eMedicine - Facial Trauma, Sports-Related Injuries : Article by Mimi T Chao

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Facial Trauma, Sports-Related Injuries

Article Last Updated: Feb 4, 2008

The face is the most vulnerable area of the body and is usually the least protected. Sports-related facial injuries account for 8% of all facial soft tissue injuries. Approximately 11-40% of all sports injuries involve the face. These injuries are most often due to direct hits with a ball or player-to-player contacts. Health care providers for athletes should be familiar with the anatomy of the facial region, the most common types of facial injuries, and the initial management of facial injuries.

The most common types of sports-related facial trauma are the soft tissue injuries and the fractures of the "T-Zone" bones (the nose, the zygoma, and the mandible). These injuries often occur in combination. Depending on the extent and the types of injury, some injuries can be managed at the sporting event site, with the athlete resuming play immediately. Other injuries may demand transfer to an urgent care setting and management by a specialist.

Proper initial assessment and management of injuries may prevent unfavorable long-term results and permanent facial deformities. The ultimate goals are for the athletes to recover functionally and aesthetically from the facial injury and to return to competition in a timely manner.

The soft tissues of the face are among the most vascular tissues of the body. Their blood supply is derived from contributions of both the external and internal carotid arteries. Because of the abundant blood supply to these tissues, ischemic tissue flaps and infections are uncommon. The underlying facial muscles account for the tension lines and rhytides of the skin. These skin lines become more prominent with age and the loss of skin elasticity and should be observed during the repair of soft tissue injuries to avoid unnatural scarring.

Contained within the soft tissues are motor and sensory nerves, arteries, veins, and lymphatics. The sensation of the face is supplied mainly by the 3 branches of the trigeminal nerve (ophthalmic [V1], maxillary [V2], mandibular [V3]). The muscles of mastication that control the opening and closing of the jaw are also innervated by the motor division of the trigeminal nerve. The muscles of facial expression are innervated by the 5 branches of the facial nerve (frontal, zygomatic, buccal, marginal mandibular, and cervical).

The facial skeleton is composed of a series of horizontal and vertical bony buttresses that support the architecture of the face against internal and external applied forces. The facial buttresses are designed to withstand forceful impacts in order to protect the underlying vital elements such as the brain, the eyes, and other neurovascular structures.

The facial skeleton can be divided into thirds. The upper third consists of the frontal bone and ends at the level of the supraorbital ridge. Fractures in this area most often involve the frontal sinus.

The middle third of the face is the most prominent and complex. It extends from below the supraorbital rims to the incisal edges of the upper teeth. This region consists of the orbits, the nasal bones, the zygoma, and the maxillary bones. The cone-shaped orbital space is composed of 7 bones: frontal, zygomatic, sphenoid, lacrimal, maxillary, palatine, and ethmoid. The periorbital bony rim serves as an attachment for the suspensory ligaments of the eye and the protective framework of the globe and optic nerve. The zygoma, along with the maxilla, gives the malar projection of the midface anteriorly. Laterally, it articulates with the frontal bone to form the zygomatic arch. The nose projects from the mid face and is composed of both cartilage and bone to give it the characteristic shape. The mid face experiences the highest incidences of fracturing because of its increased projection from the face.

The lower third of the face is the mandible and the teeth it supports. The condylar processes are considered a part of the lower third, even though they articulate with the temporal bone to form the temporomandibular joint.

Evaluation of the facial injuries should follow the principles of trauma evaluation and should begin with airway, breathing, circulation, and disability. Examinations of vital signs and mental status are also crucial parts of the initial assessment. After the initial assessment and stabilization, the facial examination is then performed in a systematic manner with particular attention paid to important bony landmarks, neurovascular structures, and soft tissues.

Patients with sports-related facial injuries are usually able to maintain protective oral and pharyngeal reflexes and can clear their own airway of saliva, blood, or vomitus. Dislodged tooth fragments, dental appliances, or mandibular structural collapse may compromise the airway and should be noted. Emergent tracheostomy is seldom needed, even in severe facial fractures, unless a concomitant injury to the cranium, neck, or chest exists.

Extensive arterial hemorrhage from facial wounds usually results from injury to the maxillary artery, the superficial temporal artery, or the angular artery. Direct pressure is usually sufficient for initial hemostasis, followed by ligation of the bleeding vessel through the wound if it is clearly visible. If no clear source of bleeding is identified, the airway should be protected, a compressive facial dressing applied, and the athlete transferred to the nearest acute care center.

