Jaw Fractures and Oral Trauma

What are the most commonly fracture bones in the dox?

Maxillary bone

Premolar and molar regions of mandible

What was the average amount of fractured bones/regions from 1 trauma case?

8.2

What % of cats that had head trauma had a skull fracture?

80%

What % of cats that had head trauma had a mandibular fracture?

86.7%

What % of cats that had head trauma had a fracture affecting a TMJ?

57.8%

What % of cats that had head trauma had tooth fractures?

64.4%

What % of cats that had head trauma had an eye injury?

15.6%

Cats with a single symphyseal separation or parasymphyseal fracture are more/less likely to have further fractures at other locations?

True

What is required to get a complete diagnosis of skull fractures?

CT or CBCT

What % of trauma fractures in cats involve the mandible or skull?

26.9%

What % of trauma patients have dentoalveolar fractures?

72%

What are some types of dentoalveolar fractures?

Crown fracture

Root fracture

Tooth displacement

What is the classification of maxillofacial trauma surgery?

Urget

What do you need to do when a maxillofacial trauma patients comes into the clinic?

Assess for all injuries

Stabilize

Place loose muzzle to support fractures

Once stable, manage soft tissue wounds, stabilize fractures

What type of muzzles should be used for patients with maxillofacial truama?

Soft muzzle like nylon or tape for support, not to prevent them from biting you

On an oral exam of a patient with a maxillofacial trauma what do you need to do?

Assess mentation

Can they open/close mouth

How is occlusion

How is dentition

How is oral cavity (tongue, cheek, lips, skin)

What is your perioperative treatment for facial trauma?

Antibiotics (open fractures) - unasyn, ampicillin, clavamox, clindamycin

Pain control - multimodal approach of opioids, NSAIDS, gaba

Decide to feed soft or liquid food

What are some causes for jaw fractures other than trauma?

Severe periodontal disease

Endodontic disease

Iatrogenic from tooth extractions

Neoplasia

What breeds can get jaw fractures from severe periodontal disease?

Toy breeds

What is the best way to assess all the bones of the skull?

CT or CBCT

Describe the use of dental radiographs for skull fractures?

Good visualization of teeth and mid rostral mandible

Limited for other bones and TMJ

Use post-op to document repair

What is the problem with skull radiographs?

Hard to visualize all of the pathology and difficult to interrupt

Rare definitive imaging

What happens during the inflammatory phase of bone healing?

Disruption of blood vessels

Hematoma

Increase in inflammatory cells

What happens during the repair phase of bone healing?

Proliferation - replication of cells for injury repair

Maturation - callous formation

What are the goals of fracture repair?

Stabilize fracture to neutralize forces on the fracture line

Preserve blood supply and soft tissue repair

Maintain normal occlusion

Avoid iatrogenic trauma to the dentition

Assess teeth in fracture area to determine if the help or hinder healing

What happens to teeth with periodontal disease in the fracture line?

Extraction

If teeth in the fracture line are endodontically affected what do you need to do?

Root canal therapy or extraction depending on the injury

T/F owners need to be informed more treatment might be needed for teeth after a fracture heals?

True

What are the 3 categories of fracture repair techniques for fractures?

Noninvasive

Open/surgical

Salvage procedures

What are the noninvasive fracture repair techniques?

Interdental wiring

Interdental wiring with an acrylic splint

Modified labial button technique

Maxillo-mandibular fixation

Muzzle

What are the open/surgical fracture repair techniques?

Intraosseous wiring

Bone plates

What are the salvage procedures for fracture repair?

Mandibulectomy/maxillectomy

Commissurorraphy

What can open surgical techniques be combined with to repair a fracture?

Nonivasive

What are the benefits of bis-acryl splint?

Multiuse system with a long shelf life (change tips between use)

Nonexothermic

What are the anchor points for a bis-acryl splint?

Teeth and wire

Where do you apply a bis-acryl splint?

2 teeth on either side of the fracture

What are bis-acryl splints used in combination with?

Interdental wiring

How do you use a bis-acryl splint?

1. Teeth are cleaned (no calculus)

2. Pumice for polishing

3. Acid etching, bonding agent

4. Shaped with diamond burr

5. Apply so it does not interfere with occlusion

6. Check occlusion while anesthetized

7. Set time is 20ish seconds

What is a symphysis?

