Thank you in advance for letting me to be introducing myself and your host today is Islam Mindy. I'm a doctor of veterinary medicine. I have master's degree in oral and dental surgery.
I'm also a staff member of the Department of Veterinary Surgery, anesthesiology and Radiology faculty of Veterinary Medicine, Zagazi University in Egypt. So hello from the land of affairs. First, we have to express our conflict of interest.
There is no conflict of interest in this. S The first question is, the presentation or the webinar is about log draw. What is a log draw?
A log draw is a presentation of a clinical case that often come to our clinic. Or our hospital where the animal is either cannot close or open its mouth. So, We can divide this situation into two types.
The first time the animal is presented with a completely open jaw, but he cannot close its stroke, or the animal is presented with a closed closed lockjaw. So, these are the two types or situations of animals that come to our clinic or our hospital. Temperament of a joint is a complex and it incriminated of this case, but he, he is not the only part of this case.
We will discuss our differential list and our approach to this case. Many conditions can affect temporalmander joint, such as congenital, traumatic, or degenerative, or also neoplastic disorders. Therefore, temperamental va joint disorders can result in difficulties in opening or closing the mouth.
A number of extra and also intra-articular conditions may be affecting the mandibular mobility by making temporomandibular joint. A few reasons for completely locked or open jaw and not only presented in temporomandibular joint only. So we have to review our anatomy, normal anatomy of the temporal manebra joint.
The temporal mandebra joint is a gondola joint. It's consisted of gondola process of mandibular, of the mandible and the glenoid fossa of the temporal bone of maxil. There is also a thin articular disc lies in between.
A fibro cartridge actually lies in between the glenoid fossa and controllo process. Making a compartment, making two compartments of the joint or dividing the joint into two compartments, non-communicating compartment, dorsal compartment and ventral compartment. The joint is surrounded by a fibrous tissue capsule.
All around the joint, and there's differences in this area in dogs and cats. Motion is performed. But A complex of muscles called muscles of mastication.
Here is the temporalis muscle, masseter muscle, superficial, and metal portion, digastric muscle, and ergoid muscles. Almost all the muscles are supplied by trigeminal nerve. All except the caudal belly of the gastrious muscle is supplied by facial nerve while rosteral one or the cranial one is supplied by trigeminal.
So all muscles of mastication is supplied by trigeminal nerve. All but scopodal belly of the gastrius is supplied by facial nerve. So, there's a little bit of differences between canine and feline tempormandibular joint.
The first difference point is. That the connective tissue capsule or fibrous tissue capsule that encloses the joint. It's almost different between dogs and cats.
How different. In dogs, there is a whole fibrous tissue capsule only surrounding the joint. My making the action of lateral joint ligament, but there is no true, there is no true lateral ligament in the Moldova joint of dogs.
While in feline patients, there is a fibrous tissue capsule enclosing the joint, but there is a true lateral lateral ligament of the joint. This is the first difference. The second difference is The condoy itself, the condo itself.
In in our feline patient are elongated transversely with a common axis of rotation. So, the joint only allows minimal lateral mandibular motion. On the contrary, our dog patient, the long axis of each condyle is slightly angled as compared to our flying patient.
So, the common axis of rotation here can Provides a lateral mobility of the mandible more pronounced than incas. There is a picture. The right picture and the left picture.
The right picture is a mandible. The roster view of Cat mandible. Here you can see.
That the condyle is slightly elongated, but the common axis of rotation is almost, I'm sorry, almost parallel to each other. So there is a little pronounced lateral motion in cats. While in dogs, there is Not much of elongation, but there is a slight angulation of the condylar process.
There's a slight angulation of the contoyer process, so the common axis of rotation can provide a lateral mobility in romantebular joint and dogs. So, What is an open lock jaw, as we discussed, a condition which the animal is presented to our clinic with open mouth and he cannot close his mouth. While closed log jaw, a condition which the animal is presented to our clinic with closed mouth and cannot be opened.
How to approach a case of a logjo. The animal is presented to our hospital or our clinic in one of two situations. The first situation is open lockjaw.
