All right. Welcome, everyone, to the National Fellow Online Lecture Series. Today we'll be talking about dental injuries and facial fractures. I'm Dana. I'm the Pete Sports Medicine Fellow at Northwestern Lurie Children's, and I'll be your moderator for today. So a few things. This lecture series is sponsored by the AMSSM Online Fellows Education Subcommittee. It's co-sponsored by the Education Committee and the Fellowship Committee. These lectures are meant to serve as an adjunct to your individual fellowship program education, provide you with some direct access to learning from experienced AMSSM members and guest speakers, and assist in CAQ exam preparation. And then a few quick reminders. Mute your microphone, turn off your video. You can submit questions at any time through the chat function. And at the end of the talk, I, as the moderator, will ask the questions during the Q&A based on the questions that you submit. And after the program, please complete the evaluation, which will be in the chat at the end of the lecture. And now to introduce you to our expert speaker today, Dr. Tolde is the program director for the Johns Hopkins All Children's Hospital Sports Medicine Fellowship. He was previously medical director for the University of South Alabama Concussion Clinic and the founding sports medicine fellowship director for the University. He's been a team physician for multiple professional, collegiate, and high school teams, as well as endurance events, serves on many regional and national committees for education, sports medicine, and MSK ultrasound. And he's also on Twitter at ToldeDR. He has published on facial trauma in sports, and we are very lucky to have him speaking here today. So thanks so much, Dr. Tolde, for being here. I'll let you take it away. Thanks so much, Dana. I appreciate the invite and being here to be able to talk with all of you today. I don't know about being an expert, but I'll try my best. I do want to say that when I lecture, I like to get up and move around a lot. So when I'm sitting here on Zoom, I tend to fidget. And if that gets annoying, please message the chat, have Dana yell at me. So I'm not doing too much of that. So no relevant disclosures on my part, except for the fact that I'm not a dentist or a maxillofacial surgeon. But I just ate a Holiday Inn Express last night. Sorry, had to put in the dad joke. Couldn't resist it. But moving on. So what I hope for you guys to get out of this today is to be able to identify the most common dental and facial injuries related to sport, and then also learn which injuries are an emergency and how to properly triage dental and facial injuries. Also be able to learn how to properly manage the most common dental and facial injuries, and be able at the end of this to discuss return to play recommendations of these injuries, and also be able to give evidence-based education to your patients on preventative measures. So I'm going to start off with a really busy slide here. And this kind of tells us about why we care about these injuries in sport, because they are pretty common. Sports activities account for up to 30% of facial injuries, and up to 42% of facial fractures. Usually these are contact in nature, high energy, and are due to actual contact between players. So like you expect, we see these most commonly in football, hockey, soccer, and also baseball. And baseball may kind of bring a little question to your mind. It's like, well, why is that up there if we're talking about contact? But baseball has two aspects of it. One, there is that contact. You think about that runner coming home, colliding with the catcher, or trying to slide in the second base to disrupt the double play. But they also have the batter. So the ball can strike them in the face. So they get it from both ends. They get the ball and also the contact aspect of that. So baseball actually accounts for almost 50% of all facial fractures in sports. And I'm just going to briefly talk about orbital fracture there. And I know Dr. Robinson did a great job on the eye and everything a couple of weeks ago. So I'm not going to get too much into it. But just to bring it up in relation to sports injuries, sports injuries are actually a third most common cause of orbital fractures. And they're just behind your traumatic injuries and your traffic accidents. And when we're talking about nasal fractures, they're also, sports are also the third most frequent cause of them as well, behind just fights and traffic accidents. But when we talk about the pediatric patients with nasal fractures, sports are actually the most frequent cause of those types of injuries in the pediatric patients. And we tend to see these facial injuries in a more younger population as far as sports goes. And it makes sense because we have more younger athletes than we have older athletes. So the highest frequency that you typically see is the 11 to 20-year-olds. And as far as the actual frequency of facial fractures themselves, nasal bone fractures account for the most of them, then mandibular fractures, and then the combined maxillofacial fractures account for the third most of them as well. And when we look at just the oral trauma itself, this tends to be a little bit younger patient population for sports related oral trauma than just their facial bones with that. So they're more on the 7 to 11-year-old. And if you actually look at all dental injuries, the majority of them, 90% of them happened before age of 19. A third of these injuries are related to sports. And although this is trending more towards equal, males still are two to three more times more likely than females to have oral trauma related to sports. And this is becoming more equal because we're trying to get a, we're trying to get away from those typical, you know, this is a female sport, this is a male sport, and we have both genders playing pretty much all sports. But ironically, when we look at this, we look at mouth guard wear. Males are actually more likely to wear mouth guards than females, but yet are still more likely to have dental trauma and injuries than females are. And we look at the most common injured teeth and start with those two front teeth, your maxillary central incisors, and then you go just laterally to the maxillary lateral incisors. And then the third most common is the mandibular incisors. And as far as the primary teeth injuries, so your little kids' injuries, that's usually due to displacement of the anterior teeth from falls. So getting past kind of the epidemiology part of that, these facial injuries, like I talked about, are, these are, it's a lot of force and a lot of trauma that causes these. So it's not only important to evaluate the injury itself, but you must look at the whole person and the fact that they went through this whole trauma. So you always start with your basic life support, your ABCs, your trauma, your ATLS. Now look for the breathing, circulation, look for any disabilities, check out their vital signs, look for mental status. Always make sure you check airway, especially with facial fractures, because they can be compromised by a lot of things, including blood, dislodged dental appliances or fractured teeth. And of course, displaced fractures, typically mandibular fractures, can compromise your airway as well. And since we're dealing with a face, which we know is highly vascular and bleeds quite a bit, it's very important to follow universal precautions because there's a lot of blood and other body fluids around in this area as well. And don't forget to check for your concussions, your closed head injuries, and also your cervical spine injuries related to the injuries that occur that cause the facial injuries. And then after you're past this kind of trauma alert, this trauma initial assessment, then you can proceed to a more focused exam. And I will tell you to try to do this in a more systematic way. So you're doing it the same way every time. I typically start from the top of the face and work my way down. So I kind of break the face up into thirds. So when you're examining kind of the upper third, so from the superior orbital rim up, mostly what you're looking for is you're looking for the stability of that superorbital rim and also the function of the frontal branch of the facial nerve. So you can palpate around the rim. You can look for any obvious step-offs or bony step-offs. Look for any tenderness to palpation in that area. Obviously, any gross deformities. You can have the patient do a little motor exam, have them lift their eyebrows up. You can do a light touch assessment on top of the forehead to test the sensation there. And after you look at that part, then you kind of get down to the middle third. And this is where a lot of the money shot kind of lives. So this is where all your ocular contents are, the inferior orbital rim. This is where the nasal bones are, your zygomatic arch to make up the prominence of your face. So I typically would start looking at the ocular contents first. And I'll look to see if there's any asymmetry with the globe position between either side. Is the globe sunken? Is it more protruded? Is it more superior oriented or inferior oriented? Do they have an appropriate light reflex? Do they respond to light at all? Are the extraocular muscles intact? Is there any entrapment going on there? And then also you can have them close their eyes and press and feel the turgidity of the globes