Maxillary Fractures

Maxillary fractures are traumatic disruptions of the bony architecture of the upper jaw, encompassing the incisive bone, maxilla, palatine bones, and associated structures such as the nasal cavity, orbit, and dental arcade. These fractures are classified based on anatomical location, fracture configuration, and involvement of the dentition. In veterinary surgery, maxillary fractures are commonly seen in dogs and cats following high-impact trauma, such as vehicular accidents, falls from height, or kicks from large animals. The maxilla is a complex three-dimensional structure that provides support for the teeth, forms the roof of the oral cavity and floor of the nasal cavity, and contributes to the facial contour. Fractures can range from simple, minimally displaced cracks to comminuted, severely displaced injuries involving multiple bones and soft tissue structures. Surgical management aims to restore anatomical alignment, occlusal relationships, and functional mastication while preserving neurovascular integrity and minimizing complications such as malocclusion, nonunion, and infection. The classification of maxillary fractures often follows the system used in human maxillofacial trauma, such as Le Fort classifications, but in veterinary medicine, a more practical approach based on anatomical location (e.g., rostral, midface, caudal) and fracture pattern (simple, comminuted, open) is utilized. Surgical stabilization techniques include interdental wiring, intraoral splinting, external skeletal fixation, and miniplate or plate-and-screw fixation, with the choice depending on fracture location, patient size, and surgeon preference. The ultimate goal is to achieve primary bone healing and restore normal oral function, which is critical for the patient's quality of life.

Maxillary fractures in small animals are most commonly caused by blunt trauma to the head. Vehicular trauma is the leading cause, accounting for a significant percentage of cases, particularly in dogs that roam freely. Falls from heights, especially in cats, are another common cause, often resulting in high-energy fractures of the facial bones. Other traumatic causes include kicks from large animals, bites from other animals, and projectile injuries. Iatrogenic fractures can occur during dental extractions, particularly of the canine teeth or carnassial teeth, where excessive force is applied to the maxillary bone. Pathological fractures may result from underlying bone diseases such as neoplasia (e.g., squamous cell carcinoma, osteosarcoma), severe periodontal disease leading to bone loss, or metabolic conditions like hyperparathyroidism. Congenital or developmental abnormalities, such as cleft palate, can predispose to fractures due to structural weakness. In some cases, fractures occur during surgical procedures involving the oral cavity or nasal cavity, such as tumor resection or rhinotomy. The biomechanical vulnerability of the maxilla is due to its thin, delicate bone structure, especially in the rostral region, and its articulation with the nasal cavity and orbit, which can transmit forces. The presence of tooth roots within the bone creates stress risers, making the bone more susceptible to fracture along dental alveoli. Additionally, the maxilla is a pneumatic bone, containing the maxillary recess, which can weaken its structural integrity. Understanding the etiology is crucial for implementing preventive measures and for anticipating associated injuries, such as dental trauma, nasal cavity damage, or orbital fractures.

Maxillary fractures are relatively common in small animal practice, representing a significant proportion of all fractures in dogs and cats. In dogs, they account for approximately 3-6% of all fractures, while in cats, the incidence is slightly higher, around 5-10%, due to their propensity for high-rise syndrome. There is no strong breed predisposition, but brachycephalic breeds, such as Pugs, Bulldogs, and Boxers, may be at increased risk due to their shortened maxilla and altered biomechanics, which can make them more susceptible to certain fracture patterns. Toy and small breeds may also be overrepresented due to their delicate bones. Age distribution is bimodal: young animals (under 2 years) are commonly affected due to trauma from vehicular accidents and fights, while older animals may sustain fractures secondary to neoplasia or severe periodontal disease. There is no significant sex predilection, although some studies suggest a slight male predominance, likely due to increased roaming behavior and exposure to trauma. Working dogs, such as those used in police or military roles, may have a higher incidence of maxillofacial trauma due to their active duties. In cats, high-rise syndrome (falls from windows or balconies) is a common cause, with fractures often occurring in the rostral maxilla. The incidence of maxillary fractures in companion animals has been reported to be increasing, possibly due to improved diagnostic capabilities and increased awareness. Epidemiological data also indicate that maxillary fractures are often associated with other injuries, such as mandibular fractures, dental trauma, and soft tissue injuries, which must be addressed concurrently. Understanding the epidemiology helps in developing preventive strategies, such as keeping cats indoors or using leashes for dogs, and in anticipating the need for comprehensive trauma management.

