Facial and Dental Injuries in Sports Medicine
Ocular injuries in sports are common and mostly preventable. Sports at high risk for eye injury include baseball, hockey, football, basketball, lacrosse, racquet sports, tennis, fencing, golf, and water polo. Screens should be conducted prior to beginning one of these sports to monitor for preexisting eye conditions or a family history that could predispose an athlete to an eye injury.
The most common mechanism of eye injury is blunt trauma; however, other types include radiation and penetration. An impact from an object smaller than the eye tends to cause more internal eye trauma, while objects larger than the eye tend to cause more orbital fractures. Penetrating injuries can be caused by fish hooks or broken eyeglasses, while radiation tends to occur while skiing.
When examining a patient, a thorough patient interview should be conducted to determine the mechanism of injury. The physical exam should include testing of the visual field, ocular muscles, pupil size and reflexes, and fundoscopic evaluation of the red reflex. The examiner may be able to treat simple abrasions and foreign body removals on site, however, should refer if any of the following signs and symptoms are found upon examination.
- Sudden decrease in or loss of vision
- Loss of field of vision
- Pain on movement of the eye
- Proptosis of the eye
- Light flashes or floaters
- Irregularly shaped pupil
- Foreign-body sensation/embedded foreign body
- Red and inflamed eye
- Hyphema (blood in anterior chamber)
- Halos around lights (corneal edema)
- Laceration of the lid margin or near medial canthus
- Subconjunctival haemorrhage
- Broken contact lens or shattered eyeglasses
- Suspected globe perforation
Returning to play after an eye injury requires careful consideration. The athlete needs to be cleared by an eye doctor, have a full visual return, and wear protective glasses.
To prevent these injuries from occurring, athletes in high-risk sports should consider donning protective eyewear during play. Eyewear should be tailored to each sport, but always made of high-impact resistant plastic that reduces ultraviolet radiation and can be made with or without a prescription.
Common sports for facial fractures to occur include baseball, softball, soccer, and horseback riding, and the most common bones fractured include nasal, orbital and skull bones. A collision, fall, or being struck with a ball is usually the mechanism of injury for facial fractures.
The patient interview is important to help gauge the severity of the injury on site, including ruling out a concussion. After a blow to the head, a player should be screened for a concussion with a test such as the Sport Concussion Assessment Tool 3 (SCAT), which evaluates signs, symptoms, balance, and memory along with a neurologic and cognitive screening. It also gives recommendations on when an athlete should return to play based on the severity of his or her score.
Management of facial fractures depends on the location and severity. On site, if a fracture is suspected, the player should be transported to the nearest hospital. Fractures sites that are especially concerning are the orbit, which could cause damage to the eye, or nasal fractures, which could impair breathing. Return to play will depend on the severity of the injury, as well as other injuries incurred with the fracture. Fracture healing time (typically up to 8 weeks) must be considered, as well as if the player is continuing to have pain or other symptoms.
To help prevent facial fractures from occurring, coaches should always adhere to the rules of the game to decrease unnecessary roughness. Protective helmets and eyewear should be worn when appropriate. Coaches also need to keep an eye on novice players because their level of skill and knowledge of the game could lead to injury of themselves or other players. Finally, coaches should ensure players get adequate rest, especially when there are multiple practices or games in a day.
Facial Abrasions & Lacerations
Sports are a tremendous contributor to facial lacerations and abrasions, causing up to 29% of all reported facial injuries . The primary fear with any athlete who has experienced a facial injury is underlying damage that may have affected consciousness, respiration, or vision. Because of the severity of these types of injuries, evaluations always start with the emergency medical response “ABCDE” approach: Airway, Breathing, Circulation, Disability, and Exposure/Environmental control . After the medical professional rules out a life-threatening injury and/or concussion, then he or she can bandage the wound for the athlete to return to competition.
Facial abrasions are a non-severe, superficial injury involving the epidermal and possibly superficial dermal layers of the skin. Most abrasions occur because of shear forces caused by an athlete sliding over a rough playing surface such as grass or turf . Athletes with facial abrasions can easily return to competition after a medical professional has washed out the wound with soap and water and removed any foreign debris from the area. If there is too much debris or if it is too deep in the wound to be removed safely, then the athlete should be taken to a doctor for removal . However, abrasions can easily become infected, so it is important to use an aseptic dressing to protect the wound. Most abrasions will heal in a few days .
