facial fractures & acute dental injuries

JANINE FERRO, ATC, CSCS

Facial Fractures & Dental Injuries

Occular & Related Maxillofacial Injuries

Injury to External Structures Contusion/periorbital ecchymosis (black eye)

Lacerations of lids

Conjunctivitis

Various Fractures

Occular & Related Maxillofacial Injuries

Anterior Segment Foreign body Corneal abrasion Corneal laceration Subconjunctival

hemorrhage Hyphema Traumatic cataract Dislocated lens Traumatic iritis

Posterior Segment Injury to the

retina/choroid Ruptured globe

Four Cardinal Complaints

Indications for further evaluation/referral: Change in vision

Change in appearance

Pain/discomfort

Trauma

Fractures of the Zygomatic Complex- Tripod Fracture

Etiology & Pathology

Etiology Blunt trauma to the prominence of the zygomatic bone

(cheekbone)

Pathology Fracture of zygomatic arch; fracture dislocation at

zygomaticofrontal & zygomaticomazillary suture lines Inferior, medial, & posterior displacement of

zygomatic bone into maxillary sinus area

Associated Ocular Complications

Retinal detachment

Dislocation of the lens

Injuries to the globe

Orbital floor fractures

Clinical Evaluation

History Blunt trauma to the prominence of the zygomatic bone

Inspection Flattened cheek with periorbital ecchymosis Subconjunctival hemorrhage/ hyphema Lowered lateral palpebral (eyelid) fissure Unilateral nosebleed on affected side Ala (winging) of the nose & lip on affected side

Clinical Evaluation

Palpation Step-off defects of the infraorbital rim & at

zygomaticofrontal suture Point tenderness at fracture site

Functional Tests Trismus (inability to open mouth due to impingement

of zygoma on coronid process) Anesthesia/paraesthesia over cheek, ½ of nose, &

upper lip (infraorbital n. distribution) Diplopia (on outer upward & downward gaze) Restricted eye movement (upward gaze)

Management

Place athlete in comfortable positionCover one/both eyes (unison movement)Cold compress to periorbital regionObserve for nausea/ vomitingAvoid blowing nose!

URGENT EMERGENT REFERRAL!

Orbital Blow-Out Fractures

Etiology & Pathology

Etiology Blunt trauma to the globe of the eye (direct) Results in rapid increase in intraorbital pressure

Pathology Comminuted fractures of the orbital floor/ medial wall Extrusion of inferior orbital soft tissue into maxillary

sinus Entrapment of inferior extraocular ms. in fracture

defect Infraorbital nerve trauma

Associated Occular Complications

Infraorbital nerve trauma

Occular injuries Retinal detachment Dislocation of the lens Injury to the globe Hyphema Bleeding into the orbit causing acute proptosis High intraorbital pressure from intraocular bleeding

Clinical Evaluation

History Direct MOI (blunt trauma to the globe- ball, fist, etc.) Indirect MOI (trauma to surrounding areas)

Inspection Periorbital ecchymosis/edema Lowered globe/sunken eye Retraction of globe Hyphema Subconjunctival hemorrhage

Clinical Evaluation

Palpation Not indicated

Functional Tests Restricted superior/lateral gaze Entrapment of nerve/muscle Vertical diplopia Paresthesia/ hypoesthesia in infraorbital n. distribution

Management Same as zygomatic complex fx. Care- EMERGENCY!!

Nasal Fractures

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Etiology & Pathology

Etiology Blunt trauma to the dorsum of the nose

Force directed anteriorly results in depressed nasal fx Force directed laterally results in lateral fx/ dislocation

Pathology Comminuted fracture of the nasal bones Associated disruption of the septal, lateral, & alar

cartilages

Clinical Evaluation

Complications Septal hematoma Abcess/ septal erosion “Saddle nose” deformity

History Frontal/ lateral blunt trauma to the dorsum of the

nose

Clinical Evaluation

Inspection Lateral deviation of nasal bones/cartilages Flattened nose Edema & ecchymosis over the dorsum of the nose Epistaxis (nosebleed) Septal hematoma & intranasal lacerations

Palpation Bony irregulatities (step-offs) Tenderness over dorsum of nose

Functional Tests Have patient look in a mirror!

Naso-orbital Injuries

Etiology & Pathology

Etiology Blunt trauma to the naso-orbital area

Pathology Comminuted fracture of the nasal bones Disruption of the septal, lateral, and alar cartilages Associated rupture of the medial canthal (palpebral)

ligaments

Clinical Evaluation

History Blunt trauma to the naso-orbital area

Inspection Signs associated with nasal fx. Associated telecanthus (increased intercanthal distance)

& almond shaped medial palpebral fissure (normally elliptical)

Palpation Bony irregularities (step-offs) Tenderness over dorsum of the nose

Clinical Evaluation

Functional Tests None.

