Notes: Anesthesiologists are responsible for maintaining the patient’s respiration and other vital functions during surgery. Mouth gags are sometimes used to hold the patient’s mouth open for dentistry, oral surgery and anesthesia. Surgical procedures for the repair of cleft palate began in the 18th Century. The first successful cleft palate surgery in the United States was performed in 1820 by John Collins Warren (1778-1856). Since the mid-19th Century, many mouth gags have been designed specifically for these surgeries. All instruments are for Human Surgical use only, if looking for Veterinary Instruments, please visit Notes: Austrian Difficult Airway/Intubation Registry, Virtual Museum of Equipment for Airway Management. http://www.adair.at/eng/museum/equipment/mouthgags/whiteheadobject01.htm. Accessed June 13, 2017. Notes: One mouth gag; Consists of two sculpted, horizontal bars, hinged together at each end, and connected on the right side to a mechanism for adjusting the space between the bars; The mechanism consists of two handles that are hinged so as to stand perpendicular to the bars; These handles hold a ratchet between them; The end of each handle is scored by hatching on its exterior side (for improved grip); In the short physical description the gag is measured in the fully open position; When the gag is fully closed, the height is 8.5 centimeters; Both bars, and both handles, are marked on the interior with the number: “25”; The lower handle is also marked with the logo, consisting of a circle enclosing the letter “J” superimposed on the letter “S”.

The Jennings gag is a modification of the gag introduced in the 1860s by William R. Whitehead, M.D. (1831-1902). Jennings removed the built-in tongue depressor of the Whitehead gag, and simplified the mechanism for opening and closing it. The Whitehead gag has two spring-loaded ratchets. The Jennings gag uses a single ratchet, located on the operator’s right, that can be manipulated by the finger and thumb of one hand. Squeezing the handles together opens the gag. To close it, the ratchet is depressed and the handles pushed apart. Both the Whitehead and Jennings gags are still being made today. During clinical and surgical practice, the dislocation and sliding were less frequent observed in contrast to the original Denhart mouth gag. The Denhart–Hoefert mouth gag has been used in a large number of patients and has not encountered any trauma to the mandible or the teeth so far. After introduction in July 2008, the Denhart–Hoefert mouth gag was used in orthognathic surgery in 250 cases. It is regularly used in bisphosphonate-related osteonecrosis or bisphosphonate-related osteonecrosis risk patient surgery in 150 cases, because of its good controlled force application to the gingiva in edentulous jaw. Additionally, it has been used minimally in another 100 cases of other surgical operations. Whitehead gag: invented in 1877 by Walter Whitehead (1840-1913), a surgeon in Manchester, England, [1] consists of two hinged metal frames that wrap around the front of the patient's head and which have sections bent to fit between the front teeth. When spread apart, the frames separate the jaws, holding the mouth open. The desired degree of separation is set and maintained by a ratchet mechanism on each side of the frame. In later times, mouth gags were used in medical situation to open the patients mouth for examination, insertion of instruments, administration of feeding or dental care. Sometimes this was necessary because of fear, but more frequently due to illness such as tetanus, epilepsy, stroke, hysteria, coma etc. [ 2]. Since the medical use of mouth gags, a wide variety of different mouth gags, with or without tongue depressors or plates, one- or double-sided, were invented and distributed [ 2– 10].

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One was introduced in 1914 by St. Louis physician John Ellis Jennings (1863-1935). Jennings' gag is a modification of the Whitehead gag, which had been introduced some fifty years earlier. Jennings removed the built-in tongue depressor of Whitehead's gag, and simplified the mechanism for adjusting it. The Whitehead gag has two spring-loaded ratchets. The Jennings gag has a single ratchet that can be operated by the finger and thumb of one hand. Squeezing the handles together opens the gag. To close it, the ratchet is depressed and the handles pushed apart. Both the Whitehead and Jennings gags are still being made today. Exhibit History Described from the operator’s perspective, with the ratchet on the right and the handles extending forward. St. Louis physician John Ellis Jennings (1863-1935) introduced a new tonsillectome (an instrument for removing tonsils) in 1913; in that article he does not mention the use of any mouth gag. The following year he published another article about the use of the instrument, which included an illustration of “the Jennings mouth gag”. Notes: Leow A-M, Lun-Jou L. Palatoplasty: evolution and controversies. Chang Gung Med J. 2008;31(4):335-345. Notes: Jennings JE. The complete removal of the tonsil in its capsule (Sluder method) by means of a new tonsillotome. Medical Fortnightly. 1914; 45:56-58.

In 1897, Snow [ 6] emphasized, that slipping of mouth gags may embarrass the operator and often seriously deteriorating his results. Therefore, this might present difficulties during surgery and may lead to an interruption of the operation process.Until now, mouth gags have been widely used in surgery. A variety of different mouth gags is described and distributed today (Table 1) [ 2– 5, 9]. Already Colt mentioned in 1907, that the number of gags in the market was large, but the number of those, which combine in one instrument all the essentials, is rare [ 4]. Many years later, on a Caribbean work trip, Dingman considered his mouth gag as “happiness” for a surgeon operating on cleft palate, but Millard stated in his book in 1976, that he experienced a couple of difficulties with that gag, mostly with its adaptability to fit to irregular alveolae [ 9].

Notes: Powers & Anderson. Illustrated Catalogue of Surgical Instruments and of Allied Lines. Richmond, Virginia: Powers & Anderson, Inc., 1917:355. The Jennings Mouth Gag offers a wide range of surgical advantages. Its principal use is to provide an atraumatic way to open the mouth without damaging the temporomandibular joint. The “JS” logo stamped on the object is unknown to the cataloger. It is unlike the caduceus logo of the German manufacturer, Jetter & Scheerer.

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Interestingly, in early 1907, Colt already mentioned, that there were enough reasons for bringing forward the subject of a mouth gag designed to suit the needs of the general practitioner, surgeon, dental surgeon and anaesthetist. In those times, he already remarked besides the large number of different gags on the market, that a single perfect gag was missing, which supplies all needs [ 4]. Notes: Whitehead, WR. Report on the best methods of treatment for different forms of cleft palate. Transactions of the American Medical Association, Volume XX. Philadelphia: Collins, 1869. a Inserting the gag with placing the hole of the pad to the cusp of the canine, b fixation of the pad to the interproximal area with a stop for additional hold