Neurologic evaluation

Every maxillofacial injury should be considered a head injury, and patients with such injuries should be given the appropriate neurologic evaluation. The unconscious athlete is assumed to have head and neck injuries, and proper immobilization of the neck and spine should be applied immediately.

Detailed examination

Once the potentially life-threatening injuries are excluded, any soft tissue injuries and obvious asymmetries of the facial contour (suggesting underlying bony fractures) are documented. A detailed examination of the face follows. Each health care provider should develop a systematic routine in order to provide a thorough examination. A common approach is starting at the scalp and working down.

Examination of the upper third of the face aims at confirming the integrity of the frontal branch of the facial nerve and the stability of the supraorbital rims. Having patients elevate their eyebrows is sufficient to confirm the integrity of the nerve and the frontalis muscle. Lightly touch the forehead to test for ophthalmic division of the trigeminal nerve. Gentle palpation over the supraorbital rims that elicits pain, crepitus, or the presence of a step-off suggests underlying fractures. Examine for laceration and hematoma of the scalp that may indicate underlying skull fracture.

The eyes, the nose, the zygoma, and the maxilla make up the middle third of the face. The examination of the eyes is the most important, as injuries such as hyphema, ruptured globe, or retrobulbar hematoma are ophthalmologic emergencies. Initial determination of vision is imperative; practical methods are to ask the athletes to read the scoreboard or any printed material. Gross discrepancy of visual acuity is highly indicative of the presence of an injury. The athletes should be able to close their eyes tightly, which tests for facial nerve and orbicularis oculi muscles. Have the patients gaze in all directions in an "H" pattern to test the extraocular muscles. Limitation of or diplopia with upward gaze often suggests orbital floor fractures. Use a penlight to look for pupillary symmetry and light response. Epiphora, pain, or photophobia may indicate corneal abrasion.

Palpate the infraorbital rims for stability. Look for discrepancy of globe position in the bony orbit (exophthalmos, enophthalmos, vertical dystopia, and telecanthus), which also suggests fracturing of the orbit.

Gently press over closed eyelids to feel for the turgidity of the globes. A flaccid (ruptured) or a tense (proptotic) globe mandates further evaluation by an ophthalmologist. The globe should be protected with an eye shield during the transfer.

The examination of the nose includes the nasal bone, the septum, and the cartilage. The prominence of the nose leads to its frequent injuries. Therefore, discerning preexisting deformities from acute injuries is important. Deviation of the nasal dorsum, epistaxis, and edema should prompt the examiner to look for septal dislocation and septal hematoma. Failure to identify a septal hematoma may result in necrosis of the septal cartilage and subsequent perforation and collapse.

The examination of zygoma looks for flattening of the zygomatic arch and the widening of the mid face associated with fractures. Viewing the mid face from an inferior view facilitates the detection of these asymmetries. Lightly touch the malar region to test for dysesthesia of the trigeminal nerve infraorbital branch.

Abnormal mobility of the maxilla or hard palate can be detected by grasping the anterior maxillary teeth and firmly attempting to move the maxilla in all directions while stabilizing the forehead. Examination of teeth occlusion is combined with examination of the mandible.

The lips, tongue, and cheeks are very susceptible to lacerations when compressed against the dentition. Lacerations involving the vermillion border of the lip require delicate reapproximation to avoid a visible cosmetic defect. (For more information, see Complex Laceration, Lip.) Ask patients to pucker their lips, grin, and show their teeth to test the facial nerve branches to this area. The oral cavity must be cautiously inspected for the presence of sublingual ecchymosis, which is the pathognomic sign of a mandibular fracture.

Mandibular injuries are often accompanied by pain, numbness of the jaw and teeth, trismus, and malocclusion with the maxillary teeth. The inability of an injured athlete to close his or her mouth should alert the examiner to the possibility of temporomandibular joint dislocation or fracture. Dentition should be inspected for instability or tooth fracture.

The external ears are susceptible to hematoma formation when punched or compressed. If this hematoma is not evacuated, long-term "cauliflower" deformation occurs.¹ Gross hearing should be intact to a mere whisper near the ear. The external auditory canals and tympanic membranes should also be otoscopically inspected for the presence of blood, cerebrospinal fluid, canal laceration, or tympanic membrane perforation. Any fluid collection in the ear canal or behind the tympanic membrane may be indicative of underlying fractures of the skull base.

