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  Discussion on Jaw fracture
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New Member:
Annknigh

Posted on Saturday, Dec 18, 2004 - 10:23 am:

My horse fractured his lower jaw 3 weeks ago. The vet did surgery which involved placing 2 screws into the mandible and wiring the teeth across the front together. He was on gentamicin for a few days and when we brought him home, we were given a 30 day supply of TMP-SMZ, 18 pills twice daily. According to the information posted on this site, this drug is not effective against anaerobes. Would anaerobes be of concern with this type of injury and would my horse need something that would be effective against them?
Moderator:
DrO

Posted on Sunday, Dec 19, 2004 - 11:47 am:

You would think so Ann, but these type fractures do have an amazing capacity to heal even in the prescence of infection. The key to healing is the stability of the bone. If anerobic infection does become a problem a bad odor will develop and consider adding penicillin to the regimen.
DrO
Member:
Annknigh

Posted on Sunday, Dec 19, 2004 - 1:06 pm:

I do notice a very slight odor, but it is similar to an odor that I notice in my other horse's mouth. I am guessing that an odor from an anaerobic infection would be really strong.

There are two other things that I have noticed recently. One is that occasionally, he will burp or something, there will be a slight noise and then you will be able to smell the food that he has eaten. We are giving him Nutrena Equine Senior that is soaked in water to make it into a gruel, and it has a distinct odor. Prior to the injury I didn't ever notice this, is it possible that something was damaged during the surgery? They put the anesthesia tube in thru his nose, I think instead of this mouth.

The other thing that I am noticing in the last week or so, (on Monday it will be 3 weeks post surgery and injury) is that his feet are cracking and peeling around the coronet band on all 4 feet. It looks like a horizontal crack that goes all around the hoof at the lower aspect of where the coronet band joins the hoof. It is not very deep at all, and if you touch it, the hoof will kind of flake off. The flaking off part is a very thin layer and not very much. Would this be a response to the stress of the injury and should I be concerned?

Also I have the xrays of his fracture, pre and and post surgery, that I would love your opinion on as far as the repair and alignment. They are on a CD in Jpeg format so it would be easy for me to send them to you or somehow post them here possibly. I am concerned about the alignment, although it looks pretty good on xray in the bone area, the lower teeth dont line up very well at the moment. The fracture line was a saggital fracture between the two front teeth, and the right teeth are more anterior than the left after the surgery. A whole piece of bone was was displaced, and the vet said what was important was the alignment in the bone area and that the teeth could be filed and as they grow the alignment can be made better. There is a concern that he might loose his lower front incisor and he cracked his upper front tooth in half. He is a dressage horse and it is really affects the judging if the tongue sticks out of the mouth, so if we can do anything to help the area heal better I would like to. He was already missing the lateral front tooth on the right (not sure what happened to it) and with this injury he cracked the one next on the top right. Thank you for you help. I have been telling all my friends at the barn about your site, it is an excellent resource!
Moderator:
DrO

Posted on Monday, Dec 20, 2004 - 7:22 am:

Yes I think the rings you describe are likely to be related to the injury and change in diet and not a cause for concern. If the odor is the same as everyone elses, that is good. I think the burps are more likely do to the change in food and ability to masticate than anything with the surgery. If you post the radiographs I would be glad to comment but if you are really concerned that further work may be indicated at this time, you should consult wirh your veterinarian and have them sent to a radiologist and orthopedic surgeon they will be able to give you a much more qualified opinion on what further could be done.
DrO
Member:
Annknigh

Posted on Tuesday, Dec 21, 2004 - 8:38 am:

The x-rays are posted at https://www.aahz.org/coban/coban1.jpg
https://www.aahz.org/coban/coban2.jpg
https://www.aahz.org/coban/coban3.jpg
https://www.aahz.org/coban/coban4.jpg

I am going to try to also take some pics of what the teeth look like today and post those also. When I do that, I will post the links. The horse is an 8 year old Oldenburg gelding.
Thank you,
Ann
Moderator:
DrO

Posted on Wednesday, Dec 22, 2004 - 6:06 am:

That is a worrysome fracture Ann. The small fragment well displaced from the body of the mandible with so many close incisor tooth roots must have everyone wondering if there is enough blood supply to support the fragment. On the otherside of the coin is the tremendous vascularity of the head.

