Facial and Dental Injuries in Sports Medicine

Original Editor - Josh Williams

Top Contributors - Caitlyn Yount, Temitope Olowoyeye, Josh Williams, Kyle Smith, Daniele Barilla, 127.0.0.1, Naomi O'Reilly, Brittany Wallace, Kim Jackson, Mohit Chand, Tony Lowe, WikiSysop and Claire Knott

Introduction

Facial and dental trauma are often encountered in sports. All sports have facial and dental sport injuries however, contact sports pose more risk to developing facial and dental sport injuries. Injuries sustained while participating in sporting activities are due to either trauma or overuse of muscles or joints.

Various dental and facial injuries encountered during sports are luxation injuries to tooth, avulsion, fracture of the facial bones, and concussion injuries. Prevention of these injuries during sports is important.

Common facial and dental sport injuries

Eye injuries

• Eyelid Laceration,
• Traumatic Optic Neuropathy
• Vision-Threatening Injuries
• Globe Rupture

Facial injuries

• Facial laceration
• Facial fracture

Dental injuries

• Tooth fracture
• Displacement
• Luxation
• Avulsion

Eye injuries

Ocular injuries in sports are common and mostly preventable. Sports at high risk for eye injury include baseball, hockey, football, basketball, lacrosse, racquet sports, tennis, fencing, golf, and water polo. Screens should be conducted prior to beginning one of these sports to monitor for preexisting eye conditions or a family history that could predispose an athlete to an eye injury.

The most common mechanism of eye injury is blunt trauma; however, other types include radiation and penetration. An impact from an object smaller than the eye tends to cause more internal eye trauma, while objects larger than the eye tend to cause more orbital fractures. Penetrating injuries can be caused by fishhooks or broken eyeglasses, while radiation tends to occur while skiing.

To prevent these injuries from occurring, athletes in high-risk sports should consider donning protective eyewear during play. Eyewear should be tailored to each sport, but always made of high-impact resistant plastic that reduces ultraviolet radiation and can be made with or without a prescription.

Facial fractures

Common sports for facial fractures to occur include baseball, softball, soccer, and horseback riding, and the most common bones fractured include nasal, orbital and skull bones. A collision, fall, or being struck with a ball is usually the mechanism of injury for facial fractures.

To help prevent facial fractures from occurring, coaches should always adhere to the rules of the game to decrease unnecessary roughness. Protective helmets and eyewear should be worn when appropriate. Coaches also need to keep an eye on novice players because their level of skill and knowledge of the game could lead to injury of themselves or other players. Finally, coaches should ensure players get adequate rest, especially when there are multiple practices or games in a day.

Facial abrasions & lacerations

Sports are a tremendous contributor to facial lacerations and abrasions, causing up to 29% of all reported facial injuries. The primary fear with any athlete who has experienced a facial injury is underlying damage that may have affected consciousness, respiration, or vision.
Facial abrasions are a non-severe, superficial injury involving the epidermal and possibly superficial dermal layers of the skin. Most abrasions occur because of shear forces caused by an athlete sliding over a rough playing surface such as grass or turf. Athletes with facial abrasions can easily return to competition after a medical professional has washed out the wound with soap and water and removed any foreign debris from the area. If there is too much debris or if it is too deep in the wound to be removed safely, then the athlete should be taken to a doctor for removal.
Sharp objects are not the only cause of lacerations. “Burst lacerations” occur when a blunt trauma of the soft tissue over a bony area will cause a tear in the skin.

Lip, Tongue, and Tooth Injuries

Lip, tongue and tooth injuries are commonplace in sports and are not limited to contact sports. Participation in sports is one of the top causes of dental trauma, accounting for 13 – 39% of all dental trauma . Lip and intraoral injuries, including injuries of the tongue, have been reported to make up almost 25% of all sports-related maxillofacial injuries .

The incidence rate of at least one orofacial injury per season among high school athletes, including dental trauma and lacerations of the tongue or lips, has been reported as 25% in soccer, 50% in basketball, and 75% in wrestling. Of the athletes included in the study, only 6% reported using mouth guards and none sustained injuries .

As a sports medicine provider, one should be able to recommend and fit sports equipment properly to reduce the likelihood of injury, including mouth guards. The effectiveness of mouthguards has been well established in sports medicine literature, including a 2007meta-analysiss. The authors concluded mouth guards provide many benefits including: reduce mandibular deformation, increase the force required to fracture teeth, reduce the number of fractured teeth at a given force, and dampen impact forces. Overall, the risk of orofacial injury was 1.6 – 1.9 times higher in those who did use a mouth guard during sport .

The severity of crown fractures can be described based on the layers affected, which can be the enamel, dentin, and pulp. Fractures involving only the enamel are not an emergency and often go unnoticed by the athlete. The athlete may report a chipped tooth that feels rough on the tongue . Fractures that extend into the dentin will be painful with air exposure, cold drinks, or to the touch. If possible, the tooth fragment should be located and placed in milk or a balanced saline solution, and the athlete should seek treatment from a dentist as soon as possible for the best prognosis . Fractures extending into the pulp are the most severe type of crown fracture. The proper treatment can be difficult to determine and is outside the scope of this article. However, if the tooth is producing pain and blood is seeping from the pulp chamber, this is a dental emergency and dental care should be sought immediately .