The second situation is closed lockjaw. First, we have to take full history from the owner. Either there is a maxillofacial trauma, swelling, any pain, any official pain that animal is presented with.
The second Term of our Examination is to perform a full maxillofacial exam. First, we have to observe and use our senses in order to approach our case. Observation and palpation of a conscious animal.
We have to palpate maitter muscle for any swelling, vein, atrophy, any sort of asymmetry that can be visible on the animal. Also, we have to palpate the bone of the maxilla, bones of the mandible. Angular process, zygomatic arch, the rearticular process of the As articulate persists of the Mozilla.
Also, we have to examine our sublingual mandibular lymph fluid or I'm sorry, mandibular lymphluid and sublingual cerebral gland. Here is our exam of the femoromandibular joint. The seromandibular joint is a syst.
Add the ventral caudal aspect of the zygomatic arch, the right picture. Our fingers in 3 landmarks. The first landmark is the angular process here.
The second finger is on the retro attacker process, and the third finger is on the causal aspect of the zygomatic process. The same fingers are presented or placed on a live animal to palpate the the temporal mandibular joint, mobility, any swelling, any sort of atrophy. Here's a presentation of the two cases.
The first case on the right picture is a kitten, I think, 4 months old, that was presented to, my clinic with a closed lockjaw. The left one is a flying patient with an open locked jaw. He cannot close its mouth.
So, this is a presentation of our two situations. Also, an orbital cavity examination is important. Why this is important?
Because there's a lot of issue or disorders that might affect our romandibular joint. Mobility. Cyst, yourlas, any sort of haemorrhage.
That will cause exothalus, the eye will be protruded. This will interfere with the temperament, the temporomandibular joint and the, the coronal process because of the coronal process is associated with the orbital cavity. And any retro dorsal displacement of the mandibular condyle will also presented in the orbital exam by an exothalamus, while in thalamus.
Is due to atrophy of my sectoral muscles. Due to any any cause. Like the trigeminal nerve paralysis.
The trigeminal nerve paralysis will cause atrophy of all muscles of mastication. So, the area surrounding The area surrounding the orbital cavity will be protruded due to the atrophy of of the muscles of mastication. The second part is a sedated or uncontrast exam of the animal.
We have to be very careful in this step. Why? Because the unconstrast or sedated exam of the animal is very important.
Because the animal can be presented with a closed log jaw. While in sedation or unconsciousness, the animal will be opening a straw. OK.
Or the vice versa, close look jaw, an animal can open its mouth. So, the, this is a very crucial step in our examination. The 2nd board Of the diagnostic approach to temporal mandola joint problems is a diagnostic imaging.
The first step is to take a plain radiograph with two prominent. Two prominent positions, it's the lateral position and the ventral dorsal position of the skull. Here is our normal mandible.
Normal zygomatic arch, and here is the coronary process, and here is the topanipola. Also in the right picture, here is the coal process. Here is the horizontal rhombus, angular process of the mandible, and here is tympanic polar.
Here is the area which Represent the temporal mandibular joint. Of course, playing radiographs can provide minimal data, but very important. Regarding our, approach.
But the gold, gold standard is computed tomography. It is our, X-ray of two different CATs. With a history of maxillo fission, trauma, heus accrinorosis was.
A callus or amass, this cat was presented with a closed mouth, and this cat also presented with a closed mouth with a history of previous maxillofacial trauma. The next step and important step is computer tomography. Computed tomography is considered as a gold standard method for diagnosing tempromandibular joint pathologist.
The left picture is representing the normal canine. Tem Mandeba joint. It is our condo and will not forsa.
With normal Contour. So that picture. Is representing A non or abnormal, not normal, abnormal mental joints.
Sorry. Normal te joint with a signs of osteoarthritis. There is an irregularity in the surfaces of the glenoid fossa and the surface of the cartilage of pondoal process of mantle.
But soloes that lead to logjo. There is some of the list that will cause our log jaw, either open log jaw or closed log jaw. The first Situation is open.
Look, Joe, there is an intra-articular causes and extra-articular causes. Intra-articular causes. And extra-articular causes that may, due to pain or mechanical blockage, will be against our mouths too close.