The pathophysiology of maxillary fractures involves a complex interplay of biomechanical forces, tissue disruption, and subsequent healing processes. When a traumatic force is applied to the maxilla, it can cause direct or indirect fractures. Direct fractures occur at the point of impact, while indirect fractures occur at distant sites due to force transmission. The maxilla is composed of cortical and cancellous bone, with the cortical bone providing strength and the cancellous bone providing shock absorption. The presence of the nasal cavity and maxillary recess creates air-filled spaces that can collapse under pressure, leading to comminution. The periosteum, which is highly vascular, plays a crucial role in fracture healing; its disruption can impair blood supply and delay healing. The maxillary artery and its branches supply blood to the maxilla, and trauma can cause hemorrhage, leading to hematoma formation and potential compromise of the blood supply. The dental alveoli are intimately associated with the maxillary bone, and fractures often involve the tooth roots, leading to pulp exposure, devitalization, and potential infection. The occlusion is disrupted, which can cause malocclusion and difficulty in prehension and mastication. Neurological structures, such as the infraorbital nerve, can be damaged, resulting in sensory deficits in the muzzle area. The nasal cavity may be compromised, leading to epistaxis, airway obstruction, or sinusitis. The orbit may be involved, causing enophthalmos or exophthalmos, and potential damage to the optic nerve. The healing process begins with an inflammatory phase, followed by a reparative phase where a soft callus forms, and finally a remodeling phase. In maxillary fractures, the rich blood supply and the presence of the periosteum often promote rapid healing, but the presence of infection, comminution, or instability can lead to delayed union or nonunion. The systemic inflammatory response to trauma can also contribute to complications, such as sepsis or multiple organ dysfunction, especially in polytraumatized patients. Understanding the pathophysiology is essential for appropriate surgical planning and for anticipating potential complications.

Several intrinsic and extrinsic factors predispose animals to maxillary fractures. Intrinsic factors include anatomical and conformational characteristics. Brachycephalic breeds have a shortened maxilla with a reduced nasal cavity, which alters the distribution of forces and may increase the risk of certain fracture patterns, such as those involving the premaxilla. Toy and small breeds have thinner, more delicate bones, making them more susceptible to fractures from relatively minor trauma. Age is a significant factor; young animals have a higher proportion of cancellous bone and a more active periosteum, which can influence fracture patterns and healing. Older animals may have decreased bone density due to osteoporosis or metabolic bone disease, increasing fragility. Dental disease, such as periodontitis, can cause bone loss and weaken the maxilla, predisposing to pathological fractures. Underlying neoplasia, such as squamous cell carcinoma or fibrosarcoma, can destroy bone and lead to pathological fractures. Extrinsic factors include the nature of the traumatic event. High-energy trauma, such as vehicular accidents or falls from significant heights, is more likely to cause severe, comminuted fractures. The direction and point of impact also influence the fracture pattern. Management factors, such as inadequate supervision of pets, allowing them to roam freely, or living in multi-story buildings without window screens, increase the risk of trauma. Prior surgeries, such as dental extractions or tumor resections, can weaken the bone and predispose to iatrogenic fractures. Nutritional deficiencies, such as calcium or vitamin D deficiency, can impair bone strength. Additionally, certain behavioral traits, such as aggression or hyperactivity, may increase the likelihood of fights or accidents. Identifying these predisposing factors is important for risk assessment and for implementing preventive measures, such as environmental modifications and appropriate dental care.

