Repairing a split hard palate

RE: Repairing a split hard palate

Rob Davis — Sat, 21 Sep 2019 10:34:00 GMT

[quote user="vetalix"]

The bvda will be running a dry lab at bsava on intraoral splinting and composite techniques. It is better to use a flowable light cured composite for cats as it’s small and fiddly but for dogs you can use protemp which is self curing.

Will post more details of the lab when it is finalised.

Alix

[/quote]

Hi Alix

Do you use acid etching / bonding agent before applying maxitemp?

RE: Repairing a split hard palate

Alix Freeman — Sat, 21 Sep 2019 09:39:19 GMT

Will post more details of the lab when it is finalised.

Alix

RE: Repairing a split hard palate

Rob Loxley — Sat, 21 Sep 2019 08:32:13 GMT

[quote user="Anthony Dennison"]Maybe worried about the wire slipping off?[/quote]

I guess glue is the answer. As a GP vet who has never done inter-dental wiring/bonding, can someone give some pointers as to products to use - ideally from NVS though we can shop around - that cures without a special light?

RE: Repairing a split hard palate

Anthony Dennison — Fri, 20 Sep 2019 10:16:15 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Anthony Dennison"]Here's a very basic diagram (as I explain to clients when I draw stuff, I did sciences not art at school)[/quote]

Me too.

The K wires are into the hard palate? Or through the maxilla?

PLEASE N.B. not criticising, but just wondering why he used wires when you've got all those teeth as ready-made anchors.

[/quote]

Into the hard palate. I'm not sure either, I think she () was treating it like a lag screw type situation. In future we will use the teeth though. Maybe worried about the wire slipping off? Will know for future ones, thank you

RE: Repairing a split hard palate

Julie Innes — Fri, 20 Sep 2019 08:58:32 GMT

I want a CT scanner now! Brilliant images! Hope all goes well with the cat

RE: Repairing a split hard palate

Evelyn Barbour-Hill — Fri, 20 Sep 2019 00:43:14 GMT

[quote user="Anthony Dennison"]Here's a very basic diagram (as I explain to clients when I draw stuff, I did sciences not art at school)[/quote]

Me too.

The K wires are into the hard palate? Or through the maxilla?

PLEASE N.B. not criticising, but just wondering why he used wires when you've got all those teeth as ready-made anchors.

RE: Repairing a split hard palate

Anthony Dennison — Thu, 19 Sep 2019 10:54:53 GMT

Sorry didn't take a photo of it at the time and cat isn't amenable to us opening the mouth to try!

Here's a very basic diagram (as I explain to clients when I draw stuff, I did sciences not art at school). Area in blue pen is loose section of maxilla. K wires have been clipped short and bent backwards so they aren't causing local mucosa irritation.

View is intra oral, looking up at the hard palate (so right side of mouth is on left of image)

RE: Repairing a split hard palate

Evelyn Barbour-Hill — Tue, 17 Sep 2019 18:33:33 GMT

I can't quite visualise where these k wires were placed. Any chance of some photos?

RE: Repairing a split hard palate

Anthony Dennison — Tue, 17 Sep 2019 16:08:22 GMT

TMJs are both fine. Yes this is a 3D composition from the CT scan, much easier to send this than the series!

My colleague place 2 k wires just behind the upper canines and placed a wire tension band to pull the 2 together which seems to have stabilised everything. I asked about wiring around the upper 08s and we decided against it for the moment. O tube placed, in recovery now. We'll see how it does

RE: Repairing a split hard palate

Evelyn Barbour-Hill — Tue, 17 Sep 2019 14:47:18 GMT

[quote user="Kate Richardson"]Are the TMJs fractured at all?[/quote]

They look OK on this image. If they are OK that's fortunate and very favourable because it means there's no difficulty using the lower jaw as an aligner and splint.

RE: Repairing a split hard palate

Kate Richardson — Tue, 17 Sep 2019 14:40:20 GMT

Wow. Cool image- is that produced from a CT scan?

Are the TMJs fractured at all? Cos that might be a longer term limiting factor. I will wait for someone far far cleverer than me to comment on what you do next, but was it possible realign things under the GA with your hands? Oral soft tissue has an amazing capacity to heal, so I wouldn't write it off based on appearance of the wound edges?

RE: Repairing a split hard palate

Evelyn Barbour-Hill — Tue, 17 Sep 2019 14:37:57 GMT

[quote user="Anthony Dennison"]

Ok well we did do a sneaky one in the end.

