Professional Documents
Culture Documents
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CONTENT:
S.NO.
1. Introduction 24-31
2. Definitions 32-33
9. Conclusion 133-136
Ϯ
LIST OF FIGURES:
S.NO TOPIC FIGURE NO. PLATE
NO.
ϭ͘ Sports Activities Can Be Better Enjoyed When Figure. 1 1
Safety Is Ensured
Ϯ͘ Usage Of Various Types Of Adequate Protective Figure. 2 2
Devices By Sportsmen. (A),(B),(C)
(A) ± Mouthguard, (B) ± Helmet,
(C) ± Mouthguard & Helmet
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ϲ
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ϭϭ
ϭϮ
ϭϯ
ϭϰ
LIST OF TABLES:
S.No. Topic Table No. Plate No.
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INTRODUCTION:
7KH ZRUG ³VSRUW´ GHULYHG IURP ROG FRPELQDWLRQ RI ZRUGV OLWHUDOO\
under a publicly agreed set of rules & with a recreational purpose: for competition, for
self enjoyment, to attain excellence, for the development of skill or some combination
of these.1 Sport related activities not only endanger the parts of the locomotor system of
an individual but also other body parts which may not be directly involved.2 (Fig. 1)
Boxing, football, track & field events have been the very initial
markers to bring to notice that traumatic injuries to dental/orofacial region could pose
serious health problems due to collision & contact involved in these sports. Physical
and exertion of harmful forces onto the opponent. These forces may also be tremendous
rollerskating.3,4
sport or athletic activity may be at risk of dental/orofacial trauma. Not only the
professional athletes but also the recreational athletes may sustain injuries with an
increased proportional risk due to lack of training.2 Therefore we may be assertive that
Ϯϰ
one of them being assurance of oral health for sportsmen and athletes. These activities
deal with avoiding mishaps that might severe the orofacial complex during training
sessions or competitions.5 'DWLQJ EDFN WR ¶V OLWHUDWXUH UHSRUWV WKDW RQH WKLUG RI
dental injuries occurred due to sports & others due to accidents mostly at home. 2 Dental
and facial injuries contribute to 39% of total injuries experienced by youth during
sporting activities as cited by Castaldi.6 Upto 35% of all children and adolescents suffer
accidents involving permanent teeth, particularly the front teeth of the upper jaw and
crown fractures being the most frequent dental sports injury.10 Injuries to the dentition
are not only distressing to children but to parents as well along with significant
psychological and social impact.6,7,8,9 Severe dental trauma calls for elaborate therapy
and exorbitant treatment costs.11 Hence, it highlights the role of a dental professional in
Academy for Sports Dentistry the main goals of sports dentistry include prevention and
injuries.2
practice, differs from other traumas mainly because it can be prevented, with the
possibility of drastically reducing its occurrence by the potent use of mouthguards and
other protective gears that propagate protection of all dental and periodontal
structures.12
Ϯϱ
for protection during sport activities however sadly there is a huge proportion of athletes
who choose not to wear them.13 Scientists have time and again stated that mandatory
orofacial protection by athletes during sporting activities will majorly help to prevent
trauma and lifelong discomfort.2 0RXWKJXDUG GLVWULEXWH WKH LPSDFW RI D µEORZ¶ HYHQO\
boxing15. Today, mouthguards are being used both at the amateur and professional
levels of several sports. In 1998, it was reported that most studies classify dental injury
to be the most common orofacial injury attributed to sports.16 Our goal as sports dentists
dental protection. By the year 2000 there were five amateur sports that mandated the use
RI PRXWKJXDUGV ER[LQJ IRRWEDOO LFH KRFNH\ PHQ¶V ODFURVVH DQG ZRPHQ¶V ILHOG
A recurring concern deals not only with peer perception, but whether
or not the mouthguard has an effect on speech, breathing, and comfort. Thickness of the
mouthguard has been an ongoing question. Several authors have stated that the ideal
maximum speaking efficacy and maximum respiratory efficiency.16-19 In the study, they
found that both forms of EVA prevented dental injuries in all subjects. That degree of
improve comfort.16-18
Ϯϲ
various mouthguard thicknesses concluded that the optimum mouthguard thickness was
stomatognathic trauma during sports.21-24 The thickness of the mouthguard influences its
preventive effects from injuries. The thickness of the mouthguard also has influence on
the feel of fitting as well as pronunciation, which will affect whether one continues to
mouthguard.26-30
forces when impacted also revealed that a preference for 4 mm thickness over critical
areas such as incisal edges and tooth cusps.35 Park et al.26 reported that the average
amount of thinning at the occlusal surface of the mouthguard was 25% and that of the
labial surface was 50%. Guevara et al.27 described a 36% rate of thinning along the
incisors. Del Rossi et al.29 showed that the average amount of thinning that occurred at
the occlusal surface overlying the molars was approximately 46%, and the amount of
thinning along the labial surface of the central incisors and canines ranged between 47%
and 60%. Geary et al.30 revealed that the sheets of 3 mm EVA stretched by 52% during
the thermoforming processes, and the material stretched by 72% at incisal sites,
reducing thickness to <1 mm. It was cleared that the thickness of the mouthguard sheet
lessened when the height of the working model was enlarged.33 Takahashi in 200331 and
2004,32 reported that how the thermoplastic mouthguard sheet elongated and how the
Ϯϳ
thickness of the sheet changed depending on the heating condition and concluded that it
was difficult to maintain the thickness of the anterior teeth area of the mouthguard.33
maintain the proper thickness of the mouthguard. There are many reports concerning the
thickness needed.35-38 The mouthguard sheet over the facial surface of anterior teeth
requires a thickness of 3±4 mm, and the sheet over the buccal surface of posterior teeth
and the occlusal surface needs a thickness of 2±3 mm.35 Hoffman et al.36 reported that a
minimum layer thickness of 3 mm was required. Tran et al.37 suggested that appliances
should be at least 4 mm thick to optimize their protective qualities. With such a high
transmission through materials of various designs and thicknesses using drop-ball and/
or pendulum devices designed to deliver impact forces.16,20,40-48 Takeda et al.49 took this
a step further by applying actual sports related impact objects (i.e. hockey puck,
baseball, wooden bat) to the model as opposed to the traditional steel rod/sphere. In an
additional study by the same author, strain gauges were found to be the most sensitive
to measure the shock absorption abilities at the impact point when considering a
relatively soft impact object such as a hockey puck.50 Study conducted by Wet et al,51 a
double layered mouthguard with a sponge insert registered the highest shock absorption.
published evidence to indicate that mouthguards reduce the likelihood of dental trauma
or facial and brain injury from the impact force.52 Since their inception more than a
Ϯϴ
century ago, a lot of improvement has been made to make mouthguards more efficient
to prevent transmission of excessive force to the teeth and jaw by absorbing high-impact
energy. Of the three main types of mouthguards i.e. stock, boil-and-bite, and custom
made, the last one had been reported to show superior properties in terms of comfort,
adaptability, stability, ability to talk and breathe along with better protection.53,54
difficulties during the game, breathing problems and compromised aesthetics. However
during training session and when competing due to its technological properties and
appropriate design.2
care professional were asked to determine whether a child with a health condition
estimating the relative risk of an acute injury to the athlete by categorizing sports as:-
Contact, Limited Contact, Non Contact Moderately Strenuous & Non Strenuous type of
sports .58
with inanimate objects including the ground with great force. eg, Boxing, Ice hockey,
Football, Lacrosse, and Rodeo. In Contact Sports athletes routinely make contact with
Ϯϵ
each other or inanimate objects but usually with less force than in collision sports. eg,
Basketball, Soccer, Boxing, Football, Field Hockey, Ice Hockey, Lacrosse, Martial
Sports like Taekwondo and Judo, Baseball, Rugby, Inline Skating, Skating and
contact sports can be as dangerous as collision or contact sports. eg, Softball, Squash,
Noncontact Sports in which contact is rare and unexpected, serious injuries can occur.
eg:- Running, Tennis, Badminton, Power lifting. Moderately Strenuous Contact sports
are Badminton, Curling, Table Tennis. The Non Strenuous Contact sports are Achery,
Golf, Riflery.58
organized sports on the basis of traumatic dental injuries (TDIs) that are High-Risk
Sports which has high physical risk sports and high probability of serious injury or
death as a consequence of practicing such sport.59 It includes Football, Field hockey, Ice
hockey, Lacrosse, martial sports like Taekwondo and Judo, Baseball, Rugby, Inline
which rough contact between the players is allowed or in which a ball, puck or stick is
used.60 Medium-Risk Sports are those with a higher probability of being injured than
encountering death, the arena where the sport takes place is limited and the environment
polo. It includes those sports in which rough contact between the players is not allowed,
but there is still a risk of contact or falling.60 Low-Risk Sports have a very low
ϯϬ
Running and Billiards. It includes sports in which rough contact between the players is
social, personal and physical development. It helps promote the adoption of a healthy
lifestyle and prevention of diseases and illness. The smile and the aesthetics of the
order to reduce their number.2 To increase acceptability and use adequately fitted
the Academy for Sports Dentistry position statements.5 Infact subsequent care and
ϯϭ
DEFINITIONS:
R
Sport: 6SRUW LV GHULYHG IURP DQ ROG FRPELQDWLRQ RI ZRUGV WKDW OLWHUDOO\ PHDQ ³WR FDUU\
DZD\IURPZRUN´DVSRUWFRQVLVWVRIDQRUPDODFWLYLW\RUVNLOOFDUULHGRXWXQGHUDSXEOLFO\
agreed set of rules, and with a recreational purpose: for competition, self- enjoyment, to
R
Sport Dentistry: According to the International Academy of Sports Dentistry (IASD),
"sports dentistry involves prevention and treatment of oro-facial athletic injuries and
related oral diseases as well as the collection and dissemination of information on dental
R
Trauma: Trauma refers to injury; damage; impairment; external violence producing
injury or degeneration.1
R
Traumatic: Traumatic means pertaining to or occurring as a result of or causing trauma.1
R
Traumatology: Is a branch of surgery that deals with wounds and disabilities from
injuries.1
R
Traumatic Injury: It may be defined as a damage to a part of the body tissue.1
R Dental trauma: Refers to trauma to the face, mouth, and especially the teeth, lips and
ϯϮ
R Injury: Any physical complaint sustained by a player that results from a sport match
eg:football or football training, irrespective of the need for medical attention or time loss
R
Medical Injury: An injury that results in a player receiving medical attention is
UHIHUUHGWRDVD³PHGLFDODWWHQWLRQ´LQMXU\64
R
Time Loss Injury: An injury that results in a player being unable to take a full part in
IXWXUHIRRWEDOOWUDLQLQJRUPDWFKSOD\DVD³WLPHORVV´LQMXU\ 64
medical practitioner.64
R Mouthguard: The ASTM (American Society for Testing and Materials) defined Athletic
Mouthguard as a resilient device or appliance placed inside the mouth (or inside and
outside) to reduce mouth injuries particularly to the teeth and surrounding structures.
