Jaw and dental injuries

Forty years ago, a goalie named Jacques Plante of the Montreal Canadiens did something that not only changed the face of hockey but affected Plante's own face as well -- he wore the first protective mask in the history of the game.

With pucks and sticks and skates and posts all posing hazards, today's hockey player probably could not shield himself from injury except perhaps with a suit of armor. Most prevalent are injuries to the face, particularly the jaw and teeth. "The precipitating cause of almost all jaw and dental injuries is direct trauma to the area," says Dr. Guy Lanzi, a member of the Association of Professional Team Physicians (PTP) and an oral and maxillofacial surgeon for the Philadelphia Flyers. "Most likely it would be with a puck or stick or via collision with other people or objects."

Join Dr. Lanzi as he discusses the nature of these painful injuries and why protection is the best prevention .

What are some of the common jaw or dental injuries?

Dr. Lanzi: Generally, these injuries fall into three categories. The first is soft-tissue injuries such as cuts or lacerations to the lips, the tongue, the inside of the mouth or the face. Secondly, there are dental injuries, which are injuries to the teeth -- fractured teeth, partially or totally knocked-out teeth and injuries to tooth-related structures like braces for a younger person. The third category would be jaw-related or bone-related injuries where you actually have some bruising or fracturing of the jaw bones. This could include alveolar fractures, which is a fracture of the bone that houses the teeth, upper-jaw fractures or lower-jaw fractures. You can also have bruises or contusions to the bone that often takes place in the lower jaw. The fractures and injuries to the bone are probably the most severe of the three and require the most attention.

What are the symptoms?

Dr. Lanzi: Soft-tissue lacerations and bruises are usually easy to diagnose because you can see them and you'll obviously have pain in the area, bleeding and perhaps swelling. The tooth-related injuries are going to be a little harder to diagnose, but generally there again will be pain, bleeding and perhaps an inability to close the teeth properly, which may lead to an abnormal bite. You'll usually be able to see a tooth injury if the tooth is significantly out of alignment. You may also be able to see fractures of the tooth where the tooth is actually cracked or no longer of normal size and shape because part of it has been lost. The tooth may also be intruded -- knocked back underneath the gumline and into the bone. Most of these conditions will exhibit the same symptoms - pain, distress, swelling and perhaps bleeding. The symptoms of jaw fracture are pain, mobility of the teeth, inability to bring the teeth together properly or severe pain when you bring the teeth together. Bleeding inside the mouth and inability to open the mouth can also be symptomatic of a fracture.

What are the common causes of these injuries?

Dr. Lanzi: Normally, the precipitating cause is direct trauma to the area either with a stick or a puck or a ball or via collisions with other people or objects. Kids ages 10 through 14 can be a little bit more susceptible to dental injuries because they tend to have large teeth for their size. When a tooth erupts in kids, it looks huge and its roots are not fully formed, making the area a little more prone to injury at that age. But at any age, a major underlying cause is that participants are not wearing proper protection.

How are these injuries treated?

Dr. Lanzi: Lacerations are cleaned and bandaged or sutured if needed. Depending on their severity, they can be taken care of on location or at a treatment site. If someone gets a tooth knocked out or fractured, he or she needs to be seen as soon as possible by a dentist or a dental specialist. A common question is what to do with a tooth that's knocked out. The tooth should be cleaned and stored in milk or in a special solution that is available commercially.

The most important thing is that a knocked-out tooth is put back into the tooth socket as soon as possible, hopefully within 30 minutes. If the socket is intact and hasn't been smashed, the tooth can be put right back in the socket and then stabilized. If the tooth is stabilized for a period of one to two weeks, many times it will "take" back into the socket. If the tooth has been out of the mouth for longer than a half-hour -- especially for more than an hour -- the chances that a tooth will "take" are much less. These days we don't worry so much about fractured-off or knocked-out teeth because we know that even if a tooth is lost permanently, we can replace it with dental implants that look and feel like the original factory part. So today, if there is any question about a knocked-out tooth or if the socket has been damaged so the tooth cannot be put back in, dental implants are an option.

