Download Oral and maxillofacial trauma in sports

Oral and
maxillofacial
trauma in sports
Dr. A. Khayampour
DDS, MS, OMFS
Objectives
 discuss scope of maxillofacial injuries in sports
 discuss on-field assessment of maxillofacial injuries
 Review common maxillofacial injuries
 PREVENTION IS KEY
Scope of the problem
 Boys: 3-9 times more maxillofacial injuries
 %50 of facial trauma occurs in mouth and teeth
 Low Speed


elbows & fists
soft tissue lacerations & contusions
 High Speed


balls, pucks, sticks
Bone / tooth fractures
Scope of the problem
 Face is the most vulnerable area of the body and is
usually the least protected
 11-40% of sports injuries are sports related
 Sports related facial injuries: 8% of all facial injuries
 Direct trauma from ball or player to player contact
 Health care providers for athletes should be familiar
with facial anatomy, facial trauma from sports and
initial management of facial injuries
Scope of the problem
 The most common injuries are occurred in facial soft
tissue and T- zone(nose, zygoma and mandible)
 Some injuries can be managed in the field and some
others need transfer to ER and specialist’s care
Scope of the problem
 Maclsaac et al: the most common age group in
children are 13-15 YO (40.7%)
 Baseball and softball: 44.3% of craniofacial fractures
 Basketball: 7.2%, Football: 3.0%
 Throwing, catching or hitting ball: 34.1%
 Collision between players: 24.5%
Scope of the problem
 Nasal Fx: 35.9%(50% in some literature)
 Orbital:33.5%
 Skull: 30.5%
 Maxillary: 12.6%
 Mandible: 7.3%
 ZMC: 4.2%
 NOE: 1.2%
Scope of the problem
 Proper initial diagnose and management may prevent
unfavorable results
 The main goal is to help athletes to recover
functionally and aesthetically from facial trauma and
to return to competition in a timely manner
Facial anatomy
 Facial blood supply is derived from contributions of
both the external and internal carotid arteries:
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.
 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)
Facial skeleton
 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
Facial skeleton
 The upper third: frontal bone and ends at the level of the
supraorbital ridge. Fractures in this area most often involve
the frontal sinus.
 The middle third :the most prominent and complex. It
extends from below the supraorbital rims to the incisal
edges of the upper teeth. orbits, the nasal bones, the
zygoma, and the maxillary bones.
 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.
On field assessment
 ABC s always come first
 Airway
 Breathing
 Circulation
 Don’t get distracted!
 C-spine precautions
A= airway
 ability to maintain protective oral and pharyngeal
reflexes and clearance of their own airway of saliva,
blood, or vomitus is preserved.
 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.
B= bleeding
 maxillary artery, superficial temporal artery, 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.
Sideline examination
 Inspection




Obvious deformity
Asymmetry
Swelling
Bleeding, LOF
 Otorrhea
 Rhinorrhea

Ecchymosis
 Raccoon’s eyes
 Battle’s sign

Dysfunction
 Neuro exam
(esp EOM)

dental exam
Sideline Examination
 Palpate

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
Orbital rims
Maxilla & malar areas
Zygomatic arches
Nasal bones
Midface stability
Jaw & alveolar ridges
Temporal mandibular joints
Teeth for dental trauma
Malocclusion
 Special tests
 Ring test for CSF
 Septal hematoma
 Hemotympanum
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.
Upper third examination
 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.
Middle third examination
 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.
Middle third examination
 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.
Middle third examination
 The examination of the nose includes the nasal bone,
the septum, and the cartilage. The prominence of the
nose leads to its frequent injuries. 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
Middle third examination
 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
Middle third examination
 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
Lower third examination
 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. 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.
Lower third evaluation
 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
History
 How?
 Other Injuries?
Other symptoms
Respiratory symptoms?
 Concussion?
Symptoms
 Leakage of fluid (LOF)?
 Able to move jaw?
 Teeth mesh normally?
Contusions and abrasions
 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.
Lacerations

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
Facial lacerations
 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.
Intraoral laceration
 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
Lip lacerations
 Compression of lip on teeth
 Look for associated dental and other hard tissue injury
Lip lacerations
 Mucosa-only lacs heal
well w/o sutures
 Deep or thru & thru
lacerations require
layered repair
 Vermilion border:
approximate border
FIRST, then repair
remainder (consider
referral)
 Prophylactic abx or
chlorhexidine rinse
bid
Tongue lacerations
 Irrigate, remove
foreign bodies
 Repair muscle with
3-0 absorbable if
deeper than 5mm
 Repair mucosa if
still necessary,
absorbable is fine
Hematoma

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
Facial bone fractures
 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 bone fracture

50% of sports-related facial fractures
 The common perception of the broken nose as
innocuous may account for its high rate of
undertreatment.
 a poorly managed acute nasal fracture leads to chronic
nasal deformities and, sometimes, breathing
difficulties that may impair the performance of
competitive athletes
Nasal injuries
Nasal bone fracture
 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
Nasal bone fracture
 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
Nasal bone fracture
 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 fracture
 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
Orbital fracture
 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
Orbital fracture
 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
Eye injuries
Lid laceration repair
 Sequence of
layered repair
 Tarsus 6-0 Vicryl
 Orbicularis
muscle 6-0 Vicryl
 Lid margin 6/7-0
non-abs
 Remainder of
skin
Ocular blunt trauma
Lid laceration
Trap door fracture
 Orbital floor fracture
usually in blunt trauma
Trap door fracture
Blow-out fracture
Orbital fracture
 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
Orbital fracture
 After the injury, if the player returns to competition
before 4-8 weeks have passed, strongly recommend
protective facial devices sufficient to prevent reinjury.


ZMC& maxillary
fracture
10% of all athletic facial fractures.
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.
ZMC& maxillary
fracture

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.

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
Facial fractures
ZMC fracture
ZMC fracture
Mandibular fracture

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.
Mouth and jaw injuries
Facial fractures
Mandibular fracture
 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.
Mandibular fractures
 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
Mandibular fracture
 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
TMJ dislocation

Cause: jaw suddenly depressed

Condyle dislocates anteriorly



Spasm pulls it superiorly
Signs

Chin deviated to side OPPOSITE
d-l

Unable to close mouth
Treatment: reduction ASAP

Hook thumbs on third molars
bilat

Apply postero-inferior pressure

Analgesics, soft diet, avoid
opening wide for 1 week or
more after dislocation
Diagnostc images

Plain film x-rays



Facial series

Waters view (Occipitomental)

Caldwell (PA) view

Lateral

Submentovertex view
Lower face series

Panorex

Lateral oblique

Other views
CT Scan – (Hi Res)
Prevention
Thanks for your attention