The IASD (International Academy for Sports Dentistry) statement on ³$ 3URSHUO\ )LWWHG
0RXWKJXDUG´,QWKLVVWDWHPHQWWKH,$6'DGRSWHGWKH$670RSHUDWLRQDOGHILQLWLRQIRUD
mouthguard. The IASD statement goes further to state that the single word "mouthguard"
ϯϯ
REVIEW OF LITERATURE:
MOUTHGUARD IN SPORT :-
Krause W (1890)249 Reed stated that the first known attempt to make a device
specifically to protect the oral structures in organised sports was done in the
1890s when a London dentist named Woolf Krause put together strips of gutta
percha and attached them on the maxillary teeth of a boxer. The main purpose of
those gutta percha strips appears to have been to protect the boxer from lip
laceration and other soft tissue injuries rather than actual dental injuries.
mouthpiece for a boxer who was also has son Young Krause was not only a
dentist but also a keen amateur boxer himself. He apparently further developed
WKH ³JXPVKLHOG´ WR VRPHWKLQJ WKDW DSSURDFKHV ZKDW LV NQRZQ WRGD\ DV D
mouthguard. He used vella rubber rather than the relatively hard gutta percha to
introduced by boxers in the 1920s and 1930s, also were used by gridiron
GHQWLVWV 7KH IRUPHU GHPRQVWUDWLQJ WKDW µWKH ZHDULQJ RI D SURSHUO\ ILWWHG
mouthguard DOO EXW HOLPLQDWHG PRXWK LQMXULHV LQ KLJK VFKRRO IRRWEDOOHUV¶
mouthguards reduced the intracranial pressure and hence the force of impact to
ϯϰ
the brain arising as a result of a blow to the chin. This effect is most likely
achieved by increasing the space between the head of the condyle and the
wearing mouthguard and measured the ventilator gas exchange its effects of
wearing a mouthguard and found that the wearing of mouthguard did not
level whereas the oxygen consumption was significantly reduced at the heavier
workload.
Danis PR, Kuolung HU and Bell M (2000)252 reviewed and assessed the
UHODWLYH LQMXU\ UHGXFWLRQ HIIHFW DQG DFFHSWDELOLW\ RI IDFHJXDUGV RQ EDWWHU¶V
helmets. They conducted a non randomized prospective cohort study among 238
youth league baseball teams in Central and Southern Indiana during the 1997
season. Coaches, parents, and players were asked to respond to pre-season and
with face guard helmets as an intervention and all others used this protection at
their discretion i.e for comparison. Parents, players, and coaches the intervention
effect of face guard use on player performance. So, they concluded that Helmet
face guards should be required for batters to prevent facial injuries in baseball.
sports mouthguards research shows that orofacial injury in sport is prevalent and
ϯϱ
Reasearch also confirms that mouthguards can prevent orofacial injuries. The
integral role in the prevention of orofacial injury in sport and promote properly
present a risk of orofacial injury at the recreational and competitive level, in both
Takeda T (2006)134 applied the exfoliation test and some treating techniques
and conditions that improve the adhesive strength on a laminated surface long
and skill in fusing sheet is required. Maximal laminated bond strength can be
obtained by minimal heating time and proper treatment with the use of solvent,
elimination and direct heating on bonding surface. The differences in the colour
of the materials influenced adhesion. Clear and light coloured materials showed
higher adhesive ability. Water sorption did not affect the adhesive strength.
Rossi GD, Marco A and Vidal L (2007)255 conducted a study that evaluated the
contribution that various dimensional characteristics of the dental arch and the
height of the stone model would have on mouthguard thinning. Fifteen subjects
three replicas of the maxillary dentition with only the height of the base varying
ϯϲ
amongst them. The total height of the three models were 20, 25, and 30 mm. A
single mouthguard was produced using each of the stone models. The material
thickness of the mouthguard was assessed at the labial and occlusal surfaces.
The results of the study indicate that the height of the model used to fabricate
custom mouthguards should be kept as low as possible but still allow for the
have established that strain transferred to the teeth through mouthguard is a good
indication of their efficiency. Here are some advantages i.e, very small size and
using FBG sensors. Finite-element analysis was performed to simulate the stress
µSKDVH PDVN¶ 7KH LPSDFW ZDV SURGXFHG XVLQJ FXVWRPL]HG SHQGXOXP GHYLFH
with interchangeable impact objects i.e. cricket ball, hockey ball, and steel ball.
Response of gratings was monitored using optical spectrum analyzer and strain
induced due to each impact was determined from the Bragg wavelength shifts
for each grating. So, the result was that Strain induced due to impact that was
calculated from the Bragg wavelength shifts. The Bragg wavelength shifts
(induced strain) for FBG bonded on the jaw model was much lower than the
ϯϳ
shift for FBG bonded on the mouthguard, indicating that most of the impact
sheet according to the holding conditions during heating. The material used in
this study was Sports Mouthguard (3.8 mm thickness), and two holding
conditions of the sheet were undertaken. The sheets were formed using a
vacuum former when the sheets were heated until they hung 2.0 cm from the
baseline. The results showed that the thickness of the sheet differed statistically
and significantly at the regions of the sheet that fitted over the anterior teeth and
posterior teeth (P < 0.01) and the palate (P < 0.05). The thickness of the
condition that the sheet was held all around the periphery was thinner than that
of the condition that the sheet was held at only four points. These results
suggested that the thickness of the sheet was maintained by holding the sheet
only at four points, and this new method could be an effective way to maintain
lightweight face guard (FG). Material was four commercial 3.2-mm and 1.6-mm
two experimental materials were examined for use in FGs. The result of the
study was the flexural strength (74.6 MPa) and flexural modulus (6.3 GPa) of
ϯϴ
the experimental material with four sheets were significantly greater than those
of the 3.2-mm commercial specimens. The first peak intensity (515 N) and
maximum stress (2.2 MPa) of the experimental material with four sheets were
results suggest that the thickness and weight of the FG can be reduced using the
Pae A, Yoo Ra, Noh K, Paek J and Kwon KR (2013)257 determined the effect
golfers. Eight professional golfers with a mean age of 20.5 were selected. These
club head speed, initial ball speed, and putting accuracy were compared and
analyzed before and after the application of equal bilateral molar occlusion.
stabilization splint, the club head speed and driving distance in the presence of
the oral appliances were significantly increased compared with those without the
were adjusted it results in unilateral molar occlusion, the club head speed and
The initial ball speed and the putting accuracy were not affected by the use of
performed. The occlusion stability that results from stabilization splints and
ϯϵ
mouthguards is thought to increase the club head speed and driving distance in
children who sustained injuries during sporting activities and were treated at
Trondheim Regional and University Hospital were included in the study. It was
found that sport accidents accounted for 27 % of all childhood accidents in this
age group. 53% of the boys and 47 % of girls were injured. The boys sustained
more severe injuries than the girls. Soccer caused the greatest number of
injuries. Horse riding and alpine skiing were the cause of the most severe
injuries. It was concluded that sports accidents were common and could be
between 1984 and 1993 and concluded that sporting injuries were becoming
ϰϬ
sports related orofacial injuries. This policy was intended to educate dental
professionals, health care providers, educational and athletic personnel about the
prevention of sports related orofacial injuries. They concluded that sports related
facemasks and mouthguard & have been shown to reduce both the frequency
classifications currently used to report dental injuries. Type and dental locations
Classifications used were Andreason, WHO, Ellis and Garcia Godoy. Accidents
within and around the home were major sources of injury to primary dentition
while accidents at home and school accounted for most of the injuries to
traffic were also common causes of it. Most frequent type of injury was simple
mouthguard and helmets while playing sport could avoid trauma. It was
problem and their prevalence has increased during the past few decades.
ϰϭ
types and severity of oral trauma and the time elapsed until seeking dental care
oro-facial trauma for children aged 17 years and younger who presented at the
which 112 patients with traumatic oral injuries visited the hospital during this
period. 79 were males and 33 were females. The highest frequency of injury was
seen in 9±11 year old children. The most common cause of trauma was due to
falls (68%). Most of the dental injuries occurred in the street (57%). The most
common types of injury were luxation injuries and complicated crown fractures.
Maxillary teeth were more affected than mandibular teeth. Maxillary central
incisors were found to be the most affected teeth. 51 patients had soft tissue
injuries and 13 patients had facial bone fractures. The largest number of injuries
presented on the same day for treatment (70%) or 1 day after (36%).So they
concluded that this study population showed trends and common cases of
years old school children in Dera Bassi. It was found that overall prevalence of
dental trauma was 14.5%, out of which 63.2% males and 36.4% females were
affected. Maxillary central incisor was found to be the most commonly affected
tooth (43.8%). The most common cause of injury reported was fall during
ϰϮ
II div I malocclusion being a greater risk factor (21.9%) for traumatic injuries. It
was concluded that enamel fracture was most prevalent. No risk factor was
significantly higher than others KRZHYHU FKLOGUHQ ZLWK $QJOH¶V FODVV ,, GLY ,
encouraged in all contact sports, as the most important value of the mouthguard
is the concussion saving effect following impact in the mandible. This fact alone
Australian Rugby Union Touring Team (the Wallabies), 80% wore mouthguard
half of these instances mouthguard was not worn at that time. Of the players
who wore mouthguard, 37.5% would not play a game without their mouthguard,
58.3% would play without their mouthguard but only if absolutely required to
and only 4.2% would be willing to play without their mouthguard. The main
complaints were difficulty with talking, breathing and uncomfortable fit. It was
concluded that the usage of custom made mouthguard was very high in the1984
Wallabies & hence, Custom made mouthguard were delivered to all the
benefits´ that dental injuries are the most frequently incurred orofacial injuries
ϰϯ
from sports activities. The public is largely uninformed about the serious
resulting from orofacial sports injuries can range from the considerable pain and
expense in replacing a lost tooth to the greater impairment and cost resulting
from a concussion that can end a sports career. Parents, athletes (professional
and nonprofessional), coaches, and trainers largely minimize and deny these
against the possibility of an injury. A survey by Karl reported that even in the
not educate the players and then make mouthguards mandatory, as are protective
helmets in hockey. They concluded that more than 5 million teeth are avulsed
each year due to sports injuries and trauma, and in certain cases these avulsions
fitted mouthguard. Not only do mouthguard protect the teeth, but they also
protect the head against a blow to the jaw that can result in a concussion and loss
of consciousness.
occurrence of dental hard and soft tissue injuries during participation in contact
sports, and the awareness and use of mouthguards in a young adult sample of
Samples consisted of 274 young adults [174 male (63.5%) and 100 female
(36.5%)] aged between 17 and 27 years of which 185 (67.5%) were tae kwon do
ϰϰ
questionnaire. All answers were evaluated and then statistical analyses were
trauma. Of these sufferers, 32 (17.3%) were boxers and 29 (32.6%) were tae
kwon do practitioners. It was found that 19 (6.9%) athletes lost their teeth post-
trauma. Of the 54 subjects (19.7%) suffering soft tissue injuries, 44 were female
(81.5%), while only 10 were male (18.5%), of which 40 (74.1%) were tae kwon
subjects, 228 (83.2%) were well informed about mouthguard usage. Of the total
sample, 153 (55.8%) of the subjects used mouthguards, all of which were boil-
and-bite type. The results of our study indicate that dentists and sports
such as tae kwon do and boxing, which have a serious risk for dental and oral
families against recreational trampoline use and discuss that current safety
measures have not decreased injury rates significantly. The AAP also states that
SUDFWLWLRQHUV ³VKRXOG RQO\ HQGRUVH XVH RI WUDPSROLQHV DV SDUW RI D VWUXFWXUHG
SODFH´ 7KH SXUSRVH RI UHYLVLRQ RI SROLF\ LV WR UHFRJQL]H WKH SUHYDOHQFH RI
sports-UHODWHG RURIDFLDO LQMXULHV LQ RXU QDWLRQ¶V \RXWK DQG WKH QHHG IRU
prevention.
ϰϱ
(2010) 260 evaluated the prevalence of orofacial injuries during practice of sports
Brazil. Out of the total number of students surveyed, 37.02% claimed to have
already sustained some kind of orofacial injury. Out of these, only 9.90% sought
dental assistance after trauma. The most common injuries were bleeding
interviewees, 19.24% had already used mouthguard and 44.89% considered its
use as important. Hence they concluded that the prevalence of orofacial injuries
during sport activities was high in the studied sample and only few of the
these injuries.
