Last month, Jai Opetaia went through arguably the best and worst experiences of his boxing career on the same night.
The Australian cruiserweight won a brutal, bloody contest against Mairis Briedis, smashing the nose of the former IBF champion, and seizing his first world title by way of a hard earned unanimous decision. But, Opetaia went through hell to do it, suffering a pair of jaw fractures and fighting a full round with blood oozing from a mouth dangling open, loose and vulnerable.
In the aftermath of the fight, Opetaia was physically incapable of producing comprehensible speech. He did speak recently with Bad Left Hook’s Lewis Watson, outlining his plans for the future and his current challenges. But, he didn’t say much about his timeline for return other than a desire to fight again “by the end of the year.”
Is that a realistic schedule for a combat sport athlete returning from this sort of facial injury? And could there be any future complications that would impact his fighting career?
For those answers and many others, we spoke with Dr. Omar Abubaker, Chair of VCU’s Department of Oral and Maxillofacial Surgery. Dr. Abubaker is not part of Opetaia’s medical team, and has no specific knowledge of his treatment or recovery status. But, he has spent decades as a maxillofacial surgeon, and has authored two different textbooks and dozens of peer-reviewed scientific articles on the subject of oral and maxillofacial surgery.
Among the highlights of our conversation: Opetaia could indeed be back in the ring before the end of the year. America differs from the rest of the world, because the leading cause of jaw fractures here is assault, not accidents. And, aspiring boxers should seriously consider removing their wisdom teeth.
A transcript of our conversation, edited for length and clarity, follows.
BAD LEFT HOOK: The ringside doctor was the first to identify Jai Opetaia’s problem as a bilateral mandibular fracture. Before we get into everything else, can you give us a basic overview of that injury?
Omar Abubaker, D.M.D., Ph.D.: Let’s just start with “mandibular.” The mandible is what we call the lower jaw. It’s a relatively new term. They used to call the upper jaw the “maxilla,” and the lower jaw was the “lower maxilla.” That changed about 100 years ago, and now we call the lower, mobile part the mandible. And “mandibular” just means something related to the mandible.
Bilateral, it helps to think of the mandible in two pieces. One from the ear down to the midline in the chin, and another on the opposite side. They actually fuse during the early development of the human body, and become one piece that goes all the way around from one ear to the other. We still refer to anything from the midline or above towards the ear on the right side as a “right mandibular fracture.” If it’s from the midline to the left, we call it a “left mandibular fracture.” And, if it’s on both sides, we call that a bilateral fracture.
We have what are called condyle fractures where the jaw is joined to the skull. There are angle fractures at the areas that form the angle of the jaw. It’s not exact, but it’s a region. And then we have what we call body fractures, which occur in the part of the jaw that has the teeth in it. There’s also a symphysis fracture near where the midpoint is, where the two sides are fused together.
Now, a mandibular angular fracture usually typically happens behind the last molar. The last molar of the jaw is the last tooth. It’s the third molar if you have a wisdom tooth, or the second if you don’t.
So, a bilateral mandibular angular fracture means that we have a fracture on both sides in the angular part of the jaw, at the area by the last molars.
I doubt the bulk of patients you see with bilateral fractures are combat sports professionals.
[Smiles] No, not that many.
In your experience, are there any common or more conventional types of accidents or incidents that lead to this sort of mandibular fracture?
Well, a bilateral mandibular angular fracture is rare. Because you almost have to have two different traumas to the two sides of the jaw. In other words, you get hit once, and you get one angle fracture. Usually, you have to have a second trauma to get another mandibular angle fracture to the other side.
We often say that here in the United States, assault is our most common cause [for mandibular angle fractures]. If you look at other countries, the causes are usually vehicle accidents, bicycle accidents. You fall and you break your jaw. But, in the United States, the most common cause is an assault. That’s also why it’s more common in males than females, and more common on the left than the right because over 80% of the population is right handed.
It’s less common to be bilateral. A car accident can cause it, though. But, assault rarely results in a bilateral fracture. Perhaps we’re courteous enough that when you get hit and have a broken jaw, you don’t usually get hit again on the other side.
Now, if you’re talking about boxers, it’s sort of expected. Because one, it’s not strange to get hit with one [mimes a punch to one side of the face, then another on the opposite side] and then the other one.
We don’t see it often. I couldn’t tell you how many times I’ve seen it myself. Unless there happens to be a boxing event nearby in Richmond [Virginia], we wouldn’t normally see an injury like this from boxing. And we don’t have many of those cases come here. So, I haven’t seen many bilateral mandibular fractures as a result of sports or specifically boxing.
When we look at the image of Opetaia’s jaw, are there any particular conclusions or observations you can make based on what’s visible there? Does Opetaia’s situation look particularly good or bad for this type of injury?