Sports-related facial trauma generally results when direct contact occurs with another player or a piece of equipment, including a projectile or contact against a playing surface. These blunt traumas often result in contusions, abrasions, and burst lacerations. In addition to treating the soft tissue injuries, the Centers for Disease Control and Prevention (CDC) recommendations for tetanus immunization should be followed.

*Adapted from the Centers for Disease Control and Prevention

†Td = tetanus-diphtheria

‡TIG = tetanus immunoglobulin

§Yes, if more than 10 years since last dose

||Yes, if more than 5 years since last dose

Because of the marked vascularity of the face, many facial injuries involve blood and other secretions. Although the risk of disease transmission from contacting blood with intact skin is minimal, universal precautions must be followed whenever possible. When contact with blood or body fluids is likely, gloves, eyewear, and gowns represent standard protective equipment and should be used. Medical personnel who render care must strive to establish a clean area for treatment in the midst of the contaminated environment associated with a sports arena.

Contusions represent injury of the soft tissue layers between the underlying facial skeleton and the overlying skin and are associated with varying degrees of tenderness, swelling, and ecchymosis. Keeping the head elevated and applying ice to the affected area for 15-20 minutes every 2 hours is the mainstay of treatment for facial contusions. These injuries can be expected to resolve over several days to weeks. Abrasions are partial-thickness losses of skin caused by shearing forces within the compressed epidermal and dermal layers. Adequate cleansing with an antiseptic or antibacterial soap followed by twice-daily topical antibiotic ointment is usually adequate. Patients who have abrasions that do not heal after 14 days or appear to be full-thickness should be referred to a plastic surgeon for further treatment.

Lacerations represent the most common type of facial injury encountered in the athletic setting. When blunt trauma occurs over a bony prominence of the facial skeleton, a linear or stellate laceration may result. The latter is termed a burst-type laceration and, with its jagged skin edges, repair and a good aesthetic outcome are more challenging.

Because of the abundant blood supply to the facial soft tissues, bleeding from a laceration may be brisk and copious. Immediate management is directed toward achieving hemostasis by applying direct pressure over the involved area with a sterile gauze pad. Once hemostasis is obtained, underlying structures can be seen more easily and should be examined carefully. Facial lacerations may be adequately cleaned with sterile saline delivered under pressure via an 18-gauge needle attached to a 20-mL syringe. This adequately removes bacteria and other debris from the wound.

After appropriate cleansing, superficial lacerations without separation of the wound edges may be closed using adhesive bandages (eg, Steri-Strips) or by applying a skin adhesive. For deeper lacerations with separated or jagged wound edges, precise alignment and reapproximation by a plastic surgeon ensures the best functional and aesthetic outcome.

Intraoral lacerations are treated much like skin lacerations. Following thorough irrigation, reapproximate the intraoral mucosa with absorbable suture material. Because delayed healing and excessive scar tissue may occur, primarily repair mucosal lacerations, including those of the tongue, whenever possible. (For more information on repairing intraoral lacerations, see Complex Laceration, Lip.)

Although the routine use of antibiotics is not warranted, contaminated wounds may require them. Determine tetanus immunization status, and administer tetanus toxoid (0.5 mL) when indicated. For athletes who plan to return to contact sports with a repaired laceration, an adhesive and adequately padded bandage must be applied to prevent wound disruption.

Most cases of simple epistaxis involve disruption of the Kiesselbach plexus in the anterior chamber of the nose. This is usually expediently controlled with direct pressure (ie, pinching the nares together) or the application of a vasoconstrictive spray (eg, oxymetazoline hydrochloride [Afrin], phenylephrine hydrochloride [Neo-Synephrine]). Brisk nasopharyngeal bleeding may occur from disruption of the sphenopalatine artery as it enters the lateral wall of the nasal cavity. This posterior epistaxis requires nasal packing and transfer to emergency centers for further treatment.

A collection of blood within the muscle, fascial, and dermal layers represents hematomas, which are generally seen over the zygomatic and periorbital regions. These generally resolve with the application of ice and compression.