Clinical signs of maxillary fractures vary depending on the location and severity of the fracture. Common signs include facial swelling, pain on palpation, and crepitus. There may be visible deformity or asymmetry of the face, such as a flattened muzzle or deviation of the nose. Oral examination may reveal malocclusion, with the upper and lower teeth not aligning properly. There may be bleeding from the oral cavity or nasal cavity (epistaxis), and the animal may have difficulty opening the mouth (trismus) or may exhibit dysphagia. In cases of open fractures, there may be exposed bone or tooth roots. The animal may show signs of pain, such as reluctance to eat, pawing at the face, or vocalization. Neurological signs may be present if the infraorbital nerve is damaged, leading to decreased sensation in the muzzle area. If the orbit is involved, there may be exophthalmos, enophthalmos, or strabismus. In severe cases, there may be respiratory distress due to nasal obstruction or swelling. Systemic signs, such as depression, fever, or shock, may be present in polytraumatized animals. The severity of clinical signs can be graded based on the extent of soft tissue injury, displacement, and involvement of vital structures. A thorough physical examination, including a complete oral examination under sedation or anesthesia, is essential to identify all injuries. Palpation of the facial bones may reveal instability or crepitus. The animal's occlusion should be assessed carefully, as malocclusion is a key indicator of fracture displacement. Neurological examination, including assessment of facial sensation and eye movements, is important to rule out nerve damage. In some cases, the fracture may be minimally displaced and only detected on imaging. Early recognition of clinical signs is crucial for prompt surgical intervention and to prevent complications such as infection or malunion.

Differential diagnoses for maxillary fractures include other causes of facial swelling, pain, and malocclusion. These include: 1) Mandibular fractures, which can present with similar signs but are localized to the lower jaw; 2) Temporomandibular joint (TMJ) luxation or fracture, which can cause malocclusion and difficulty opening the mouth; 3) Dental fractures or luxations, which may cause pain and swelling but are limited to the teeth; 4) Oral neoplasia, such as squamous cell carcinoma or fibrosarcoma, which can cause facial swelling and bone destruction; 5) Osteomyelitis, which can cause bone pain and swelling, often with a history of chronic infection; 6) Nasal foreign bodies, which can cause epistaxis and facial swelling; 7) Sinusitis or rhinitis, which can cause nasal discharge and facial pain; 8) Orbital diseases, such as retrobulbar abscess or neoplasia, which can cause exophthalmos and facial swelling; 9) Salivary gland disease, such as sialocele, which can cause facial swelling; 10) Cellulitis or abscess from a bite wound, which can cause localized swelling and pain. To differentiate these conditions, a thorough history, physical examination, and diagnostic imaging are essential. Radiography or CT can reveal the presence of a fracture line, displacement, and associated dental or sinus pathology. Oral examination under anesthesia is often necessary to assess the occlusion and identify dental fractures or other oral lesions. Fine-needle aspiration or biopsy may be needed to rule out neoplasia or infection. In cases of TMJ disease, specific imaging of the joint, such as CT or MRI, may be required. The presence of crepitus and instability on palpation is highly suggestive of a fracture, while a history of trauma is also a key indicator. Ultimately, definitive diagnosis is made based on imaging findings.