When a fracture occurs in the jaw, it could just break in a way that the pieces stay next to each other. Or, it could break in a way where the pieces move. And when they move out of position, then the person can’t open or close their mouth.
For example, in young kids with softer bones and more water content, you could see something called a “greenstick” fracture. With that sort of break, things stay in the same place. Obviously, in adults especially, the kind of injury mechanism means it’s likelier to be displaced.
The chance of being displaced is much likelier when it’s bilateral rather than just on one side. So, his fractures, they’re displaced but not severely displaced, at least on one side, based on what we can see.
To touch on something you just said about being unable to close your mouth, one of the most striking things about the last round or so of the fight was Opetaia fighting with his mouth hanging open. Afterwards, he wasn’t even able to produce normal speech.
And that’s obviously scary to see as a layman. But it sounds like it was not as bad as it could have been if there were more severe displacement. Is that correct?
Well, for clinical purposes, we just define “displaced” versus “not displaced.” We don’t really evaluate severe displacement versus mild displacement. It would have no impact on the treatment. Either way, you have to take the pieces and put them back together when you fix the fracture.
With his displaced fracture, it’s hard to call it a “severe” displacement, because the pieces are still touching each other. But, it’s significantly displaced when I look at his pictures. You could tell that he’s off from both sides. And that’s the reason he had such severe issues with closing his mouth and speech. Because it was bilateral.
How do you repair an injury like this? What exactly happens in a surgical repair? How do you set it, and how do you get the fractures to heal correctly?
That’s a good question.
There are two pieces on each side of the angular fracture. The piece that has the teeth, and then the one that continues the angle of the jaw. You could go back and try to line them up visually after you’ve made an incision. But, the easiest way is to line up the lower teeth to the upper teeth. Because that’s how he has used them before.
So, when you align the upper and lower teeth together, you kind of wire them together so they stay tight. Then, you take the back piece and reposition it so it will line up [leaving the teeth in the position they held before]. Once it’s lined up, you put in one or two plates. It depends. With a bilateral fracture, you need to fix one of them rigid enough, but the other can be lined up with a plate that doesn’t have to be as rigid. The plate has screws in both sides. At least two screws, possibly three. Typically we put two screws on one side of the fracture, and two on the other side.
Sometimes we do that from the inside of the mouth. Sometimes, we do it from the outside of the mouth. In the case of an angular fracture, it could be either way, or both. Most people, the data shows that opening from the inside and inserting a plate, that’s an appropriate solution.
Some people need it to be very rigid. For an athlete here, he’s going back to fight eventually. Then we may do something called “belt and suspenders,” with a plate on the top, a small one. Also a plate on the bottom, a larger one.
I personally treat all fractures with at least one plate. And sometimes, to guard that and make sure the tiny screws don’t come loose, we wire the person’s jaws shut for a certain period of time. Once healing takes place around the screws, we can open the mouth and let them function, even if not 100%. We normally do that at about six to eight weeks, similar to other bones. If you break your leg, they keep you in a cast for six to eight weeks. We use that for the mandible, although the mandible heals faster than the leg. We still use that orthopedic principle, that after six to eight weeks the bone will fuse, and you’ll be okay.
Are there any potential complications that tend to happen, either during or after surgery, that could slow a recovery or cause secondary problems that extend initial recovery past eight weeks?
Yes. If the fracture is fixed well and done by an experienced surgeon who knows how the teeth fit together, we avoid something called dental malocclusion.
But, one thing that could occur from the injury or placement of screws, is injury to a nerve that runs inside the lower jaw. And that nerve actually carries sensation from the lower lip. If you’ve ever gone to the dentist and had a lower filling, and they’ve given you an injection in the back? When it makes your lip feel numb, or fat, that’s the same nerve. It runs inside the bone. And if the fractured piece moved, the nerve could be severed and the patient will have numbness.
If that displacement is severe enough, that person would lose sensation in the lower lip. If it’s fractured without displacement, or just slightly displaced, that person could have lower lip numbness temporarily. Sensation would return weeks or months later.
Now, sometimes that injury to the nerve can occur from the treatment. Because we’re inserting screws into the bone, and the nerve is right under the surface of the bone. If we put the screw into the nerve, you can cause that numbness from the surgery.
We hope that if [a nerve injury] does happen with a bilateral fracture, that it would only happen on one side at the most. That way, the whole lip wouldn’t be numbed. Only half.
Opetaia is a world class athlete, so “normal” means something very different for him than the typical patient. So, for a typical, non-athlete patient, how long does it take to resume a normal lifestyle?