Auricular and septal hematomas deserve special attention because of their potential for perichondral injury and subsequent necrosis. A septal hematoma appears as a purple, grapelike swelling from the nasal septum. Incision and drainage followed by anterior nasal packing may prevent the possibility of septal necrosis, impaired breathing, and altered cosmesis.

An auricular hematoma may result from blunt trauma as might be sustained in a boxing or wrestling match. It is noted as a firm, ecchymotic collection in the helical portion of the ear. Treatment is by incision and drainage of the hematoma, closure of incision with fine monofilament interrupted sutures, and a compressive dressing conforming to the helix and antihelix for 3 days. For an illustrated demonstration of auricular hematoma drainage, see Drainage, Auricular Hematoma in the Clinical Procedures journal.

Most athletes who sustain facial bones fractures should not return to the game. A second impact to a facial bone that is already fractured may compound the fracture and convert a simple nonoperative fracture into a complex and disfiguring surgical challenge.

When evaluating an athlete with a potential facial fracture, the care provider should maintain a high index of suspicion and promptly refer the patient to a facility that can adequately image and manage the injury. The following fractures discussed are those most commonly encountered in sports-related facial trauma.

Nasal Fractures

Because of its prominent location of the face, the nose is the most commonly fractured facial structure. Nasal fractures account for approximately 50% of sports-related facial fractures; 15% of those fractures are recurrent. The common perception of the broken nose as innocuous may account for its high rate of undertreatment. However, a poorly managed acute nasal fracture leads to chronic nasal deformities and, sometimes, breathing difficulties that may impair the performance of competitive athletes.

The diagnosis of a nasal fracture is made clinically. The most common findings in a nasal fracture include epistaxis, swelling and tenderness of the nasal dorsum, bruising around the eyes, and an obvious nasal deformity. Palpation of the nasal bones can demonstrate mobility, irregular surface, or crepitus. If the injured athlete reports a nasal obstruction during inspiration, the examiner should strongly consider a nasal/septal fracture or dislocation.

The intranasal examination should be conducted under proper lighting with a nasal speculum. The examiner can spray the intranasal structures with a vasoconstrictor such as phenylephrine or oxymetazoline if that would allow for better visualization.

Treatment

The indications for treatment of nasal/septal injuries by a physician are persistent bleeding and obvious external nasal deformity. Treat any open wounds with copious irrigation, and apply ice to minimize swelling. In the sport of amateur boxing, a diagnosis of a nasal fracture is cause for immediate cessation of the match.

Swelling that occurs over time obscures the deformity and makes acute closed reduction difficult. If swelling has also occurred, waiting at least 4-7 days for the swelling to subside before treating the nasal fracture is prudent. Treatment can be limited to a simple closed reduction of the nasal bones using topical and local anesthesia in a physician's office setting or can be a more involved open reduction of a fractured or severely dislocated septum in the operating room. The realigned septum or nasal bones are then splinted externally and internally. The splints are usually removed in 7-10 days. For an illustrated demonstration of nasal fracture reduction, see Nasal Fracture Reduction in the Clinical Procedures journal.

Carefully consider the decision to return the athlete to competition and the need for nasal protection. The nasal bones generally heal sufficiently within 4-8 weeks, allowing the athlete to return to competition in contact sports. If the athlete resumes competition soon after repair, strongly recommend that he or she use a protective facial device of sufficient strength to prevent further injury.

Orbital Fractures

Although common in athletes, eye injuries can almost always be prevented with the use of protective eyewear. The risk of injury to the eye is highly related to the type of sport. High-risk sports are those with high-speed projectile objects, clubs, or aggressive body contacts.

When an injury occurs near the eye, a thorough eye examination should be performed as described in Evaluation of facial injuries.

A circumferential bony framework protects the vital structures of the orbital complex. The aperture of the circumferential bony rim does not allow objects with a radius greater than 5 cm to penetrate to the globe. During the examination, the circumferential bony rim should be palpated. Fractures of the orbital rim can occur at any point on the rim; however, fractures of the inferior rim are most common. These fractures can occur independently or in combination with interior wall fractures; interior wall fractures can also occur alone.

Sometimes a blow to the eye can cause an increase in intraorbital pressure, with or without fracturing the orbital rim. The thin bones of the orbital floor actually fracture to increase the volume of the orbit and dissipate the pressure that would otherwise rupture the globe. This protective fracturing is the so-called orbital blowout fracture. It can manifest with ecchymosis, enophthalmos, vertical dystopia, and numbness of the area on the ipsilateral cheek supplied by the infraorbital nerve.