themselves. If it's soft, then you may be concerned for a possible globe rupture. If it's too firm, then you're concerned for a possible retrovulver hematoma back there. Then you look more towards the center of the face, look for nasal symmetry or asymmetry. Obviously check for any bleeding in the nose and look for any septal hematoma. And we'll get into that a little bit more when we talk about nasal fractures. And for the zygomatic arch, you're looking for any flattening or widening in the face or loss of that prominence, which may indicate a fracture. And then you can check the maxillary teeth by grabbing them and seeing if there's any movement or any instability there. And then next, you're really looking just at the lower face, which is mainly just made up of the mandible. And again, you're looking for assessment overall symmetry, looking for any gross abnormalities. You can have them smile, open and close their mouth, see if there's any malocclusion there. If you have a Popsicle stick on them on you, or you can check the bite test. And basically what that is, you stick in the back teeth and have them bite down, see if they have any difficulty doing that. Check the other side as well and see if there's any asymmetry between the bites with that. If there is, then you may want to look a little bit further at the TMJ, look for any dislocation or fracture there. So after we've done our initial evaluation, then we're going to get into our actually a little bit more specific. So we'll start with dental injuries first. And before we get into the injuries, I think it's a good idea to review the anatomy. I know I sure did when I was making this slide. So even the number of teeth, a normal adult mouth has between 28 and 38, 32 permanent teeth. And those four are basically those wisdom teeth that some people have, or some people don't. If you look at each section, so each quarter or each half of the jaw, you have your two incisors, your one canine, your two premolars and two or three molars. If you have a kid that's younger than five, most likely all of those teeth are primary. So you want to keep that in mind as well. The first eruption of permanent teeth doesn't usually start until around six or seven. And that usually starts with incisors first. And then by 13, most of all the, most of the teeth that everybody by 13 are usually permanent at that point. And then looking at the actual anatomy of the tooth, there's, there's really two parts of it. So there's the crown. That's the part that you see that's above the gum line. And then there's the root, which is below the gum line, the periodontal ligament that kind of goes through here is what anchors the, the root to the alveolar bone. And then the tooth itself has three layers. So the outermost and hardest layer is the enamel that protects the crown. Then just underneath that is the dentin, that's a little softer. And this does also have dentin tubules, which is a neurovascular structure. And if there's any injury to that, that can lead to decay due to the presence of that neurovascular structures there. And then the internal aspect of the tooth is the pulp, and that contains all the blood, the blood vessels, the nerves, everything that supplies the tooth. So moving on to the actual injuries, one of the most common types of injuries to the mouth and the most common fracture of the dental area is a crown fracture. And these can be three different types of fracture depending on how deep or how involved the fracture is. So if it's just a superficial area, it can involve just the enamel. If it goes a little bit deeper, it can be the enamel and the dentin. Obviously, if it goes even deeper than that, you can have the enamel, dentin, and the pulp. So with enamel fractures, which is what this picture is showing here, usually it's asymptomatic, and the athlete may not even know that they had anything happen here. Um, sometimes they'll feel a roughness if they move their tongue around it. Sorry about that. But typically, no other real pain or any other sensations there. When we're talking about returning to sport, if you do see this, and it's just an enamel only fracture, if they have a mouth guard, you can consider returning to the sport the same day. No matter what, if you do recognize this, though, they should be evaluated by a dentist within 24 hours to make sure that there's nothing else going on or any deeper injury. The next deeper injury for crown fractures is the enamel with the dentin. That's shown here a little bit. So typically, when the dentin is exposed, it's painful, elicits a painful sensation to cold air, cold drinks, or to touch. So when you're examining this, if you, you know, have a, a popsicle stick or anything that you're examining the mouth with, or even your gloved hand and have a lot of pain there, then you're thinking that there's probably at least a dentin exposure there, maybe a dental dentin fracture. If there's any loose fragments, you want to either one, try to put it back on if you have any cement or glue with you. And if not, then you want to store and a nice solution, either cool, cool milk, balanced saline solution, but never water. And I'll tell you about that a little bit. If there's a large fragment and you don't see it, you should do a search and try to find it. You want to make sure that you're looking at all the soft tissue mucosal surfaces to make sure it's not embedded in there and also make sure that there was no aspiration of any pieces there. These you want to get in again with the dentist within 24 hours, if not sooner, delayed treatment can lead to necrosis of the pulp and lead to root damage as well. The next most deep injury is the pulp injury. As you can see here, that's almost the whole entire length of the crown here. This is a serious injury and requires immediate dental referral most of the time. Typically you'll see like a red spot here and that's a bleeding spot. That's when you know you're into the level where the vasculature is. They typically have heightened sensitivity and increased pain to that. Sometimes you'll see this in the, and it could be an older injury when you're examining their mouth for something else. If there's no red spot, if there's more of like a brownish color or it's completely dry, that's the only time that this is not an emergency because that's probably an older injury, but they still need to be referred to a dentist, but just not on an emergent basis. If there's a lot of bleeding there and you want to try to stop the bleeding with sterile gauze, it's available in your bag. If you have calcium hydroxide paste, you can put that on the gauze as well and hold that there until the bleeding stops. And then also if you have some cement, you can try to put a little cement on there after the bleeding stopped. Even with these measures and treatment right away, you usually end up needing a root canal because the pulp is exposed for too long and ends up causing further damage. If this happens in a primary tooth, usually this ends up needing either an extraction or a pulpectomy. And then going deeper when we're beyond the crown, now we're getting down into the root fractures. You might want to suspect this if you notice that there's any mobility to the tooth itself or there's some tenderness and percussion while you're doing your exam. These typically require radiographs or verification. You can see that here on the right. There's three types of root fractures and it's all based on location. So the apical obviously is the most superficial, then the middle, and then the cervical is the deepest. And as you can imagine, the apical root fracture has the best prognosis. It may actually be undetected by the athlete themselves. If there's no mobility there and there's no pain, no real treatment is needed if there's no displacement of the crown or the coronal fragment itself. The middle root fracture, which is one that's a little bit deeper, this is when you start to see kind of what we're seeing here is this coronal segment is longer and more exposed than the adjacent tooth here. It's partially extruded from the alveolar socket. If treated initially and quickly, this has a good prognosis. And so basically what you do is you'll take some sterile gauze and you'll just reposition the tooth back down into the socket and then have the athlete or patient hold that there and emergently get them over to the dentist. Once the dentist evaluates them, typically they need some timeline of splinting. This can be up to six to eight weeks. If there's any bleeding involved, then you may need some oral antibiotics and definitely some daily fluorohexidine antibiotic rinses as well. The cervical root, as you can imagine, it's the deepest one that has the poorest prognosis, and that usually leads to requiring extraction and or prosthetic replacement. Return to sport on these are really based on the dentist's recommendations. So with the apical root fracture, you may decide or with a dental guidance to wear a mouth guard and be able to put them back in as long as there's not too much contact. With the middle root fractures, again, this usually with splinting, the dentist may allow them to play if they have a mouth guard that's custom built that fits over the splinting. And then with the cervical root fractures, typically, since they're extracting that anyways, you may be even back return to sport sooner than than the other two. The next type of dental injuries are referred