One for the dentists...

RE: One for the dentists...

Rob Davis — Wed, 18 Nov 2020 15:58:47 GMT

Cool video (not for the cat obviously....). Nothing to add to the good advice above, but please let us know what you end up doing and how it does.

RE: One for the dentists...

Alexander Geddes — Mon, 16 Nov 2020 16:50:09 GMT

Were you thinking transposition of the temporal? I'm not sure how much coverage you would get around the intact eye, and I agree I'm not sure what you would secure it to. If I couldn't plate this cat I would agree with Evelyn some form of non-invasive support may help. I might try netting around the cats head with some dressing between it and the frontal bone to minimise the emphysema. Nothing is going to be secure enough to really help I think....time is needed

RE: One for the dentists...

Evelyn Barbour-Hill — Mon, 16 Nov 2020 01:12:55 GMT

[quote userid="8991" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/29494/one-for-the-dentists/226718#226718"]Essentially both upper arcades are fractured sagittally along the hard palate lingually with gross instability.[/quote]

That injury in itself would be quite straightforward to fix with the across-palate wires plus the inter-jaw fixation, as long as you are careful to get perfect occlusion. Sorry if this is granny and eggs, but key things are to not use too thick a wire (0 is OK, that's 3.5 metric, not sure what it is in swg) and to tighten it only just enough otherwise you will squeeze the maxilla out of occlusion.

[quote userid="8991" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/29494/one-for-the-dentists/226718#226718"]There appears to be some root exposure too. [/quote]

Don't worry about it. Those teeth might survive, they might not. Deal with them when everything else is healed.

[quote userid="8991" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/29494/one-for-the-dentists/226718#226718"]And the referring vet isn't wearing gloves. [/quote]

RE: One for the dentists...

David Mills — Sun, 15 Nov 2020 23:28:03 GMT

Thanks for this reply, very helpful. I can send the videos to your email, or a link to them, if you want to send a private message. I'm dtm266 at googlemail.com if you want to ping me.

Essentially both upper arcades are fractured sagittally along the hard palate lingually with gross instability. There appears to be some root exposure too. And the referring vet isn't wearing gloves.

I have several expired plastic credit things to use as an anchor. The cat is currently breathing through its nostrils and has an O-tube in place.

Some nurses are raiding their sewing boxes as I type for buttons.

Yes ankylosis is a potential issue, but have done several condylectomies successfully in the past for cases of fall from heights etc so can deal with that as required in the future.

RE: One for the dentists...

Evelyn Barbour-Hill — Sun, 15 Nov 2020 23:11:47 GMT

Wot Alex said.

But I must add my two – well, five – penn'orth.

Sorry, I nearly fell asleep waiting for the videos to come through so I haven't seen them.

I'm all for the pragmatic approach.

Conventional radiographs in the case of the mangled cat head do help a great deal when combined with careful palpation. You might not be able to analyse and list every single fracture but you can work out what needs to be done. Palpate again after the radiography while looking at the images.

CT is all very nice but don't sweat it, it might not help all that much in practical terms.

The first thing to do is to put in the oesophagostomy tube. This is an absolute sine qua non in such a case.

Repair soft tissue damage. In many cases that begins to stabilise things. Remove damaged teeth if, only if, they are going to interfere with bone healing. If they are not, leave them till later when everything else has healed. later. There will in any case probably be more teeth to remove at that time,, that are not visibly damaged at present but are doomed to die.

Then the overall principle will be to brace the whole skull into a single monocoque structure once more – not addressing individual fractures. It is very fortunate that (as far as I can see) each mandible is intact (the midline symphysis may have gone – but that's easy to fix).

So the main thing to do is to first brace across the palate with wires (not too heavy a gauge!) using probably the upper 8s as anchors. Don't be afraid of damaging these teeth in the process, they can be regarded as sacrificial. Tension the wires "just enough", not too tight. Then fix the upper jaw to the lower jaw in correct occlusion..The labial buttoning looks like the technique of choice if you have no resin composite. Or, if there are sufficient tooth remnants to us as anchors you can do it just with fine wire or heavy (e.g. 2/0) nylon. Whatever, it must achieve sufficient stability in correct occlusion.