OK, so the first causes, the first sort of causes, inarticular causes that will cause pain to our feline or canine patient, fracture, fractures any maxillofaci fracture. Especially in the vertical or horizontals, logization, neublasia, osteoarthritis, osteomyelitis in the bone of mandibu and maxilla, mechanical blockage, any sort of mechanical blockage that will be against our temporalmandominal joint to close, such as flextures and luxations, luxation of process luxation of the chondrallar process. There is also extra-articular causes.
That will cause a mechanical blockage to the timber and double joint biomechanics, occlusions. Such as clusion type 2. Open mouth jaw locking, oral foreign body oropplasia, bilateral mandibular fracture, especially in the vertical ramus, neuromuscular diseases such as transgeminal nerve paralysis or idiopathic neuropathy.
That that's the differential list that will cause our line or canine patient to have a difficulty in opening the mouth. Also, there is an intra-articular causes, extra-articular causes. The intra-articular causes causing pain are fractures, neoplasia, osteoarthritis, osteomyelitis.
Extra-articular causes that will make pain to our patients. Midle diseases, middle ear diseases, or infection, because there is a closer relationship between temporomandibular joint, anatomically, timbermandoba joint and tympanic polar. Salivary gland affections, especially mandibular and sublingual salivary glands.
Neuromuscular diseases such as mastectomyositis, stomatitis, ocular, and electroulbar infections. Mechanical blockage. Such as true ankylosis.
Also, there is a plasia such as osteochondroma, osteosarcoma. Osteoarthritis, osteomyelitis of the bone, extra-articular causes that will make a mechanical blockage such as psychomatic, harsh, or coal process fracture and deformation that will make a mechanical hindrance or Plug to our patient by a normal timber and joint biomechanics because there is a, a relation between the corona process and zygomatic arch. The coal process is mobile under or lateral to the zygomatic arch.
There is also a false ankylosis. There is a difference between true and false alosis that we will discuss later in this webinar. Neuromuscular diseases such as mastectomyositis, craniomandibular osteopathy, scar tissue formation around the lip.
Comissions or erythropular masses, cyst, nelasia, and hemosh. The first of our pathology is Terumandibular joint dysplasia. Terumander joint dysplasia is very common in certain canine breeds such as hounds, retrievers, cocker spaniels, and duckshund.
It's it's incidents in cats, it's unknown. Here in Egypt. I had experienced a few cases of joint dysplasia in cats.
But the evidence-based between the medicine in this area is unknown about the thermomondova joint dysplasia in cats. But it's very common in and has been diagnosed in dogs. The mandibular, what happened or boophysiology in this case is the mandibular fossa and articular eminence may appear flat and retroartricular process is shortened.
The retroarricular process is the guard of the guard of the joint. It prevents the caudal movement of the condylar process of the mandible. So, if the mandibular fossa is Flat and retourer process is shortened.
This will make the controller process more mobile and can be located or moved from its original place. There's also some causes where. Result in this case, such as the mandibular condo become flat and abnormally angled.
Articular space wider and normal due to due to the fibrous tissue capsule is become, has become wider. The initial observation of clinical science starts in young adults. We should observe our patients closely.
We should observe located episodes that may occur multiple times daily. The animal. Especially dogs Can can be presented.
With a history of episodes of locking its mouth open. Or just occasionally, occasionally in several weeks or months. This incidents can happen daily.
1 or 2 times per day. Or months. Most dogs will vocalise, most dogs will.
Will be in pain, actually shake the head and bow to the muzzle to grab the muzzle because there is a pain associated with the mouse. The animal mouth cannot be closed correctly. So most locking episodes are short are of short duration and also self-correcting by a spontaneous reduction.
But maybe in some cases, the animal is presented with a chronic, chronic case of dysplasia, fibrous tissue will will be present, so the animal will be presented with a stable open jaw. Dysplasia is asymptomatic because it can be happening if the animal is in the garden a few times a day and the owner is not looking or not observing the animal. And this also can be diagnosed as an as an incidental finding during the image imaging of the skull.