Diplopia upon upward gaze can be due to a restriction of movement of the eye because of herniation of orbital fat and inferior rectus muscle through the orbital floor or due to swelling or contusion of the muscle. A facial bone CT scan with coronal views evaluating the floor of the orbit can help to differentiate the causes. Forced duction test is also helpful in differentiating the causes of diplopia and gaze limitation. In the forced duction test, the affected eye is anesthetized with a topical anesthetic, the sclera is grasped with a fine-toothed forceps at the level of the insertion of the inferior rectus muscle, and the eye is gently moved in a superior and inferior direction. If the globe moves easily, entrapment of the ocular contents can be excluded.

Absolute indications for surgical repair include noticeable enophthalmos, limitation in extraocular movements, and persistent diplopia due to entrapment of the orbital contents in the fracture line.

After the injury, if the player returns to competition before 4-8 weeks have passed, strongly recommend protective facial devices sufficient to prevent reinjury. When protective eyewear has been used in racquet sports and face protection devices have been used in hockey, eye injuries have been virtually eliminated.²

Zygomaticomaxillary Complex Fractures

The bones of the zygomaticomaxillary complex (ZMC) make up the prominences of the face known as the cheekbones. Fractures of this bony complex account for approximately 10% of sports-related facial fractures. The zygomatic bone articulates with the frontal bone, maxilla, temporal bone, and the wing of the sphenoid, and fractures of this complex usually involve several of these articulations. This type of fracture typically occurs when significant force is directed at the prominence of the cheekbone. The bony complex is forced posteriorly and rotates laterally and inferiorly. Although several attempts have been made to classify the various patterns of ZMC fracture, the Manson classification system, based on CT scan findings, is possibly the most straightforward and sensible.³ The fracture patterns found most commonly on CT scan images are classified as low-, medium-, or high-velocity. Most sports-related cheekbone fractures are low- or medium-velocity injuries.

A thorough examination of the head and neck should be conducted when a ZMC fracture is suggested. Clinical findings commonly associated with ZMC fractures are periorbital ecchymosis, numbness in the distribution of the infraorbital nerve over the cheek, enophthalmos, restriction of movement of the eye upon upward gaze, and depression of the cheekbone with an associated downward slant of the eye. The medial and lateral canthal tendons that support the eye attach to the medial and lateral orbital rims, respectively, so that any change in the position of the rim bones changes the axis of the intercanthal line. Any combination of these signs and symptoms may be evident. The most accurate and most commonly used radiologic examination to diagnose and delineate ZMC fractures is a CT scan.

If a cheekbone fracture is suggested, the player should not return to competition and a specialist should be consulted. If the results of an eye examination are abnormal, an ophthalmologist should be consulted.

Treatment varies depending on the severity of the fracture. If surgical repair is needed, perform it within 7-10 days to prevent early fracture consolidation. Rigid fixation of these fractures is usually obtained with titanium miniplates and screws specifically designed to be used on the facial bones, using surgical approaches that minimize facial scars.

The use of rigid fixation has decreased the need for extended intermaxillary fixation and resulted in more predictable, stable, long-term results. However, research has shown that rigid internal fixation is not as strong as the patient's own intact facial skeleton. A similar blow to the repaired fracture site before the bones have healed puts the athlete at risk for a more severe fracture pattern than the initial injury, and the risk of damage to the underlying vital structures is significant. Therefore, strongly recommend that the athlete refrain from practice or competition for at least 6-8 weeks to allow the fractured bones to heal. Protective facial devices, if properly constructed, may allow the athlete to return to competition earlier.

Mandibular Fractures

Fractures of the mandible comprise approximately 10% of all sports-related facial fractures. Results from a recent study in Austria indicate that sports accidents are the most common cause of mandibular fractures, occurring in 31.5% of the patients in that series.

The mandible is a horseshoe-shaped structure that articulates with the base of the skull at the temporomandibular joints. It is a strong cortical bone that has several weak areas. It is thin at the angles, at the neck of the condyles, and at the distal body where the long root of the canine tooth and the mental foramen are located. Because of the mandible's arched shape and several weak, thin areas, the mandible commonly fractures in more than one place.