Right side of the skull separated from the rest of it - full split of the hard palate and bony area as well as the nasal bone fractured and there's also a break where the zygomatic arch originates. Right maxillary arcade has also been pushed back about 1cm and the nasal septum is also smushed.

At the limit of our clinical skills to fix and well out of the clients price range, plus the edges of the hard palate wound are getting nasty and necrotic now.

[/quote]

I can't get over these wonderful images from CT. Just brilliant to see exactly what's going on. Technology really is wonderful (sometimes).

Despite the complexity of the fractures, i think that's well fixable, rather as I originally suggested only more so. I'd start with wire 108 to 208, wire and composite 104-204, inter-jaw fixation with composite both sides. (I see 204 is broken but treating that can wait)

Don't fret about the soft tissues, they will come right in the end with treatment

RE: Repairing a split hard palate

Anthony Dennison — Tue, 17 Sep 2019 14:21:36 GMT

Ok well we did do a sneaky one in the end.

At the limit of our clinical skills to fix and well out of the clients price range, plus the edges of the hard palate wound are getting nasty and necrotic now.

RE: Repairing a split hard palate

Evelyn Barbour-Hill — Tue, 17 Sep 2019 12:19:01 GMT

[quote user="Anthony Dennison"]Are you seriously suggesting we do a CT for free?! Tony you really are out of touch. [/quote]

To be fair, I think he was suggesting that if you really can't work out the best thing to do from ordinary radiographs, you have your own CT machine in the practice and a CT would really help you, just quietly do the CT but don't tell the client.

RE: Repairing a split hard palate

David Mills — Tue, 17 Sep 2019 10:54:03 GMT

You often here the line that correct occlusion is essential. Why? Plenty of animals don't have it and cope fine. I see it's desirable, but essential? I don't understand that.

I suppose with the op it depends on where the hard palate is fractured or split. I can't remember needing to wire these, have just approached them like a cleft palate repair with the soft tissue mobilisation. All did fine.

RE: Repairing a split hard palate

Anthony Dennison — Tue, 17 Sep 2019 10:34:16 GMT

[quote user="Kate Richardson"]Nothing to add on the repair procedure, but I think it would be a good idea to place an O tube regardless[/quote]

Yes - whatever happens an o' tube is going in!

[quote user="Anthony Todd"]

Wot's the cost of a CT shot in the scale of results.

Not having a shot at you at all, but if the result is not-so-good, for the sake of your, or yours, paying for a CT scan, er, like the electricity which is ,er, not too much.....

[/quote]

Are you seriously suggesting we do a CT for free?! Tony you really are out of touch.

RE: Repairing a split hard palate

Kate Richardson — Tue, 17 Sep 2019 09:21:55 GMT

Really hoping you can post some photos Anthony and of any xrays and your repair. Nothing to add on the repair procedure, but I think it would be a good idea to place an O tube regardless- cat can eat with it in anyway, but if it doesn’t want to eat at least you won’t have to anaesthetise the cat again to place one and it’s a good way of medicating the cat as well and means you can use oral meds which will help with costs

RE: Repairing a split hard palate

Evelyn Barbour-Hill — Mon, 16 Sep 2019 23:24:51 GMT

The reason I'm suggesting interjaw fixation is that when it is as the OP described – parasagittal split close to the tooth arcade – it's very likely there are other fractures and, for instance, a chunk of maxilla is potentially unstable. If that is not addressed then malocclusion will be the end result. Of course if that's not the case everything becomes easier.

When the injury is a true midline split – sometimes, on radiography you find much of the whole skull has split down the middle, but fixing the palate is all that is necessary – there has been, in my hypothesis, relatively little force in the trauma. So there may well be no other fractures. Whereas if the fracture is as the OP describes, the trauma must have been much more violent – much more mechanical energy has been expended within the skull – and it is very likely, almost invariable, that there are a number of other fractures, some of which unquestionably need stabilisation.

I agree, oesophagostomy is rarely necessary if all your repairs have just gone across the roof of the mouth, as it were. Stabilise the fractures in correct occlusion, relieve pain and the cat will eat. On the other hand, never be reluctant to place an oesphagostomy tube – it's a classic part of the jaw repair armamentarium (I've always wanted to use that word )

RE: Repairing a split hard palate

Bob Partridge — Mon, 16 Sep 2019 20:15:27 GMT

Absolutely agree with *NOT* doing a CT if the client is not going to pay for it. Otherwise - how can you *ever* justify charging for any CT?

The client has a choice, document it & do what you can within limitations set by client.

Obviously without seeing the case.... Close soft tissues. Agree with Rachel 5/0 Monocryl is my choice.

