C-23 Clinical Case Slide – Football

Abstract

HISTORY: A 27 year old female, an athletic trainer for a Division I softball team, was in the dugout during practice when she was struck in the face with a line drive foul ball that caused a laceration to her upper lip and a loose tooth. There was no loss of consciousness. An initial headache resolved after 30 minutes. There was no dizziness, nausea, vomiting, or any changes in vision. She was seen in the university emergency department a maxillofacial CT scan showed no evidence of an orbital floor or maxillary fracture. An ENT surgeon closed the facial laceration to the right upper lip. The patient complained of the loose tooth, but the surgeon said it could be due to the swelling from the trauma and to just observe it. He expected it would firm up in several days. The next morning, while preparing for a road trip, part of her tooth fell off. This became a management issue to determine whether she needed emergent dental management or could travel with the team. PHYSICAL EXAMINATION: Initial exam in the ED revealed a 2.5 cm obliquely oriented laceration to the right upper lip (almost to the oral mucosa) with a loose right maxillary incisor (tooth #7). The laceration did not cross the vermillion border. Laceration was repaired using a two layer closure with a running locked stitch (5-0 prolene) externally. Tooth #7 was slightly loose on palpation but appeared intact in the socket. The next day the facial suture appears clean, dry, and intact. Rather than tooth #7 being loose in the socket, it had an oblique fracture involving the majority of the crown. The root and pulp remained intact. DIFFERENTIAL DIAGNOSIS: Le Fort Fracture, Orbital Fracture, Luxation of the tooth, Avulsion of the tooth, Crown fracture, Root fracture, Facial laceration TEST AND RESULTS: Maxillofacial CT scan without contrast - Mild to moderate sinus disease - Negative for acute bony abnormality - Minimal soft tissue air seen in the upper lip FINAL WORKING DIAGNOSIS: Oblique crown fracture of tooth number 7 TREATMENT AND OUTCOMES: 1. Since the root was intact, it was not an emergency and saw the dentist two days later. Exam then revealed root and pulp were intact. 2. Root canal was done. Plan for follow up in 3 weeks to allow resolution of swelling. 3. Sutures from facial laceration removed after 1 week with good approximation. 4. Crown placed over oblique dental fracture of tooth at follow up visit.