to as the luxation injuries, and these are include concussion of the tooth, subluxation of the tooth, extrusion of the tooth, and lateral luxation, avulsion, and intrusion. And they go just in that order from least severity to most severity. So concussion of the tooth is just kind of what it sounds like. It's a minor injury, usually happens with a blow to the tooth. There's some sort of temporary or small damage to the surrounding structure, the supporting structures. And the big thing with this is that there's no mobility of the tooth at all. So they might have a little bit of pain due to the inflammation around the supporting structures, but there's no mobility at all. Treatment usually is just pain management with NSAIDs if they need it, a soft diet, and then referral to a dentist. Usually with these, since there's no real risk of movement or mobility or having an extrusion, these athletes can return to play. I would probably want to put them at least in a mouth guard, but they're usually safe to return to play at that point. They still do have a small risk of pulmonary necrosis, so that's why they should be followed with a dentist. The next most severe is the subluxation. And just like with any other musculoskeletal subluxation, this is actually where you get some movement of the tooth in the alveolar socket there. It's a little bit more significant of an injury. You can get some bleeding around the gums, which is what you see here in this picture. Treatment again is pain management with NSAIDs, soft diet. If there is blood, you want to make sure that you put them on antibiotics as well as antibiotic rinses, and then referral to dentists. And sometimes they'll end up splinting these based on the amount of mobility or movement that the tooth has. This also, since it's a higher level of injury, has a higher incidence of subsequent pulmonary necrosis as well. Return to sport is based on the degree of mobility of the tooth. If there's not a lot of risk of the tooth falling out, then there's little danger of their return to play as long as they're wearing a mouth guard. However, if there's a lot of movement, then I'd be a lot more reluctant to put them in the sport without a dentist's clearance. The next most severe injury of the luxation brand is the extrusion injuries. And it's just like, what do you think it is? Looking over here, this is a partial avulsion or dislodgement of the alveolar bone. And typically what you'll see is the teeth appear longer than the surrounding teeth around it. And they usually have an interior or a tilt towards the palate as well. This injury is down to the periodontal ligaments and it's usually torn or almost completely ruptured depending on the severity of it. And of course, as you can see here, this is going to impair your occlusion. So with these, you can attempt to reposition these, again, take some gauze with a firm but gentle superior pressure for the ones on the maxillary ridge and try to reposition them in there. However, if the athlete's having too much pain, then just stop at that point and refer them off to the dentist. If it's a primary tooth and they have more than three millimeters of extrusion, then the best course of action is actually just to manually extract that tooth with a sterile gauze. And regardless of whether you're able to reposition it back in on the sidelines, these athletes need to be removed from play and be cleared by a dentist before they're back out into activity. And of course, you want to get them on prophylactic antibiotics. This is just a picture of some of the splinting that the dentist may end up doing. The next injury in the luxation series is the lateral luxation. And even though it's called lateral luxation, this can actually be displacement laterally, or it can be in the anterior posterior direction. And usually this occurs with a concomitant alveolar bone fracture. So what happens is you get a force down here on the crown of the tooth that's pushing it in towards the mouth. And then the apex of the tooth is going to come up through the alveolar bone and usually cause a fracture there. And it actually gets wedged in there and gets stuck. So these are actually pretty hard to move. I don't know that it's a good idea to try to reposition these ones. I would leave this up to the dentist to do. And you should get them with a dentist as soon as possible. They usually end up repositioning the tooth in their office and then splinting them for four weeks, putting them on antibiotics. And usually with this part, since there's a complete luxation of this and a fracture of the bone, the pulp is usually damaged and revascularization is unlikely. Root canals are usually necessary. Then the next one in the luxation is intrusion injuries. And it's exactly what you think it is. It's a tooth that's displaced into the socket. And this is the most serious of all luxation injuries. And this is the reason for that is because there's possible damage, obviously, to the socket, the surrounding periodontal ligament. And with that, you can actually get root resorption and actually lose the root itself. If this happens with primary tooth, you can actually lose the primary tooth. You can get damage to the underlying permanent tooth. When the permanent tooth does come out, you can get like a yellow to brown discoloration of the crown. You can sometimes get hypoplasia of the permanent tooth. These are immediate referral to the dentist for when you have a primary tooth, because the risk of loss of permanent teeth is true and real. If it's greater than six millimeters intrusion, then it's really a poor prognosis for saving that tooth, whether it's primary or permanent tooth. You should not try to reposition these on the sideline at all. Typically, dentists may even wait. They wait sometimes up to three weeks because they may erupt on its own and they may not have to do anything at that point. But if they do reposition it, if they bring it out, manually extract it and reposition it, they usually splint for at least seven to 10 days and do daily antibiotics and chlorhexidine rinses. Sometimes if it's so severe where you can't even see the tooth and you're not sure if it was actually an avulsion or an intrusion, you may need some x-rays to see if the tooth is actually up in the alveolar ridge or not. There are some people out there that will say, and I say they're a little bit more brazen than me, that since this is, uh, this tooth is firmly in the socket, then the risk for the athlete is minimal. So they can return to field, return to play in the same day. Uh, I wouldn't necessarily do that. I think the risk for further injury is too great, especially if it's a pediatric patient, I wouldn't even consider that because we don't want to risk any injury to the permanent teeth. And with all of these fluxation injuries, our primary goal is just to maintain the viability of the periodontal ligament, and that will help prevent the pulp necrosis. So moving on to our next series of dental injuries, um, is our avulsions. And these are the most serious of all dental injuries, and they're actually quite common. So 21% of, of all dental injuries are tooth avulsions, and 10% of all dental injuries related to sports are tooth avulsions as well. And as you can tell from the name, these are complete traumatic displacement of the tooth out of the alveolar socket. If you're there and on the sideline, the best treatment for these is immediate, uh, replantation of these. And within five minutes is the best prognosis for these. The only time that you shouldn't immediately replant these is if there's a force or trauma in the patient's unconscious, obviously you don't want to replant that where they can possibly aspirate or aspirate a loose tooth into the, into the lungs at that point. But other than that, you want to make sure you get this in as soon as possible. Primary teeth, however, should not be replanted because that replantation of the primary teeth can actually damage the adult tooth, but we don't want to do that. So if you do see one of these and you're able to recover the tooth, what you should do is never handle the tooth by the root. Always try to handle it by the crown, quickly rinse it off. Do not scrub the tooth at all. If you have cold water and that's it, just use that. But, um, saline's a little bit better and you can also use milk as well. And if you're unable to replant it for whatever reason, then you want to store it in one of those solutions as well. So physical, physiological saline, milk, or the Hank's balanced salt solution. Um, do not store this in water. The periodontal ligament has a low osmolarity in pH. If it's stored in water, it's going to result in cell rupture and, uh, damage and death to the periodontal ligament, which we don't want to do. So if once the, they see the dentist, so after you're implanted, you should get into the dentist ASAP. Once the dentist permanently replants the tooth, they also decide to perform a root canal either at that time or within the first two weeks afterwards. And then they typically apply a splint, um, at least for two weeks, um, to help allow that to heal and, um, form back into the socket. Of course, you want to treat these with oral antibiotics. Um, since this is an actual avulsion, you want to think about tetanus prophylaxis and daily chlorhexidine rinses as well. These have a lot of close follow-up with dentists. They usually follow up at two weeks, four