Maxillary fracture

RE: Maxillary fracture

Kate Richardson — Fri, 06 May 2016 20:33:56 GMT

My hugest apologies, I think the markers are wrong☺️ I

RE: Maxillary fracture

Evelyn Barbour-Hill — Fri, 06 May 2016 17:28:42 GMT

Ooooops I think I see where confusion has arisen.

I think on the DV view, the middle radiograph, the R marker is on the left side of the cat................

Fracture in the left TMJ then. I thought the fracture was of the neck of the mandibular condyle, Peter Southerden thinks it is of the mandibular fossa. He is more likely than me to be correct.

Peter has CT, the jammy beggar, so as you are not too far away he might be able to get fully diagnostic images. Personally I think some more radiographs well aligned and collimated could do the trick.

Maybe a mobile bone fragment is sometimes drifting round and blocking the joint and then driting out and unblocking it?

RE: Maxillary fracture

Kate Richardson — Fri, 06 May 2016 15:53:01 GMT

That is correct Evelyn Barbour-Hill the initial wiring of the mandibular symphysis was unstable and was re-stabilised

Can you possibly highlight the area where you think there may be a fracture?

He was seen yawning widely today!

RE: Maxillary fracture

Evelyn Barbour-Hill — Fri, 06 May 2016 13:46:28 GMT

[quote user="Gerry Henry"]Hard to say from X Rays but the mandibular repair doesn't look too good at all; would it be worth doing it again and improving what looks like a bad malocclusion.[/quote]

I understood that the radiographs were of the state when the cat was presented, and that the mandibular symphysis was indeed done again.

But you know you will never stabilise the mandible by fixing the front end if the back end is unstable!

RE: Maxillary fracture

Gerry Henry — Fri, 06 May 2016 08:33:01 GMT

Had a cat years ago with multiply comminuted # of mandible; numerous K wires and dental acrylic, lovely repair, perfect occlusion, smug smug smug. Didn't eat so client (ungrateful B) went to another practice, had a dislocated hip! So ... have you checked rest of cat for injury?

Hard to say from X Rays but the mandibular repair doesn't look too good at all; would it be worth doing it again and improving what looks like a bad malocclusion.

RE: Maxillary fracture

Kate Richardson — Fri, 06 May 2016 07:56:49 GMT

ppps I should clarify the maxilla cleft is in the left lateral aspect of the hard palate. I'll take photos when I re Xray although owner is now stalling

RE: Maxillary fracture

Kate Richardson — Thu, 05 May 2016 19:26:05 GMT

PS thanks

RE: Maxillary fracture

Kate Richardson — Thu, 05 May 2016 19:25:51 GMT

[quote user="Noweia"]Given jaw movement was ok 7 days ago, and he wasn't eating, could it be pain? On another note is it normal for fibrosis to occur so rapidly, and so long after the original injury?[/quote]

That's what I find a bit odd, how this reduced opening has suddenly occurred.

Ok more xrays and will post them.

RE: Maxillary fracture

Kate Richardson — Thu, 05 May 2016 19:24:15 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Kate Richardson"]Good stability when assessed and caudal teeth aligning nicely but when motuh fully closed, remaining canines impinging and penetrating into mucosa on upper/lower jaw[/quote]

I don't quite see how that could happen if the occlusion was as correct as you thought. Also, if the occlusion were correct I wouldn't expect a part of the maxillary soft tissue wound to stay so open it had to be left to granulate.

[/quote]

I am kicking myself I didn't take photos at the time. The maxillary cleft/defect is on the left side, initially an area approx 2-3mm wide running from 206 to 209. Most of the bony tissue between the lateral margin of the cleft and the buccal aspect of the teeth was fragmented. The occlusion was assessed mainly on the right side as no maxillary teeth to assess occlusion on the left side, initially it appeared that the canines and incisors occluded normally when the mandibular symphysis wire was replaced, but nothing looked anywhere near normal at that stage, but I was pretty happy with the alignment initially.

He has only been off pain relief over the last week or so, so maybe I'll re instate that. The cat is so bright and active otherwise, but obviously, he could still have pain when trying to move his jaw, however, has been yawning and stretching his mouth wide open with no signs of discomfort until this week. But I guess eating is a different kettle of fish than yawning. He still has O tube in.

RE: Maxillary fracture

Noweia — Thu, 05 May 2016 19:05:53 GMT

We had one like this last year, the whole left side of his face was mangled, mandibular symphyseal fracture, broken teeth, the lot. His left maxilla was fractured and compressed inwards, so 204 to 207 were angled slightly inwards and sitting medially (Looks like this cat has the same problem on the right side). We removed loose bone chunks and ended up leaving the left maxilla in its new position as it was too tricky to remove. We had problems getting him to eat and ended up giving him quite high doses of Comfortan until he was managing by himself - we were surprised at how much he tolerated.