Both the postsurgical radiographs do not have enough detail to evaluate carefully. This is partially a limit of jpeg but also the #3 radiograph appears underexposed. From the lateral the outlines of the margins of the fractured piece and body of the mandible seem to line up fairly well.
DrO
Member:
Annknigh

Posted on Thursday, Dec 23, 2004 - 7:56 am:

Well, I did ask the vet about the blood supply to the fragment as it appeared to be completely displaced, and he didn't seem concerned about it. He said when he was in there, that it looked like there was plenty of blood.

If there is damage to the blood supply to the fragment, what clinical signs would we be seeing by now. It has been 3.5 weeks post injury/surgery. The injury and surgery were on the same day about 5 hours apart, maybe that was helpful in minimizing damage to the blood supply.

The vet was out two days ago to look at it, and he said all looked fine. I thought that it might be good to rexray now to see how the calus is forming as well as to rule out any osteomyelitis, etc, but the vet didnt see a need to do that yet. He is planning to rexray in a few more weeks and pull the wires out. The vet said that from visual observation that it looked like the piece has slipped a bit more forward since he set it, but when I look at the teeth alignment, they actually look like they are less displaced than initially. He said the only way to correct that would be to rebreak the fragment and reset it. He said that once the fragment heals that he shouldn't stick his tongue out and should be fully functional with no deficits.

You had mentioned obtaining an opinion from an ortho surgeon, how would I go about finding one. The vet who did the surgery is an eq dentist as well as a diplomate ACVS.
Thanks again,
Ann
Moderator:
DrO

Posted on Thursday, Dec 23, 2004 - 10:59 am:

Not any at this early date, in time it just will not heal, but the surgeon's comment implying the area bled freely is a excellent sign. He sounds very well qualified Ann, but if you are concerned ask to have the radiographs and records sent to a university with a veterinary college, most veterinarians are glad (or at least they ought to be) to have a second opinion. Realize though it is difficult to evaluate stability, the most important factor in regards to bone healing, from a set of pictures.
DrO
Member:
Annknigh

Posted on Thursday, Dec 23, 2004 - 10:27 pm:

There is what appears to be a slight swelling under the jaw along the fracture line, I asked the vet about it, and his comment was that he thought it was the calus formation. If he is correct, that is a good sign. There has been some swelling all along, but in the past week or so the swelling has become more peaked and almost looks like a ridge and is less generalized. I have not palpated it, but I may do that tomorrow to see if it feels bony or softer like soft tissue swelling.

Can you evaluate stability proactively or do you have to wait until it heals to know that there was enough stability to heal it?
A
Moderator:
DrO

Posted on Sunday, Dec 26, 2004 - 4:22 pm:

Yes, you see if it wiggles when forces similar to that applied during regular activity are applied.
DrO
Member:
Annknigh

Posted on Saturday, Feb 5, 2005 - 8:04 am:

Dr O,
Would you be so kind as to take a look at the new xrays of my horse's jaw fracture. There are two new sets of xrays taken on 1-13-05 and 2-3-05. It has been 8-9 weeks post injury and on thursday (2-3-05), I noticed some tissue changes along the gum margin behind the teeth on the side of the fracture. There was also a strong smell in his mouth and all three right teeth were loose. Until then the teeth had been tight and were not loose at all. On 2-3-05, the vet removed the central right tooth as it was very loose and it came out easily. The smell has seemed to be reduced since then. He also removed the wires on the right side and removed the anteriormost screw. We dont have post procedure xrays at this point.

I am concerned about the other two teeth as to the viability and what to do to preserve them as much as possible. From the xrays, there is a lucent area just under the second tooth, which I dont think is a great sign, and it isnt as clear about the most lateral tooth as the screw overlays the end of it. The vet attempted to remove the second tooth with gentle pulling, but it stayed in.