weeks, three months, six months, then one year, and then annually for the first five years afterwards. Um, these, I let the dentist decide, um, when they're going to be allowed to go back to support, but usually it's not at least for those first two weeks while they're splinted. Um, and since they're seeing the dentist very frequently, uh, they'll need to get, get a clearance from them before I allow them to go back into support with a, an avulsion injury. And so with all these scary dental injuries, is there a way that we can prevent these? Of course there is. And it's a simple method, right? So mouth guards, mouth guards are great. Um, they actually decrease the risk of all oral injuries. And you think about it, it makes sense, right? So one, of course they, um, they're shock absorber and they can dissipate the transmitted force that you can get through the mouth in the facial region. And of course they, uh, they separate the teeth from the mucosal surfaces, from your cheeks, from your lips, and decrease the chance of laceration or soft tissue injuries. When you're looking at mouth guards, they should be fitted properly. They should be comfortable. They should actually do what they're supposed to and protect. They should be resilient, tear resistant, odorless, tasteless, non-bulky, and have minimal interference with speech and breathing. Now there's multiple different types of mouth guards out there. And I'm sure most of you have seen different ones, maybe even use some different ones. Um, and they, they usually vary by comfort fit and of course cost. But if you look at just the studies in general, any of those mouth guards are better than no mouth guards. And one of the papers I looked at, she actually showed up to 93% decreased risk of tooth injury with wearing just any mouth guard compared to non-mouth guard. So it's like, why would you not wear a mouth guard at that point? And then there's this other meta-analysis in 2020 that didn't, that looked at all oral facial injuries and not just tooth injuries, and actually showed that mouth guards versus not wearing mouth guards, there's a two times higher risk of suffering facial fractures and dental injuries compared to those wearing one. So definitely mouth guards, and we'll talk about which sports are required in the next couple of slides. So there's three main types of mouth guards. There's your stock, your ready-made ones off the shelf, there's the boil and bite ones, and there's the custom-made ones from your dentist. So the stock mouth guards are obviously the least expensive, large amount of variability or availability. Um, they usually come in like small, medium, and large. So they're not that custom. Um, they're the least protective out of all of them, even though that's debatable. And I'll tell you about that in a second. Um, they can be used right out of the package, but typically they're bulky. They interfere with breathing, speaking, and a lot of athletes don't like them. So what they end up doing is altering them or cutting them, and then they're not good for what they were designed to do. Then the most common ones are your boil and bite mouth guards. I think we're all pretty familiar with those. You get those, you put them in some boiling water, you stick it in your mouth, you bite down on them, you use your fingers to kind of mold it around your gums and your teeth, and it gets a more personal fit. Um, it doesn't cover the posterior teeth with most of these. And one of the big caveat and why a lot of dentists don't recommend these type of mouth guards is that during this process, during the boil and bite, you can actually get them, um, too thin. If you bite too hard, it'll actually disperse it out too thin, and then you're not getting much protection at all. So a lot of dentists actually don't recommend these boil and bite mouth guards at all. And then the third most common type is, uh, um, custom dentist made mouth guards. These are the ones that, they're the most expensive. They're the most comfortable. They're made from actual dental impressions. They have a custom fit, less interference with speech and breathing. They're more adaptable if you have any sort of orthotic appliances or if you have any braces and they offer the best protection, but of course they're the most expensive. And then mouth guard care is just like anything else in your mouth. You want to clean and wash these every day. So this can be with just cool water, or it can be with mouth rinse or actual toothpaste. And then you want to store these in a container by themselves that actually has good air circulation. And I know, I know, I mean, I would rinse mine off every once in a while when I played sports, but I had a, it was always tethered to my helmet. I never took it off and put it in a separate thing. Um, but the things that you know now that you didn't know then, and of course you don't want the athletes chewing on these or cutting the mouth guards because they're going to decrease the effectiveness. The ADA, the American Dental Association has been huge on trying to get more people, um, to wear mouth guards. Uh, they did a study and they estimated that in just high school and collegiate football alone, mouth guards prevent approximately 200,000 injuries a year. That's a lot. And especially when you consider that, uh, the lifetime costs of improperly treated tooth avulsion is about $20,000, let alone all the time that you're going to spend in a dentist's chair and office. So they're really pushing for mouth guards. In fact, they recommend mouth guards for pretty much all sports. You can see that list that I have there on that slide. Um, but it's pretty encompassing. And the reason they kind of came out with this is that until recently there was really no, um, nationwide requirements for mouth guard use for any sports. But now the NCAA requires mouth guards for football, ice hockey, lacrosse, and field hockey. American high schools require it for all those sports. And as well as any wrestlers who wear braces, uh, they require a mouth guard for it. So things are moving in the right direction. Uh, I will tell you, I mean, I wore it when I played, uh, lacrosse and football, and I always kind of laughed at the people who, uh, wore mouth guards playing basketball. And now it's like, well, those are the smart people. And thankfully I didn't have any big dental injuries or facial trauma, but, um, those are the smart people. And I definitely recommend it to all my athletes now. All right. So moving on from dental injuries, more towards facial fractures. So let's talk a little bit about facial bone development and the type of fractures that we can see. So obviously the patient's age has significant impact on both the types and injuries, uh, the types of injuries and treatments, um, that you can see with facial injuries. Uh, females usually have facial growth and development up until about 13 to 16 years old. And of course, males are always behind, so they don't complete their facial bone development until about 16 to 20. And if you think about when you look at a younger person's face compared to an adult's face, uh, the face usually develops an inferior to anterior projection. So you get more prominent as you get older. And as you get more prominent, obviously that leads to increased risk of injury, contact injuries, ball striking injuries, anything like that. And so, um, adults are actually a little bit more prone to injuries along the prominent aspects, you know, with the nodes, the, uh, zygoma, the mandible than the younger patients are. And the other thing is that adults usually take a little bit longer to heal because the younger patient's, uh, face is a little bit more, or bones are a little bit more elastic and have better healing, uh, potential as well. When we look at facial fractures themselves, evolutionary, the skull has developed remarkably well. And what is done is, you know, the skull is there to protect what's inside the cranium, it's there to protect the brain, most of all. So evolutionary, this is, um, uh, developed well. So the facial cells contain several bony buttresses that consist of thick bones, you know, I think it's zygoma maxillary intervening with some, some of the thinner bones. I think a lot of your orbit bones, your, uh, uh, nasal bones, and then inside of all that bony lattice is the sinuses. So you have all this space and, uh, ability to disperse all the energy and force that's, that's applied to the, um, to the anterior inferior facial region and the bones of the face actually act like a crumple zone. So they, they take all that force, they disperse it out and actually crumple in instead of the force impacting in and going in towards the cranium. So evolutionary, we've done a great job with that. And as you know, the face is very vascular and it's also well innervated. So any injury to this area almost has immediate pain. There's usually significant swelling, edema, bleeding as well. So let's start with mandibular fractures. Besides nasal fractures, these are the most common facial fractures that you'll see in sport. Um, overall, you know, not just the sport, these predominantly young males have the highest prevalence and there's not great epidemiological studies on this, but they're likely similar rates in sports as well. Um, most cases require operative intervention and with 50% of them actually requiring open reduction or rigid internal fixation. And we'll talk a little