Given jaw movement was ok 7 days ago, and he wasn't eating, could it be pain? On another note is it normal for fibrosis to occur so rapidly, and so long after the original injury?

RE: Maxillary fracture

Evelyn Barbour-Hill — Thu, 05 May 2016 18:08:17 GMT

I can't make out the right TMJ properly, even on the DV radiograph (but of course the hemimandible is angled there) but it doesn't look quite "right" (very scientific).

There's a midline split in the premaxilla which may have some small significance. And on first presentation to you of course the occlusion was very poor, with the symphyseal wire not really maintaing a proper relationship between the hemimandibles: which strongly suggests an instability in one TMJ.

This is the bit I don't quite understand:

Bear in mind I've only got your description to go on!

So I'm thinking that probably the right TMJ was damaged, hence unstable and hence a malocclusion, and hence also as you speculate a fibrosis.

Yes, more radiographs are indicated I think. I'd do a separate one for each TMJ so that the beam goes straight down DV across the joint.

Then, yes, attempted manipulation to open the joint..... but I don't think "gentle" will do it! Rather a lot of force may be needed, albeit applied in a slow, careful, patient manner.

Just to be gloomy, in the occasional case if there's ankylosis an excision arthroplasty might ultimately be needed..... don't worry about that yet.

I haven't any really bright ideas about his not eating.... except, obviously, that something may still be painful. Has he still got the oesophagostomy tube in?

PS The more I look the more sure I am that the right TMJ is fractured on the mandibular side.

RE: Maxillary fracture

Kate Richardson — Thu, 05 May 2016 16:48:14 GMT

Hoping for some advice here

6yo MN British Short Hair cat, RTA 21st March 2016. Referred to our practice- fractured 304 and extracted, mandibular symphysis wired, and Right eye enucleated as had proptosed, thought to have other skull fractures hence referred. Multiple head injuries, in a pretty bad way, will cut a long story short, intensive care and stabilised, blood transfusion, and supportive tx for 10 days until stable enough for a GA to assess further. Xrays on first post. Also intra-oral xrays which am unable to post as old fashioned manual processing. Essentially maxilla fracture, split rostrally with a deep cleft medial to maxillary teeth, 207/208 fractured with ++bone fragments and instability in surrounding bone. 304 root still in situ. No other convincing fractures, but any comments on above radiographs welcome. Lots of detached gingiva on lateral aspects of mandible bilaterally. So extracted 207/208 and cleaned up mouth, sutured mandibular gingiva back in place, attempted extraction of 304 root, but too much instability so left alone and cosed mucosa over it. Managed to close rostral part of maxillary cleft, left caudal part to fill with granulation tissue. No oronasal fistula evident. O tube placed (had NO tube prior).Good alignment of upper and lower jaws but only able to assess on RHS, but happy with alignment.

Cat continued to do well, vision verified on left eye, and HCT returned to normal, gradual return to a functional cat. Good mobility etc and responsive. Reassessed healing under GA after 2 weeks, still being tube fed, no interest in eating as yet, but not too concerned due to extent of trauma and lots of healing to go, yawning and opening mouth well ast home. Good stability when assessed and caudal teeth aligning nicely but when motuh fully closed, remaining canines impinging and penetrating into mucosa on upper/lower jaw, so decision made to extract. Cleft in maxilla granulating nicely.

Really pleased with the way the mouth looks and moves at appointment last week, but still not eating on his own, so mirtazipine and cyproheptadine have been trialled plus withholding feeding for 24hrs to make him hungry. Owners initially thought he had lost sense of smell, but over last couple of weeks showing signs of awareness of stronger smells. has picked up a couple of toys in mouth and shows hunger but no voluntary eating. I re-examined him last night, and now he cannot open his mouth fully (he is VERY difficult to examine his mouth conscious, even wrapped in a towel), it will only open about 60% of the way, so I am thinking maybe some fibrosis occuring around TMJs, but wanted to see if anyone Evelyn Barbour-Hill especially can see anything I have missed on original radiographs, before I repeat GA and re xray/assess.

If there is no other fractures, then would I be right in thinking fibrosis and gentle manipulation to open mouth fully under GA would be appropriate? I also plan to administer IV diazepam once he has recovered from the GA (as he would need sedation to manage an IV injection otherwise....) to see if that will 'remind' him how to eat!

Any tips/advice welcome (as they are helpful and not critical unless in a good way)