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Q: I have dislocated my patella twice in my left knee. My right knee is beginning to hurt a lot especially after doing several athletic activities in a week. An orthopedist that I talked to a couple of years ago mentioned that I had 'floating' knee caps. What type of exercises should I be doing and what type should I be avoiding? What can I do to curb the pain caused by 'floating kneecap' while still maintaining a very active lifestyle? -- Jim, Philadelphia, Penn. A: From Dr. Bruce Moseley, team physician for the Houston Rockets: "There are few hard and fast rules for patella ("kneecap") problems, as there tends to be great variability in how they present and in their response to treatment. However, there are a few good guidelines to follow: Exercises that strengthen the quadriceps muscles are emphasized, as the quadriceps muscles control the patella. However, some exercises, like knee extensions, can aggravate the pain from patella problems and should be avoided if painful. The classic exercises for patellar instability are straight leg raises, short arc quadriceps sets, one-half squats, and bicycling with the seat elevated (to allow the knee to go almost completely straight on the down-stroke of the pedal). Almost any exercise is permissible as long as the knee doesn't hurt during or after the exercise. The only exercises to definitely avoid are the ones that aggravate or worsen the pain in the knee. For patellas that continue to dislocate even after rehabilitation, surgery is recommended. Often this surgery can be done arthroscopically. If you have any further questions about this, a visit with your orthopedic surgeon or a sports medicine physical therapist could prove beneficial." Do you have a question for a team physician? Click here to ask. And check out more "Ask the Pro Doc" answers to users' questions.

Fractures generally involve the same kind of treatment as a fractured arm or a fractured leg -- you basically want to immobilize the fracture. The only difference with jaws is the immobilization can involve wiring the teeth together and that can be problematic for athletes as it usually delays recovery time. Recently developed plates and screws for the jaw are alternatives to wiring and sometimes these are used when appropriate to get the athlete back to action quickly.

What can be done to prevent jaw and dental injuries?

Dr. Lanzi: The main way to prevent these injuries is to wear approved protective equipment. This can include helmets with face shields and/or cages to protect the face. Mouthguards are critically important. They are more difficult for really young kids to wear because their mouths are growing and changing all the time, but there are some easily managed, affordable mouthguards available for kids. For everyone else, there are custom-made mouthguards that can be made by your dentist. Mouthguards not only prevent direct dental trauma, but they can lessen the chance of jaw fractures, joint injuries, contusions and concussions. Because our lower jaws hinge at the base of the skull, if you are hit on the lower jaw (for example, in boxing), the jaw can be driven back into the base of the skull and cause concussion. Mouthguards can absorb some of that shock so the brain absorbs less of it. We've also found that the lower jaw is more susceptible to injury and fracture in some patients with impacted wisdom teeth. So for athletes like the Flyers who engage in a high- contact sport, we try to get their wisdom teeth out as soon as possible because that seems to be an area of inherent weakness. The Oral and Maxillofacial Surgery Society (www.aaoms.org) has educational information available about maxillofacial protection in sports.

What is the prognosis for these injuries?

Dr. Lanzi: Depending upon the age of the patient and the severity of the injury, recovery is generally good. With lacerations, we worry about scarring, but scars can be revised to yield a good result. Implants have been a great advance for lost teeth and look, feel and act like real teeth. Fractures tend to heal very well. Occasionally, jaw joint injuries result in problems chewing, but that is rare. Concussions are the biggest concern we have because we know repetitive concussive injuries can cause permanent damage and cut a career short. So we try to protect the athletes as best we can. From an oral surgical point of view, that means making the most shock-absorbent, thickest custom mouthguards that can be tolerated and advocating head and facial protection where possible. Fortunately, the structures of the mouth and face have an excellent blood supply and therefore generally heal very well.

Dr. Guy Lanzi, a member of the Association of Professional Team Physicians, (PTP) is an oral and maxillofacial surgeon for the Philadelphia Flyers. Dr. Lanzi received his undergraduate degree from Rutgers College in New Brunswick, N.J., and his dental degree from Fairleigh Dickinson University School of Dentistry in Hackensack, N.J. Dr. Lanzi completed his residency in Oral and Maxillofacial Surgery at Denver General Hospital in Denver, Colo., and is certified by the American Board of Oral and Maxillofacial Surgeons.

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