bit about that later as well. And the mandibular fracture is actually the highest risk of all facial fractures to the athlete themselves. And the reason for that is, is that these fractures typically, um, are multi-location, multi-piece fractures. So usually two or more. So you have multiple, multiple segments of the mandible and these tend to like the displaced. If they displaced posteriorly, then you can lead to airway compromise there. And most of these are actually open fractures and you'll get mucosal lacerations and injuries. So there's a lot of bleeding as well. So the last thing you want to do with these patients is lay these patients flat because one you'll get the posterior force of the fractured mandible which can go down and close the airway and also all the bleeding can obviously cause problems and airway compromise that way is too that way as well. So you want to make sure that they're they're more sitting upright until you get everything triaged and managed appropriately. And of course since these are high trauma you also want to look at co-existing head trauma cervical spine like we mentioned in the beginning. So some of the classical signs for mandibular fractures are exactly what you think. You're going to have pain particularly with motion of the jaw. You're going to have trismus a restricted range of motion of the jaw. You have lacerations and bleeding from the mucosal tissues. There could be displaced teeth. There could be a subjective or an obvious altered bite. You can see an obvious or just a palpable step off in the dental arch. You can get bruising or hematoma over the skin where the fracture may be or in the sublingual space and you can damage the alveolar nerve and its branches and then lead to numbness of your lips and chin as well. So again initial management of these fractures is of course to ensure airway patency and not only to ensure it but also you want to make sure that the patient has the ability to maintain it on their own as well. Like I said these sometimes are loose parts multi-segments and they can move so you want to make sure that they can maintain it on their own as well. The good thing is that bleeding is usually self-limited. Usually just have them close their mouth or bite down on the gauze and you can stop them bleeding that way and also you know they're in an anatomic position. The good thing is that the muscle activity actually tends to reduce these fractures back to their pre-trauma anatomy and then you can just use have them do a natural splint which is just having them close their mouth until you can get further evaluation of that. I did put a picture down here there was one paper that came across that did show that there there are these actual splints for these fractures that you can put them on but if the patient is able to maintain it conscious enough and can just hold their mouth closed that's probably all you need on the sideline unless they're really unstable. Now looking at the different patterns of diagnosis the most common is what you see is an angular fracture on one side with a contralateral condylar process fracture on the other side and the definitive diagnosis for these is actually plain film. Everything else in the face the orbit and everything else is a ct image but if it's just an isolated mandibular fracture all you really need is a plain film. More specifically the orthopantamomammogram I think I said that right that's your panorex or your panoramic x-ray that you typically get at the dentist and the good thing is that most ERs have this capability to do that. So most ERs will be able to do this and you don't need anything further especially if there's a pediatric patient you want to avoid the ct if you if you can at all costs. If sometimes with a ramus or a condylar fracture they can be communated or they can be displaced so at that point maybe you want to get a ct but for most of the fractures the x-ray is good enough and of course if there's other facial trauma where you're already getting a ct scan where you're staying the head or you're staying the upper face then it's not too much to just add on the the maxillary mandible portion of the ct scan as well. MRI really doesn't have much utility for these fractures or injuries the only real reason why you may consider getting the MRIs if you're concerned for TMJ involvement or dislocation there and then you can look at the soft tissues involved around there. Treatment-wise it all depends on the patterns and what else is going on is there any other fractures is the patient able to be compliant with what we prescribe to them so they go from least to most invasive with least as if it's a simple fracture non-displaced you can sometimes observe them with just dietary and functional restrictions all the way up to open reduction internal fixation as well as external fixators application. Typically if they have a fracture of the ramus or condyle you're going to immobilize this with plus or minus open reduction the immobilization can last from a few days in a younger patient that heals quickly to over four weeks and someone who's older or has communation you also want to take in consideration that the close proximity to the facial nerve in this injury so that can be damaged either when the initial trauma happens or even more likely it happens during the repair of these fractures if there's an open reduction and typically after they're gone through their period of immobile immobilization you're going to get them into rehab they're going to need to regain the range of motion of their jaw as well as the power of the masticator muscles to be able to get back to eating solid foods again. If you're dealing with a fracture of the angle or the body of the synthesis is this is typically your open reduction with internal fixation they try to do these mostly through a transoral approach so that limits the amount of scarring that you see on the face itself. Some complications that can happen with these fractures the biggest most prevalent complication is malocclusion this could be minor and just need simple tooth adjustment by dentists or orthodontists that can be major where you have major malocclusion or you can't close your mouth at all and these are more common with condylar process or multi-segmental fractures and these typically end up being surgical revision they can be osteotomies, bone grafting, reconstructive plates, the whole lot there and of course like I mentioned earlier since a lot of these are open infections are possible and that's why we want to get them on antibiotics right away and then the longer that you wait to be treated the more likelihood that there is going to be an infection. Infections can lead to non-union and this increases the longer the delay in treatment happens. You can also get sensory nerve injury like we talked about with the alveolar nerve definitely with the angle of the body in the synthesis almost 100% chance of having sensory nerve injury there they can go anywhere from just a straight plain stretch injury to all the way to a transaction and if you notice that there is a transaction there that usually the surgeons usually notice that then that will need to be surgically repaired to be able to have sensation in that area. Motor nerve injuries these typically happen as a result like I mentioned of operative intervention the temporal and marginal mandibular branches are the most common but the good thing about these is that they usually get at least partial and sometimes complete functional recovery most of the time. So what about return to sport after mandibular fractures? Well I will caveat with saying that there is not a lot of good evidence out there at all. Most of the evidence is consensus opinion or case theories but if you look at just kind of the the length it takes for initial bony healing which is usually in that four to six weeks for most adults then that's probably about the minimal amount of time that you want to keep them out of contact sports. Pediatrics may be a little bit earlier where they can show calisformation within two weeks but you do want to make sure that you're careful with your pediatric patients as well as you don't want to have any prolonged immobilization because that can lead to ankylosis of the temporal mandibular joint and other problems there and of course older adults may take a little bit longer. So there are some studies out there that are suggesting that they can return to aerobic and strength training after three days but the general consensus is around 10 to 14 days and then increase in a stepwise fashion with more intensity and more duration. You should be off opiates obviously for going back to exercise and then you should be able to avoid activities that may cause displacement or fracture. So you don't want to obviously be near any ball sports or anything like that. These are typically just returning to you know your self-driven conditioning exercises and if you are doing some strength training you want to make sure that the patient's not going to clench their teeth during exertion or straining at all because obviously that can lead to problems with mandibular fractures and possible non-union as well. When we're talking about contact sports it really should be a minimum of eight weeks returning them and up to three months or more if for those high contact sports your hockey, your football, your soccer and especially any like martial arts or combat sports. And