So the questions are, what to do to attempt to preserve the remaining two teeth, and if they cant be saved, what are the options for tooth replacement. The horse was already sticking his tongue out of his mouth some, and the concern is that without those teeth, that the tongue will stick out alot more, which is career ending for a dressage horse. Some people have mentioned a bridge, but with worse case if all 3 of the right teeth fall out, what would you anchor it too, and another possiblilty mentioned was implants. Any input would be appreciated.

www.aahz.org/coban/coban0113051.jpg
www.aahz.org/coban/coban0113052.jpg
www.aahz.org/coban/coban02030051.jpg
www.aahz.org/coban/coban02030052.jpg
Moderator:
DrO

Posted on Monday, Feb 7, 2005 - 7:30 am:

The same principles apply that we discussed earlier, the bone fragment must be stable Ann. All else is secondary. If local infection is a problem flushes with hose under pressure, rinse with a chlorhexidine solution, and systemic antibioics would seem indicated. Ann if you and your veterinarina feel the bone is not as stable as it needs to be consider a referral.

I do not know anything about how a bridge or tooth implants might be used in such a situation, perhaps that could be part of the referral, some alternate ideas on this. However I don't anyone doing that type work.
DrO
Member:
Paul303

Posted on Tuesday, Feb 8, 2005 - 2:44 am:

Dr. O, I have a question: But first, let me say that I'm blown away by the healing that has taken place so far. I thought the radiolucency at the root tips of the two incisors might indicate developing pathology, but hearing that one was removed with ease, it sounds like they were knocked up out of their sockets and could not re-seat. If the tooth removed was the central incisor, it makes sense, because it looks like the root tip might be under the screw in the x-ray. If it is, it's best to take note of it in case it migrates in the future, or becomes infected ( not likely ). I'd be a bit leery of bridges or implants in a jaw that has been broken like this....if they do them. I do recall reading an article awhile back on orthodonture for horses with parrot mouth. Haven't seen anything on it since so it might not have gone so well. Dr.O, I would wonder if the displaced incisors could gradually be shaved down to be more in line with the other incisors, not for looks, but for function. If those incisors are flared, shaving them back slowly, to avoid premature contact would ease torque on unstable roots. The other thing ( if it can be done in horses ) would be a permanently cemented brace behind those incisors connecting them all.
Moderator:
DrO

Posted on Tuesday, Feb 8, 2005 - 6:51 am:

At eight years of age the big concern is staying out of the pulp cavity. They are quite prominent in a 8 year old. However when I look at the lateral radiographs the teeth have displaced rostrally and distally so at this time opposing occlusal forces would not seem to be a problem. I almost suggested this be addressed before but have to admit if this is a stable position at this time would be hesitant to mess around with it since the incisors are in such a fragile state.
DrO
Member:
Annknigh

Posted on Tuesday, Feb 8, 2005 - 9:38 am:

Update 2/8/05

Yesterday the vet removed the remaining hardware. The two remaining teeth on the right had tightened up quite a bit from when they were loose, however the vet decided to put more wires on them and connect them to the canine tooth to help them to stabiize more.

It was the central incisor that was removed the other day and one to the right of it was still attached firmly yesterday and was not easily extracted, although the vet thinks that it will eventually come out. We are hoping that the lateral most one on the right will stay in as that will allow more options if we need to do something as far as bridge or implant.

Now, what about the issue of implants/bridges into a previously fractured jaw? Would it not be advised even after the fracture is healed?

There are no upper teeth to create opposing forces on the right lower teeth. He was already missing the lateralmost upper tooth from something previous (I dont know what) and the next one was cracked in half from this injury and only the medial half of it remains. It has been suggested that as the lower teeth grow that they could be filed down to assist in alignment. It is also the hope that the upper cracked tooth will grow out with more substance and that it wont die.

Moderator:
DrO

Posted on Wednesday, Feb 9, 2005 - 8:16 am:

The implants and bridge will have to be taken up with someone familiar with such procedures: not only am I ignorant I have no published information on such a procedure in a horse. You might want to get a interested human dentist involved. Elizabeth above is a dental technician and may have more information.
DrO
Member:
Paul303

Posted on Wednesday, Feb 9, 2005 - 7:27 pm:

Wow, I would sure be hesitant in a horse. The success in humans is very good, but humans can do post op care which becomes a bit complicated once the new tooth is inserted. In people, a flap is made in the gum tissue, and a titanium screw is imbedded in the exposed boney ridge. The flap is then closed, and healing takes place. After a certain time period ( wks. to months ), an x-ray is taken to determine bone regeneration around the threads of the screw, if all is well and the implant is solid, the screw top of the screw is exposed and a post is inserted in the top of the screw. A regular crown is then fabricated and cemented on this post.
The main problem, I think, would be that the horse has no way to protect that surgical area while eating - to avoid trauma. Plus, there is no way of knowing what the wound would be exposed to while he is nosing around on the ground. If infection occurred, the screw itself presents an avenue for bacteria. In a healthy tooth, there are periodontal membranes lining tooth sockets, that are actually attached to the cementum of the tooth root. Once destroyed, this attachment does not regenerate- thus it leaves a perfect location for bacteria to thrive undisturbed. Humans have the ability to do the daily care required, and to have regular check - ups. They can also alert their DDS quickly if they feel something is not right.
A bridge done in the manner of a permanent splint - fabricated with a short pontic where the space is ( Short, so that anything that might lodge under it would easily come out ) could work. It would be cemented to the inside of the lower incisors ( perhaps even farther to the canine on the bad side to make sure of a solid anchor tooth ) with only the minimally invasive procedure of creating a "seat" for the "bridge". This would also give added support to the damaged roots. The more stable those damaged roots are, the better the chances that they will remain intact. Should they go bad, they could be cut above the gumline, and the roots surgically removed. If well cemented, the crowns would remain with the appliance which would (hopefully) be attached to solid undamaged teeth. That way, you wouldn't lose the incisor function.
But, would you really want to do this? Any change to this area could take a tongue habit to extremes for your horse ( ever chip a tooth and find that your tongue just can't leave it be? ). I would be more inclined to just leave them splinted with wire and to work on them slowly every 3 months or so, to shave them OUT of occlusion with the maxillary incisors AND, if they flare out, to minimize the flare and avoid having the injured teeth make premature contact with the ground ( when grazing ) or his feed
( when diving into his feed bucket ). The less pressure these teeth encounter for the next six months, the better. If the teeth are ground in tiny increments, after each session, the pulp chamber will shrink in response to trauma. In the future, the teeth will "grow" until they occlude....somewhere. In the meantime, he can
"lip" his grass.
Again, I'm amazed at the result as it appears right now!! Good luck!
Member:
Annknigh

Posted on Tuesday, Apr 19, 2005 - 2:07 am:

I wanted to post an update on my horse. He is doing great. The vet says he has healed and all the hardware is out. He only lost one of the three teeth that we were concerned about. The two remaining ones on the left side seem stable. He does stick his tongue out of his mouth a little bit when he doesnt have a bit in his mouth, but with a bit, his tongue stays in, so the prosthetics are not needed. He went to his first show since the injury and did excellent. No one even noticed that he has a different tooth arrangement, not even the bit checkers! I have to floss his teeth frequently as there are gaps between a couple of them, but he doesnt mind too much as long as the dental floss is minty. He is evidently a mint freak.
Moderator:
DrO

Posted on Tuesday, Apr 19, 2005 - 8:20 am:

That's great Ann, I know it was touch and go about those other 2 teeth. How about a photo of the end result if possible?
DrO
Member:
Paul303

Posted on Wednesday, Apr 20, 2005 - 1:33 am:

Oh, Ann, I'm amazed and so pleased!! Thanks so very much for the update! A photo would be so wonderful. Thanks again!
Member:
Annknigh

Posted on Tuesday, Apr 26, 2005 - 3:43 pm:

Sure I'd be happy to post one. I tried to take some the other day with my cell phone, but he kept moving before I could get a pic. I will take my other camera out and do that soon!
Member:
Annknigh

Posted on Friday, Oct 7, 2005 - 9:01 pm:

Finally getting to that photo that was requested. Coban

I still need to take some close up pics of his teeth. He is actually getting gum growth back between the teeth on the segment that was fractured.
Member:
Corinne

Posted on Saturday, Oct 8, 2005 - 12:29 am:

You two look amazing! Good for him for healing and good for you for helping him rehabilitate back to what looks like a wonderful dressage horse!
Congratulations! He is beautiful!

v/r
Corinne
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