Fibrocartilaginous union (joint)

What is a type 1 symphyseal separation?

No soft tissue laceration

What is a type 2 symphyseal separation?

Soft tissue laceration present

What is a type 3 symphyseal separation?

Major soft tissue trauma, fractured bones, exposed bones, fractured teeth

What are the steps to fixing a symphyseal separation?

Debride, clean, flush wound

Repair soft tissue lacerations

Stabilize mandibles with a wire

What are the benefits of a maxillo-mandibular fixation?

Maintains occlusion

Limits movement

What is a maxillo-mandibular fixaiton?

Use acrylic to bind the canines together in normal occlusion

What are the downsides of a maxillo-mandibular fixation?

Easy to fracture teeth when removed

Aspiration and hyperthermia concerns (cannot open mouth to vomit)

Can predispose to long-term limited TMJ mobility

How can a cat with a maxillo-mandibular fixation eat?

Lap up liquid diet or E-tube

When would you use a muzzle to prevent movement?

If the maxillary fracture is small or if owner has no money to do a different fixation type

How do you use muzzles to help with symphyseal fractures on the mandible?

Send several home to switch when dirty

Limits mobility and maintains occlusion

What are the concerns of muzzles for symphyseal fractures on the mandible?

Aspiration if vomits and can overheat easily

What do you need to avoid when using intraosseous wiring or a bone plate?

Avoid tooth roots or neurovascular strcutre

What can intraosseous wiring be supplemented with?

Muzzle and splint

What mandibular symphyseal fracture repair technique gives the most rigid fixation?

Bone plate

What are extra concerns for juvenile patients when they have a jaw fracture?

Watch out for adult tooth buds

When do you use a commisurorraphy?

Bilateral caudal mandibular fracture that failed to heal

What is a commissurorraphy?

Close the back of the mouth with sutures

Why do you need to extract all caudal teeth for a commissurorraphy?

You will not be able to reach the teeth back there anymore

What causes fractures that need a commissurorraphy usually?

Periodontal disease

What home care do patients with mandibular or maxillary fractures need?

Antibiotics if open, pain control, soft food, E-collar, not toys and chews, no mouth playing with housemates

When do you recheck after a fracture?

1-2 weeks and 2-4 weeks after depednign on patient

When you do you need to consider an anesthetized exam in young puppies?

Assess healing at 3-4 weeks

When you do you need to consider an anesthetized exam in older dogs?

Assess healing at 6-8 weeks

If you are concerned of a nonunion of a fracture when should you remove the device?

2-4 weeks longer

What is the most common etiology of facial trauma?

Animal bite, then blunt force, then vehicular

What is the most common weight of animal that gets facial trauma?

<10kg then juveniles

What are the types of direct bone healing?

Direct healing

Gap healing

How is direct bone healing accomplished?

Rigid fixation

When does indirect bone healing work?

Minimally invasive repair techniques

Why is indirect bone healing possible in the face?

Bones do not support much body weight and only need to withstand the forces of mastication

Where should you use dental wiring?

Two teeth in front and two teeth behind the fracture site

What are some types of interdental wiring techniques?

Ivy loop

Stout

Essig

Risdon

Where is symphyseal separation?

Between mandibles in the middle

How do you repair a symphyseal separation?

Cerclage wire around the mandible with 2 approaches

• Bring wire through bottom of jaw through skin coming out lateral to canine bring through mouth and same on the other side tightening ventrally

• oral approach where you do the same approach but tie off on side of the teeth

Can do a figure 8 interdental wire between canines

What is the modified labial button technique used for?

An alternative to using acrylic for a maxillo-mandibular fixation

how do you do a modified labial button technique?

A button on each side of nose and one under chin sutured together to maintain occlusion

What is the benefit of a modified labial button technique?

It is easy to remove

What is bone sequestrum?

A non-vital piece of bone that has become separated from vital bone

What is delayed union?

A fracture that did not heal as fast as expected

What is malocclusion?

Deviation from normal occlusion which can be physiologically unacceptable

What is malunion?

Healed fractures in which anatomic bone alignment was not achieved

What is nonuion?

An ununited fracture that will not join because healing process has ended

What is a oronasal fistula?

Abnormal communication between oral and nasal cavity

What are complications of facial trauma repair?

Bone sequestrum, delayed union, malocclusion, malunion, nonunion, oronasal fistula, osteomyelitis