then you know for the sports that typically require headgear or helmets or even that don't you may want to consider either wearing headgear or modifying headgear so they cover that fracture site. So if we're talking about the mandible you've seen those baseball players that kind of have that extra little piece that goes over the jaw and mandible I would definitely consider those for baseball players getting back. And then like we talked about with mouth guards you know it's probably a good idea to have a custom dental fabrication for these when you have when you're returning from a facial fracture or mandible fracture. And then since there isn't really great evidence out there in return to sport you should really individualize these in all occasions. Don't just say hey in eight weeks you're going to be back out there because they might not be. And then the other big thing to consider is the psychological effects of this injury. I mean these are trauma these are big injuries and so especially if they're you know someone going back to a big contact sport they're going back into football if they're going back into baseball where you know they have to go back up the bat where they got hit with a pitch in the in the jaw they may not be psychologically and mentally ready to go back out there. And you must assess that their readiness to return before you're clearing them to go back there as well. And don't forget that you have your friendly sports psychologist that you can lean on and help a lot with these patients as well. So moving on to more of our mid-face or maxillofacial fractures. The maxillofacial region is typically considered of everything from the mandible up. So you have your large frontal bone, your paired zygoma, your paired maxillary bones, your paired nasal bones, and then your ethmoid palatine portions of the sphenoid are all considered mid-face. This part I'm just going to be focusing on the maxillary and zygoma. In the next section I'll get into the nasal fractures a little bit more. So zygomatic fractures are secondary in prevalence to mandible fractures and sports for facial fractures. As you can see here they form a large proportion of the bony orbit. So any injury here can be a threat to vision. This can cause a lot of bleeding. You can end up with a retroviral hematoma. You can end up with muscle entrapment. So you always want to make sure that the eye is evaluated along with these injuries as well. The isolated maxilla fractures are actually uncommon because this is part of that crumple zone that I talked about. And that's, they're sort of protected by some of the surrounding bones. So you typically get more fractures along with that. And if it is present, then you want to look at more severe injuries as well. You want to look at closed head injuries, cervical spine injuries, look for airway compromise, severe bleeding, etc. Everything that we talked about earlier. So some of the signs and symptoms, some of these are pretty obvious. For maxillary fracture, obviously pain with jaw motion. You can have bleeding from lacerated oral mucosa. You can have nose bleeding, have displaced teeth, mean alteration in bite. You can have facial elongation from actually inferior and some posterior displacement of the maxilla. You can have paresthesia along the infraoral nerve distribution due to injury of the nerve. And then zygoma fractures, of course, pain over the cheekbone. You look for that kind of widening or flattening of the face where the loss of the zygomatic arch. Again, these can have infraoral nerve paresthesias as well. They can have obvious or palpable step-offs in the infraoral rim. You can have eye displacement. You can have double vision. You can have entrapment of extraocular muscles like we talked about, significant periorbital maxillary ecchymosis and edema, and of course, subconjunctival hemorrhage as well. So how do we make these diagnoses? So unlike the mandible fractures where x-rays the best, CT is really needed for the diagnosis here, especially since we're dealing with part of the orbit. We want to make sure that these are small cuts. So you want to order CT max space in orbit with less than one millimeter cuts. Usually like a half a millimeter cut is a typical for seeing the ocular components in the orbit as well. Plane films really just aren't helpful. CT allows us to look at the different amounts of displacement and also the commutation, which is very prevalent in these type of fracture. And of course, you want to get your ophthalmologist on board because the orbital contents are also likely damaged or very likely damaged with these types of injuries as well. And as you guys probably know, there's multiple different types of patterns and descriptions of how to describe these maxillary fractures. The most common probably is the Leflore 1, 2, and 3. And I put this diagram up here, the Leflore 1 fracture. This is a fracture line that is basically, it fractures the maxilla off of the pterygoid plate. And Leflore 2 is that pyramid shaped fracture. So that has the whole central midface fracture. And then Leflore 3 is basically the fracture all the way through here. So you have a complete disjunction of the maxilla from the skull base. And so treatment really depends on the amount of displacement and the injury pattern. Um, nearly all of these though are treated in delayed fashion and a couple of reasons for this. One is because there's usually a lot of swelling and edema, and you want that to kind of calm down and go away before you can fully assess the amount of injury that's there. And also, since I talked about, there's a high prevalence of ocular injuries as well. This gives us time for the ophthalmologist to look at the ocular injuries and manage those as well. If you have a simple non-displaced fracture, um, sometimes just observation, soft diet, pain control is all that's needed. You obviously want to counsel them on avoiding activities that can displace the bone. So no big dorsalva maneuvers. You really don't want them blowing their nose. Um, so you may want to put them on a, on a decongestant or a stool softener. So they're decreasing the risk of those happening. With displaced fractures, uh, the most common, um, repair is the open reduction with internal fixation, like I mentioned earlier. With the maxillary, maxillary fractures, uh, and with the Lefort fractures, these are very delicate, um, reconstructions, uh, because one with maxillary fractures, you want to make sure that your bite is intact. Um, so you want to make sure that you're, you know, you're not getting that off the back. And then with Lefort and Zygoma fractures, what we've talked about with the, they involve the lateral orbital rim and sometimes the inferior orbital rim. So you want to make sure that you're reconstructing that orbital volume. So you're not getting any, um, uh, eye problems or diplopia, double vision, or, uh, any problems with, with muscle imbalancing there as well. So these are very, uh, very precise, uh, and accurate, um, surgeries. And I'm thankful I'm not a surgeon for that. So some of the complications that occur as we talk about maxillary fractures, uh, the most common complication is malocclusion. Um, if these are treated with closed reduction, that lowers the rate of malocclusion. Natural sinusitis can happen, but it's relatively rare. Um, malunion or nonunion can occur. And that's usually, uh, increases as the, as you delay treatment. So the longer you wait to get treated, um, the, usually the increased risk of malunion or nonunion. And then, uh, the lacrimal duct can be, uh, involved and they can end up with a lot of, uh, epiphora or tearing of the eye. With zygomatic fractures, you usually get a little bit more of the paresthesia. You got the inferior orbital nerve, especially with Lefort 1 and 2. Um, the Lefort 2 fractures of the orbital floor, you can get, like I mentioned, uh, diplopia, uh, orbital dystopia, which is just the displacement up and down some enol thalamus, which is the, um, uh, the eye moving into the skull more, um, and then possible complications, uh, happen even though, uh, with repair, even sometimes because of the repair. And a big thing to mention the, with these as little four fractures, typically a third of these end up requiring intubation or tracheotomy because of the airway obstruction, um, due to these injuries. Um, and like we mentioned, eye injuries can happen, blindness can happen. It's rare, um, but it can happen. And of course, the biggest thing that most people complain about is the aesthetic deformity from improper reduction or repair. So return to sport for maxillofacial fractures follows the same general guidelines that we mentioned for the mandible. And again, very limited evidence on this. Um, the only big thing that's different between this and the mandible one is that the prevalence of the ocular injuries. So that may extend your time returning to sport based on, uh, if there's any ocular injury involved with that or not. So let's briefly talk about nasal fractures a little bit, and we'll just mention the anatomy. So there's really four parts of the, of the nose and nasal bones. Uh, you have the upper third, uh, sorry, the upper third, which is typically your paired nasal bones. This is the bony vault. This is, uh, what forms the bridge of your nose. Um, deep to this is the lacrimal and ethmoid bones, and they help support the projected position of that. The next part