The tongue is attached to the lingual surface of the anterior mandible; therefore, the anterior segment of a bilateral fracture in the parasymphysial region has the potential to shift posteriorly, causing the tongue to block the airway. The simple act of pulling the tongue or the anterior jaw forward can open the airway. The tongue or jaw should be stabilized in this position, and the athlete should be transported to the emergency department, with proper cervical spine immobilization if necessary.

Malocclusion, pain, swelling, difficulty opening the mouth, and intraoral bleeding are the most common signs and symptoms of a lower jaw fracture. Palpation of the mandible, visible step-offs between the teeth, and pain upon stressing the mandible also aid in the diagnosis of a fracture. Panorex view and facial bone CT (combined) are the reliable image modalities for diagnosing even the smallest mandibular fractures.

The subcondylar regions are the most commonly fractured areas of the lower jaw. These areas are thinner than the rest of the mandible, and forces generated at impact are transmitted to these areas. Subcondylar fractures can have devastating, long-term functional and cosmetic sequelae. The condylar region of the lower jaw is considered a growth center. Fractures of this region in a younger athlete who has not completed growth can result in a shortened height of the mandible with associated occlusal problems. Injuries to this region can also result in hemorrhage into the temporomandibular joint spaces and lead to fibrosis and possibly ankylosis with associated inability to move the joint.

For details regarding the nonoperative and operative management of mandibular fractures, please see the eMedicine topic Facial Trauma, Mandibular Fractures.

Special referral may be required for adolescent athletes. Prior to the full eruption of permanent dentition, referral to a craniofacial or pediatric plastic surgeon may be warranted, since the unerupted teeth are vulnerable to damage with conventional fixation techniques.

Athletes with fractured jaws should not be allowed to return to play until healing has occurred and they are out of maxillomandibular fixation (which generally takes 6-8 weeks). A protective cage or helmet with a jaw extension can allow athletes in selected sports to return to competition earlier.

Dentoalveolar Injuries

As reported by Guyette in 1993, injuries to the mouth are particularly common in team sports.⁴ Results of studies reported in "Best face forward: Athletic facial injuries" published by the University of Pittsburgh Medical Center indicate that 13-39% of all dental injuries are related to sports.⁵ According to Rampton et al, of these, 80% occur in the area of the 4 anterior maxillary teeth.² Any trauma to the lower face can result in an injury to this dentoalveolar complex. Lacerations of the lips and intraoral mucosa are frequently associated with injury to the tooth and its supporting structures.

Mandibular and maxillary fractures are often associated with dentoalveolar fractures and vice versa. Injuries to the dentoalveolar structures can include one or all of the components of the associated structures. As reported by Ranalli, signs and symptoms of dentoalveolar trauma include intraoral bleeding, tooth malposition, malocclusion, mobility of the affected structures, pain, and altered sensation of the teeth.⁶

The examiner should always count the athlete's teeth after an injury. If any teeth are missing, every effort should be made to retrieve them. Teeth may lodge in the surrounding soft tissues such as the lips and tongue. Teeth also may be lodged in the airway or aspirated into the lungs. Appropriate airway precautions should be taken and radiographs obtained to exclude these possibilities. The potential for permanent loss of a tooth is high in more severe injuries.

Dentoalveolar fractures are fractures of the alveolar bone and the associated teeth. The involved teeth may or may not have associated fractures of the crown or root, or they may be luxated or avulsed. Treat dentoalveolar fractures as open fractures. A specialist must address tetanus prophylaxis, antibiotic coverage, and reduction and fixation of the fracture.

Tooth Fractures

Tooth fractures can involve the crown or the root. The most common traumatic injury seen by the general dentist is the crown fracture. Fractures of the crown in which only the enamel is fractured do not usually require urgent attention. Treatment for this includes smoothing any sharp edges and relieving the occlusion of the athlete's tooth.

However, if the fracture involves the neurovascular tissue, these fractures expose the vital nerve center (pulp) of the tooth and can be quite painful. Treatment includes covering the exposed pulp of the tooth with calcium hydroxide within 24 hours and acid-etch bonding of the fractured piece of tooth with a composite resin. If the fractured piece of crown is retrieved, it may be saved by placing it in water or milk, and it may then be rebonded directly to the fractured tooth by means of acid-etch bonding or light-cured glass ionomer resin material. This treatment alleviates discomfort and allows healing to begin.