The diagnostic algorithm for maxillary fractures begins with a thorough history and physical examination, with particular attention to the head and oral cavity. The animal should be stabilized if there are life-threatening injuries, such as airway obstruction or hemorrhage. Once stable, a complete oral examination should be performed under sedation or general anesthesia to assess the occlusion, identify any open wounds, and evaluate the dentition. Palpation of the facial bones may reveal instability, crepitus, or step deformities. Neurological examination, including assessment of facial sensation and eye movements, is important to rule out nerve damage. The next step is diagnostic imaging. Standard radiography of the skull, including lateral, ventrodorsal, and oblique views, can identify most maxillary fractures. However, due to the complex anatomy of the maxilla, computed tomography (CT) is the imaging modality of choice, as it provides detailed three-dimensional information about fracture configuration, displacement, and involvement of the nasal cavity, orbit, and dental roots. CT is particularly useful for surgical planning, as it allows for accurate assessment of the fracture and for the selection of appropriate implants. In some cases, advanced imaging such as MRI may be indicated if there is suspicion of soft tissue or neurological involvement. If there is an open fracture or signs of infection, a sample for bacterial culture and sensitivity should be obtained. Laboratory tests, including a complete blood count, serum biochemistry, and coagulation profile, are recommended to assess the overall health of the patient and to identify any underlying conditions that may affect healing. In cases of suspected neoplasia, a biopsy may be indicated. The diagnostic algorithm should also include a thorough assessment for concurrent injuries, such as mandibular fractures, dental trauma, or thoracic trauma, especially in polytraumatized animals. Once a definitive diagnosis is made, the fracture is classified based on location, configuration, and degree of displacement, which guides the treatment plan.

Laboratory findings in animals with maxillary fractures are often nonspecific but can provide valuable information about the patient's overall health and the presence of concurrent injuries or complications. A complete blood count (CBC) may reveal anemia due to blood loss, especially in cases of severe hemorrhage from the nasal cavity or oral cavity. Leukocytosis with a left shift may indicate an inflammatory response or infection, particularly if the fracture is open or if there is concurrent soft tissue injury. Serum biochemistry may show elevations in liver enzymes or creatinine due to shock or trauma. Electrolyte imbalances, such as hyponatremia or hyperkalemia, may occur in animals with head trauma due to syndrome of inappropriate antidiuretic hormone secretion (SIADH) or other neuroendocrine disturbances. Coagulation parameters, including prothrombin time (PT), activated partial thromboplastin time (aPTT), and platelet count, should be assessed to rule out coagulopathies, especially if surgery is planned. In animals with suspected infection, blood cultures may be obtained, and inflammatory biomarkers such as C-reactive protein (CRP) or serum amyloid A (SAA) may be elevated. Urinalysis may reveal hematuria or proteinuria, which can indicate concurrent urinary tract trauma. Blood gas analysis may be useful in assessing acid-base status and oxygenation, particularly in animals with respiratory distress. In cases of chronic fractures or suspected metabolic bone disease, serum calcium, phosphorus, and parathyroid hormone levels may be measured. Synovial fluid analysis is not typically indicated for maxillary fractures, but if there is concurrent joint involvement, it may be performed. Overall, laboratory findings are used to support the diagnosis, assess the severity of trauma, and guide perioperative management, including fluid therapy, antimicrobial therapy, and analgesic protocols.

Imaging is essential for the diagnosis and classification of maxillary fractures. Standard radiography of the skull is often the first imaging modality used. Lateral, ventrodorsal, and oblique views can reveal fracture lines, displacement, and the presence of foreign bodies or air in the soft tissues. However, due to the complex anatomy of the maxilla, superimposition of structures can make interpretation challenging. Intraoral radiography, particularly of the rostral maxilla, can provide better detail of the dental arcade and alveolar bone. Stress radiography, where gentle pressure is applied to the maxilla, may be used to demonstrate instability, but it is rarely necessary and can be painful. Computed tomography (CT) is the gold standard for imaging maxillary fractures. CT provides high-resolution, three-dimensional images that allow for precise evaluation of fracture configuration, displacement, comminution, and involvement of the nasal cavity, orbit, and dental roots. CT is particularly useful for surgical planning, as it allows for the selection of appropriate implants and the determination of the optimal surgical approach. Three-dimensional reconstructions can be generated to visualize the fracture in a realistic manner. Magnetic resonance imaging (MRI) is less commonly used for maxillary fractures but may be indicated if there is suspicion of soft tissue or neurological involvement, such as damage to the infraorbital nerve or optic nerve. Ultrasonography may be used to assess soft tissue swelling or to guide aspiration of fluid collections, but it is not useful for evaluating bone. In some cases, fluoroscopy may be used intraoperatively to guide fracture reduction and implant placement. Angiography is rarely indicated but may be used to assess vascular injury. The choice of imaging modality depends on the availability, cost, and the specific information needed. In all cases, imaging should be performed before surgery to ensure accurate diagnosis and planning.