is the, um, septum and anteriorly we, it's all cartilage and posteriorly it's, it's bone. So the bony septum is made up of the perpendicular plate of the ethmoid bone, which is this, um, the vomer and the nasal crest of the palatine and the maxilla, all those down there. The cartilaginous septum is made up of the quadrangular cartilage. And then it has this bony groove, which actually lends stability to the bony cartilaginous articulation. It actually allows for some lateral mobility too. And that mobility is good because when you get struck, instead of it being rigid and causing a septal fracture, it actually disperses a little bit of the force by allowing some movement. So this helps prevent some of the septal fractures. The next part of the nose is the middle third, and this is made up of the paired upper lateral cartilage. These are fused in the middle to that quadrangular septal cartilage. You can kind of see this coming through here. That's the anterior aspect of the quadrangular cartilage. And this is the kind of the keystone area. So when you're reconstructing the nose, this is a very important part to reconstruct to get the true anatomic reconstruction there. And then the next part is the lower lateral cartilage. And these are paired structures again, and these are made up by different cura. So we have the medial, the intermediate, and then the lateral. So this leads to the major support of the tip of the nose. And that support is usually done by the overlapping of the lower and upper cartilage. And then actually where the medial cura interacts with the bony parts, or the cartilaginous part of the septum as well. And of course, we know that when we injure our nose, we have a lot of bleeding, right? So 90% of that bleeding happens in tessellate plexus, which is made up of both the internal and external carotid artery system. The internal carotid artery branches into the ophthalmic artery, which then branches further into the anterior posterior ethmoid arteries, dorsal nasal artery, and external nasal artery. And then as far as the external carotid, that branches further into the facial and internal maxillary arteries. So that tessellate plexus, like I talked about, that's the anterior inferior portion of the nasal septum. And if you wanna know what makes up the anastomosis, it's all here. So it's got portions of the ophthalmic artery, the maxillary artery, and the facial artery. So recognition and management. So 50% to 60% of all facial injuries in sports are due to nasal fractures. And of course, like I keep mentioning over and over again, because it's very important, the first and foremost is assessing airway competency and the ABCs of the trauma management. You should get a quick history, either from the player, if they're conscious, or from witnesses, if you didn't witness itself, to make sure that there's no concussion or concomitant cervical injury as well. When you're looking at nasal deformity, you wanna ask the athlete if they've had any prior trauma or they had an altered appearance. Because if they did have a prior nasal fracture and they had a prior kind of asymmetry, if you try to put that back and make it symmetrical, it's not gonna hold, and it may even be more painful because that's not where their normal is at this point. If you don't know or they can't answer, then you can try to find a picture of them and see and compare it to that. Ocular injury, just like with the maxillofacial, is very common, so you wanna make sure you're testing your vision, your pupils, your visual field, asymmetry of the clobes. And then of course, you wanna not miss a CSF leak. So if you do see a CSF leak, you wanna get an emergency ER evaluation with CT imaging. Some signs of that is that they have persistent rhinorrhea that's clear, watery, salty tasting, or they have a compressible bluish or reddish appearing submucosal mass. That can also be a sign of a CSF leak as well. Bleeding is common, hemostasis is the primary goal. I think we all know kind of how to stop bleeding of the nose. You can do eye pinching, intranasal packing, basal constrictors. And of course, if you're unable to stop that, you wanna get them to emergency room right away. To get that stopped and prevent any further complications from that. So once the hemostasis is controlled, then next you should proceed to a more thorough inspection. So you wanna make sure you use a nasal speculum and have adequate lighting. And the biggest thing you're looking for here is inside the nose. You wanna make sure they're not developing any septal hematomas. Signs of that can be a large blue or purple color fluctuants on one or both sides of the septum. You wanna make sure if you do see this, that these are drained and packed appropriately and immediately. Because after three days, you can get pressure induced avescular necrosis that can lead to cartilage necrosis, septal degradation in our saddle nose deformity, which is what this picture is showing over here. Is basically you get this shortened vertical height, you get the bulbous tip, and you can get some recessed area here as well. And even if you do end up draining the septal hematoma, you wanna make sure that they have proper follow-up with ENT within a couple of days, because these often do reoccur. And if you do see a gross deformity in the nose and you're thinking that there's an obvious fracture there, and you do have experience in being able to reset these, then you can attempt to actually reset the nose and put it back into anatomical anatomy before the swelling sets in. However, if you don't have the experience with this, you're not comfortable in it, the only time that this is absolutely necessary is if there's an airway compromise. That's the only time that you should absolutely set the nose and try to reset the fracture at that point. And then make sure that they have follow-up with ENT, whether you set the fracture or you don't. Usually within three to five days, because that's when the swelling kind of subsides and then they can have a better look at it to make sure and see if there's any need for surgical intervention or a closed reduction at that point. Imaging-wise, imaging really is not needed for these. And plain films have actually been shown to have limited values and are considered unnecessary in the immediate form. I know when I've always looked at nasal imaging, it's kind of hard to see. Obviously, this one I put up here is pretty obvious. The better diagnosis is more clinical, especially if you have photographs of what the athlete or patient looked like beforehand. That is much more useful clinically than getting an X-ray. And in fact, there was a paper that looked at 100 consecutive patients who presented to ER with nasal bone fractures, and they determined that the radiograph did not significantly change or impact the diagnosis or management of nasal trauma. So clinical determination is really all you need. I did see one thing that was interesting is that there is utility for high-resolution ultrasound, and that actually has shown that there's a higher diagnostic value than even CT scans and much higher than plain radiographs. So all of you who love your ultrasound and you want to do it on the sideline, this is another utilization that you can use for your ultrasound to kind of look at nasal fractures. So some potential complications. We've talked about most of these. You can get a cephaloabscess if you leave an undrained cephalohematoma. You can get cephalomacrosis if you leave an undrained cephaloabscess. These can all lead to perforation, saddle nose infirmity, and possibly even intracranial infection. Undrained cephaloabscesses can end up leading to cavernous sinus thrombosis. You can end up with meningitis, brain abscess, sepsis. So don't do that. Cerebral spinal fluid leak we've talked about already. Lachrymal duct obstruction we briefly talked about. Sinusitis can happen. Usually this is with untreated cephalodeviation. So another reason why you want to get all of these nasal injuries in with ENT to have a better look at the septum as well. If you do pack them, make sure you take the packing out because that can lead to toxic shock syndrome and intracranial infection and sepsis, which we don't want. And then untreated nasal orbital ethmoidal fractures can lead to face deformities, widened nasal dorsum, and alteration of facial appearance. So return to sport. So like with all of our other fractures, there's no real good evidence out there. There's not a lot of studies that are looking at return to play timelines, and there's not a lot of recommendations regarding when clearly when to bring an athlete back. So the good thing is with these is that once you kind of exclude all the other major injuries, an isolated nasal fracture typically does not influence an athlete's capability to perform in a sporting activity. So typically you can get these back pretty quickly. I will caveat though that, you know, these should be protected and covered, obviously, especially if there's a fracture. But, you know, these things go back within the same week, especially if they're minimally displaced, especially if you have a face shield on top of that. There's actually one report, one paper that's on CGSM that actually talked about sending them back immediately in game following a nasal fracture, as long as it was minimally displaced and it had been not an open fracture, no other fracture along the face, no visual field