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of airway, breathing, and circulation, as well as neurologic compromise. Once
stabilized, the emergency physician should perform a thorough extraoral and
intraoral examination to identify the presence of injury to the jaws, teeth, and
surrounding soft tissue. Identification of those injuries that require emergent care
from a dentist is imperative.

Clinical Considerations
Clinical Assessment
Children with facial injuries are usually frightened and apprehensive. The
examination should be organized to include inspection and palpation of extra- and
intraoral structures. Appropriate analgesia can facilitate the examination;
procedural sedation may be required in some cases.
Extraoral examination. The extraoral examination should start with evaluating
symmetry of the face in the anterior and profile views. The clinician should
carefully note the location and nature of any swollen or depressed structures, the
color and quality of the skin, and the presence of lacerations, hematomas,
ecchymoses, foreign bodies, or ulcerations. Evaluation of the temporomandibular
joints (TMJs) involves observation and gentle bilateral digital palpation while the
mouth is opened and closed. There should be equal movement on both sides
without major deviations. Mandibular deviation during function or limited mouth
opening may signify TMJ injury or condylar fracture. Range of motion should not
be forced because it may increase the extent of injury. The infraorbital rim should
be palpated to ensure it is continuous and intact all the way to the inner canthus of
the eye. Examination continues across the zygoma to the nose, palpating for
crepitus or mobility. The clinician should inspect for lip competency (the ability
of the lips to cover the teeth) because loss of competency may indicate
displacement of the teeth from trauma. Attention should focus on the mandible,
feeling along the posterior border of the ramus and moving anteriorly along the
body to the symphysis, palpating for any discontinuity, mobility, swellings, or
point tenderness. The child should be questioned and examined for any evidence
of paresthesia (numbness) of the lips, nose, and cheeks, which may indicate a

fracture through the bony foramen in which the nerve exits. Figure 105.1 shows
the main nerve supply to facial structures.