Lacerations are the most common sports-related injuries to the face . Sharp objects are not the only cause of lacerations. “Burst lacerations” occur when a blunt trauma of the soft tissue over a bony area will cause a tear in the skin. These injuries usually occur on the forehead, cheek, teeth, or chin . Lacerations bleed easily, so it is important to put pressure on the wound to control it. Once the bleeding is under control, the medical professional should sterilise the cut with saline to prevent infection. Many trainers will choose to close the wound with sutures, but if it is not a significant laceration then some will opt to use a Band-Aid or other type of adhesive bandage until after the game is over and the athlete can be taken to a doctor . Most studies recommend that adhesive should be used for superficial cuts smaller than 4 cm while sutures are used for deeper and larger lacerations. One randomised control trial shows that Dermabond (a brand of tissue adhesive) had a better cosmetic outcome than sutures at 1 year following facial plastic surgery, and it had no increased risk for wound dehiscence or infection . As physical therapists, it is better to use adhesives in competition settings until a doctor can evaluate whether the athlete will need stitches or not.
Eyelid lacerations are also a big concern because of the possibility of foreign bodies or penetrating injuries into the eye itself. Eyelid lacerations can cause vision loss since the cornea will dry out when the eyelid is unable to close properly . Lacerations to the medial part of the eyelid can damage the tear ducts while lacerations to the upper eyelid can damage the levator palpebrae muscle, which can cause the eyelid to permanently drop . Eyelid lacerations during competition are cared for a little differently than other facial lacerations due to the possibility of the eye drying out and causing permanent damage. The primary goal immediately following an injury to the eyelid is to apply an antibiotic ointment or artificial tears to the wound and cover the entire eye with moistened gauze to prevent the cornea from getting too dry; athletes with an eyelid laceration are taken to the doctor immediately for surgical repair .
If lacerations are not treated properly, excessive scar tissue can form and alter the cosmetic appearance of the face . This can cause significant psychological and psychosocial effects on the athlete, especially if they are female. Some lacerations may have significant complications if they involve a severed nerve, vessel, or gland . A laceration of the facial nerve will cause a possibly permanent facial droop and asymmetry. The earlier that a facial nerve laceration is diagnosed, the better chance the athlete has for nerve regeneration. Deep cheek lacerations typically involve the parotid duct, so saliva draining from the laceration is a common symptom . In summary, many underlying structures are apt to be injured with a facial laceration. The job of athletic trainers and physical therapists is to clean and dress the wound, and any complicated laceration injuries should be immediately referred to a surgeon .
According to Romeo, Hawley, Romeo, Romeo, & Honsik (2007) , athletic trainers and/or physical therapists should adhere to the following steps in the sideline management of facial injuries:
- Assess the athlete’s airway, breathing, and circulation following typical emergency response guidelines
- Evaluate for an intracranial or cervical spine injury
- Inspect all parts of the face for bleeding, swelling, bruising, and asymmetry
- Palpate the bony aspects of the face (forehead, cheekbones, jaw, etc.) for pain, instability, and/or subluxation
- Assess cranial nerve function
Romeo et al.  also provide a list of criteria for the athlete to be able to return to competition following a facial laceration:
- Trainer/Therapist has ruled out any underlying injury including eye injuries, fractures, nerve lacerations, and cervical spine injuries
- Bleeding stopped and hemostasis achieved
- Vision is normal
- Athlete has decided to return to competition after being informed of the risks
- The rules allow the athlete to return to play with an open wound OR if the rules do not allow an open wound then it is closed and bandaged temporarily
Medical professionals should follow these rules to ensure that athletes will not worsen the injury if they decide to return to play. It is important to know the rules about returning to competition with an open wound for each specific sport that the trainer or therapist is covering.