EDVNHWEDOOSOD\HUVLQ%HQLQ&LW\1LJHULDDQGVXUYH\HGWKHDWKOHWHV¶DZDUHQHVV
attitude and use of mouthguards. Amongst basketball players in the Benin City
was 3.7 ± 1.8. The prevalence of both facial and oral injuries among the
respondents was 62.8% with the lip and gingiva most commonly involved
respectively. The common causes of the orofacial injury reported were from
elbows of opponents, falling and collisions with other players. The prevalence of
ϰϲ
and duration of participation. More than half had heard and seen mouthguard
and the coach was the leading source of information. The reasons for non-use of
Hence, concluded that the high prevalence of orofacial injury among basketball
players reported in this study justifies the need for multidisciplinary injury
injuries still occur even with the use of a conventional mouthguard. We have
developed a mouthguard the Hard & Space mouthguard with sufficient injury
prevention ability (more than 95% shock absorption ability against impact) and
EVA layer and a middle layer of acrylic resin (hard insert), with a space to
prevent contact between the inner surface of the mouthguard and the buccal
surfaces of the maxillary front teeth or teeth already weakened through prior
which the Hard & Space mouthguard may easily be fabricated. We believe that
this new type of mouthguard has the potential to reduce sports-related dental
injuries.
ϰϳ
the frequency and severity of orofacial injuries, but it is not always used as
athletes find it difficult to tolerate. Study determined the awareness and the
extent of mouthguard use in a sample of young rugby athletes in the North West
of Italy. Material was the athletes of four amateurs rugby teams based in the
use and type of mouthguards, disturbs associated with mouthguard use, and
general attitudes towards mouthguards. The results was only 53.85% of the
subjects reported wearing their mouthguard all the time both during training and
non-use of mouthguards was observed and the conclusion of the study was
limited knowledge about oral injury prevention and limited use of mouthguards
were observed. Also it is suggested that educational courses for rugby players
to reduce common complaints about these devices and increase their usage.
etiologic factors and the use of protective devices during contact sports.
buffering the impacts or blows that might otherwise cause moderate to severe
injury, some authors claim that mouthguards can enhance athletic performance.
ϰϴ
players, there habits with regard to mouthguard usage as well as their general
that most frequent sport injury and the cause of injury was a blow from another
player, they were unaware about mouthguard the awareness was only 15.6% and
no one used mouthguard. Conclusion drawn was that handball players needed
mouthguards, in which it is clearly said that now the main focus has been on
ϰϵ
ϱϬ
The tremendous popularity of organized youth sports and the high level of
competitiveness have resulted in a significant number of dental and facial injuries.66 The
accidents(9%).68 The majority of sport-related dental and orofacial injuries affect the
upper lip, maxilla with 50-90% of dental injuries involving the maxillary incisors.66,67
Studies have affirmed that increasing over jet, inadequate lip coverage, class II division
1 occlusal relationship, and so on, are the most common risk factors for dental trauma.69
All sporting activities have an associated risk of orofacial injuries due to falls,
collisions, contact with hard surfaces, and contact from sports-related equipment. Sports
accidents reportedly account for 10-39% of all dental injuries in children.67 Children
most susceptible to sports-related oral injury are those between the ages of 7 and 11
years.66 The administrators of youth, high school, college football, lacrosse, and ice
hockey have demonstrated that dental and facial injuries can be reduced significantly by
basketball, soccer, softball, wrestling, volleyball, and gymnastics lag far behind in
injury protection for girls and boys.66 As the number of individual involved in sports
ϱϭ
fractures. Many of the published studies regarding dental injuries and participation in
contact amongst players and those which do not. Contact sports are defined as the sports
in which players physically interact with each other, trying to prevent the opposing team
or person from winning. The intensity and frequency of the contact during competitions
can be the main determinants of dental injury. Consequently, the type of contact can be
classified as direct contact with rival competitors (taekwondo, kickboxing, boxing, etc),
indirect contact with rival competitors (handball, basketball, football, soccer, ice
hockey, etc.) and no contact with rival competitors (volleyball, badminton, etc.) during
Dental trauma in sport activities, especially in children and young adults has
been reported with injuries quantifying to 11-60% (Caglar et al. 2005).70 Facial trauma
results in fractured, displaced or lost teeth and can have significant negative functional,
aesthetic, and psychological effects on children. The 7-13 year age group is considered
the most prone to any form of dental trauma, because this is school age where
increased physical activities & playing sports mainly which is contact type.71 Also at
this age children learn a variety of individual and team sports involving body contact or
use of hard objects i.e hockey sticks, cricket balls etc.72 Furthermore, boys sustain
dental trauma almost twice as much as girls, exhibiting significant gender differences
ϱϮ
Sahlin Y73 in 1990, stated that 5 to 14 years of age was the most commonly
affected during sporting activities. Similarly, Al-Malik M74 in 2007, stated that the
highest frequency of injury was seen in 9-11 years old children in Saudi Arabia. Dua R,
Sharma S69 in 2012, stated that 7 to 12 years age group is considered the most prone to
In all the studies, it is generally found that males tend to suffer more sports-
related dental injuries as compared to females. Sahlin Y73 in the year 1990, stated that
53% of the injured were boys and 47% were girls. Al-Malik M74 in 2007, stated that
70.5% males and 29.3% females suffered injuries Dua R, Sharma S69 in 2012, stated
participation Sahlin Y73 in 1990, stated that it was found that sports accident accounted
for 27% of all childhood accidents. Dua R, Sharma S69 stated that in 2012, overall
prevalence of dental trauma was 14.5%. Nishimura et al75 reported a higher injury rate
McNutt et al75 in 1989 reported that 40% of basketball and baseball players
experienced oral trauma. Sahlin Y73 in 1990, stated that soccer caused the greatest
number of injuries whereas horse riding and alpine skiing were the cause of most severe
injuries. Dua R, Sharma S69 in 2012, stated that the most common cause of injury
ϱϯ
Al-Malik M74 in 2007, stated that maxillary teeth were more affected
(92.9%) than mandibular teeth (3.5%) with maxillary central incisors found to be the
most affected teeth. Dua R, Sharma S69 in 2012, maxillary arch was involved in 93.7%
of the cases, most common type of teeth affected were the permanent maxillary central
incisors, the maxillary right central incisor being the most commonly affected
tooth(43.8%).
Hence, from various studies, it has been concluded that sports accident reportedly
account for 10-39% of all dental injuries in children. Children between the ages of 7 to
11 years are more susceptible to sports-related oral injuries with boys being affected
trauma. The literature indicates that the maxillary central incisors are injured more
The most frequent cause of injury is fall. Fall when playing (37.5%) were
significantly higher than other causative factors like fighting or bicycle fall. Fifty-two
percent of the patients encountered injury in and around their home, 41% in school, and
Sports were the most common cause of mandibular fractures, accounting for
31.5% followed by road traffic accidents (27.2%) and falls (20.8%). The yearly
55.3%, whereas cycling and soccer accounted for 25.4% and 8.9%, respectively. Sex
ϱϰ
distribution showed a male-to-female ratio of 2.5:1. In cases of cycling-related
accidents, there was a considerable prevalence of associated injuries (133.3 injuries per
100 mandibular fractures), with significantly higher rates of facial lacerations (73.2),
tooth fractures (39), tooth luxations (24.4), and orbital fractures (3.7) than in the case of
soccer, mucosal lacerations, tooth luxations, and cerebral concussions were the only
Tooth fracture were the most common type of traumatic injury, and resulted
in 42% of all reported cases. A single fractured tooth was involved in 65% of these
incidents. Permanent teeth accounted for 70% of all fractures. The fracture cases were
divided according to fracture type, using the Ellis classification system. Twenty two
percent of fractures of permanent teeth were class I fractures, 61% were class II
fractures, and 12% were class III fractures. Root fractures involved only 5% of the
fractured permanent teeth. Thirty ± five percent of fractured primary teth were class I
fractures, 25% were class II fractures, and 18% were class III fractures. Root fractures
were present in 23% of fractured primary teeth. These results are summarised in table -
3.
Dental and maxillofacial injuries are infrequent during first year of life, but
can occur occasionally due to fall from a stroller, bed or chair. One peak incidence
period for dental injuries is just beginning of school age and mainly the result of falls. In
young children, bicycle accidents are more common, but trauma could be due to an
basketball, playground activities, football and a few other sports. Some sports injuries
ϱϱ
result from accidents; others are due to poor training practices, improper equipment, and
Sport accident accounted 13% injury, literature reported 59% falls occurred
indoors and 41% out of doors. 3% injury is being by hit by an opening door, bicycle
accident resulted in 12%, car accident accounted for 2%.80 Falls appear to be the most
common factor in dental injury in both primary and permanent dentition. 45% falls,
11.3% accident 22.6% sport injuries reported by Caliskan and turkun in 1995,81 82%
falls,13% sport accident, reported by onetto et al in 1994,82 26% falls, bicycle accident
engaging in contact sports are at greatest risk for dental injury.71 Literature review by
Kumamoto and Maeda, in 2003, which included 104 articles published on international
sports-related orofacial trauma during the last 20 years, indicates that the injury rates
varied depending on the age of the athletes, the sport, and the geographical location of
B).Site:
Face is the most vulnerable area of the body and is usually the least protected.
Sports-related facial injuries account for 8% of all facial soft tissue injuries.
Approximately 11-40% of all sports injuries involve the face. These injuries are most
often due to direct hits with a ball or player-to-player contacts. Health care providers for
athletes should be familiar with the anatomy of the facial region, the most common
types of facial injuries, and the initial management of facial injuries. The most common
types of sports-related facial trauma are the soft tissue injuries and the fractures of the
ϱϲ
combination.77, 78
Depending on the extent and the types of injury, some injuries can be
managed at the sporting event site, with the athlete resuming play immediately. Sports
injuries can cause potentially serious broken bones or fractures of the face. Three group
children and adolescents, middle-aged athletes, and women are particularly vulnerable.
Contact sports have inherent dangers that put young athletes at special risk for severe
injuries.77,78
ϱϳ
1. Object: Most injuries in sports are related to the impact of blunt objects as a
result of collision between players, falls, injury by a fist, ball, hockey stick etc.
the physical nature of the object (shape, size and density), force and actual
a) Age: In children, sports injuries are mostly seen in the 7-13 year age group.
At this age children learn a variety of individual and team sports involving
body contact or use of hard objects i.e hockey sticks, cricket ball, etc.
d) Malocclusion: Class II div I molar relationship, over jet greater than 4mm,
short upper lip or incompetent lips, mouth breathing increases the risk of
dental injuries. Enamel fracture i.e. Ellis Class 1 was the most common type
ϱϴ
emotionally stressful states etc. Among the earlier causes of traumatic dental
injuries describes in the literature are: Increased over jet with protrusion and
inadequate lip coverage, Anterior open bite in children younger than 5yrs of
age, Home and its neighbourhood are the most common place of injury in
violent incidents and traffic accidents account for most TDIs among
adolescent.
e) Body growth: During period of growth spurts, the child adjusts to newly
f) State of mind: It effects the players level of concentration. Under stress his
h) History of previous injuries: Some players are more prone to injury than
others.
3. Type of sports activity: The nature of the sports event influences the tendency
a) Contact sports: Football, Hockey and Rugby are common contact sports with
ϱϵ
b) Non contact sports: Billiards, League bowling etc are less likely to cause
injury.
4. The coach: Needs to be skilled in the physical and tactical training of players
and teach them to avoid injury. He must encourage the players to use
5. Referees and Umpires: They have an important role in identifying players who
intentionally cause injury to opponents. The referees and umpires should ensure
pose a risk to the players and should interact with consultants in sports medicine
and dentistry to devise physiologically safe and easy to use protective devices.
7. Conditions of the playing area: The players should have a good look at the
benefitted.
According to WHO, certain factors have been identified that could predispose a child
1. Children who are careless and come from broken home are more prone to
injuries.
2. Children with accident-prone facial profiles are more susceptible to injuries, the
ϲϬ
a) Increased over jet with protrusion of upper incisors and insufficient lip
closure
susceptibility to trauma.79
ϲϭ
Dental traumas can involve both the primary and permanent dentition.