obstruction, appropriate hemostasis and pain control, and that the athlete, one, understands the risk that there may have some worsening injury and that the athlete wants to return. If all of those are met, they suggested that you can actually return to sport that day. If I didn't have a facial shield, I would not consider that going back that same day, especially with the trauma that's needed for nasal fracture. They're most likely has an underlying concussion as well. As we all know, concussions can sometimes take a little bit to develop. So the risk of sending them back out there is not only a risk for the nasal fracture, but worsening concussion symptoms as well. Long-term treatment of nasal fractures. Usually you can put them in a mask four weeks is the typical initial return to where if they required surgery, may increase that up to six weeks. And if they're in combat sports or martial arts, they may be up to three months. They should usually follow up with ENT within that first week. And looking at this stat, this kind of surprised me that the incidence of septal deviations after a nasal fracture has been reported to be as high as 96%. So that's pretty high. So you definitely want to get them in with the ENT, make sure they don't have any breathing issues, anything leading to chronic sinusitis or anything like that. So there's a couple of key points in just the nasal fractures themselves. So when it occurs during a game, it's imperative to establish the airway like we talked about. Make sure there's no other severe concomitant injuries, no concussion, eye injuries, or leakage of CSF. If you're comfortable with it, you can make an attempt to reduce the nasal fracture there on the sideline or on the side of the court. If you don't do that, then the ideal timing is to have it reduced between three and 10 days. That's what after the swelling subsided. Anything longer than 10 days, then you actually start getting some healing and some abnormal positioning. So you don't want to wait that long. And then most athletes with a nasal fracture can return to the game during any concurrent serious injuries. Maybe not that same day, but shortly thereafter. Obviously they can't have any airway compromise or any other injuries. And they should be wearing a face mask if you decide to return to the play. So in summary of everything, facial and dental injuries in sports happen frequently. There's a high prevalence. Your initial evaluation, I've said this over and over again, needs to be a trauma evaluation. Your ABCs, look out for any concomitant brain or cervical injuries. And then prevention-wise, any type of mouth guard is beneficial for decreasing the risk of dental and soft tissue injuries. Obviously the custom dentist made one is the best, but it's also the most expensive. But just any type, recommending any mouth guard is better than not having a mouth guard. And then there's limited evidence on return to sport guidelines. But most advice is that you should not do contact until there's at least sufficient bony healing has been achieved. And then also the important part is like I talked about, you must assess the psychological readiness to return as well. These are traumatic injuries and they may take a little bit longer for the psychological aspect and the confidence to return over the actual injury. And don't be afraid to reach out to your colleagues, especially your sports psychologist. And of course, with any of these injuries, get ENT involved, get ophthalmology involved, have them help you manage these and help them get you back and return to sport as well. And here are some of my references. And I thank you guys for all sitting here and talking and listening to me. And I'll open it up now to any questions. Thanks, Dr. Tolde. That was jam-packed, lots of information. Thank you. We have a question from Steven. Are there different return to play recommendations for those with orthodontic appliances? Yeah, so the orthodontic, so you're talking about just braces or we talk about splints or bridges or anything like that, or all of the above? I assume all of the above. Oh, he said braces primarily. Yeah, so the braces primarily, you really wanna make sure with those, in any of them, that you're with your dentist, you're with your orthodontist, and you're most likely, you're gonna need that custom dental mouth guard because you wanna protect that. The normal off-the-shelf for the boil and bite ones don't really give you good protection and they may actually interfere with some of the braces and some of the dental work you have. So you really wanna make sure that you have that custom fit one that's made from the dentist. Awesome. I think Thomas had his, oh, he had his hand raised and I asked him about typing in a question. Thomas, do you want, oh, maybe it's a case, that he can talk. Hi, Dr. Coley, thanks. Sorry. No, just, I covered like a wrestling event this past Saturday, not like high school Greco-Roman, but like WWE style. And at the end of the event, like they asked me to come like see one guy who wore like a mask, like what, I forget what those, like litra d'ore, whatever those masks are called. Yep. And he had basically like nothing wrong, like ocularly, but just, I guess, all around like the, below the eye maxillary, lateral zygomatous and then above the eye superorbital, just a pretty big bruise, along with like a little bit of maybe a hematoma forming over the eyelid. I did basically like extraocular movements, no pain, pupillary reflex, everything symmetrical, nothing wrong with that. There was no kind of like bony step off or anything that I could appreciate it in terms of a fracture. The only thing that he would have is he would, when he moved his eyes all the way, like laterally, this was on the right where he got kicked on his right eye, he complained of just a little bit of like tingling at the end of like lateral movement of the eye. Is that, would that be like more of like just a little bit of maybe a infraorbital nerve, I don't know, neuropraxia, paresthesia. I basically just gave him a list of things to look out for if it didn't get better and just said like, just keep eyes around the affected area in the meantime. Yeah, I mean, it could be. I mean, the tingling is kind of a weird sensation. You know, the sensations are more around the face that you'll get. And, you know, if their extraocular movements were intact, then you know, it's not one of the big cranial nerves that can move the eye around, which is great. The one thing that kind of jumped out at me, you said he did get kicked though? Or did he not? Yeah, he got kicked. Okay, so the first thing before I heard the trauma, I was thinking, you know, with these masks, it's possible that he had just increased pressure under that mask and, you know, broke some capillaries from the increased pressure surrounding the eye there. And that can definitely, you know, cause a little bit of the hematoma and some soft tissue swelling and maybe a little sensory nerve deficit as well. But I think you did right. You know, you checked everything you need to check. Probably the only other thing that you might've checked was just the globes themselves to make sure that there's maybe not hardening or increased turgidity, where there might be a sign of a retrobulbar hematoma. But I'm sure you gave him all the warning signs that, you know, any vision changes or anything like that, increased pain, then go get checked out. Yeah, and do you just press on the globe for that? Yeah, it really is. You know, you have him close their eyes and you take it both at the same time and you're just kind of pressing. Just lightly, not a lot, but you can tell, like, if there's a big hematoma behind there, you're going to feel one, one's going to be a little bit more proctotic or maybe even a little bit more firm. If there's any signs of even like a laceration of the globe or a ruptured globe, obviously one's going to be a little bit softer compared to the other. Great, thank you very much. Dr. Tully kind of related to that. I was going to ask before about pressing on the globe that, well, I guess, first of all, I never did it on myself. So I guess I should get what the normal feels like. But do you ever worry that even the light pressure could cause rupture if it was, if there had been enough pressure to the face almost? Yeah, I mean, that's why, that's the last thing I do in my ocular exam. I want to make sure everything else, you know, is not pointing to anything there. You know, their vision's intact because that's usually the biggest thing that happens first. I mean, if there's a ruptured globe, a complete ruptured globe, or even a little laceration, their vision's most likely going to be off, whether it be visual field or decreased visual acuity. They're going to have pain. Something's going to be off. That's the very last thing that I would do. Because, of course, you don't want to induce any injury. Right? Right. Good point. Save it for the end. All right. Well, thank you. I don't see any other comments at this point. I appreciate everyone for staying on a little bit late, but great lecturing from Dr. Tully. Thank you again. Thank you all. That was fun. Have a good night, everyone.

3rd Edition, CASE 23

3rd Edition

HEENT

dental injuries

facial fractures

sports injuries

mouthguards

crown fractures

luxation injuries

avulsions

mandibular fractures

maxillary fractures

protective gear

return-to-sport