Dermatologic Conditions Affecting the Face, Head, and/or Mouth
Impetigo is a superficial skin infection caused by the bacteria Staphylococcus aureus or Streptococcus pyogenes . It is common in young children and is highly contagious. There are two types of impetigo: bullous and nonbullous . Bullous impetigo is characterised by bullae that will rupture and leave dried and crusty clear yellow fluid on the skin. Nonbullous impetigo is more common and usually presents with red skin and pustules that rupture and leave a golden yellow crust on the skin . People with either type of impetigo can also present with an itchy rash, skin lesions, and swollen lymph nodes . If the infection is mild, some doctors may recommend simple hygiene tips to clean the infection and prevent it from spreading . If the infection is more involved, medication is necessary. Topical antibiotic treatment is usually enough for most people with impetigo, but some patients require systemic medication if the infection is extensive . Usually, doctors prescribe bacitracin or mupirocin for 7-10 days, but people with a penicillin allergy can also take azithromycin or erythromycin as a second-line treatment .
Folliculitis and Carbunculosis
Folliculitis is an infection of the hair follicles characterised by erythema, papules, and pustules. Carbunculosis is a deeper infection of the hair follicles with nodules that contain an inflammatory drainage . Folliculitis is usually not symptomatic, but the person may have some pain, redness, and itching around the area. The most common areas where this occurs are in areas with a high number of hair follicles including the occipital scalp, posterior neck, armpits, and beard area in males . Carbuncles are usually more painful because the nodules are larger and deeper in the follicle, and carbunculosis usually involves fever and fatigue as well . Folliculitis can usually be treated with a topical antibiotic (clindamycin or erythromycin) and washing of the area with warm water three times a day. Carbuncles usually require a systemic antibiotic, especially if the person is having systemic symptoms . Sometimes larger carbuncles require incision and drainage to help clear the infection quickly. If the patient develops MRSA, the doctor will also prescribe vancomycin or doxycycline to go along with the topical treatment .
Ecthyma is a skin infection that often occurs because of impetigo that has not been taken care of. It is characterised by thick crusty ulcerations, and it typically happens in homeless people or in soldiers that are serving in hot, humid areas . Usually, ecthyma starts with small vesicles and bullae that turn into punched-out ulcerations with a surrounding crust that scar after they heal . Ecthyma is treated the same as impetigo, as described above.
Cellulitis is an infection/inflammation of the epidermal and dermal skin layers that can extend deeper into the subcutaneous layer as well. People who have lymphedema, diabetes, obesity, venous stasis, alcoholism, or some kind of trauma are more likely to develop cellulitis . Cellulitis is typically characterised by warmth, redness, tenderness, and swelling and has poorly defined borders. The person might have systemic symptoms as well, including fatigue, chills, sweating, and muscle aches. If the skin starts to blister or have red streaks and the person starts to feel drowsy or lethargic, then that usually signifies that the infection is spreading . Doctors usually choose penicillin to treat cellulitis, but if the person is allergic than they can take clindamycin instead. The patient is on medication four times a day for 7-10 days, and good hygiene, warm compresses, and elevation of the infected area can help to speed up the healing process .
Necrotizing fasciitis is an infection of the fascia and subcutaneous tissue that will eventually lead to necrosis . It is a rare skin condition, but it can be quite serious if left untreated. Usually, the infection will begin by causing redness, warmth, tenderness, and inflammation that will rapidly spread to surrounding areas . Within 2-3 days, the skin becomes dark, bullae start to form, and the area develops necrosis and gangrene. If necrotizing fasciitis is not treated immediately, the person will develop a fever, organ failure, and eventually experience shock and possibly death . Necrosis usually requires emergency surgery with possible amputation if the infection cannot be prevented from spreading. The doctor will also prescribe an antibiotic – gentamicin or clindamycin – that is mandatory to help clear the infection . However, even with treatment, the mortality rate for people with necrotizing fasciitis is high.
Fungal and Yeast Infections
Dermatophytoses is a fungal infection of highly keratinized tissue like skin, nails, and hair . Tinea capitis is a fungal infection of the scalp that is most common in kids. The child usually has scaly skin, hair loss, and nodules that appear on the skin . Tinea faciei is a fungal infection of the face that is characterised by a scaly plaque on the skin of the face. The majority of these fungal infections are treated with topical agents like terbinafine, clotrimazole, econazole that are applied twice a day for up to eight weeks. Fungal infections of the scalp are often treated with griseofulvin or fluconazole .