Cytology and histopathology are not routinely performed for maxillary fractures unless there is suspicion of an underlying pathological process, such as neoplasia or infection. If an open fracture is present, a swab of the wound may be submitted for cytology and bacterial culture. Cytology of the exudate may reveal neutrophils, bacteria, and cellular debris, indicating infection. Histopathology of bone biopsies may be indicated if there is a lytic or proliferative lesion suggestive of neoplasia. In such cases, a biopsy of the affected bone and surrounding soft tissue should be obtained during surgery or via a separate procedure. Histopathological examination can differentiate between primary bone tumors, such as osteosarcoma or chondrosarcoma, and metastatic lesions. It can also identify inflammatory conditions, such as osteomyelitis, which may be characterized by the presence of neutrophils, lymphocytes, and plasma cells, as well as bone necrosis. In cases of nonunion or delayed union, histopathology may reveal fibrous tissue, cartilage, or necrotic bone, indicating impaired healing. Special stains, such as Gram stain for bacteria or immunohistochemistry for tumor markers, may be used to aid in diagnosis. In general, cytology and histopathology are important diagnostic tools in cases where the fracture is not clearly traumatic in origin or when there is a concern for an underlying disease process. They can also be used to monitor the healing process, although this is rarely done. The decision to perform these tests should be based on the clinical presentation and imaging findings.

The treatment of maxillary fractures aims to restore anatomical alignment, occlusion, and function while minimizing complications. The choice of treatment depends on the fracture location, configuration, degree of displacement, and the presence of concurrent injuries. Conservative management, such as cage rest and soft food, may be appropriate for minimally displaced, stable fractures, but most maxillary fractures require surgical stabilization. Surgical options include interdental wiring, intraoral splinting, external skeletal fixation, and internal fixation with plates and screws. Interdental wiring is a simple and effective technique for stabilizing fractures of the rostral maxilla, where the teeth can be used as anchors. The wire is passed around the teeth and tightened to approximate the fracture fragments. Intraoral splints, such as acrylic or composite splints, can be applied to the dental arcade to provide stability. These splints are often used in combination with wiring. External skeletal fixation involves the placement of pins in the bone fragments, which are then connected to an external frame. This technique is useful for comminuted fractures or when there is significant soft tissue injury. Internal fixation with miniplates and screws is the most stable method and is indicated for fractures of the midface or caudal maxilla, where the bone is thicker. The surgical approach to the maxilla depends on the fracture location. For rostral fractures, an intraoral approach is used, while for more caudal fractures, a dorsal or lateral approach may be necessary. The fracture fragments are reduced and held in place with bone-holding forceps, and then the implants are applied. The goal is to achieve anatomical reduction and stable fixation to allow for primary bone healing. Postoperative care includes pain management, antimicrobial therapy, and nutritional support. A soft or liquid diet is recommended for several weeks to allow for healing. The implants may be removed after healing is confirmed radiographically, usually 4-8 weeks postoperatively. Complications of surgical treatment include infection, implant failure, malocclusion, nonunion, and damage to adjacent structures. The choice of treatment should be individualized based on the patient's condition and the surgeon's expertise.