Then have a look at the nasal bones and so on and see what's still grossly displaced. if you manoeuvre the larger fragments back to about where they ought to be, they may stabilise after a fashion. Myself, I'd try to fabricate some sort of shell or arch over the top, fixed to my intergnathic fixation, but I'd use acrylic; and individual fragments could be wired or sutured to that. Maybe you can do similar with one of the lightweight casting materials – there's one that looks like a string vest, the name of which I cannot remember – Vet-lite?. Or use heat to shape an expired credit card, or the plastic out of your old BSAVA Congress badge. Or wire from heavy electrical cable. Or even stiff cardboard at a pinch.

One worry immediately post-op would be whether the cat could breathe through its nostrils. I think I'd be ready to do a tracheostomy.

Nasal discharge may go on for many weeks.

In the longer term, the cat may lose most or all of its teeth. The face will be deformed of course. The important worry would be the development of ankylosis in the right TMJ.

RE: One for the dentists...

David Mills — Sat, 14 Nov 2020 22:10:34 GMT

[quote userid="2122" url="~/001/veterinary-clinical/small-animal/dentistry/f/discussions/29494/one-for-the-dentists/226686#226686"]Can I please seek clarification? What exactly do you mean by "Nurse Language"?[/quote]

The nurse who took the video of the cat's breathing and said "what the f**k?" on it.

RE: One for the dentists...

David Mills — Sat, 14 Nov 2020 22:09:50 GMT

Hi Alex, thanks for the reply. Yes there are some skull rads, attached below. I don't think they add much as you say. No access to dental rads. Charity so no access to CT, referral offered but declined. The TMJ was luxated and replaced. OG feeding tube was placed at the time of the video. This is a referral from one of our other hospitals, so I haven't seen the cat as yet but it is due surgery next week with myself, currently hospitalised.

Thanks for the paper, I will read this more closely tomorrow but appears do-able.

One concern is the degree of RHS frontal bone destruction and the sq emphysema/bellows action from this. I suspect the soft tissues will be a mess under the skin. Is there any value is a muscle transposition to make more air tight?

RE: One for the dentists...

George Cooper — Sat, 14 Nov 2020 19:39:37 GMT

Can I please seek clarification? What exactly do you mean by "Nurse Language"?

RE: One for the dentists...

Alexander Geddes — Sat, 14 Nov 2020 19:34:12 GMT

www.vetsurgeon.org/.../1055.70DBF59D_2D00_8F23_2D00_42D4_2D00_BAA3_2D00_E8CD6866B471.pdf

Hi David,

I presume this client has declined referral for a head CT?

If they have I would take head films - they are fairly unhelpful but better than nothing. Do you have access to dental radiographs also?

It is likely that there are many fractures of this cats face based on the occlusion - all of my comments are based on a significant degree of unknown.

It will be important to prepare the client that things will be somewhat unknown going forward: Malocclusion, TMJ dysfunction, tooth death, dehiscence are all possible. Having said that most of these cases can live well even with minimal treatment so I almost always recommend trying.

Unless you have human titanium mini-plates and are experienced using them in the face there is no metal work that will be appropriate for this cat.

My recommendation would be debridement and closure of soft tissue lacerations and damaged teeth seen in the video. And then application of the labial button technique. This will allow you to get the cat in occlusion and hope for a combination of bony/fibrous union enough the cat will be functional. Because of the destabilised superior face no conservative technique will work really well - but we just need it to work well enough.

If the cat doesn't already have a feeding tube I think its a good idea once its in buttons considering its degree of trauma - can always remove it.

As for the emphysema, hopefully closing the oral soft tissues will help a little - otherwise time.

Let me know if you have any questions. I will try and post the paper for the technique. Good luck.