palate. 4 th ed. London: William Heinemann Medical Books; 1970.  Back to cited text no. 18
    
19.Preparations and Appliances. Br Med J 1926;2:642.  Back to cited text no. 19
    
20.Preparations and appliances. Br Med J 1951;2:52-3.  Back to cited text no. 20
    
21.Bloem JJ, Hage JJ. The cleft palate gag line: Connect the Dotts. Ann Plast Surg 1993;30:475-8.  Back to cited text no. 21
    
22.Dingman RO, Grabb WC. A new mouth gag. Plast Reconstr Surg Transplant Bull 1962;29:208-9.  Back to cited text no. 22
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23.Lopchinsky RA, Kanarek L. Use of the Dingman mouth gag in transhyoid pharyngectomy. Plast Reconstr Surg 1982;70:758-9.  Back to cited text no. 23
[PUBMED]    
24.Thompson LW. Modified Dingman mouth gag. Br J Plast Surg 1969;22:286-7.  Back to cited text no. 24
[PUBMED]    
25.Millard DR Jr, Slepyan DH. Modification of the Dott-Dingman mouth gag. Plast Reconstr Surg 1977;59:593-5.  Back to cited text no. 25
[PUBMED]    
26.Rao LP, Peter S. Modification of the Dingman Mouth Gag for better visibility and access in the management of cleft palate. Cleft Palate Craniofac J 2014 [Epub ahead of print]  Back to cited text no. 26
    
27.Holdsworth W. Cleft Lip and Palate. 2 nd ed. London: William Heinemann Medical Books; 1957:89.  Back to cited text no. 27
    
28.Lehman JA Jr, Burger K. A new light for the Dingman-Millard mouth gag. Plast Reconstr Surg 1985;75:280.  Back to cited text no. 28
    
29.Zook EG. A reinforced tongue blade for the Dingman mouth gag. Plast Reconstr Surg 1974;54:682.  Back to cited text no. 29
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30.Ring WH. A new device for exposure of the oropharynx. Arch Otolaryngol 1972;96:86-7.  Back to cited text no. 30
[PUBMED]    
31.Murakami S. A new mouth gag with modified tongue-plate. Anesth Analg 1970;49:791-2.  Back to cited text no. 31
[PUBMED]    
32.Laitung JK. A modification of the Kilner-Dott mouth gag for improving exposure to the nasopharyngeal area. Br J Plast Surg 1986;39:268-9.  Back to cited text no. 32
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24]


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