Tinea versicolor is a yeast infection of the superficial layer of the skin. This infection usually occurs in people who live in hot, humid environments, and incidence increases based on oral contraceptive use, heredity, corticosteroid use, Cushing’s disease, malnutrition, and immunosuppression . A person with tinea versicolor will usually have scaly skin that is well demarcated, and plaques on the skin can be either hypo- or hyperpigmented. Tinea versicolor is usually treated with sulphide shampoo that is applied to the scalp or other affected area daily for five days, and then once a month after that . There are also many different antifungal creams including terbinafine, clotrimazole, or econazole that can help clear the infection. The creams must be applied twice a day for eight weeks to take effect .
Herpes simplex virus (HSV) is recurrent dermatitis that usually causes painful vesicles to form on the reddened skin. The virus is spread through direct contact, but it can travel to distant sites in the body and remain dormant until it is activated by stress, illness, trauma, or sunlight . There are two types of HSV: Type 1 is an orofacial disease, and Type 2 involves a genital infection. The primary infection normally occurs in children and presents as reddened vesicles and erosions on the mucosa, palate, tongue, and lips . Herpes labialis is the reactivated HSV infection in adults that characterised by fever blisters and cold sores. Acyclovir is the drug of choice for most doctors, but newer medications like famciclovir and valacyclovir can be effective as well. Sometimes suppression treatment is needed with recurrent HSV infections .
Herpes Zoster – “Shingles”
Herpes zoster (shingles) is dermatitis that is acutely painful and often occurs in people with immunosuppression . Shingles usually happen in adulthood due to the reactivation of the varicella virus (chicken pox) that lies dormant in the sensory ganglia from childhood. Herpes zoster begins with pain, paresthesia, and the formation of vesicles in a dermatomal pattern. The person might also experience systemic symptoms with the infection . If the virus affects the trigeminal nerve (cranial nerve V), nasociliary nerve involvement is likely along with pain and a rash of the tip and side of the nose. Most patients only receive treatment for their symptoms and respond well, but rest, pain medication, and compresses can help accelerate the healing if given within 24 to 72 hours of onset of symptoms .
Measles is a viral infection occurring in the cells of the throat and lungs that are highly contagious with coughing and sneezing . Measles starts like a common cold with fever, funny nose, and a cough, but the hallmark sign is a reddish-brown rash that develops on the face and spreads all over the body. After a few days, tiny red bumps with a light blue centre will start to appear on the inside of the cheeks . The rash usually lasts a week, but if measles is not treated properly then ear infections, pneumonia, and encephalitis can occur. The measles/mumps/rubella (MMR) vaccine has eliminated many cases of measles in the US. There is not a good treatment for measles except to rest, drink plenty of fluids, and let the body recover .
Other Dermatologic Conditions
Skin cancer is a very common condition affecting the face due to the high exposure to sunlight. There are four major types of skin cancer: actinic keratosis, basal cell carcinoma, squamous cell carcinoma, and melanoma. Actinic keratosis is a form of pre-cancer that usually produces red, rough patches of skin on the face or other sun-exposed areas . It usually develops into basal cell carcinoma in people with a history of skin cancer if not diagnosed early. Actinic keratosis and squamous cell carcinoma look very similar and are often misdiagnosed . Basal cell carcinoma is the most common type of skin cancer, and it affects the deepest layer of cells of the epidermis. It is very slow-growing and rarely spreads to other parts of the body . Most basal cell carcinomas present as waxy pink bumps on the surface of the skin, but infiltrative basal cell carcinoma can make the skin appear translucent with blood vessels very near to the skin surface . Squamous cell carcinoma is more aggressive and spreads faster than basal cell carcinoma. It produces rough, red scaly lesions similar to actinic keratosis . Melanoma is the least common, but most dangerous, form of skin cancer. It affects the melanocytes and causes irregular moles or lesions that follow the “ABCD” pattern: Asymmetrical shape, Border irregularities, Color (not uniform throughout), and Diameter more than 6 mm . Treatment usually involves chemotherapy and/or radiation.