There is mainly lesion of the supporting periodontal tissues (Luxation And Avulsion),
seen in deciduous dentition whereas traumas involving the hard dental tissues (Crown,
Crown-Root and Root Fractures) are more frequently observed in the permanent
dentition.85 Therefore dental injuries have been classified according to a variety of
factors, such as etiology, anatomy, pathology, or therapeutic considerations.79
Rabinowitch has classified injuries to the primary teeth in the following way:
5. Comminute fractures.
6. Displaced teeth.
ϲϮ
2) Classification by Ellis and Davey (1960)68,79,86,87
Ellis and Davey have succeeded in classifying all the injuries simply and clearly. It is
one of the most widely accepted methods of classification on numeric system.
Class II ± Extensive fracture of the crown involving considerable dentin, but not the
dental pulp.
Class III: Extensive fracture of the crown involving considerable dentin and
exposing the dental pulp.
Class IV: The traumatized teeth that become non vital with or without a loss of
crown structure.
Class VI: Fracture of the root with or without a loss of the crown structure.
This classification includes the injuries to the teeth, supporting structure, gingiva
and oral mucosa and is based on anatomical, therapeutic and prognostic consideration. It
can be applied to both the primary and permanent dentition.
ϲϯ
b. Uncomplicated Crown fracture: A fracture confined to the enamel or but not exposing
the pulp
c. Complicated Crown fracture: A fracture involving enamel and dentine, and exposing
the pulp
f. Root fracture: A fracture involving enamel, dentin, cementum, and the pulp.
b. Fracture of the Alveolar socket wall: A fracture contained to the facial or lingual
socket wall.
c. Fracture of the Alveolar process: A fracture of the alveolar process which may or may
not involve the alveolar socket.
ϲϰ
d. Fracture of the Mandible and Maxilla: A fracture involving the base of the mandible
or maxilla and often the alveolar process(jaw fracture). The fracture may or may not
involve the alveolar socket.
This classification is a simpler and clearer version of the Ellis classification based
on the anatomic and morphological aspect of the anterior tooth.
Class 2: Extensive fracture of the crown involving considerable dentin, but not the
dental pulp.
Class 3: Extensive fracture of the crown with an exposure of the dental pulp.
Is a numerically descriptive classification that holds good for the primary and
SHUPDQHQWWHHWK,WLVEDVHGRQ$QGHUVRQ¶VPRGLILHG:+2¶VFODVVLILFDWLRQ
ϲϱ
Class 7 ± Concussion.
Class 8 ± Luxation.
Class 10 ± Intrusion.
Class 11 ± Extrusion.
Class 12 ± Avulsion.
A. Fracture of enamel.
B. Fracture of the crown with indirect pulp exposure through the dentin.
ϲϲ
ϲϳ
Infra-occlusion
Presence of sinus or swelling in the mucosa over a tooth
5.Lee-Knight et al. 99
Tooth infraction
Chipped tooth
Fractured tooth
Lacerated lip
Traumatized TMJ
1.Kania et al.100
Enamel injury only
Enamel and dentine injury
Pulpal exposure
Fracture at or below the gingival margin
Restoration present, trauma status not determinable
ϲϴ
Crown-root fracture
Alveolar bone fracture
ϲϵ
ϳϬ
Physical fitness, skill development, stress reduction and team building are
among the many positive aspects associated with participation in vigorous recreational
activities and organized sports. Despite these benefits, certain risks exist to those who
sports.107 Stats reveal that all 18 years old have sustained dental injuries, out of which
1/3rd can be categorized as serious injuries and have caused permanent damage.108
Dental and oral injuries are more in contacts sports. Health benefits should always be
activity.1 (Figure - 2)
are being used such as helmets, facemasks and mouthguard which ensure reduced
likelihood and severity of sports related traumatic injuries to the head, face and mouth
of an athlete.1
HISTORY:
x The exact origins of the mouth guard are unclear. Most evidence indicates that
ϳϭ
x
Originally, boxers used to wear mouth guards out of cotton, tape, sponge, or
small pieces of wood. They would bite and hold the material between their
teeth.109
These gum shields were originally made from gutta percha and were held in
x Mouthguard are regarded as being essential for protection of the orofacial region
1980 generally mouthguards are either worn early in a sporting career, usually as
a result of parental decision, or later often only after some type of injury has
been sustained.110
x
In the early 1900s, Jacob Marks created a custom fitted mouth guard in
London.109
x ,QPRXWKSURWHFWRUVZHUHLQLWLDOO\LQWURGXFHGDVER[HU¶VPRXWKSLHFH7KLV
x Philip Krause was an amateur boxer used his own device before 1921.109
x In the 1920s and1930s, mouthguard were first introduced by Boxers. Soon after
of American dentists including Cohen & Borish and after that Cathcart , the
IRUPHU KDG GHPRQVWUDWHG WKDW µWKH ZHDULQJ RI D SURSHUO\ ILWWHG 0RXWKJXDUG
ϳϮ
x
In 1927 boxing match between Jack Sharkey and Mike McTigue and McTigue
was winning for most of the fight, but a chipped tooth cut his lip, and he was
forced to forfeit the match. From that point on, mouth guards were acceptable.109
procedure for making and fitting the acrylic mouth guard was described in detail
by Dr. Lilyquist, he was awarded nationwide as the father of the modern mouth
x In 1960, the ADA recommended the use of latex mouth guards in all contact
sports.109
x
In 1962, the use of mouthguard became mandatory in US high-school football
and in 1974, the same rule was introduced at college level. This Proved to be an
x The National Collegiate Athletic Association (NCAA) followed suit in 1973 and
made mouth guards mandatory in college football. Since the introduction of the
ϳϯ
orofacial injuries.66
The AAPD recommends the following guidelines for prevention of sports related
orofacial injuries: 66
ϳϰ
Dentists play an active role in educating the public in the use of protective
equipment for the prevention of orofacial injuries during sporting and recreational
certified face protector is required (according to the playing rules of the sport).
teeth).
effective sports mouthguard to facilitate more widespread use of this proven protective
device.
education to parents and patients regarding prevention of orofacial injuries as part of the
ϳϱ
8. That third party payors realized the benefits of mouthguards for the prevention and
injuries so that there will be decreased chance of dental injuries. Use of various
protective devices like helmets, facemasks and mouthguards this will reduced the
chance and severity of intraoral traumatic injuries, during various sports and practice
session.112
- Routine checkups should be done for any physical or mental condition that might
- Completion of any ongoing dental treatment e.g. orthodontic treatment should be done
- Use of preventive devices like mouthguard, helmets and face masks should be done
1) Mouthguard (Figure ± 3)
2) Helmet (Figure ± 3 D)
ϳϲ
3) Facemasks/faceguard (Figure ± 3 E)
1) Mouthguard
removable soft plastic intraoral appliance that covers all occlusal surfaces and the palate
and extends to the vestibular surfaces or the teeth; used to protect lips, cheek and teeth
mouthguard is a resilient device or appliance placed inside the mouth to reduce mouth
mouthpiece. This device gained importance particularly in boxing but the participants of
other sports did not adopt the voluntary use of mouthguards. Since 1962, various
organizations related to sports and athletics made regulations which enforce mandatory
Dental injuries are the most frequently incurred orofacial injuries from
sports activities. In addition to injuries to teeth that may result in pulpal injury and need
for orthodontic treatment or loss of teeth, an impact to the base of the skull via a blow to
the chin in a vertical direction may result in concussion. In both types of injuries, use of
Dentistry has listed some sports in which mouth protection would be advantageous for
the participant. The list includes the following sports and activities: Acrobatics,
baseball, basketball, boxing, cycling discus, equestrian sports, field hockey, football,
ϳϳ
gymnastics, handball, ice hockey, judo, karate, lacrosse, motorcross, martial arts,
participating in sport will protect against dental injuries. Players of all ages involved in
sports and activities where they are at risk of an injury to the face should protect their
normal breathing, speech and swallowing. It does not cause gagging or irritation. The
mouthguard are designed to protect the lips and intraoral soft tissues from bruises and
laceration. They also protect the teeth from any kind of fractures or luxation injuries and
(1) Protection ± The mouthguard must provide maximum protection to teeth , lips, oral
mucosa and gingival by cushioning the shock from a traumatic force to prevent stress
(2) Retention ± The mouthguard must be retentive and must remain in place by being
readily adaptable to the teeth to reduce the chance of dislodgement. It should be pliable
and constructed of resilient material that is bite resistant tear resistant. It should be
comfortable to wear and not impinge on the oral soft tissues. It should cover all of the
ϳϴ
teeth in one arch (usually maxillary arch, except in patients with mandibular
(3) Function ± The ideal mouthguard should not encroach on the airway, interfere with
breathing nor interfere with speech. Athletes wearing the ideal mouthguard can
communicate freely and can, with only a little practice, produce all of the speech
sounds. Athletes can also project normal speech during the sports activity. The
athlete.
limited chair time and lab time. The cost must be reasonable for acceptance by the
athlete.
Textbook and Color Atlas of Traumatic Injuries to the Teeth, Andreasen and
(1) Mouthguards prevent laceration and bruising during impact by acting as a buffer
between the soft tissues of the lips and cheeks and the teeth.
(2) Mouthguards prevent tooth fractures or dislocations by cushioning the teeth from
(3) Opposing teeth are protected from seismic contact with each other.
(4) The mandible is afforded elastic, recuperative support that can prevent fracture or
ϳϵ
(5) Mouthguards help reduce neurologic injury by acting as shock absorbers between
the upper and lower jaws. Without a mouthguard, the trauma of the jaws violently
jarring together can distribute the impact from the condyles of the mandible against the
(6) Mouthguards can provide positive reinforcement in the prevention of neck injuries.
feel more confident and aggressive when they have the proper protection.
(8) Mouthguards fill edentulous spaces and thereby help support adjacent teeth. This
Types Of Mouthguards
The American Society for Testing and Materials(ASTM), the ASD,the National
Classification of Mouthguards
Type I: Ready Made or Stock Mouthguard (Figure -3 A) - They are brought over-
thermoplastic tray that fits loosely over the teeth. This mouthguard type is fabricated in
an inexpensive, ready-for- wear model and is sold in limited sizes (ranging from small
ϴϬ
7R EH KHOG LQ SODFH LW UHTXLUHV WKH ZHDUHU¶V PRXWK WR EH FORVHG WR SURYLGH DQG
protection benefit, which can interfere with breathing and speaking. For these reasons,
in two varieties:
1) The shell-liner mouthguard which consists of a polyvinyl chloride outer shell that
fits loosely over the dentition and a inner lining of plasticized acrylic gel or silicon
rubber. This appliance is less commonly available and usually bulkier than a boil-and-
bite mouthguard.
thermoplastic material (such as ethylene vinyl acetate- EVA). It can be formed by first
softening it in hot water, followed by brief cooling in cold water, placing it in the mouth
and then shaping the material with fingers, tongue and some biting pressure to form a
stable impression.114
PRGHO RI WKH SDWLHQW¶V PRXWK ,W LV DYDLODEOH LQ VHYHUDO W\SHV LV LQGLYLGXDOO\ GHVLJQHG
custom mouthguards can be the most expensive option, they are preferred as provide
better retention and comfort, less interference with speech and breathing and more
The simplest of these is a vacuum formed guard made from a single layer
ϴϭ
multiple layers or laminations of the material, under high pressure and high temperature
to form the final unit. This technique allows sport specific designs such as incorporating
hard inserts over the incisors for ball or missile sports or the use of more shock
absorbing material for collision sports. For enhanced reduction and absorption of
(2) Polyvinylchloride
(3) Polyurethane
(5) polyurethane
now a days, because it has lower shock absorbency, lower hardness and less tear and
tensile strength than EVA or polyurethane. Also Silicon rubber, natural rubber, soft
which helps to provide maximum coverage of overall teeth and it is adapted over
maxillary teeth unless mandibular teeth. Ethylene vinyl acetate material has shock
maxillary teeth and gingivae. Class III occlusion may require mouthguard placement on
ϴϮ
x
Use Of mouthguard should be encouraged in all contact Sports, as the most
Impact to the mandible. This fact alone should make the wearing of mouthguard
work on cadavers that mouthguard reduced the intracranial pressure and hence
the force of Impact to the brain arising as a result of a blow to the chin. This
effect is most likely achieved by increasing the space between the head of the
x Mouthguard is very essential for the protection against intra-oral soft tissue
lacerations, tooth fractures, bruising of the lips and cheeks, dislocations, and
fractures of the jaws, it also provide support for those athletes who wear
and death. Any impact to the lower jaw reduces the possibility of direct impact
of head of condyle to the glenoid fossa, thereby decreasing impact and forces to
hard and soft oral tissue injuries, jaw fracture, neck injuries. Some studies
related orofacial trauma.262 Some more studies showed that mouthgaurd are
ϴϯ
A. Occlusal contact:-
layer laminated mouthguard at the occlusal supportive areas, using an artificial skull
model and a pendulum impact device. The researchers noted that wearing a mouthguard
without good occlusal contact over a large area can potentially cause a bone fracture of
the mandible. The appropriate occlusal relationship and incisal guidance can only be
thickness to be created.
