Enrique Amy is Assistant Professor at the Department of Physical Medicine-Rehabilitation and Sport Medicine of the School of Medicine at the University of Puerto Rico.
The prominent position of the nose makes it a common site of injury during team sports.
The lower portion of the nasal bone is broad, thin, and subject to fracture. Direct frontal force to the nasal dorsum usually results in fracture of the lower half of the nasal bone.
Lateral impact accounts for most nasal fractures.
Fractures and dislocations of the anterior (cartilaginous) septum often accompany nasal fractures.
In a nasal fracture, crepitance and mobility of the fractured segments is often found.
External nasal deviation may be present, but it can be masked by edema. The intranasal structures should be thoroughly examined and shrinkage of the mucosa with a vasoconstrictor may be required.
A complication that should not be missed is hematoma of the septum, because it can lead to collapse of the nasal structures due to the loss of septal cartilage secondary to abscess formation or pressure necrosis.
The basic treatment for this injury is similar in children and adults.
Under intravenous sedation or general anesthesia, nasal bones should be realigned and an osteotomy may be required in some instances to improve facial symmetry.
Approximately six weeks is required for the injury to heal.
FRACTURE OF THE MANDIBLE
Fracture of the mandible or the inferior maxilla occurs very often in sports.
The parts affected in are the base of the mandible and the alveolar process. Of all the bone fractures, 50 percent involve teeth in the line of the fracture, more frequently in the area of the third molars, canines, and premolars. In many occasions, periodontal defects and defects in the bone are related to the position of the line of fracture.
Some typical signs that can be observed in case of fracture are:
- Tooth displacement
- Alteration in chewing
- Abnormal movements of the mandible
- Loose teeth
Palpation is recommended to verify changes in contour of the bone or crepitation (sounds) in the joint. Bimanual manipulation helps to detect mobility between the fragments.
As a general rule, x-rays should be taken at different angles.
FRACTURES OF THE MAXILLA
Maxillary fractures are classified by location and severity in: Le Fort I, Le Fort II, and Le Fort III.
In Le Fort I fractures, the palate and alveolar process are separated from the maxilla by a fracture line above the antral floor and the floor of the nose.
The clinical signs of this type of fracture are: edema, hematoma, disocclusion, open bite, mobility of the alveolar process, epistaxis, and paresthesia.
Emergency treatment should include temporary immobilization and referral to an oral and maxillofacial surgeon.
In Le Fort II fractures, the line of fracture goes through the lateral and anterior walls of the maxillary sinus and continues through the infraorbital borders to unite with the bridge of the nose.
This fracture is commonly known as “floating fracture”.
The signs and symptoms are: bilateral infraorbital paresthesia, diplopia, and abnormal skin sensations.
Treatment should include the immediate intervention of a maxillofacial surgeon in a hospital setting.
Le Fort III fractures are similar to Le Fort II except that the patient presents with loss of cerebral-spinal fluid through the nose.
The patient may present other features of traumatic brain injury.
FRACTURES OF THE ZYGOMA
Fractures of the zygoma occur frequently because of its prominent lateral position in the facial structure. Diagnosis of this condition is performed through a clinical exam and a series of x-rays.
The zygomatic bone should be palpated, feeling for flatness of the cheek or steps in the orbital rim.
Other signs and symptoms of this fracture include periorbital ecchymosis, edema, molar prominence, orbital margin deformity, epistaxis, crepitation, diplopia, and difficulty with opening or closing the mouth.
Treatment may vary and depends on the extension of the fracture. In many cases, this fracture will require surgical treatment with reduction under general anesthesia.
The temporomandibular joint is found on both sides of the face, immediately under the ear, close to the hearing canal.
Trauma is the etiologic factor in the majority of the disorders of the temporomandibular joint.
There is a higher probability of trauma to this joint in athletes that participate in contact-collision sports.
Many of these athletes suffer direct or indirect hits to the joint that, in the long run, cause chronic injuries that are very difficult to correct.
In the diagnosis of condyle fractures, the following signs and symptoms should be taken into consideration:
- Evidence of facial trauma, especially in the area of the mandible and symphysis, accompanied by pain.
- Swelling in the joint area.
- Limitation of the oral opening.
- Deviation when opening the mouth toward the affected area.
- Open bite in the counter-lateral area of the trauma.
- Blood in the external hearing canal.
- Pain when the place of fracture is touched.
The changes suffered in the temporomandibular joint cause pain, inflammation of the chewing muscles, ligaments, cervical region, and the arm, in some cases.
Chronic symptoms of the joint can be associated with psychological problems, such as anxiety and depression.
CUSTOM-BUILT MOUTH PROTECTORS
Mouth protectors are used to protect various structures in the oral cavity during athletic events, and their construction is an essential service provided by sports dentistry.
Mouth protectors are removable appliances that usually cover the upper teeth; but they can also cover the lower teeth as well.
These protectors are made up of a flexible material that is constructed from a plaster model of the patient’s teeth.
Custom-made mouth protectors are preferred and a trained dentist should fabricate them.
Mouth protectors are essential for athletes involved in contact sports.
The main functions of mouth protectors are:
- Protection of soft tissue and lips from lacerations caused by the teeth in times of contact
- Cushioning and distribution of direct punches to the jaw, reducing the incidence of fractures
- Providing support to the jaw, absorbing the punch, and minimizing the possibility of a fracture to the condyles
- Helping prevent trauma to the temporomandibular joint
- Serving as a splint, keeping teeth in their place when a strong hit is received
A mouth protector should have the following properties:
- Custom made for a specific patient.
- Fine and smooth edges.
- Enough retention to avoid coming out of place during competition.
- Strong enough so that teeth cannot penetrate it.
- Lasting approximately two years.
- Thermal resistant so that it can be sterilized.
- No smell or flavor.
- Reasonable cost.
TYPES OF MOUTH PROTECTORS
There are three types of mouth protectors:
Ready-made. They come in a universal size and are placed over the upper teeth. These models are sold in most sporting good stores.
Mouth-formed protectors. There are two types: thermo-set and chemo-set. The thermo-set type is found in sporting goods stores and is softened in hot water, tempered in cold water, and adapted directly over the teeth.
The chemo-set type is adapted through the use of soft auto-polymerized resin and it is used by the majority of athletes.
Custom-built protectors are fabricated on a stone model of a mold of the athlete’s teeth.
This type is preferred because it is more adaptable to the oral tissues, comfortable, and interferes minimally with breathing and speech.
These are fabricated by a dentist or a dental technician.
More durable than the other types of mouth guards, these are the only ones that really guarantee maximal protection.