Management

Referral

Differential Diagnosis Concussion Blow-out fracture Globe injury

Mandibular Fractures

Etiology & Pathology

Etiology Blunt trauma to the mandibular arch of symphysis

Pathology Fracture through cuspid area (common); multiple

fracture including: Cusid area & 3rd molar area on opposite side Cuspid area & subcondylar area on opposite side Symphysis & angle of the mandible Symphysis & one/ both subcondylar areas

Clinical Evaluation

History Blunt trauma

Inspection Malocclusion Facial asymmetry Ecchymosis in the floor of the mouth Bleeding at base of tooth (3rd molar) External contusion/edema/ecchymosis Otorrhea (condylar fx)

Clinical Evaluation

Palpation Step-offs Point tenderness at fracture site(s) Crepitus/ inability to feel condyle w/ finger in ear

(condylar fx)

Functional Tests Crepitus & instability (passive “rocking” of mandible) Paresthesia/ anesthesia over jaw & lower lip

(mandibular n.) Positive “tongue blade test”

Clinical Evaluation

Complications Mandibular n. trauma Airway obstruction from blood Avulsed teeth Prolapse of tongue (w/ mandibular instability)

Management Immobilize; refer Surgical repair (plate) frequently required Fixation 4-6wks Return to sport 8-12wks

Fractures of the Midface

Etiology & Pathology

Etiology Severe blunt trauma to the midface

Pathology LeFort I, II, or III fractures

Complications

Infraorbital n. injuryOccular injuriesAirway obstruction in soft palate area due to

hemorrhage & edema (LeFort I)Nasal airway obstruction due to bony

displacement/hemorrhage & edema (LeFort II &III)

Cerebrospinal rhinorrhea due to fx in cranial vault (LeFort II & III)

Intracranial injuries

Classification of Midface Fractures

LeFort I Fracture of the maxilla at the level of the nasal floor

LeFort II (pyramidal fx) Fracture in the central portion of the face that

includes both maxillae, medial ½ of both antra, medial ½ of the infraorbital rim, medial portion of the orbit & orbital floor, & nasal bones

LeFort III (craniofacial disjunction) A LeFort fx plus fractures of both zygomatic bones/

separation of facial bones from cranial vault

Clinical Evaluation

History Severe blunt trauma- not usually from sport activity

Inspection Facial asymmetry (elongation, flattened/ “dish

panned” naso-orbital area) Gagged/ open-bite occulusion (impaction of upper &

lower molars) Telecanthus (increased intercanthal distance) Facial edema/ ecchymosis Intraoral ecchymosis in zagomaticomaxillary buttress

areas Cerebrospinal rhinorrhea (LeFort III)

Clinical Evaluation

Palpation “Step-off” defects/ point tenderness at LeFort I, II, III

fracture site

Functional Tests Instability- grab front teeth & try to move Crepitus (passive “rocking” of maxilla) Paresthesia/ anesthesia over cheek, ½ nose, & upper

lip (infraorbital n.)

Dental Injuries/ Inflammatory

Injuries

General Information

Subluxations/Avulsions Partially displaced teeth (intruded, extruded) Avulsed teeth

Fractures Crown fractures Root fractures Alveolar fractures

Inflammatory Conditions Gingivitis Periodontitis Pericoronitis Dental Abscess

Subluxations/Avulsions

Disruption of the supporting structures (periodontal membrane) involving: Sensitivity w/o mobility/ displacement Mobility w/o displacement Intrusion/ partial displacement Extrusion/ partial displacement Complete avulsion

Subluxations/ Avulsions

Handle by crown onlyRinse w/ sterile saline (don’t wipe)ReplaceStabilize (bite on gauze)Re-implant w/in 30min (highest success)If unable to re-implant:

Save a Tooth Cold, whole milk Saline-gauze Under tongue Water

Intruded Tooth Lateral Luxation

Subluxations/Avulsions

Crown Fractures

Direct trauma (hit by object)/ indirect (force through mandible/ contact of mandible & maxillary teeth)

Fractures involving: Enamel with/ without loss of tooth structure (cracked/

chipped) Enamel & dentin or Enamel, dentin, & pulp

Crown Fractures

Enamel Irritating Not sensitive to temperature Can wait

Enamel & Dentin Sensitive to temperature Possibly cover with sugarless gum for temporary relief

Pulp Extremely painful- “hot tooth” Exposed nerve Bloody Save broken portion (Save A Tooth)

Crown Fractures

Root Fractures

Etiology Direct trauma (hip by object) or indirect trauma (force

through mandible/ contact of mandibular & maxillary teeth)

Pathology Vertical crown-root fracture with/without pulp exposure, or Horizontal root fracture of apical (apex) middle, or cervical

third Pain Mobility on finger pressure (primary sign) Pulpal necrosis

If tooth is pushed back, it should not be forced forward (broken below gum line)

Root Fractures

Alveolar Fractures

Etiology Direct trauma (hit by object)

Pathology Fracture of alveolar process of the mandible/ maxilla

with disruption of the tooth socketSigns & Symptoms

Pain Displacement/ simultaneous mobility or two/ more

adjacent teeth (primary sign) Pulpal necrosis

Alveolar Fractures

Protect Your Teeth!!!

Shoulda worn a mouthguard little man! Prom picts

aren’t gonna look so good!