Lupus is an autoimmune disease that causes a non-painful rash to form on the head and face . There are two types of lupus: systemic lupus erythematosus (SLE) and cutaneous lupus erythematosus (CLE). SLE affects many different organs in the body including the kidneys, brain, arteries, and lungs; CLE affects the skin . Lupus generally presents like the flu, so patients will experience fatigue, fever, headaches, and joint pain and weakness along with the rash . There are many different ways that lupus can affect the skin. Discoid lupus will cause a small red, scaly rash on the ears, nose, and cheeks, and it can leave a permanent discoloration on the skin even after it fades. It can also cause hair loss if it is on the scalp . Subacute cutaneous lupus (SCLE) produces a rash that looks like scaly red rings on areas of the skin that are exposed to sunlight. Acute cutaneous lupus (ACLE) is recognised by the “butterfly” rash, which is a rash that looks like a sunburn and spreads over the nose and cheeks . Lupus is a disease that is commonly seen in physical therapy due to the significant joint pain and weakness.
The most common skin condition in the United States is acne, affecting over 90% of the population at some point during life . Acne occurs because oil, bacteria, and dead skin clog pores in the skin and cause pimples to form. Most people develop acne during puberty or pregnancy when the body is undergoing many hormonal changes, but certain medications and a poor diet can also contribute to acne . Acne most commonly occurs on the face, but it can happen at any place on the body that has a high number of sebaceous glands like the back, chest, shoulders, and neck. There are four primary skin lesions that can occur with acne: papules, pustules, nodules, and cysts . Papules are small red bumps that occur due to an infected hair follicle. Pustules are papules that have pus at the tips. Nodules are solid lumps under the skin that are painful, and cysts are infectious lumps under the skin that are painful and contain pus . The best way to treat acne is to wash the skin with soap and water daily to remove dirt and oil. If the acne does not respond to simple washing, there are over-the-counter acne creams and gels that contain benzoyl peroxide, sulphur, or salicylic acid that will help kill bacteria and dry the skin. Severe acne may require oral antibiotics that kill the bacteria that cause clogged pores .
Hemangiomas are growths that are noncancerous and form because of an unusual collection of blood vessels. Most hemangiomas form in the womb and are asymptomatic. Skin hemangiomas usually appear as small scratches on the face, head, or neck of babies that grow larger and protrude as the child ages . Most hemangiomas do not produce symptoms unless they are large or in a sensitive area. They do not typically require treatment as they will go away on their own, but if the hemangioma causes a skin lesion or sore then laser treatment, medication, or surgical removal might be required .
This is one of the most common skin conditions in adults. Psoriasis is an autoimmune disorder in which the brain tells the skin to produce new skin cells too quickly, so the skin becomes red and scaly . There are five main types of psoriasis: plaque psoriasis, guttate psoriasis, inverse psoriasis, pustular psoriasis, and erythrodermic psoriasis . Plaque psoriasis is the most common type of psoriasis and is characterised by thick red patches on the skin. Scalp psoriasis is plaque psoriasis that is located on the scalp or nape of the neck . Guttate psoriasis presents as small, red, tear-shaped spots on the limbs, trunk, face, and scalp. Inverse psoriasis is a form of the disease that is red, shiny, and only affects skin folds . Pustular psoriasis is similar to all other types of psoriasis, but it causes white, pus-filled blisters to form over the red, scaly patches. Erythrodermic psoriasis is fairly serious and produces a severe, burn-like rash that covers the majority of the body . Most doctors initially prescribe topical treatment including corticosteroids, Vitamin D cream, and salicylic acid ointment. If these do not work, a doctor will try a more invasive treatment like injections, oral medication, or light therapy .
Rosacea is a common skin condition that has no known cause and no known cure. There are four subtypes summarised below :
- Subtype one: flushed face, swelling, and visibly broken blood vessels
- Subtype two: resembles an acne breakout; oily skin; usually in middle age
- Subtype three: rare; skin of the nose thickens; bumpy skin of the chin, forehead, nose, and cheeks; usually in men
- Subtype four: affects the eyes – bloodshot, watery, itchy, dry
There is no treatment for rosacea, but people can control their symptoms by cleaning their skin, avoiding products that may irritate their skin, using antibiotic creams or gels, and avoiding triggers that may make rosacea worse .
Hives are raised welts on the skin caused by an allergic reaction to a medication or other skin irritant. Usually, hives are swollen, red, and painful to touch . They typically start out in one area of the skin, grow larger, and spread to other parts of the body. The most important part of treatment is to figure out what is causing the reaction and remove it. Treatment also includes taking antihistamines, avoiding skin irritants, and in severe cases possibly taking an injection of steroids or epinephrine .