B. Thickness:-
mouthguard with a thickness greater than 3 mm so the arches are adequately separated.
greater than 3 mm, consistently thicker than the vacuum-formed mouthguard. The
results may indicate that the pressure-laminated mouthguard allows the creation of a
In 2004, Patrick et al117 identified the following criteria for design of the pressure
laminated mouthguard:
ϴϰ
a. The mouthguard should enclose the maxillary teeth to the distal surface
margin.
reflection.
In a 1999 study by McClelland et al.118 participants reported that the last three features
mentioned above created a mouthguard that was more comfortable to the lips, gums,
and tongue, felt less bulky; was less likely to keep the teeth apart or to cause pain in the
jaw muscles compared with a mouthguard that was under-extended and had an
unadjusted occlusion.119
Researched study examining the length of the distal end of the mouthguard
and response to simulated impact shows that a mouthguard should cover at least up to
the second molar to ensure efficient absorption and/or dispersion of force. Other
researchers argue for extending the guard as far back onto the molar areas as the client
can tolerate, to maximize the force dissipation. In addition, some league rules require
full molar coverage; however, care must be taken in fabrication, as many athletes cannot
ϴϱ
mouthguard did not perform as expected and produced the lowest value on the tests for
rebound and thickness in the incisor region. This suggests that caution should be taken
is located over the incisors. The mouth-formed mouthguard had problems with
slumping of the facial portion of the mouthguard after boiling. This resulted in thicker
material over the occlusal surface but a lack of material over the facial surface of the
posterior teeth. The other surprising finding was that none of the mouthguards tested
by ANSI/ADA Specification No. 99. It should be noted that not all custom-made
mouthguards have problems with thickness in the incisor region; as Waked et al. point
out, the pressure laminate mouthguard gives the best results in the incisor region.121
into the EVA (ethylene vinyl acetate) mouthguard material to determine if it will
improve performance. The first study was conducted in 2002,122 using regulated air
inclusion in an EVA mouthguard material. The air inclusion was found to reduce the
transmitted force by as much as 32% when tested with a pendulum impact. However,
the second study in 2002 did not show the same energy absorbing qualities of air
mouthguard materials. The control was an EVA polymer and the test samples were the
ϴϲ
same EVA polymer injected with a foaming agent to form indiscriminate gas cells
The researchers found that the foaming agent did not produce statistically
However, dual-arch mouthguards also called bimaxillary mouthguards cover the upper
and lower teeth and provide more protection for the jaw joint and the mandible
compared with a single-arch mouthguard.124-126 The lower guard can be help to cushion
the lower teeth with orthodontic fixtures or space maintainers fixed on the lower
The American Society for Testing and Materials (ASTM) recommends that
using a maxillary arch impression, those with a class III malocclusion should use a
mandibular arch impression.127 However, further research in this area may be warranted
since most injuries occur in the maxillary incisors and the mandibular arch impression
aged
129-133
who provided feedback on the comfort of acrylic resin and silicone rubber
ϴϳ
materials. The silicone rubber (a softer material than acrylic resin) mouthguards were
less stable than the acrylic ones, since the softer material was broken down more
quickly by soccer.
standard steps:
mouthguard will be made (an impression of the opposing arch and a bite
articulated cast). The impression should include all remaining teeth (except
erupting third molars), the gingival (up to the mucolabial fold), labial frenulum,
(3) Forming one or more sheets of thermoplastic material (such as ethylene vinyl
acetate, polyvinyl chloride, polyvinyl acetate, natural rubber, soft acrylic resin or
(4) Seating the mouthguard with proper occlusal balance and equilibration.
ϴϴ
(2) Pressure lamination, which combines heat and high pressure to laminate multiple
After 1980,there were no data published and support found for stock and
boil and bite type of mouthguards. Cleared data have been found in support of custom
Improvement In Mouthguards
preventing injuries in the orofacial area, especially in contact sports. Today, the use of
material that is immersed in hot water and then formed in the mouth using the fingers,
because they are cheap and easily available. However, they are defective with regard to
fit and occlusion, so they interfere with pronunciation, cause discomfort, decrease
custom-made.134
Nevertheless, the accessibility, affordability and ease of use associated with these
devices seems to have swayed a large number of mouthguard users as these types of
mouthguard continue to be the most commonly used with 90±95% of all athletes relying
ϴϵ
DFXVWRPILWDGHQWLVWPXVWWDNHDQLPSUHVVLRQRIWKHDWKOHWH¶VGHQWDODUFKW\SLFDOO\WKH
maxillary teeth) and fabricate the mouthguard from a stone or plaster model of the
fabricate, they do offer certain advantages that the others do not. These include optimal
adaptation, maximum retention, superior comfort and minimal interference with both
breathing and speech.138 Needless to say, professionally fitted mouthguards have a high
acceptance rate.139,140
are generally fabricated using a single sheet of ethylene vinyl acetate (EVA) that is
softened using low heat and then formed using low to moderate suction (vacuum)
pressure. Because of the limited heat and pressure that is used in the fabrication process,
material, which can occur during the manufacturing process, resulting in a final product
that is unevenly thick.136 Takeda et al.141 have reported that an insufficient covering at
the occlusal surface may potentially result in, or predispose the wearer to, mandibular
fractures.
high pressure. Because of the quality of adaptation that results with this method of
fabrication, pressure-formed mouthguards generally offer the best fit of all.136 Another
ϵϬ
is that the manufacturer can control the final thickness of the mouthguard, and therefore,
make certain that with appropriate adjustments the desired or necessary thickness is
obtained.
available product on the market, there is still some concern regarding the amount of
(thermoforming effect) or perhaps related to other factors such as jaw size. Thus,
conducted study evaluated the contribution that various size characteristics of the
of the stone model had on mouthguard thinning. Even with the custom-made type, a
protective effect cannot be expected unless adequate thickness is ensured in the labial
surface of the front teeth142 and on the maxilla, which is frequently injured by direct
impact. Hence, the shock absorption ability is proportional to the thickness of the
143-150.
mouthguard It is also necessary to maintain adequate thickness on the occlusal
surface to establish suitable occlusion151 and protect from an impact force applied on the
mandible. 152-156
has been reported that the entire thickness decreases because of heating and vacuuming
and that it becomes stronger as the angle of the model surface becomes steeper.157
Therefore, it is difficult for this type of mouthguard to secure the adequate thickness
ϵϭ
required to demonstrate the ability to absorb impact forces after it has been
absorption ability as they are fused with another sheet of material, which restrains the
whole thickness but provides adequate thickness to the necessary part where dental
considered to be necessary from the standpoint of safety and comfort. However, there
are no clinical reports of problems with defective adhesion during manufacture and de-
lamination of the adhesive surface when the mouthguard is worn. The fabrication
Using a mouthguard material of the EVA type, studied examined not only
adhesive strength on the laminated surface but also some methods of promoting
together with an adhesive area of 5X5 mm2 and with one end used for holding it. Before
lamination, 10-mm width tape was pasted on the surface of the first material to cover
the holding part. Later, it was cut with a heated knife, and the process completed with a
bar and a disc. Three laminated samples were manufactured under each condition and
two specimens were cut from each sample. Five samples were tested and the one
remaining was assumed to be a spare. Then six factors that influence adhesion took
place: heating time, the use of solvent in the laminate surface, elimination of the
laminate surface, direct heating of the second material in the laminate surface, the
colour of the material and water sorption. In the untreated condition, the heating times
ϵϮ
used were 120, 135, 150, 165 and 180 s. Before lamination, chloroform, as a solvent,
Specimens were laminated with two pieces of 3-mm thick mouthguard material together
with an adhesive area of 5 · 5 mm2 and with one end as the holding part.
heating of the laminate surface, after heating the laminate surface of the second material
directly for 60 s, the material was reversed, maintaining heat and pressure. The
white and black. The influence of water sorption was examined by facilitating water
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examined at a heating time of 165 s, which showed good adhesive ability after
atm). They stated that its operation and conformity were excellent, and also mentioned
WKDW LWV ORVV FRXOG EH SUHYHQWHG E\ LQFOXGLQJ LQIRUPDWLRQ VXFK DV SOD\HU¶V QDPH DQG
with the vacuumed type, indicated that the pressure laminated type was more uniform
ϵϯ
and could maintain better the thickness of the mouthguard to preventing injury. Jagger
They mentioned that if the pressure-laminated method was applied, it was possible for
the bi-maxillary-type mouthguard to adhere more strongly and easily than the vacuum
formed one.
materials should have adequate strength, and it is desirable that a mouthguard withstand
the hard force of occlusion, even when used over long periods of time. Chaconas and
thickness of a mouthguard before and after use, all mouthguards were recognized to
decrease in thickness, but the decrease in thickness varied depending on the materials
used. The decrease was marginal in hard and soft pre laminated materials other than
urethane, and a single layer of EVA. It could be suggested that the laminated-type
mouthguard of sufficient thickness was the most suitable of all mouthguards. The
materials together. Sometimes they are damaged on the adhesive surface by saliva,
heating, adhesion by solvent (adhesion by melting the surface) and adhesion by bonding
ϵϰ
plastics that are mainly hardened by continuous heating. Adhesion by heating is the
method by which the material is softened and pressed. Therefore, many contributing
There are 4 parts to the fabrication of custom- made mouthguards they are:-
1.Impression
2.Fabrication
1). A cast in low expansion stone is derived from an accurate, fully-extended, alginate
impression, set for 24 hours, and trimmed to a thickness representing the eventual
2). The ideal cast height should be minimal for optimal adaptation of the EVA material.
The cast is coated with silicone spray and allowed to dry. The pressure laminating
machine is set for the application of a 2 mm layer of EVA material and the cast is
ϵϱ
3). The heating cycle is reached and the pressure chamber attached to the platform.
Cooling ensures for 2 minutes prior to removal. The applied EVA layer is separated
from the cast and trimmed with surgical scissors to 1-2 mm from the border of the cast.
(Figure - 5 F)
4). The margins are refined and palatal thickness thinned using a small felt wheel at
2000-4000 rpm. (Figure - 5 G) The formed material is relocated to the cast and placed
in a low heat oven at 250°F for 2-3 minutes, just until the surface becomes tacky (Figure
subsequent layer.
5). While still in the heated state, the assembly is placed again on the sample platform
6). The laminated form is removed and trimmed again, this time to the extent of the cast
border. The edges are refined with the felt wheel and finished by applying burnished
heat with a micro torch. (Figure - 5 I) The finished mouthguard (Figure - 5 J) can be
the last several years. Even so, the custom-fitted mouthguard represents only about 10
percent of all devices used in sports despite the documented incidence of athletic oral
injuries.
The cost of such a device is small compared to the expense, pain and suffering to
Compliance is also an issue with the young athlete and the importance of consistently
wearing such oral protectors. There have been additional potential benefits of oral
ϵϲ
avoidance of concussion and mandibular fracture, which may prove to encourage use.
