– Written by Mohammed Alsaey, Qatar

The majority of sports-related injuries are musculoskeletal. However, one of the most sensitive areas for athletes is the face. A forceful direct impact is the most common cause of lower (mandible) or upper (maxilla) fractures in athletes. Jaw fractures in athletes are particularly problematic as they can lead to significant absence from sports. Due to the high risk of major complications, it is essential for medical staff to be knowledgeable about how to deal with these acute injuries. It was believed that athletes playing combat sports such as boxing were at the highest risk of being knocked in the face. However, studies have shown that football, handball and basketball players are at higher risk of these injuries because athletes such as boxers expect to be knocked in the face, and therefore constantly protect this area.

Individuals between the ages of 20 to 30 years are most frequently affected by jaw fractures. This may be due to the maxilla being the largest component of the facial skeleton. It is intimately associated with adjacent osseous structures providing structural support between the cranial base and the occlusal plane. In contrast, less than 10% of all facial fractures occur in children. This is perhaps due to the high resilience of a child’s facial skeleton.

With high impact trauma, even the opposite side of the face may fracture. If the trauma is severe enough to fracture both mandible and maxilla, other areas of the face, neck and back may also be affected.

There are several types of facial fractures:

• Zygomatico maxillary complex ‘Tripod fracture’.
• Le fort fractures.
• Zygomatic arch.
• Alveolar process of maxilla.

he most common type of facial fracture is a zygomatico maxillary complex ‘tripod fracture’. This fracture involves separation of all three major attachments of the zygoma from the rest of the face.

Le fort fractures involve the maxillary bone and surrounding structures in a bilateral, horizontal, pyramidal and/or transverse plane. Named after French surgeon Rene Le Fort (1869-1951) this fracture is classic in facial trauma and subdivided in three types (Figure 1):

1. Type 1: Horizontal Maxillary Fracture. This separates the teeth from the upper face. This fracture line passes through the alveolar ridge, lateral nose and inferior walls of maxillary sinus.
2. Type 2: Pyramidal Fracture. This involves the teeth at the pyramidal base and has frontal suture at its apex. This fracture line passes through posterior alveolar ridge, lateral walls of maxillary sinuses, inferior orbital rim and nasal bones.
3. Type 3: Craniofacial disjunction. This is a fracture line that passes through the frontal suture, maxillo-frontal suture, orbital wall and zygomatic arch.

Mandible fractures are generally obvious during a clinical exam. Clinical findings include facial distortion, malocclusion of the teeth or abnormal mobility of portions of the mandible or teeth (Figure 2).

When double fractures occur, they are usually on the contralateral side of the symphysis. Common combinations include the angle and the contralateral body or condyle. Triple fractures occasionally occur and the most common type is the fracture of both condyles and the symphysis.

DIAGNOSTIC HISTORY AND PHYSICAL EXAMINATION

Clinical examination starts with an examination of the mechanism of injury and evidence of prior injury. The most important clinical findings are:

• Numbness.
• Ear pain.
• Alignment of the jaw in relation to the face.
• Signs of swelling.
• Cuts.
• Bruising.
• Tenderness.
• Loose broken or displaced teeth.
• Injury to the tongue or soft tissue of oral cavity.

The clinical signs can include but are not limited to:

• Bruising.
• Swelling and tenderness.
• Malocclusion.
• Inability of the eye to move in all directions.

A dental X-ray and/or CT scan is very useful.

TREATMENT

To fracture the mandible, significant force is required therefore care must be taken to evaluate the athlete for possible concussion and/or brain injury. To determine if the athlete has a concussion or possible brain injury, the following symptoms may be detected:

• Dizziness.
• Headache.
• Confusion.
• Nausea.
• Ringing in the ear.
• Inability to answer simple questions.

If any of these symptoms are present, it may be safe to assume that the athlete may also have a concussion. If the above symptoms are not immediately present, treatment should be focused on maintaining an open airway. With the athlete in a seated position, instruct the athlete to support his or her lower jaw. This position will allow the blood to flow forward and out of the mouth rather than to the back of the throat. When immobilising the jaw, care must be taken to ensure that the jaw is not displaced posteriorly; this could compromise the airway. Bandages can be wrapped under the chin and over the top of the head. An ice pack can be applied to the area to reduce the amount of swelling. Jaw fractures necessitate emergency hospital care.

THERAPY

If the athlete has sustained a non-displaced jaw bone fracture, the healing can be managed conservatively with analgesia and rest to allow the fracture to heal properly. The athlete should only eat soft food for up to 4 weeks or as long as is recommended by the treating physician.

In displaced fracture of the jaw, surgery will usually require fixation of the jaw with screws and plates. These will be in place for roughly 10 to 12 months. During this time, several follow-up visits will be necessary.

Most displaced jaw bone fractures will require closed reduction and internal fixation for 4 to 6 weeks. While the athlete’s jaw is wired shut, the athlete should be consuming a high protein, high carbohydrate liquid diet which should be co-ordinated with a nutritionist.

RETURNING TO SPORTS

In the initial phase, the athlete is only able to breathe through the nose and not the mouth. Light activities such as stationary cycling, walking and light resistance exercises can be performed during the time of fixation. It is recommended that the athlete should not return to contact sport without protection.

COMPLICATIONS

Apart from initial acute trauma risks in jaw fractures, complications can also occur from surgical repair of maxillofacial injuries. The most frequently reported complications of surgery are temporary or permanent loss of sensation in the face, loss of smell and/or taste, meningitis, sinus infection, infection in the bones (osteomyelitis), damage to the teeth, malocclusion, scars and other cosmetic concerns. Infections can be a cause of delayed union, non-union, osteomyelitis and loss of teeth and bone structure.

PROGNOSIS

In most cases, the prognosis is good, especially when the fracture is treated promptly and properly. In rare cases, when the fracture is ignored or healing is poor, long-term complications including facial deformity, long-lasting facial pain, limitation or pain of movement at the jaw joint and malocclusion can occur.

HOW TO REDUCE THE RISK OF JAW FRACTURE

The risk of jaw fractures in sports can be reduced by wearing a mouthguard especially in contact sports. The use of a mouthguard can also protect the teeth, lips, cheeks and tongue. They can even prevent more serious injuries of the head and neck.

There are three types of mouthguards:

1. Custom-made.
2. Boil and bite.
3. Stock.

Custom-made mouthguards provide the highest degree of protection, comfort and durability with optimal fit. These are designed to cover all back teeth and cushion the entire jaw.

CONCLUSION

Jaw fractures are a serious injury risk for athletes, including those who play non-combat sports. However with correct protective equipment and timely, appropriate treatment, long-term complications and play delays can be limited.

Mohammed Alsaey

Oral Surgeon

Aspetar – Orthopaedic and Sports Medicine Hospital

Doha, Qatar

Contact: mohammed.alsaey@aspetar.com

Image via Don Shrimpton