It varies. Even though the literature doesn’t address it. During the recovery period, we make sure the patient doesn’t use their jaw functionally. We don’t want them trying to chew hard foods. And to do that, you have to wire the jaw together.
For some patients, if they’re a teacher for example, once I’ve put in a plate that I’m comfortable with, I may trust them to follow instructions when they can go and talk, but not chew or bite food. Or, get into a fight, for that matter.
But, even if the patient is unlikely to follow instruction, and I have to wire them shut, usually no longer than six weeks. If they’re over sixty, maybe I’ll give them seven weeks or so. But, after four weeks for a young person or eight weeks as an older person, we remove the wiring. And they can partially function, then gradually regain it at six to eight weeks.
Regardless of age, I tell people that after eight weeks, they can go and eat anything they want. I’m not sure that getting into a fight at that point is wise, because that’s a much more powerful force than chewing or talking.
Typically, there is a delay in functioning that’s no longer than eight weeks for most patients. Boxers are not most patients.
One thing that’s unusual about boxers is how they constantly have to manage a delicate balance between caloric intake, weight management, and other body and health needs. Opetaia fights at around 200 pounds, and the distribution and management of those 200 pounds is much different than what would be necessary for a more traditional patient at that same weight.
So, how does an injury like this impact Opetaia’s nutrition, or his ability to maintain something close to ideal boxing fitness while waiting to fully recover?
Well, when you wire people shut, they can’t have anything that’s solid. At best, they can eat milkshakes and smoothies, so they can ingest calories and get vitamins, some protein. At best.
But, the reality is that they cannot maintain adequate caloric intake similar to before the accident. When one has a break and is healing, the body needs even more calories for that healing and recovery. And it may not be possible to get those calories when you can only take in liquid.
I’ve been doing this for over thirty years. And almost everybody who gets wired shut, they lose weight. The question is, how long are they wired shut, and how much weight do they lose? If you can’t eat normal food for six or seven weeks, the range can be from ten pounds to fifteen pounds. That’s a lot for an athlete.
It’s almost enough to drop him a weight class.
For an athlete like him, you may have to modify the treatment. Maybe you don’t wire him shut for that long, and let him eat normal, but softer foods, earlier. For example, eggs can help you get calories and protein in a way that doesn’t require a lot of chewing. Maybe after four or five weeks, you modify that way, and then after eight weeks allow a full diet.
Another thing we sometimes do in this type of surgery that involves wiring people shut is to insert a feeding tube. A feeding tube is a tiny, IV-sized tube that goes through the nose down to the stomach. With that, you could have as much volume as you want. You’d put in a high protein, high calorie diet to feed the patient. You get a nutritional consult while in the hospital to guide how you maintain your caloric intake.
Someone like him, you’d put him through a nutritional consult even if he’s not wired shut, but just not allowed to eat regular food. And with the input of the surgeon saying: “No chewing for the first week, soft foods only for the second and third weeks.” With the surgeon telling the nutritionist what function and chewing is allowed at each stage, the nutritionist can design a plan for nutrition.
So, it sounds silly, but for an athlete who needs to maintain a certain level and type of caloric intake, one solution for the first few weeks may literally be to eat meals through their nose.
Yes. Through a feeding tube! Not quite as it sounds to try to eat through your nose. [Laughs]
But, yes. People who have a tube inserted, even for two or three weeks, lose less weight than people without a tube. So, why not give everybody a tube? Well, because it’s something in the nose. Even though it’s not painful, and you can tolerate it, it’s not really comfortable.
The second part to the functional aspect of rehabilitation and recovery of an athlete is, when can they go back and do some exercise? Because they can not maintain their muscle mass only through consuming enough protein, but also by using the muscles. And I generally say no exercise earlier than the second to fourth week.
One can use the treadmill, use a stationary bicycle, maybe walk or run in the street, but not exert the kind of force that requires you to clench the jaws. After eight weeks, one can expect to go to the gym and do what you want for exercise.
If the plate I put in is still in place, if the bite looks good, if the x-ray looks good? Normally, in a situation like this where there’s a hurry to go back to function, I’d do a consultation, tell them they can go, but to come back if they have any problems or discomfort.
So, it’s possible he could already be doing some light exercise. Obviously, he’s not going to be sparring, or anything that risks contact with the face. But, the other aspects of a boxer’s fitness and preparation, Opetaia could be a month or a month and a half away from getting back to that?
I think that’s fair. Anything that doesn’t include trauma to the jaw, such as a stationary bicycle or running and jogging on the street or a treadmill, I think one could do that as long as he feels strong enough.
The fight where Opetaia suffered this injury was a professional breakthrough, which makes the timing of this even worse for him. Can we expect him to come back from it? Does an injury like this jeopardize Opetaia’s future as a championship level fighter?