Vitiligo is a condition in which a person loses pigment in certain areas of the skin. Most people lose pigment in small areas or on one side of the body, but some cases of vitiligo can cover over half of the body . Usually, the affected areas are high sun-exposed areas including the face, arms, legs, and hands. There are three different patterns of depigmentation :
- Focal pattern: in a few small, secluded areas
- Segmental pattern: only on one side of the body
- GGeneralisedpattern: both sides of the body in a symmetrical pattern
Vitiligo is non-painful and has no negative effects on health, so treatment is purely to restore pigment to the skin for cosmetic purposes. However, results usually take several months, so restoring skin pigment is usually a long-term process . Doctors can re-pigment the skin by using topical steroid medications, immunomodulators, or ultraviolet light. In severe cases, the person might require skin grafting .
Lip, Tongue, and Tooth Injuries
Lip, tongue and tooth injuries are commonplace in sports and are not limited to contact sports. Participation in sports is one of the top causes of dental trauma, accounting for 13 – 39% of all dental trauma . Lip and intraoral injuries, including injuries of the tongue, have been reported to make up almost 25% of all sports-related maxillofacial injuries . The incidence rate of at least one orofacial injury per season among high school athletes, including dental trauma and lacerations of the tongue or lips, has been reported as 25% in soccer, 50% in basketball, and 75% in wrestling. Of the athletes included in the study, only 6% reported using mouth guards and none sustained injuries .
As a sports medicine provider, one should be able to recommend and fit sports equipment properly to reduce the likelihood of injury, including mouth guards. The effectiveness of mouthguards has been well established in sports medicine literature, including a 2007meta-analysiss. The authors concluded mouth guards provide many benefits including: reduce mandibular deformation, increase the force required to fracture teeth, reduce the number of fractured teeth at a given force, and dampen impact forces. Overall, the risk of orofacial injury was 1.6 – 1.9 times higher in those who did use a mouth guard during sport .
Following an injury to the lip, tongue, or teeth, the athlete’s overall status should be evaluated by the sports medicine provider, including vital signs, airway integrity, and neurologic signs as indicated. All orofacial injuries should be assessed immediately, as many are considered urgent and may cause significant morbidity and mortality if not addressed within a few hours. Fractures and avulsions of the teeth or alveolar ridges and significant lacerations of lips or tongue are all considered urgent and the athlete should seek treatment promptly .
Lacerations of the lip or tongue should be covered with gauze and given pressure, and when blood flow slows down the wound should be examined, cleaned, and determined if sutures are required for closure . A tongue may not require surgical closure if the laceration is superficial and does not gape widely when the tongue is extended . Simple lacerations may be closed with sterile dressings, tissue glues, or steri-strips . On the other hand, tongue lacerations with continued excessive bleeding should be referred for surgical intervention . Following any significant intraoral laceration, the use of penicillin prophylactically is supported by current evidence .
Prior to evaluating a tooth injury, the initial sports medicine provider must consider evaluating the athlete for a concussion and head or neck injury . Dental trauma typically occurs as a result of a direct force to the teeth or from a force to the mandible causing a tooth to tooth contact . If the affected tooth is air sensitive, this is considered an urgent situation requiring dental treatment as soon as possible . The goals of treatment for any trauma to a tooth are the same , with the first goal being of primary concern for initial sports medicine providers:
• Retain tooth in dental arch
• Maintain vitality of dental pulp
• Prevent internal and external root resorption
• Restore injured tooth to form, function, and esthetics
The severity of crown fractures can be described based on the layers affected, which can be the enamel, dentin, and pulp. Fractures involving only the enamel are not an emergency and often go unnoticed by the athlete. The athlete may report a chipped tooth that feels rough on the tongue . Fractures that extend into the dentin will be painful with air exposure, cold drinks, or to the touch. If possible, the tooth fragment should be located and placed in milk or a balanced saline solution, and the athlete should seek treatment from a dentist as soon as possible for the best prognosis . Fractures extending into the pulp are the most severe type of crown fracture. The proper treatment can be difficult to determine and is outside the scope of this article. However, if the tooth is producing pain and blood is seeping from the pulp chamber, this is a dental emergency and dental care should be sought immediately .