,W LV WKH GHQWDO SURIHVVLRQ¶V UHVSRQVLELOLW\ WR HGXFDWH DQG SURPRWH RUDO VDIHW\ DQG WKH
injuries.222
x Rinse the mouth guard in soap and warm water after each use. Allow it to air-
dry.
(Figure ± 6 A)
x Disinfect the mouth guard from time to time with a mouthwash. (Figure ± 6 B)
x Keep the mouth guard in a well-ventilated plastic storage box when not in use.
x 'RQRWOHDYHWKHPRXWKJXDUGLQGLUHFWVXQOLJKW LQDFORVHGFDURULQWKHFDU¶V
x Ask your dentist to inspect your mouth guard at every dental check-up.
x 5HSODFHDFKLOG¶VPRXWKJXDUGHYHU\WRPRQWKVHYHQLILWDSSHDUVWREHLQ
good condition. Growth and new teeth can alter the fit.
x 5HSODFHDQDGXOW¶VPRXWKJXDUGDIWHUGHQWDOWUHDWPHQWRUWRRWKORVV2WKHUZLVHLW
x Wear the mouth guard at all times, including games and training sessions.
ϵϳ
x Players undergoing dental treatment can have a custom-fitted mouth guard made
by their dentist to fit comfortably and accurately over their braces. (Figure ± 6 E)
comfort, fit, ease of speech, resistance to tear, and ease of breathing. These qualities are
best obtained with the custom made mouthguard. The custom made mouthguard can be
impact energy or force transmitted to the surface beneath the mouthguard material.
Various techniques have been tested in the past to measure this characteristic, and one
that is, less rebound, more shock absorption. Another direct shock absorption
quantification method is the force measured on a transducer, that is, accelerometer and
strain gauge beneath the mouthguard material once a known force (from a pendulum,
dropped weight, or piston) is applied to the top of the material Takeda et al. 166,167,168
measured and explained that only acceleration keeping the mass and the distance at
which the pendulum was released constant. The change in acceleration was used to
deduce the shock absorption ability. Later, Takeda et al.169 derived the shock absorption
ability by using strain gauge to record the strain developing on a dental model with and
without a mouthguard separately. Greasley and Karet170 described that to gain direct
ϵϴ
MDZ¶
different types of impact materials and sensors. It was found that shock absorption
abilities vary with different impact objects and sensors. It is recommended to test more
than one impact object to select appropriate material for each sport.166 It was also found
that the strain gauge is one of the most sensitive sensors to measure the shock
optical sensors, which are being used in measuring strain and temperature changes.171
The strain measurement using FBG sensor has been found to be in close agreements
with those measured with the strain gauges.172 Because these fibber optic sensors offer
interference, and compatibility with medical and dental composite materials, 173 they are
to establish suitable occlusion and protect from the impact of force applied on the
used currently have been reported to undergo decrease in thickness during fabrication
because of heating and vacuuming. Therefore, it is difficult for this type of mouthguard
to ensure the adequate thickness required to demonstrate the ability to absorb impact
higher shock absorption ability as they are fused with another sheet of material, which
ϵϵ
restrains the shrinkage and provides adequate thickness to the specific part where dental
The majority of injuries affect the upper arch, with the maxillary incisors often
accounting for as many as 80% of all cases.176 Children with malocclusion in the
anterior segment of the maxilla are also more prone to traumatic injuries.177 The
presence or absence of malocclusion of the maxillary teeth would certainly influence the
striking force.
Mouthguards have been worn by sportsmen for almost a hundred years and
were initially used by boxers. Mouthguard made from a piece of natural rubber that had
been trimmed and hollowed out so that it would fit over the maxillary dentition, was
worn to prevent chipped or broken teeth resulting from blows to the head. As it was not
adapted to the teeth, the jaw had to be clenched to hold the mouthguard in place, making
it difficult for the wearer to breathe.179,180This type of unfitted mouthguard can still be
bought today, although the materials have changed, ethylene vinyl acetate (EVA) being
substituted for rubber. Most sports shops sell them and, surprisingly, they are sometimes
offers a very low level of protection to the wearer; it also has the added danger of the
possibility that it may become dislodged and obstruct the air passage causing
ϭϬϬ
mouthguard.181
Previous work on the efficacy of mouthguards and their use, and the
compliance of athletes with rulings concerning their use during training and actual play,
has recommended the wearing of custom made mouthguards, advising that stock
mouthguard to prevent oral trauma has been recognized as the best option. Brittle
lacquer tests184 have shown the effect that impact forces transmitted through
mouthguards can have on teeth, and the fact that wearing a mouthguard can prevent
knock outs and repetitive concussion is now gaining more credence, years after it was
initially reported.185 Work carried out on the protective capabilities and physical
responses to an impact of standard mouthguard material (EVA) and novel laminates for
use in mouthguards has shown the levels of protection that are present. 186 The
processing of EVA during the manufacturing process has also been indicated as a factor
to be accounted for in any testing regimen that is to correctly assess the physical
sports, where the incidence of oral trauma or concussion is high, more aware of the
level of protection that a mouthguard may offer, a grading system of the various types
Mouthguard Assessment
Mouthguards and the materials from which they have been made have
generally been tested in the same way over the years. There have been many
ϭϬϭ
However, typical tests on the material do not really reveal the ideal properties being
model so that tooth deflection caused by an impact from a pendulum ram could be
recorded. Data from the teeth protected with a mouthguard were compared to data from
unprotected teeth and it was found that the cushioning effects of the mouthguards were
directly correlated to their thickness and that the force distribution was governed by the
protectors whilst on a standard sized maxillary plaster model. A drop weight impact
tester was constructed with the falling weight designed to simulate an ice hockey puck
and mouthguards were constructed from two layers of material with a resilient layer
next to the teeth. Using stepwise regression analysis, the only variable that had any
statistical significance on the guarding capacity was the thickness of the soft layer next
to the teeth.
mechanism that was attached to an American football helmet so that a blow of known
force could be delivered to the chin of an intact male cadaver. They did not examine the
ϭϬϮ
design of the mouthguard or the material from which it was made but did examine the
element analysis. A flat ended indentor and a disc representing a colliding object were
produced so that the stress distribution within mouthguard materials could be recorded.
The tested laminates consisted of a hard and a soft material with a bi-laminated structure
rather than a sandwich panel or a multi-layered structure. When the soft layer was
uppermost (in contact with the indentor) there was no significant difference compared to
a monolithic test piece. However, when the hard layer was positioned uppermost there
controlling the ratios of modulus and volume fractions of the top and bottom layers.
applications because of its shock absorbing properties, was tested by Bulsara and
transducer was used to measure the peak force transmitted through samples with and
without the Sorbothane layer from a free falling steel ram. Bulsara and Matthew
concluded that using an intermediate layer of Sorbothane may significantly dissipate the
assessment, Greasley and Karet192 and Greasley et al193 constructed an upper jaw made
from a rubber arch containing replaceable ceramic teeth and a renewable composite
energies were impacted on to the model jaw by dropping them down a clear plastic tube
whilst a mouthguard was in situ and damage to the teeth and jaw was recorded. The
ϭϬϯ
objective of the exercise was to produce a testing regime that could easily be applied to
impact machine and fitted with a blunt striker on the pendulum. Tests showed that the
force transmitted through the mouthguard material was inversely related to the thickness
transmitted force of 34%. Westerman et al195 also assessed the energy absorption
properties of a material containing pockets of air. It was reported that the inclusion of
Further to their earlier work, Godwin and Craig184 examined the stress
transmitted through mouth protectors. Brittle lacquer coatings on maxillary models that
were then fitted with mouthguards demonstrated quite graphically the effectiveness of
determining material property tests for impact, energy absorption and resistance to
impact penetration tests were performed using a rebound pendulum method. It was
concluded that the dynamic energy data from the rebound test should be interpreted
cautiously and that a high energy absorption level does not necessarily mean maximum
protection, since some of the absorbed energy may be transmitted directly to the
Mouthguard Proposal
ϭϬϰ
construction with a very compliant centre region and a more rigid outer layer, such as
EVA. In this way, a reduced impact force will be transferred to the teeth due to the
shock absorbing capability of the compliant material layer. Harmful rebound energy
will also be reduced as the composite laminate will return to its original shape more
During the course of this research the effect of heat processing on the physical
properties of EVA was observed. Heat treatment reduced the process stresses, resulting
process, therefore, may compromise the performance of EVA as a protective device, the
Grades Of Protection
GRADE ± 0:- Not wearing a mouthguard, clearly offers the lowest protection for the
obvious reasons of teeth being knocked out, lacerations to the lips, chipped teeth, and
concussion.
ϭϬϱ
GRADE ± 1:- A stock mouthguard of the type that has to be clenched between the teeth
to stay in the mouth is ranked next. As previously stated, these mouthguards are
dangerous and should not be worn as they instill a false sense of security in the wearer,
GRADE ± 2:- Boil and bite mouthguards are generally regarded as being little better
than stock mouthguards. The fitting process may not result in a good, close fit. Also, if
the mouthguard is bitten too hard during the fitting process, the occlusal thickness may
GRADE - 3:- An old custom made mouthguard >5 years old will have lost much of its
initial properties and therefore will not be effective enough in the event of an impact.
Such mouthguards become hard, may wear down on the occlusal surface, and become
too thin to prevent concussion. They may also not fit very well after a few years if teeth
GRADE - 4:- Mouthguards between 2 and 5 years old may suffer some or all of the
same problems of mouthguards >5 years old depending on the amount of use and/or
DEXVHWKH\KDYHUHFHLYHGDQGKRZPXFKWKHZHDUHU¶VGHQWLWLRQKDVFKDQJHG
GRADE - 5:- If the mouthguard is too thin there will be insufficient thickness to offer
adequate protection.
GRADE - 6:- A custom made mouthguard offers the best protection against trauma and
ϭϬϲ
1. They should enclose the maxillary teeth to the distal surface of the second
molars.
4. The palatal flange should extend about 10 mm above the gingival margin.
5. The edge of the labial flange should be rounded in cross section whereas the
However, as regards point 4 above, the palatal flange would be more easily tolerated if
it was kept to a minimum: a palatal flange of 1±2 mm beyond the gingival margin
would be ideal.
protection against oral trauma such as broken or avulsed teeth, soft tissue lacerations,
in the range of 18±24% polyvinyl acetate.198 After taking into account other factors such
as tear strength (41.7 kg/cm), water absorption (0.106 mg/cm2), static energy absorption
(7.14 mJ), and elastic gradients, a material containing 18% polyvinyl acetate is
ϭϬϳ
GRADE - 7:- Improved materials that are better at absorbing repeated impacts and
GRADE - 8:- Improved mouthguard design. Mouthguard design has not changed for
years and is limited by the parameters, but the most at risk teeth need to be properly
GRADE - 9:- An effective, instrumented, test for mouthguards is required so that new
GRADE - 10:- By combining items 1±3 above, we can obtain the ultimate
mouthguard.
protective capabilities. Athletes probably know that a custom made mouthguard is the
best option, but in many instances price determines which mouthguard is used. Custom
made mouthguards cost around 1500-2000 rupees, while a stock or boil and bite
mouthguard costs around 350-500 rupees, depending on the retailer. A grading system
ranking mouthguards from 0 to 10 would allow a more informed choice, so that fewer
poorly rated mouthguards would eventually be used and most would be custom made.