No. Short answer is no, I don’t think so.
Once the bone fuses to the way it was before, the likelihood of it fracturing from another trauma is not any higher because of these fractures. If you take a look at the x-ray a year after, the only thing you’ll see is the screws and the plate used to fix the fracture. You won’t see a fracture. Whether it was in the front, or the back, or if it was displaced. His jaw will fuse back.
So, for someone like him, I’d do plates on the top and the bottom. You take precautions, you allow waiting time for healing. Maybe modifications to treatment, because this is his life, and you do everything you can for their treatment.
We have a concept in medicine called patient centered treatment. If you’re a teacher, we treat your jaw fracture differently than someone who stays at home or works in a way that doesn’t require as much talking. So, as a boxer, I’m sure his surgeons have taken special consideration of his circumstances. It has to be modified for patient needs. And the goal is to get that patient back to the ring as soon as possible.
In a previous explainer about retina injuries, we got into the concept of patient centered treatment a little bit. The doctor there explained that if I came to him after a retina injury and said I wanted to start boxing recreationally, he would strongly advise against it because of the potential risks. But, for a person with a life built around a boxing career, there’s a totally different calculation around the acceptable risks and treatment path for them.
Yes. Yes. That’s exactly the concept of patient centered treatment.
If you break your leg, you may have needs focused on regaining normal movement and function. But if you are a runner, I have to modify the treatment, the post-operative instructions, and the activities compared to how we treat someone that doesn’t plan on running a marathon.
You’ve discussed this recovery process in a way that indicates it isn’t likely to result in recurring problems. We’ve seen other fighters suffer different fractures that turn into chronic issues. Usually, that’s hand or orbital related. But, it sounds like Opetaia probably doesn’t have to worry any more about future jaw fractures than any other fighter would, right?
That is correct. Other than what we discussed before about numbness in the lower lip. If those nerves are severed, they will not come back. There may be some compensation, some return, but also possibly no return at all if the nerve is damaged.
Sometimes, if the surgeon does not line up the teeth well, and creates a malocclusion, that could predispose them to repeat problems. But…
That seems unlikely here. I can’t imagine a world class boxer going shopping for a cut-rate surgeon in a situation like this.
Yes. Exactly. This is not a very specialized, complicated surgery to do.
Now, it’s very unusual, but I will mention it. I have seen a plate damaged or broken from a second trauma. And the jaw would re-break from the second trauma. But, again, that’s unusual during the recovery process, and it’s unlikely to be relevant here.
Another thing to mention is that the presence of wisdom teeth is a risk for fractures for a boxer. Breaks don’t happen randomly in which part of the jaw is affected. When a fracture occurs in the front part of the jaw, it’s usually related to the canine teeth. They have long roots, and that long root takes a significant part of the height of the mandible. The root of the tooth is weakness rather than strength in the jaw. And wisdom teeth by the angular part of the jaw, they also take a significant part of the depth and width of the jaw. You basically have a wedge that’s sitting there, a weak part of the jaw where it’s likelier to break.
It’s been discussed in some instances that some recommend a boxer may want to have their wisdom teeth taken out so they don’t have that weak spot. And the bone heals from removed wisdom teeth in about six months. If you take an x-ray, you can’t even tell there was a tooth. So, there’s the thought that removing the wisdom teeth, even if they aren’t impacted, could help minimize that risk of unilateral or bilateral angular fracture.
What sort of timeline might we assume for an Opetaia comeback? If we’re being conservative, or being optimistic, what sort of range could it be until he’s ready to start a training camp for a professional fight?
I think he could start eight weeks out for training purposes. For a young person, that’s plenty of time for the bone to fuse. Once we know he’s healing, his bite is correct, the plates and screws are still in place, he could gradually start back into training. And, as time goes by, he could do more and more and start working his way back to the ring by the third month or so.
[Dr. Abubaker asks questions about when and how Opetaia might wear headgear]
He would wear headgear to train and spar. But, as a professional, he would have to fight without it. So, he could start a training camp for a fight and go through it all with the protection of headgear. But, for the fight itself, which would probably be about two months after starting a training camp, he would be fully exposed. How does that influence the timeline?
I think that’s reasonable. Three or four months to get back into the ring? And he knows now that he needs to avoid severe trauma.
I believe I read the first of the fractures happened in the second round of his fight?
That was the word from his team right after the fight.
And he probably got the second fracture from trying to protect the side that was already broken. Turning, protecting his head, makes it more likely to get hit on the other side. Then, you have the other fracture.
I think in three months, somebody like him could go back to the ring. I am not his trainer, so I don’t know what is going on. But, if I were his oral surgeon? Maybe three months, probably no more than four months, he could get back to normal life including getting back in the ring.