And, of course, during computer tomography of the skull. In some, in some cases, There is a deviated gondola process that will stretch the articular capsule. The articular capsule will be stretched due to the mobility of the controller process.
And this can lead to joint instability and subization. Localization It's not Like dysplasia, luxation is completely deviated from doy outside the fossa, and the animal will be presented in an open looking. The situation.
Also, one of the causes are the chronoic process deviation. Not the process, but the coo process deviation. Outside the dromatic arch, such as the pictures that we are seeing right now, the process is outside the orbital and dromatic arch.
And this cause the animal to manifest pain. During this episode. And can be self-correcting if the animal opens its mouth widely, the chops will relook will repositioned into a normal place.
The second, the second disorder is osteomyelitis of the bone, osteomyelitis of timromando joint bone, either in gondola process or the temporal bone. This will be, of course, secondary to middle ear infection such as Infection of the tympanic bola? Because the anatomical relation between the temporal mantebral joint and the tympanic pole.
The 3rd affliction is osteoarthritis. Osteoarthritis is commonly diagnosed. Termanderma joining disorders, but It is diagnosed in a very old and chronic chronic stage, both in dogs and cats.
It can happen primary or secondly, to a temporalmanella joint disorder such as dysplasia, maxillofiial trauma, or in after a complication of a unilateral mandibullectomy. It can cause pain and decreased motion of the mandible. The chronic stage of osteoarthritis will cause the animal to be either in closed mouse or limited motion of the mouse.
The animal will express pain during opening and closing the jaw, while palpation of the joint will also make animal very painful. Mandibular fossa and Judela process are becoming flat. Also, osteophytes will be gaing in this area.
Marginal osteophytes are visible inside our computer tomography. It is the left picture expressing our normal joint, the right picture is an osteoarthritic changes in the tempormandova joint of a dog. The first disorder.
It's very important because it gets animal very distressed and unable to swallow with the mouth wide open. Why? Because the animal in the presented pathology.
We will be in a great vein actually. The double joint, luxation. It's apparently more frequent in cats and dogs, and it, it can happen in a dorsal direction, Rostro dorsal direction.
It cannot happen in a caudal direction because the retroartrial process. Is guarding the joint. With the condyle is positioned over the articular eminence and called the ventral direction.
A man inclusion will occur. Of course, there is a pain, severe pain actually. In this case, the animal is presented with an unopened.
Non open joints. Occlusion of contact between epsilateral bimolar and molar teeth and traumatic occlusion between the canine and the tissue in the opposite jaw will be presented. If estro dorsalization is bilateral, mandibular, prognosis may develop.
Dislocation actually occurs commonly here in Egypt. If a code of ventral dislocation develops, instead, the animal will becaudally deviated. The animal mandual will appear cordially deviated toward the affected site.
The mandible appears more mobile than usual. And there will be a crebitus. Will be felt during temperman the joint palpation.
Echinosis and very pinpoint haemorrhages will be occurring at the caudal oral mucosa due to trauma. Manual closure of the mouse is possible in these cases, however, dislocation and deviation will relapse immediately. This is a recurring pathology actually in cats and dogs.
It can be happen due to fractured reartuar process. If the rearur process is fractured, then the controller process will have a wide range of motion. Maxillomandibular fixation after treatment of this case is very crucial to maintain normal occlusion in the animal.
It is the case The tlo and joint dislocation or localization. We can see in the left picture. Is a ventro dorsal.
View of the cat's skull. Is that right? Teromandula joint and the left tempormandoma joint, we can see here that the condo in this, in this area or in this left temporomandibular joint.
Is abnormal due to the luxation of the condyle outside its normal position. Fracture of the gondola process, it's very common and it can occur during maxilloficial trauma such as high-rise syndrome or car accidents. It may cause pain at mandibular extension as well as difficulty as well as causing difficulties during cloning the mouse.
So, what are the clinical symptoms or the clinical signs of this animal? This animal will be presented with a clicking noise. Also, a mandibular extension.