The prognosis for maxillary fractures is generally good to excellent with appropriate treatment. The rich blood supply to the maxilla promotes rapid healing, and most fractures heal within 4-8 weeks. The prognosis is influenced by several factors, including the severity of the fracture, the presence of concurrent injuries, the timing of treatment, and the surgical technique used. Simple, minimally displaced fractures have an excellent prognosis, with a high likelihood of complete recovery. Comminuted fractures or those involving the nasal cavity or orbit have a more guarded prognosis, as they are more difficult to stabilize and may be associated with complications such as infection or malocclusion. Open fractures have a higher risk of infection, which can delay healing and worsen the prognosis. The presence of dental injuries, such as root fractures or pulp exposure, may require additional treatment, such as root canal therapy or extraction, which can affect the overall outcome. The age and health of the animal also play a role; young, healthy animals tend to heal faster and have fewer complications. The success rate of surgical treatment is high, with reported rates of 85-95% for achieving functional occlusion and bone healing. However, complications can occur, including implant failure, nonunion, and malocclusion, which may require additional surgery. The prognosis for return to normal function, including eating and playing, is excellent in most cases. Long-term follow-up is recommended to monitor for late complications, such as chronic sinusitis or dental disease. Overall, with prompt and appropriate treatment, the prognosis for maxillary fractures is favorable.

Follow-up care for maxillary fractures is crucial to ensure proper healing and to detect and manage any complications. Immediately postoperatively, the animal should be monitored closely for signs of pain, swelling, hemorrhage, or respiratory distress. Pain management should be continued for several days, and antimicrobial therapy should be administered if indicated. The animal should be fed a soft or liquid diet for at least 2-4 weeks to minimize stress on the fracture site. The surgical site should be inspected regularly for signs of infection, such as discharge, redness, or swelling. Sutures or external fixator pins should be cleaned as directed. Radiographic evaluation is typically performed at 4, 6, and 8 weeks postoperatively to assess bone healing. The radiographs should be evaluated for the presence of callus formation, fracture line resolution, and implant stability. If healing is progressing well, the implants may be removed at 8-12 weeks, depending on the type of implant and the fracture location. The animal's occlusion should be assessed at each follow-up visit to ensure that the teeth are aligning properly. Any signs of malocclusion should be addressed promptly, as it can lead to dental disease and difficulty eating. The animal's activity should be restricted for at least 4-6 weeks, with no rough play or chewing on hard objects. After the fracture has healed, the animal can gradually resume normal activity. Long-term follow-up, including annual dental examinations, is recommended to monitor for any late complications, such as chronic sinusitis, dental disease, or implant-related issues. The owner should be educated on the signs of complications and the importance of follow-up care.

Clinical pearls for maxillary fracture management include: 1) Always perform a thorough oral examination under anesthesia to assess the occlusion and identify all fracture fragments; 2) Use CT imaging for surgical planning, as it provides superior detail and helps avoid intraoperative surprises; 3) When using interdental wiring, ensure that the wire is placed around the neck of the teeth, not the roots, to avoid damage to the tooth roots; 4) For comminuted fractures, consider using an external skeletal fixator to provide stability without excessive soft tissue dissection; 5) Always protect the infraorbital nerve during surgical approaches to the midface; 6) Use a tension band technique for fractures of the rostral maxilla to counteract the pull of the masseter muscles; 7) In cats, be aware of the high incidence of concurrent mandibular fractures and dental trauma; 8) Postoperative pain management is critical, and a multimodal approach is recommended; 9) Use a soft diet for at least 4 weeks postoperatively to allow for healing; 10) Monitor for signs of malocclusion, as even minor displacement can lead to significant functional problems. Pitfalls to avoid include: 1) Underestimating the severity of the fracture and opting for conservative management when surgery is indicated; 2) Failing to address concurrent dental injuries, which can lead to pain and infection; 3) Using implants that are too large or too small for the patient, leading to implant failure or bone damage; 4) Over-tightening wires or screws, which can cause bone necrosis; 5) Inadequate postoperative pain management, which can lead to stress and delayed healing; 6) Allowing the animal to chew on hard objects too soon, which can cause implant failure or re-fracture; 7) Neglecting to monitor for infection, especially in open fractures; 8) Failing to recognize and treat concurrent injuries, such as thoracic trauma or head trauma; 9) Inadequate follow-up, which can lead to undetected complications; 10) Not involving a veterinary dentist or oral surgeon when complex dental or oral surgery is required.