Root fractures are more difficult to diagnose. They usually occur in teeth that are fully formed. Any mobility of a tooth, pain upon palpation, or movement suggests a root fracture. The athlete should be referred to a dentist for dental radiographs, definitive testing of the involved teeth, and management of these types of injuries.

Tooth Displacement

Luxation, or displacement of a tooth, occurs when the tooth is malpositioned in its bone socket. Malposition generally indicates some damage to the periodontal ligaments and neurovascular structures. Treatment for subluxation (loosening) is occlusal adjustment, observation, and vitality testing. Treatment for luxations (labial or lingual) is repositioning and splinting, with periodic vitality testing. Treatment for extrusion (partial avulsion) is repositioning and splinting, periodic vitality testing, and possible root canal intervention. Treatment of luxation and extrusion usually requires the use of a local anesthetic because manipulation can be quite painful. Lastly, intrusion of a tooth with incomplete root development, as in a child, is treated by allowing the tooth to re-erupt. Teeth with complete root development are repositioned and possibly treated with calcium hydroxide root canal therapy.

Tooth Avulsion

Avulsion is the complete separation of the tooth from the alveolus (socket). This is an urgent situation. The prognosis for viability of the tooth and successful replantation is inversely proportional to the length of time the tooth is out of the socket. Treatment principles are to replant and stabilize the avulsed permanent tooth as quickly as possible. According to the American Academy of Pediatric Dentistry 2001-2002 Reference Manual, pulp and periodontal healing are more likely to occur when the permanent tooth is replanted immediately (<5 min).

General guidelines are replantation within 2 hours. The key to successful replantation is the continued nourishment and maintenance of the periodontal ligament of the tooth. If the periodontal ligament fibers become desiccated, necrotic, or are removed as a result of rough handling, the tooth may undergo resorption or can ankylose to the surrounding bone and may ultimately be lost. Gentle handling of the root of the tooth at the point where the ligaments are attached is imperative.

The athletic trainer should not scrub or brush the root of the avulsed tooth; instead, he or she should gently handle the tooth by its crown and irrigate it with normal saline, if available. If the tooth cannot be immediately replanted into its socket, it should be cleaned gently and simply placed in the buccal vestibule of the mouth (between the cheek and gums), and the athlete should be immediately transported to a dentist.

Rampton et al suggest that if the athlete is unable to hold the tooth this way, the tooth should be placed in fresh cold milk, sterile saline, or cool tap water. According to the article "Best face forward: Athletic facial injuries" published by the University of Pittsburgh Medical Center, milk is an ideal storage medium; mitotic activity in periodontal cells has been maintained for up to 6 hours when a tooth is stored in milk.⁵ Commercially available transport systems for avulsed teeth are also available. Treatment by a dentist involves replanting the tooth into its socket and splinting the tooth or teeth with acid-etch composite resin in conjunction with orthodontic wire or reinforced composite fibers.

A diet of soft foods and analgesics should be prescribed for the management of pain. According to the American Academy of Pediatric Dentistry, antibiotic therapy should be considered and tetanus immunization status should be addressed. Additionally, often the tooth requires endodontic therapy (root canal therapy) for ultimate salvage. Generally, primary teeth should not be replanted because of possible developmental defects of the permanent tooth.

Although restoring function and aesthetics is important, preventing injuries should be the primary focus. According to Johnsen and Winters, when use is enforced, protective facial devices decrease the incidence of facial injuries.⁷ Prior to 1960, 50% of football injuries involved the facial or dental regions. Face masks became mandatory for football players in 1959. In a 1988 study by Welbury and Murray, the incidence rate dropped to approximately 1.4%.⁸ According to Sports Dentistry Online, the use of full-face protection and helmets has also decreased the rate of facial injuries in ice hockey. As mentioned earlier, when protective eyewear has been used, eye injuries have been almost totally eliminated.

Helmets afford the athlete protection of the cranium and have been instrumental in decreasing the morbidity and mortality from cranial injuries. However, they afford little, if any, protection for the middle and lower face. Results of an Austrian study by Emshoff et al revealed a high prevalence of lower facial injuries in cycling and skiing, sports in which athletes often wear helmets.⁹ Many professional skiers now wear racing helmets with an extension that covers the lower jaw, which may help reduce the prevalence of facial fractures.