Only through education and awareness of the efficacy of mouthguards can athletes
make an informed choice and opt for the best mouthguard available. The mouthguard
must be comfortable and easy to wear, an aim achievable if guidelines for size and
ϭϬϴ
shape are followed. In addition, if a wide range of colours were available, then athletes
with not wearing a mouthguard, is suggested. This would highlight the potential for
trauma, allow mouthguards to be easily and quickly assessed, and would influence the
type of mouthguard chosen. Over time it is hoped that the use of stock mouthguards
would diminish in favor of the custom made mouthguard thereby reducing the incidence
Mouthguards
Several studies have been conducted to know the attitude and awareness of
the players towards mouthguard usage. Sport activities often increase the risk of
traumatic injuries to dental and oral tissues. These injuries are reported to be most
rotational torque as well as repeated direct impact forces to the head are hypothesized
mechanisms of head injury in boxing. Boxing poses a high risk for severe focal and
diffuse neurologic injuries, intracranial hemorrhage, cerebral edema and diffuse axonal
injury.204 Recent reports mentioned that participation in a number of sports does carry a
considerable risk of dental injury, not only in contact sports such as rugby and hockey,
but also in less dangerous sports such as basketball. There have also been attempts to
that seasonal variation of traumatic injuries was classified by month, the highest
ϭϬϵ
incidence of oral trauma was seen in the month of September and October. A graphic
The average age for exposure to dental trauma was 16.65 years (16.77 in
males, 16.16 in females). These athletes were most prone to dental trauma at 16 and 18
years of age.200The importance of using mouth protectors has been widely accepted.
Injuries, including dental and orofacial soft tissue injuries, as well as jaw fractures have
aware about using mouthguards. Dentists and sports authorities should promote the use
of mouthguards in martial arts and also other amateur sports, which have a risk for
prevention, information on the risk of injury, and availability of more comfort can lead
mouthguards reduce the incidence of concussion as well as dental and mandibular jaw
injuries. Masahiro et al209 reported that mouthguards relieve the stress concentrated on
the anterior teeth in a frontal collision by absorbing and dispersing some of the shock
The utilization rate61 for mouthguard use varies by sport and although they
are mandated in some sports, table ± 10 shows their use remains very low.210,211,212,213
athletic community has not fully incorporated their use. There is therefore a need to
address compliance issues in sports that already make the use of mouthguards
mandatory. The statistical data are lacking in some sports such as cycling, gymnastics,
ϭϭϬ
influenced by the attitudes of players, officials, coaches, and parents. For mouthguards
to be effective, they must be well accepted and adopted by athletes. It is clear by the
statistics in football, where mouthguards are mandatory, that factors other than the risk
RIDSHQDOW\DUHLQIOXHQFLQJDSOD\HU¶VGHFLVLRQWRZHDUDPRXWKJXDUG)RUH[DPSOHD
survey of 102 rugby players taken during the second rugby world cup in 1991 shows
that although all the players believed that mouthguards provided protection,
DSSUR[LPDWHO\RQHLQILYHGLGQRWZHDURQH7KLVJDSEHWZHHQSOD\HUV¶EHOLHIVDQGWKHLU
behaviour is also reported in a study by Cornwell et al.214 Similar findings emerge: even
though players realized the benefits of mouthguard use, they frequently did not wear
one. Athletes do not wear a mouthguard for a number of reasons. Lack of mandatory
their cost and the negative effect on their appearance all play a role. Attitudes towards
mouthguard use may also be partly influenced by professional sport practices. For
example, two of the most visible contact professional sports, hockey and football, do
perceived image that they create; comfort, since some mouthguards may cause a
headache; and how difficult the mouthguards make talking, and breathing.
Among male high school basketball players, there were some reasons that
players gave for not wearing a mouthguard include discomfort, difficulty with
breathing, and difficulty with speaking.215 This may because most players were wearing
stock or mouth-IRUPHG PRXWKJXDUGV ,W LV H[SHFWHG WKDW SOD\HUV¶ GLIILFXOW\ ZRXOG
ϭϭϭ
guarantee compliance. Even with mandatory rules for mouthguards, many athletes are
still not wearing mouthguards.216 This may be due partly to a lack of appreciation by the
players of the benefits of wearing mouthguards. Two studies showed that only 50% of
athletes thought mouthguards prevented injuries and 82% of soccer players and 26% of
2WKHUIDFWRUVWKDWLQFUHDVHWKHDWKOHWH¶VOLNHOLKRRGRIZHDULQJDPRXWKJXDUG
include starting to wear a mouthguard at an early age,213 a previous injury, and player
position.
were more frequently worn by those who had experienced a previous oral trauma. Some
players, such as quarterbacks, may not wear a mouthguard since some find that it
interferes with their ability to call signals.213 Similarly, defensive hockey players, who
have to talk more than offensive players, report more negative attitudes toward
mouthguard use.217
impact on whether or not a player wore a mouthguard. Cornwell et al. 214 2003 in
was 62% at games and 25% during training. Although 90% of athletes acknowledged
the protective value of mouthguards for basketball, youths after the intervention, did not
increase mouthguard use, and adults increased their use by only 14% for training and
10% at games. Players who had previous injuries were 2.76 times more likely to wear
mouthguards.
ϭϭϮ
professional athletes218 and found that although mouthguard prevention material was
presented to athletes, there was little use of mouthguards. It appears that a previous
LQMXU\ KDV D FRQVLGHUDEOH LPSDFW RQ DQ DWKOHWH¶V GHFLVLRQ WR wear a mouthguard
that would somehow allow players to experience a virtual injury to better influence
decision making. Officials are expected to follow the National Collegiate Athletic
Association (NCAA) rules that state a time-out is to be charged when a player is not
wearing a mouthguard. They can also give a 5-yard penalty to a team if the limit for
time-outs KDV EHHQ H[KDXVWHG $OWKRXJK WKHUH DUH UXOHV LQ SODFH RIILFLDOV¶ DWWLWXGHV
towards mouthguard use affect enforcement. In 1993, Lancaster and Ranalli219 surveyed
109 college football officials and found that officials were unlikely to charge a time-out
or to enforce penalties for mouthguard violations, even though they indicated that not
all players were in compliance. Officials also reported that coaches should be
responsible for player compliance. Officials believed that coaches have more influence
&RDFKHV¶DWWLWXGHVWRZDUGVPRXWKJXDUGXVHDUHDOVRDQLPSRUWDQWIDFWRULQ
during practices and games, so would have a longer period of time during which to
influence their behaviour. Coaches are also assisting players to develop consistent
ϭϭϯ
98 division 1-A college head football coaches and found that they viewed themselves,
the players, or the trainer as most responsible for players wearing mouthguards, not
referees.
7ZR VWXGLHV RQ RIILFLDOV¶ DWWLWXGHV WRZDUGV FRDFKHV LQGLFDWH WKDW RIILFLDOV
also believe that coaches should be accountable for athletes wearing mouthguards,129
and they believe that coaches are more influential in convincing players to wear a
mouthguard.213 There is some evidence that coaches are not making the best use of their
influence in injury prevention. Berg et al.220 in 1998 conducted a survey of 508 high
Researchers found that 31% of coaches reported that they would not
encourage mouthguard use, even if provided for free. In addition, only 13.2% of
coaches reported that they offered education programs and information on mouthguard
use. Somewhat more positive results are reported by Gardiner and Ranalli in 2000.213
This survey of 89 coaches found that 74% of coaches would speak to the player directly
3DUHQWV¶GHFLVLRQVDERXWPRXWKJXDUGXVHDOVRDIIHFWPRXWKJXDUGXWLOL]DWLRQ
since they have decision-PDNLQJ SRZHU LQ FKLOGUHQ¶V DFWLYLWLHV 'LDE DQG 0RXULQR LQ
1997221 conducted a survey of 1,800 parents with grade school children and found that
basketball, baseball, and soccer, even though these are sports with the most frequently
reported injuries. Despite the evidence for the efficacy of mouthguards and the
mandatory regulations and positive attitudes about mouthguards in some sports, there is
not always compliance amongst athletes. In addition, coaches and referees are not
ϭϭϰ
addressed with educational information about orofacial injuries and the benefits of
mouthguards which targets players, officials, coaches and parents. One of the
educatiRQDOSURJUDP¶VJRDOVVKRXOGEHWRFKDQJHDWKOHWHVSDUHQWVEHKDYLRXUVRWKDWLWLV
2) Helmet: 112
Helmets are designed to protect the skin, skull, brain, central nervous
system, and ears of the athlete from abrasion, contusion, laceration, fracture,
Organised sports at the amateur level that mandate the use of helmets
- One type is known as the suspension helmet which is lined with soft plastic-covered
foam that absorbs traumatic forces and possesses the capacity to spring back to the
original shape.
- The other is the so-called air helmet, which has the added safety feature of an
nose, eyes, nasal pyramid, and zygomatic arches, depending upon the style of face mask
ϭϭϱ
used. One major disadvantage of the facemask is that it presents a protruding object
within the ready grasp of an opposing player. When the facemask is pulled or twisted by
an opponent during the course of a play, serious physical consequences such as muscle,
neck, or spinal column damage can result.111 They are recommended in ice hockey,
soccer, rugby, football.225-229 The faceguard has been introduced as a protective device
for the early and safe return to play of athletes after sustaining maxillofacial traumatic
The moulding temperature of the thermoplastic resin is a very important aspect of the
faceguard fabrication process. If the required moulding temperature is low enough, then
expensive vaccum and pressure thermoforming machines are not required because the
materials can be easily moulded using hot water and finger pressure.236,239-241 However
thermoplastic resins with low moulding temperatures exhibit relatively low mechanical
properties, therefore, faceguards that use these thermoplastic resins are generally thicker
ϭϭϲ
Previous research on the impact absorption properties of faceguards and
To further improve the capacity for shock absorption, lining the inner
surface of the hard thermoplastic material with the cushioning material is more effective
than placing the cushioning material on the outer surface of the hard thermoplastic
material. However the outer surface of the faceguard then has to be covered with soft
material to prevent injury to the wearer and other players 239-241, 247,243.
material with fibreglass. Thermoplastic material that are reinforced with fibreglass are
ϭϭϳ
SAFETY:-66
(1) An athlete is 60 times more likely to sustain damage to the teeth when not wearing a
(2) The cost of replanting a tooth and follow-up dental treatment is estimated to be
approximately $5,000. Individuals who experience an avulsed tooth that is not properly
preserved or replanted may face lifetime dental costs of $15,000 to $20,000 per tooth.
(3) Each athlete involved in a contact sport has about a 10% chance per season of an
orofacial injury, or a 35% to 56% chance during his or her athletic career.
(4) Every year hospitals in the United States see thousands of cases of lost or damaged
teeth as a result of sports injuries. Treating these injuries can cost thousands, even tens
(5) The total cost to replace an avulsed tooth (complete displacement of the tooth out of
its socket) can be 20 times more than the cost of a custom-fabricated mouthguard.
(6)The ADA recommends wearing custom mouthguards for the following sports:
acrobatics, basketball, boxing, field hockey, football, gymnastics, handball, ice hockey,
skiing, skydiving, soccer, squash, surfing, volleyball, water polo, weight lifting, and
wrestling. There are newer sports such as rollerblading, mountain biking, and
ϭϭϴ
mouthguard may prove beneficial. With their increased participation in sports, female
an important public health issue and have adopted position statements on injury
prevention and the use of mouthguards. Notable in the following list is the paucity of
and concussions in soccer in which they call for mouthguards to be worn during
participation in soccer, due to the dental protection and the possible role in concussion
prevention.
counsel clients about orofacial protection and encourages organized activities to develop
6HYHUDOSURIHVVLRQDOKHDOWKRUJDQL]DWLRQVKDYHUHFRPPHQGHGWKHXVHRf mouthguards
unorganized. These organizations include the American Medical Association and the
ϭϭϵ
7KH $PHULFDQ $FDGHP\ IRU 6SRUWV 'HQWLVWU\ UHcommends the use of properly fitted
mouthguards and supports mandates for their use in all collision and contact sports for
7KH $FDGHP\ RI *HQHUDO 'HQWLVWU\ LQ WKH 8QLWHG 6WDWHV UHFRPPHQGV ³WKDW SOD\HUV
and martial arts, whether for an athletic competition or leisure activity, wear
PRXWKJXDUGV´
7KH $PHULFDQ $FDGHP\ RI 3DHGLDWULF 'HQWLVWU\ UHFRPPHQGV WKH FRQWLQXDWLRQ RI
preventive practices in youth high school and college football, lacrosse and ice hockey,
and call for mandating mouthguards in other organized sporting activities with risk of
orofacial
injury.