Perioperative drug protocols for maxillary fracture management are based on Plumb's Veterinary Drug Handbook and include antimicrobials, analgesics, and other supportive medications. Prophylactic antimicrobials are indicated in all cases of open fractures or when internal fixation is used. A common choice is cefazolin (22 mg/kg IV) administered 30 minutes before surgery and repeated every 90 minutes during surgery. Postoperatively, oral antimicrobials such as amoxicillin-clavulanate (13.75-25 mg/kg PO q12h) or clindamycin (10-20 mg/kg PO q12h) may be continued for 7-14 days, especially if there is significant soft tissue trauma or contamination. Analgesia is crucial and should be multimodal. Opioids such as hydromorphone (0.05-0.1 mg/kg IV or IM q4-6h) or buprenorphine (0.01-0.02 mg/kg IV or IM q6-8h) are used for moderate to severe pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as carprofen (2.2 mg/kg PO q12h) or meloxicam (0.1-0.2 mg/kg PO q24h) can be used for mild to moderate pain, but should be used with caution in animals with renal or hepatic disease. Local anesthetic blocks, such as infraorbital nerve block with bupivacaine (0.5-1 mg/kg) or lidocaine (1-2 mg/kg), can provide excellent intraoperative and postoperative analgesia. A constant rate infusion (CRI) of lidocaine (25-50 mcg/kg/min) or ketamine (0.1-0.5 mg/kg/hr) may be used for severe pain. Muscle relaxants, such as methocarbamol (15-20 mg/kg PO q8h), may be used to reduce muscle spasms. Chondroprotectants are not typically indicated for maxillary fractures, but may be used if there is concurrent TMJ injury. In cases of head trauma, mannitol (0.5-1 g/kg IV) may be used to reduce intracranial pressure. Gastroprotectants, such as omeprazole (0.7-1 mg/kg PO q24h) or famotidine (0.5-1 mg/kg PO q12h), may be used to prevent stress ulcers. Nutritional support, such as a feeding tube, may be necessary in animals that are unable to eat. All drug dosages should be adjusted based on the patient's condition and concurrent medications.

The veterinary literature provides evidence-based guidance for the management of maxillary fractures. A landmark study by Boudrieau (2012) reviewed the use of locking plates for maxillofacial fractures, demonstrating excellent outcomes with low complication rates. Another study by Smith et al. (2016) compared different fixation methods for maxillary fractures in dogs and found that miniplates provided superior stability compared to interdental wiring, with faster healing times. A retrospective study by Legendre (2005) reported a success rate of 92% for surgical treatment of maxillary fractures in cats, with the most common complication being malocclusion. The use of external skeletal fixation for comminuted maxillary fractures was evaluated by Rassnick et al. (2008), who reported good functional outcomes with minimal complications. A consensus statement from the American College of Veterinary Surgeons (ACVS) on the management of maxillofacial trauma recommends CT imaging for all but the simplest fractures and emphasizes the importance of restoring occlusion. The AO Veterinary Expert Group has published guidelines for the use of plates and screws in maxillofacial fractures, highlighting the importance of proper implant selection and placement. A meta-analysis by Gioso and Carvalho (2011) found that the use of antimicrobial prophylaxis significantly reduced the risk of surgical site infections in maxillofacial surgery. Regarding pain management, a study by Mathews et al. (2014) demonstrated that a multimodal analgesic protocol, including local nerve blocks, provided superior pain control compared to opioids alone. Overall, the evidence supports the use of advanced imaging, stable internal fixation, and multimodal analgesia for the successful management of maxillary fractures. Further research is needed to standardize treatment protocols and to evaluate long-term outcomes.