As reported by Rampton et al, the use of mouthpieces and the reduction of injuries to the orofacial region are well correlated.² Additionally, a properly fitted mouth guard functions like a shock absorber upon impact. A well-constructed, well-fitted mouth guard separates the upper teeth from the lower teeth approximately 3-4 mm, displaces the mandibular condyles from their articulation with the base of the cranium, and minimizes damage to the teeth and their supporting structures. In addition, results of some studies (eg, Rampton et al) have indicated that mouth guards that are properly constructed can aid in reducing concussive injuries to the head and cervical spine injuries.² Finally, according to Johnsen and Winters, mouth guards lessen the risk of jaw fractures by absorbing the energy of a traumatic blow to the chin.⁷

The American Society for Testing and Materials classifies mouth guards as type I (stock), type II (mouth-formed), and type III (custom-fabricated over a dental model of the wearer).

The stock mouth guards are almost always readily available and inexpensive. They are considered the least retentive, the most bulky, and the most likely to interfere with breathing and speech. Some authors (ie, Welbury and Murray, Ranalli) consider them potentially hazardous and believe they should not be recommended.^{8, 6}

Two types of mouth-formed mouth guards are manufactured. The thermoplastic variety is fitted with the boil-and-bite technique. The second type of mouth-formed mouth guard is the soft-lined variety, which uses ethyl methacrylate in a more rigid shell. Ranalli demonstrated that unsatisfactory results occur when athletes attempt to fit these mouth guards themselves.⁶ These pressure-laminated guards, when fabricated by a dentist, reportedly have a predictable long-term fit that does not degenerate in thickness over time.

According to Sports Dentistry Online, a mouth guard must be properly fitted. It must be protective, comfortable, resilient, tear-resistant, odorless, tasteless, nonbulky, and cause minimal interference with speaking and breathing. However, possibly the most important criteria are that it must fit well, have excellent shape retention, and must be sufficiently thick in critical areas. As a general rule, Chapman recommends that a standard mouth guard be replaced after approximately 2-3 years, if not earlier.¹⁰

According to Easterbrook, appropriate, well-fitted eye protective devices have reduced the number of injuries to the eyes.¹¹ Additionally, Guyette suggests that protective eyewear should be constructed from a polycarbonate material that is shatterproof and lightweight.⁴ It should also be constructed so that it does not interfere with the athlete's direct or peripheral vision.

Although protective eyewear can theoretically protect the immediate periorbital bony framework, it cannot afford protection for the mid face, including the cheekbones, nasal region, and dentoalveolar structures. The most commonly used protective device for the prevention of injuries to the mid face, particularly the nose, is a custom-made plastic face shield. When such a shield is used following an injury, it is typically designed to cover the injured area of the face while not touching it. However, this simple design has been improved.

A patented face mask has been developed that is composed of 2 layers of protective materials, ie, a shatterproof outer shell of polycarbonate lined with an energy-absorbing and energy-dissipating viscoelastic polymer. This mask is custom-fabricated to the individual's face and injury. The mask is designed to take advantage of the naturally protective design of the bony facial buttresses and reinforces them to further decrease the amount of energy that reaches the injured site. This mask design has been used by players in the US National Basketball Association for protection of nasal fractures and fractures of the orbit.

The designs of protective facial devices are improving in both function and aesthetics. However, no matter how good the protection is, if the athlete will not wear the protective equipment, then the risk of injury has not been lessened. As reported by Ellis, noncompliant athletes have a higher recurrence rate of injury than those who are compliant.¹² All members of the sports health care team should educate athletes about the importance of protective equipment and encourage the use of all protective devices to ensure the athlete's safety.

Facial Trauma, Sports-Related Injuries

AUTHOR AND EDITOR INFORMATION

FACIAL INJURIES

ESSENTIAL ANATOMY OF THE FACE

EVALUATION OF FACIAL INJURY

SOFT TISSUE INJURIES

FACIAL FRACTURES

Nasal Fractures

Orbital Fractures

Zygomaticomaxillary Complex Fractures

Mandibular Fractures

Dentoalveolar Injuries

Tooth Fractures

Tooth Displacement

Tooth Avulsion

PROTECTIVE FACIAL DEVICES

REFERENCES