Fractures occurring within the root are categorised based on thirds. Fractures occurring in the apical third have the best prognosis of all root fractures and often go unnoticed . Fractures occurring in the middle third have a good prognosis for proper healing, but treatment should be sought as soon as possible. Upon examination the affected tooth will appear longer and partially raised from the alveolar socket and bleeding at the gums may be present. Immediate care should include carefully repositioning the tooth manually followed by having the athlete bite down on gauze to place pressure on the tooth to keep it in place. Following stabilisation, the athlete should seek dental care immediately to determine the necessary treatment . Fractures occurring in the cervical third, in the region where the root and crown meet, have the worst prognosis for maintaining tooth vitality. The initial management is the same as described for middle third fractures .
With a complete tooth avulsion, it is essential to begin treatment as quickly as possible following the avulsion. If the tooth can be located, it should only be handled by the crown and cleansed with either saline or milk. The tooth can then be placed back into the alveolar socket and the athlete should bite down to stabilise the tooth and seek dental treatment immediately. Re-implantation of the tooth within 30 minutes results in a greater than 90% chance of saving the tooth. While a delay of more than 2 hours results in a 5% chance of survival .
Temporomandibular Joint Injuries
Temporomandibular joint (TMJ) injuries are not very common injuries in athletics. The most common sporting events that involve TMJ injuries are those that are classified as contact or collision sports. The most common sports include football, rugby, soccer, wrestling, karate, boxing, and mixed martial arts . TMJ injuries are a sub-category of temporomandibular dysfunctions (TMD). TMD includes:
• Preauricular pain
• Temporomandibular joint dysfunction
• Pain in the muscles of mastication
• Limitations or deviations in mandibular range of motion
• Crepitus during mastication or mandibular function
• Combination of the above 
There are multiple causes of TMD or TMJ injuries. The most common are direct trauma to the mandible. Trauma to the mandible and face itself is protected by wearing proper headgear, such as the case in football, wrestling, hockey, and baseball. However, this headgear is often inadequate in the protection of the mandible . Sports that do not require headgear, but have collisions or contact, including soccer, rugby, and boxing. Direct blows to the mandible may lead to dislocations, acute capsulitis, TMJ disc displacement, ligamentous laxity, or TMJ derangements .
TMJ dislocations involve a non-self-limiting displacement of the condyle outside of its functional position within the glenoid fossa and posterior slope of the articular eminence . The most common TMJ dislocation is anterior to the auricular eminence, however, there have been reports of dislocations medially, laterally, posteriorly, and intracranially . Acute dislocations are normally isolated events, and when proper care is taken, usually have no long-term implications.
Acute capsulitis is characterised by an acute inflammatory response resulting from direct trauma to the mandible. This inflammatory response leads to irritation of the synovial tissues lining the joint and increased volume of synovial fluid within the joint space, resulting in pain . This injury leads to the immediate development of swelling in and around the joint, painful function of the mandible, and occlusal changes.
Direct trauma may cause disc displacement of the TMJ. This disc displacement may result in significant reduction in Range Of Motion of the mandible and may be painful in some cases. The joint may be locked in closed or open tendencies, with a limited range of motion in the opposite directions . When this type of injury happens, athletes may become extremely anxious at their inability to control the motions of their mouth, and it is very important to control the situation and athletes’ emotions in a calm, timely manner.
TMJ injuries may also arise from stress. Trauma is often the primary cause of injury, but the symptoms of the injury are exacerbated by stress of the athlete. Athletes face varying levels of stress in their playing careers, such as competing for playing time, concern over performances, maintaining eligibility, and the stress of everyday life .
Another cause of TMJ injuries in sport is structural anomalies. Structural anomalies include malocclusion, enlarged mandibular condyles, decreased joint space, or missing teeth (sailors). These structural anomalies predispose athletes to TMJ injuries by altering mandibular function and mechanics.
Evaluation of suspected TMJ injuries should include a thorough history, postural inspection, palpation, Range Of Motion testing, muscle testing, and referral for special testing. While collecting a thorough history, the athlete should be questioned over recent and past dental history since dental procedures may lead to development of TMD. Common signs and symptoms of TMD include jaw ache, earache, headache with possible dizziness, facial pain, decreased Range Of Motion, and crepitus with movements of the mandible . The sports medicine practitioner should be conscious of what falls within his or her scope of practice with issues of the TMJ and know when a referral is appropriate.
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