Fractures occurring within the root are categorized based on thirds. Fractures occurring in the apical third have the best prognosis of all root fractures and often go unnoticed . Fractures occurring in the middle third have a good prognosis for proper healing, but treatment should be sought as soon as possible. Upon examination the affected tooth will appear longer and partially raised from the alveolar socket and bleeding at the gums may be present. Immediate care should include carefully re-positioning the tooth manually followed by having the athlete bite down on gauze to place pressure on the tooth to keep it in place. Following stabilisation, the athlete should seek dental care immediately to determine the necessary treatment . Fractures occurring in the cervical third, in the region where the root and crown meet, have the worst prognosis for maintaining tooth vitality. The initial management is the same as described for middle third fractures .

With a complete tooth avulsion, it is essential to begin treatment as quickly as possible following the avulsion. If the tooth can be located, it should only be handled by the crown and cleansed with either saline or milk. The tooth can then be placed back into the alveolar socket and the athlete should bite down to stabilise the tooth and seek dental treatment immediately. Re-implantation of the tooth within 30 minutes results in a greater than 90% chance of saving the tooth. While a delay of more than 2 hours results in a 5% chance of survival.

Temporomandibular Joint Injuries

Temporomandibular joint (TMJ) injuries are not very common injuries in athletics. The most common sporting events that involve TMJ injuries are those that are classified as contact or collision sports. The most common sports include football, rugby, soccer, wrestling, karate, boxing, and mixed martial arts. TMJ injuries are a sub-category of temporomandibular dysfunctions (TMD). TMD includes:
• Preauricular pain
• Temporomandibular joint dysfunction
• Pain in the muscles of mastication
• Limitations or deviations in mandibular range of motion
• Crepitus during mastication or mandibular function
• Combination of the above
There are multiple causes of TMD or TMJ injuries. The most common are direct trauma to the mandible. Trauma to the mandible and face itself is protected by wearing proper headgear, such as the case in football, wrestling, hockey, and baseball. However, this headgear is often inadequate in the protection of the mandible. Sports that do not require headgear, but have collisions or contact, including soccer, rugby, and boxing. Direct blows to the mandible may lead to dislocations, acute capsulitis, TMJ disc displacement, ligamentous laxity, or TMJ derangements.

TMJ dislocations involve a non-self-limiting displacement of the condyle outside of its functional position within the glenoid fossa and posterior slope of the articular eminence.The most common TMJ dislocation is anterior to the auricular eminence, however, there have been reports of dislocations medially, laterally, posteriorly, and intracranially. Acute dislocations are normally isolated events, and when proper care is taken, usually have no long-term implications.

Acute capsulitis is characterised by an acute inflammatory response resulting from direct trauma to the mandible. This inflammatory response leads to irritation of the synovial tissues lining the joint and increased volume of synovial fluid within the joint space, resulting in pain. This injury leads to the immediate development of swelling in and around the joint, painful function of the mandible, and occlusal changes.

Direct trauma may cause TMJ disc displacement . This disc displacement may result in significant reduction in Range of Motion of the mandible and may be painful in some cases. The joint may be locked in closed or open tendencies, with a limited range of motion in the opposite directions. When this type of injury happens, athletes may become extremely anxious at their inability to control the motions of their mouth, and it is very important to control the situation and athletes’ emotions in a calm, timely manner.

TMJ injuries may also arise from stress. Trauma is often the primary cause of injury, but the symptoms of the injury are exacerbated by stress of the athlete. Athletes face varying levels of stress in their playing careers, such as competing for playing time, concern over performances, maintaining eligibility, and the stress of everyday life.
Another cause of TMJ injuries in sport is structural anomalies. Structural anomalies include malocclusion, enlarged mandibular condyles, decreased joint space, or missing teeth (sailors). These structural anomalies predispose athletes to TMJ injuries by altering mandibular function and mechanics.

Prevention

The use of personal protective equipment such as faceguards and mouthguards have been found to significantly reduce the incidence of facial and dental sport injuries.

Management

Consideration should be given to the age of the involved individuals; their medical history and compliance need to be carefully reviewed in order to outline the most ideal treatment plan. The site of the injuries, extent of trauma and the mechanism of trauma. Proper evaluation should be done checking the airway, breathing, circulation, vital signs, and mental status. Check for lacerations, pain or tenderness, mandibular deviation, tenderness along zygomatic arch, angle, or lower mandibular border. Radiographic examination also may be necessary for dental fractures and luxation. Involved individuals should also be assessed for concussion and traumatic brain injury as many of these injuries are as a result of high impact.

Management therefore should be tailored to findings from the evaluations.

Team Members Involved in the Care of Sports Injuries

In managing sports injuries, a diverse team collaborates to provide tailored care. Here are key members typically involved:

1. Physicians with Sports Medicine Expertise: These doctors specialize in sports injuries, offering precise medical care based on their experience.
2. Orthopedic Surgeons: They perform surgeries for severe injuries, like repairing bones, joints, ligaments, and tendons.
3. Physical Therapists: Vital for rehabilitation, they design exercise programs to restore strength and flexibility.
4. Occupational Therapists: Assist in identifying workplace modifications for individuals with overuse injuries.
5. Emergency Physicians and Primary Care Providers: First responders for initial evaluation and treatment of sports injuries.
6. Physical Therapy Assistants: Work under physical therapists' guidance to deliver treatments during rehabilitation.
7. Specialists Referral: Primary care providers may refer individuals to specialists like orthopedic surgeons for further evaluation and treatment.

Collaboration among these professionals ensures a comprehensive treatment plan tailored to each individual's injury and requirements.

Physiotherapy Management

See Facial Trauma