Mandibular abnormal mobility, if the animal is sedated and under general anaesthesia, after animal stabilisation, of course. Reaching out with our hand inside the mouth, we, we, we will feel the crepitus and the abnormal mobility of the vertical gammas of the joint, I'm sorry, vertical gas of the mandible. Here's an AO craxilificial classification system to the controller process.
The fractures There is a two system of classification. System B in the B picture and the C picture. The B picture.
It's it's expressed in 123 numbers. The first number Represent no fragmentation. There is a line of fracture, but no fragmentation.
Number 2, major fragmentations, and number 3 is major fragmentation. Picture C is fractured displacement and classified into. 012.
All is a complete full surface contract. One is a partial. Or some of the surface contact.
And 3 is loss or no contact between the two surfaces. Of course, this type of fracture is diagnosed during our diagnostic imaging of the head, especially in computer tomography diagnostic imaging. Nelasia, most commonly occurring in neuroplasia, is osteosarcoma, not very common to occur.
But it will occur, especially the mandibular osteochondroma osteochondrosarcoma, squamous cell carcinoma. The animal will be presented with a swelling, causing articular pain, and with t timbermandibular joint deformity and ankylosis will occur. Here's a computer tomography of a mandible with mandibular osteoma.
Of course, this animal was presented to an external clinic, not in Egypt. But there is an that's an example of mandibular neplasia. Not a very common occurrence, but it can be surgically reconstructed.
Ankylosis, there is an ankylosis and pseudo enclosis. The difference between both is that through ankylosis or intra-articular temporomandibular joint encloses develops following gondola fracture. Or Primary osteoarthritis of the joint, any.
Possibility that a fibrous tissue or bony callus. Will be formed inside the joint will cause a true t and the joint. Actually, here in Egypt, I have treated so, so many animals, especially cats.
suffered from, timber, timbermandola joint encloses and C encloses. At less common causes of intra-articular ankylosis is osteomyelitis of the bone, osteoarthritis, and new lesion. Even if one mandibular, even if one mandibular joint.
Is affected the mandibular extension. Of the joint will become progressively reduced or absent, and also the mandibular deviation, malclusion, and mobility will be reduced until the animal cannot open its mouth, only 1 centimetre or less than 1 centimetre allowing the tongue to be reduced. Letting the animal to leaking water or eating soft tissue.
Very painful condition. Of course, radiographic examination in this case can help, but computer tomography is the best and gold standard diagnosing approach of this case. He's an animal presented with brought through the tongue.
Animal cannot open its mouth. There is an atrophy. He Is this joint?
Of the mastect your muscles due to chronicity of the case, diagnostic imaging of the case. Revealed Temporal mandibular joint ankylosis, as you can see here, there is a flattening. And osteo osteophyte and callous formation, making the two bones connected together.
There is also the beginning of abnormal changes here. In the joint. Making it difficult to to open the mouth.
This is a case presented to my hospital with the previous, with unific trauma, but the animal. It is presented in a chronic stage, animal cannot open its mouth. Radiographic examination in, in an oblique lateral position.
Revealed Fractured vertical gums and bony formation. Around the timber Mandela joint area due to honour refusal of proceeding with computer tomography. We didn't actually solve this case due to financial restrictions.
But here's an example of acido ankylosis. Had occurred in the right joint of a cat. Can you see How much of a a bone colours has formed.
Here is the original joint. I'm sorry, it is the original joint, but this Carlos. Has eaten much of the joint and there's deformity and abnormal bone.
Of the condo process of the mandible, making animal difficult to open the mouth. There is also a miscellaneous causes. That can lead to our locking jaw a situation such as cranium mandibular osteopathy, mastic muscle myositis, orbital and biorbital lesions such as aromatic.
Zygomatic gland tumour, cellocele, or abscess, zygomatic gland affections such as tumour, salocele, or abscess. Trigeminal neuritis or neuro neuropathy, and tetanus. Cranium mandibular osteopathy is a non-neoplastic, non-inflammatory proferative bone disorder that occurs to immature dogs.
Involving the occipital bone, tympanic polar zygomatic. Portion or possess of the temporal bone and mandibular rauss. It is a self-limiting disease.