7KH $PHULFDQ 3XEOLF +HDOWK $VVRFLDWLRQ ³UHFRPPHQGV WR VFKRROV DQG RWKHU
TXDOLW\ILWWHGSURWHFWLYHPRXWKJXDUGV´
protectors (such as mouthguards, face shields and helmets)and endorses the use of
significant risk of injury, all levels of competition including practice sessions, physical
ϭϮϬ
0RXWKJXDUG use is encouraged in the U.S. document Health People 2010, which
outlines goals and objectives for improving oral health. One of the objectives calls for
WKHIROORZLQJ³,QFUHDVHWKHSURSRUWLRQRISXEOLFDQGSULYDWHVFKRROVWKDWUHTXLUHXVHRI
appropriate head, face, eye, and mouth protection for students participating in school-
VSRQVRUHGSK\VLFDODFWLYLWLHV´
The rationale for appealing to schools is that healthy habits are formed early in life, and
by the time athletes reach young adulthood they will be familiar with the hazards
inherent in sports and be more familiar and comfortable with mouthguard use.
ϭϮϭ
type of orofacial injuries sustained during participation in sports. The main aim of
primary protection is prevention against injuries. It has been widely reported that
fractured or avulsed teeth and injuries to the periodontium. Due to direct impact on
equipment available to present day athletes. These includes mouthguard, facemask and
helmet. Wearing these protective device can reduces the chance of dental and orofacial
injuries.
1. Preventive management
2. Therapeutic management
deviation in the respiratory, cardiac, or vascular function in the athlete must be attended
prevention of shock. Therapeutic Management of Oral and Dental Injuries include: 112
ϭϮϮ
v) Tooth Luxations
vii) Infraction
viii) Concussion
ix) Subluxation
and cleaning the wound from foreign materials to permit visibility of the region.
be ruled out based on the mechanism of the injury, clinical findings, and in some cases
Assessment of the oral cavity should include ruling out tooth, tongue,
performed.
ϭϮϯ
required to ensure and maintain an airway prior to stabilizing the athlete. It is necessary
to control haemorrhage using gentle pressure to the region followed by nasal packing. A
concussion that has occurred and the athlete should be treated for shock and transported
to a hospital.
injuries comprising approximately 10% of all injuries to this region. The area most
frequently fractured is the supracondylar region followed by fracture to the body of the
the potential for respiratory compromise with mandibular pathology. This should
include stabilization of the fracture site, assessment for potential concussion, and
with most injuries resulting from direct trauma to the head, the athlete will likely
intracranial haemorrhage. Finally, pain and haemorrhage may induce shock and every
Mandibular dislocations present similar problems as the masticatory muscles spasm and
ϭϮϰ
stabilize the mandible in its luxated position. Reduction is accomplished by placing the
hands bilaterally on the mandible with the thumbs on the anterior region of the
mandible and the index and middle finger grasping the mandibular eminence.
combined with fractures to the root. Root fractures generally present hyper mobility or
can be displaced. These fractures usually require alignment and stabilization by internal
fixation. Acute management of a suspected root fracture requires stabilization that can
tooth is mal aligned or displaced, gentle realignment should be attempted using finger
the tooth crown. When fracture occurs, a complete evaluation of the injury should be
C).Crown/Root Fracture
D).Root Fracture
ϭϮϱ
the pulp.
Treatment objectives: To maintain pulp vitality and restore normal aesthetics and
function. Injured lips, tongue and gingiva should be examined for tooth fragment. For
small fractures, rough margins and edges can be smoothened. For larger fractures the
Diagnosis: Clinical and radiographic findings reveal a loss of tooth structure with
pulp exposure.
Treatment objectives: To maintain pulp vitality and restore normal aesthetics and
function. Injured lips, tongue, and gingiva should be examined for tooth fragments.
3ULPDU\WHHWK3XOSDOWUHDWPHQWDUHSXOSRWRP\SXOSHFWRP\DQGH[WUDFWLRQ
3HUPDQent teeth: Pulpal treatment alternatives are direct pulp capping, partial
exposure.
the gingiva with or without a pulp exposure. Radiographic findings may reveal a
ϭϮϲ
radiolucent oblique line that comprises crown and root in a vertical direction in primary
permanent teeth. While radiographic demonstration often is difficult, root fractures can
Treatment objectives: To maintain pulp vitality and restore normal esthetics and
function.
3ULPDU\ WHHWK :KHQ WKH SULPDU\ WRRWK FDQQRW RU VKRXOG QRW EH UHVWRUHG WKH HQWLUH
tooth should be removed unless retrieval of apical fragments may result in damage to
fragment. Definitive treatment alternatives are to remove the coronal fragment followed
orthodontic extrusion to prepare for restoration. If the pulp is exposed, pulpal treatment
gingiva that may be displaced. Radiographic findings may reveal 1 or more radiolucent
lines that separate the tooth fragments in horizontal fractures. Multiple radiographic
ϭϮϳ
functional integrity.
3HUPDQHQWWHHWK5HSRVLWLRQDQGVWDELOL]HWKHFRURQDOIUDJPHQW
v). Tooth luxations: Refers to a tooth that has been displaced in one of three positions,-
A). INTRUSION
Definition: Apical displacement of tooth into the alveolar bone. The tooth is
driven into the socket, compressing the periodontal ligament and commonly causes a
crushing fracture
Diagnosis: Clinical findings reveal that the tooth appears to be shortened or, in
7KHWRRWK¶VDSH[XVXDOO\LVGLVSODFHGODELDOO\WRZDUGRUWKURXJKWKHODELDOERQHSODWHLQ
primary teeth and driven into the alveolar process in permanent teeth. The tooth is not
mobile or tender to touch. Radiographic findings reveal that the tooth appears displaced
Treatment objectives:
3ULPDU\WHHWK([WUDFWLRQLVLQGLFDWHGZKHQWKHDSH[LVGLVSODFHGWRZDUGWKH
3HUPDQHQW teeth: To reposition passively or actively and stabilize the tooth in its
ϭϮϴ
neurovascular supply while maintaining esthetic and functional integrity. In teeth with
immature root formation, the objective is to allow for spontaneous eruption. In mature
teeth, the goal is to reposition the tooth with orthodontic or surgical extrusion and
initiate endodontic treatment within the first 3 weeks of the traumatic incidence.
B). EXTRUSION
Definition: Partial displacement of the tooth axially from the socket. The
Diagnosis: Clinical findings reveal that the tooth appears elongated and is mobile.
Treatment objectives:
3ULPDU\WHHWKUHSRVLWLRQDQGDOORZIRUKHDOLQJ
periodontal ligament is torn and contusion or fracture of the supporting alveolar bone
occurs.
Diagnosis: Clinical findings reveal that a tooth is displaced laterally with the
crown usually in a palatal or lingual direction and may be locked firmly into this new
position. The tooth usually is not mobile or tender to touch. Radiographic findings
ϭϮϵ
Treatment objectives:
3ULPDU\WHHWK7RDOORZSDVVLYHUHSRVLWLRQLQJRUDFWLYHO\UHSRVLWLRQDQGVSOLQWIRUWR
2 weeks as indicated to allow for healing, except when the injury is severe or the tooth
is nearing exfoliation.
3HUPDQHQWWHHth: To reposition as soon as possible and then to stabilize the tooth in its
of the tooth is done with little force and digital pressure. The tooth may need to be
extruded to free apical lock in the cortical bone plate. Splinting an additional 2 to 4
immediate reimplantation, which is essential to maintain vitality of the tooth and its
the tooth while handling usually results in complete recovery of the tooth. If the tooth
has been displaced longer than an hour or if re-implantation cannot be achieved, the
tooth should be placed under the athletes tongue during transport. Following a complete
dental evaluation the tooth is generally stabilized for a period of 2 weeks with internal
ϭϯϬ
vii). Infraction
structure.
viii). Concussion
Diagnosis: Because the periodontal ligament absorbs the injury and is inflamed,
clinical findings reveal a tooth tender to pressure and percussion without mobility,
ix). Subluxation
clinical findings reveal a mobile tooth without displacement that may or may not have
ϭϯϭ
neurovascular supply.
3ULPDU\WHHWK7KHWRRWKVKRXOGEHIROORZHGIRUSDWKRORJ\
3HUPDQHQW WHHWK 6WDELOL]H WKH WRRWK DQG UHlieve any occlusal interferences. For
comfort, a flexible splint can be used. Splint for no more than 2 weeks.
ϭϯϮ
CONCLUSION:
Dentistry involves the prevention and treatment of orofacial athletic injuries and related
athletic injuries which is related to oral diseases. There is a high incidence of sport
related injuries and it is important to provide treatment for dental emergency and
educate athlete regarding usage of various protective devices in sports and also educate
the facial bones, temporomandibular joint displacements and soft tissue injuries.77
Sports accidents are very common and there number and severity could be reduced by:73
mouthguard
x In general training, there will be increased practice, which leads to better body
younger children.
ϭϯϯ
significant medical, financial, cognitive, psychological, and social costs. Research also
confirms that mouthguard can prevent orofacial injuries.61 The most important aspect in
in terms of creating an awareness about various protective device which can be reduces
opportunity for dentist to protect the health and safety of children and adult in sport by
supporting and promoting mouthguard use. Sports that are considered less dangerous
such as soccer, baseball, field hockey and basketball also have the potential to cause
orofacial injury.61
preventing orofacial injuries. The evidence for the role of mouthguard in preventing or
reducing the severity of concussion is very weak and further research is needed in this
area. Custom- fabricated mouthguard, particularly the pressure laminated type, appear
to provide a number of benefits over other mouthguards, the thickness can be adjusted
for specific sports, it can be extended to the second molar and the mouthguard can be
7KH PRVW LPSRUWDQW IDFWRUV DIIHFWLQJ WKH DWKOHWH¶V UHIXVDO WR XVH
mouthguards in sports are as follows: vomiting reflex, interference with speech and
ϭϯϰ
breathing, discomfort, bulkiness, decreased retention and stock and self adaptating
made mouthguards, the possibility of distortion of the buccal flange over a period of
time, hardening of the mouthguard from continued exposure to oral fluids, the need to
UHPRXOGPRXWKJXDUGVGXHWRFRQVWDQWFKDQJHVLQJURZLQJFKLOGUHQ¶VGHQWLWLRQFRVWWKH
non- existence of rules which would require participants in sports to use mouthguards,
involved athletes complain about discomfort, poor retention, inappropriate fit and cost.2
information on the risk of injury, and availability of more comfort can lead to the
low compared with the medical, financial, cognitive, psychological and social
needed to increase the number of players who wear mouthguards. They can help the
public to develop positive attitude to mouthguard use, influence behaviour, and address
compliance issues in sports where mouthguards are mandated. Third, there is a need to
Timely referral to the doctor and early management along with the recent advances in
treatment modalities help to achieve better results.77 In order to increase the use of
mouthguards during sports activities, professional athletes should serve as role models
for young athletes, performing public service announcements promoting the use of
properly fitting mouthguards. If professional athlete suggest the use of this appliance, it
ϭϯϱ
would enhance the willingness of young athletes to follow that example, professional
athletes, team physicians, trainers and team dentists should be advocates for the use of
sports mouthguards.113
and parents about the importance of preventing orofacial injuries. By cultivating their
knowledge of sports dentistry, dentists can popularize the use of various protective
device in different sports programme and interact with sports person, coaches and sports
administrators as well as Indian dentist to familiarize with this relatively new field i.e
6SRUWV'HQWLVWU\´77
sports dentistry by extending our help beyond the dental clinics. Recently sports
dentistry is in its initial phase of development, but it will grow in a continuous phase to
ϭϯϲ
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