Often I will stabilise maxilla with loop of wire between 108/208 (if present). Agree with Evelyn - avoid danger of over-tightening and deviating maxillary dental arcade palatally. Sometimes will add a further loop to 104/204 if required. Then ensure occlusion is correct (extubate & close mouth fully!). Then ProTemp Garrant - or similar cold cure acrylic to the hard palate. Check occlusion again before sets hard.

Unless concern re TMJ or other oral instability will often leave with just this - rather than Max/Man fixation (104-404, 204-304).

Cats will usually return to function very rapidly (eat that night) - if you Max/Man fixate - then will always take longer. Rarely need to use oesoph feeding.

If acute dental fractures may well perform a speedy vital partial pulpectomy -= bandaging procedure to pulp. Otherwise dental trauma may have to wait for a second GA procedure when a healthier patient.

Pain relief paramount

These are always fun

All best

Bob

RE: Repairing a split hard palate

Joyce Whitehead — Mon, 16 Sep 2019 19:55:57 GMT

And if you do the CT for nothing (as I think you’re suggesting Anthony) they will tell the whole world who will expect the same for their cat...

interesting are and I’d love to see photos (even though I probably wouldn’t tackle it myself).

RE: Repairing a split hard palate

Anthony Todd — Mon, 16 Sep 2019 17:53:33 GMT

[quote user="Anthony Dennison"]

Thank you for the information. We do have an on site CT scanner but after further discussion with the owner that is outside their price range (classic 'cost is no issue' at admit) so we'll have to see how that goes.

[/quote]

So wheh it isn't so good, and it could have been perfect, the client will only blame you or the profession....

Wot's the cost of a CT shot in the scale of results.

Not having a shot at you at all, but if the result is not-so-good, for the sake of your, or yours, paying for a CT scan, er, like the electricity which is ,er, not too much.....

If all is fine they'll tell a few; if it's not they'll tell everyone!

RE: Repairing a split hard palate

Anthony Dennison — Mon, 16 Sep 2019 17:42:50 GMT

RE: Repairing a split hard palate

Roland Bulkyn-Rackowe — Mon, 16 Sep 2019 17:27:02 GMT

I've treated quite a number of these. I've tried interdental wire across the 108s, just soft tissue PDS and just soft tissue vicryl. The only really bad outcome was the pds where the cat was really irritated and I had to remove it (and replaced with vicryl).

RE: Repairing a split hard palate

Evelyn Barbour-Hill — Mon, 16 Sep 2019 15:22:03 GMT

[quote user="Anthony Dennison"]

[quote user="Evelyn Barbour-Hill"]inter-jaw fixation with resin composite.[/quote]

So composite between the maxillary arcades or between mandibular and maxillary on the same side?

[/quote]

Between mandibular and maxillary on the same side.

[quote user="Rachel Perry"] Final decision will be based on assessment of stability/instability of fractures found.[/quote]

Absolutely. We are only guessing at the moment.

CT is a great luxury if you have it, of course. If you don't you can generally work out the essential features of what's going on by looking very carefully at radiographs. One good idea is to have a skull with you and keep referring from radiographs to skull. I wouldn't be without my cat skull, I keep it handy throughout when repairing these things.

Correct occlusion is essential. Which is partly why I am such an enthusiast for inter-jaw fixation.

It's quite possible that the whole chunk of maxilla which contains the alveoli of the cheek teeth is mobile: radiographs or CT and palpation will reveal this.

Tooth trauma likely, yes, but I'd give priority to the bone repair.

Rachel, two things. You seem to be suggesting to repair the soft tissues and the bony fracture will look after itself, whereas, as a generalisation, I'd suggest quite the opposite. Discuss? And, while I quite agree with your wire method if you are wiring between canines, I see wiring between canines as not the most sound mechanically in what the OP describes. Discuss?

RE: Repairing a split hard palate

Rachel Perry — Mon, 16 Sep 2019 15:03:12 GMT

These cases will often have multiple fractures, so if you have CT on site it would be far better than skull radiographs as it's far more sensitive. Also don't forget 72% of these cases will also have tooth trauma requiring action. Can the cat close its mouth and is occlusion normal? Assuming this is a para-sagittal fracture from your description (rather than mid-line palate?). Digital compression of the two sides may be all that is needed, suture soft tissues (I prefer something like 5-0 Monocryl). Final decision will be based on assessment of stability/instability of fractures found. A wire between the maxillary canines covered in composite/temporary crown material can be helpful. Rather than figure of 8 I prefer to twist around the canine then twist the wire in the inter-canine gap, then twist again around canine.

Post pictures if you can!