It can be resolved with a corticosteroid injection. Abnormal bone percolation prevent animal from closing its mouth. There is a mast to muscle mesitis, very important in our differential list.
It's an autoimmune disease, focal inflammatory myopathy of muscles of mastication, especially temporal and seal muscles. Making it hard to open the the mouth. The disease has two stages or two phases, acute and chronic phases.
During the acute phase, the hypertrophy of muscle of mastications with myellesia, vein of the muscle will occur. Also, there will be a feverish animal and yaxia, enlargement of mandibular and biscabular lymph node. This animal is presented with inability to open the mouth.
The diagnostic approach of this case is about EISA testing for a circulating antibody in the serum against the type 2 muscle fibres. Clinical signs and LISA testing. Is a confirmatory diagnosis of masse muscle my fibres, masse muscle myositis.
Management of this case. As corticosteroids as immunosuppressive agent 2 milligramme bike until maximum zu function has been regained. Trigim and neuropathy, the, the animal Rottweiler.
Has a flaccid paralysis to muscle groups that are supplied by the mandibular nerve of trigeminal. All muscles of mastication are supplied by. Trigeminal nerve, all but the caudal belly of the gastrial muscle is only supplied by the facial muscle.
So, it's important to Regain this piece of information of anatomy and anatomic innervation of the muscles of plastication because the animal will be presented with a unilateral or often bilateral atrophy in the temporal bone, as shown in the right picture. And the muscle, I'm sorry, the temporal muscle is atrophied. The temporal muscle is atrofied and also the mast muscle masseter muscle is atrofied.
The diagmatic arch is pronounced and very big. Due to the atrophy of the two muscles. Management, non-surgical management of log jaw.
Manual reduction of the open locking. Show animals. We can do the pencil technique, the bend technique in order to resolve this case.
Here is a series of pictures. To represents a technique, a pen or a pencil. Will be placed in cuts.
Behind the first free molar and in dogs behind. The Mueller. The first P as in dog.
I'm sorry? We will be reviewing the CAT technique first. The pen or pencil is placed.
While the hand is placed upon the Mazilla and Mandel trying to Closing the mouse while rolling the pen or pencil to return or to be able to return the coal process behind the thematic process. The same technique is used for dogs, but the pencil or the wooden. Pencil.
I placed behind the molars trying to closing the mouth while the chronoprosis is pushed behind the zygomatic arch in order to fully reduction of the chronos. And we have to. Make a maxillo mandibular fixation after this technique because.
This pathology or timberman joint luxation can reoccur. So we have to. Revise our conclusion in a normal state.
Through maxilum mandibular fixation by a composite illustration such as the picture, or making a maxillo mandibular suing of the mandible at maxzilla, letting the animal 1 or 2 centimetres to just put out the tongue to lake water or introducing a soft, soft, food. Of course, we can place an inogastric tube in order to feed our animal, but this will help with complete reduction in a normal maocclusion and the scar tissue. When, will be regenerated around the joint, making recur very rare.
So, this is a non-surgical management of Lucho. We can revise our surgical management of Lo Joe. As in dysplasia and luxation, recurrent dysplasia and luxation is a manual reduction.
Failed to, regain our normal occlusion. There's some of surgical procedures that we can perform such as zygomatic process excision, coronate process shortening. We can perform actually the two processes in the animal.
In order to. Prevent the care of the mandibular chrosis. Loization outside thematic process.
So we perform the zygomatic process cutting and we process shortening. In regard of the ankylosis and pseudo ankylosis, also nelasia, there is a few. Surgical procedure that we can perform such as chondulectomy, colonectomy, and gap arthroplasty.choulolectomy is in the left picture, is a surgical excision of the gondola process of the mandible.
While in gap arthroplasty, we make A big, a very big, a big excision, zymatic archronoid process, and part of the vertical rhamus to make a very big space to prevent. The scar tissue formation and recur of the ankylosis or pseudo ankylosis. Thank you very much for your attention.
Any questions can be received through my email and I hope that you enjoyed my webinar and session.