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