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CONTENT:

TOPIC PAGE NO.

S.NO.
1. Introduction 24-31

2. Definitions 32-33

3. Review Of Literature 34-50

4. Incidence, Site And Prevalence Of Dental Trauma From 51-57


Sports

5. Predisposing Factors Of Sports Injuries 58-61

6. Type Of Traumatic Dental Injuries Secondary To Sport 62-70

7. Prevention Of Sport Injuries 71-121

8. Management Of Sport Injuries 122-132

9. Conclusion 133-136

10. Bibliography 137-166

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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


ϯ͘  Various Protection Devices Available For Figure.3 3


Prevention Of Trauma From Sports (A),(B),
(C),(D),(E)
(A) - Stock Mouthguard, ( B) - Mouth Formed
Mouthguard, ( C) - Custom Made Mouthguard
(D) - Helmet, (E) ± Facemask
ϰ͘  Mechanism By Which Protection Is Offered By Figure. 4 4
Mouthguards
ϱ͘  Technique Of Fabrication Of A Mouthguard Figure. 5 5,6
(A) Impression Making With Elastomeric 5.(A),(B),(C),(D),
Impression,
(B) Maxillary Arch Impression (E),(F)
(C) Stone Cast, (G),(H),(I),(J),(K)
(D) Pressure Laminating Machine (Biostar),
(E) Cast Is Placed On Biostar Machine,
(F) Mouthguard Model Cast And
Vaccum Formed Unfinished Mouthguard
(G) Mouthguard Finishing Process,
(H) Mouthguard Is Placed In Low Heat
Oven For 2-3 Minutes For Placing Tags For
Customizatio(Optional Step)
(I) Through Micro Torch Heat Is Passed
Over Mouthguard For Finishing
(J) Finished Mouthguard
(K)Tried In Mouth And Adjusted For Fit
And Occlusion


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ϲ͘  Hygiene Maintenance Of Mouthguards (A) ± Figure. 6 7


Rinse The Mouthguard In Soap And Water, (B) (A),(B),(C),(D).
± Disinfect The Mouthguard With Mouthwash, (E)
(C) - A Soft Brush To Clean A Mouthguard, (D)
- Plastic Container To Keep Mouthguard, (E) ±
Custom Fitted Mouthguard For Players Made By
Dentist


ϳ͘  Mouthguards Work Out To Be More Cost Figure. 7 8


Effective Than Oral Rehabilitation.


ϴ͘  Ways How Mouthguards Ensure Safety Figure. 8 8


ϵ͘  Frequency Of Dental And Soft Tissue Trauma Figure. 9 9
By Age Groups
ϭϬ͘  Seasonal Variations In Trauma Figure. 10 9

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LIST OF TABLES:
S.No. Topic Table No. Plate No.

1. Orofacial Injury Studies 1 1

2. Teeth Injured Most Frequently In 2 2


Sports Activities

3. Frequency Of Traumatic Injury By 3 2


Type

4. Injury Rate In Sports 4 3

5. Sports Which Need Mouthguards 5 6

6. Dentist Attitude Towards 6. (A), (B), 4


Mouthguards Protection. (A) ± (C)
Practicioner Mouthguard Preference,
(B) ± Practitionerss That Routinely
Recommend Mouthguards For Their
Athletic Active Patients, (C) ±
Mouthguard Fabrication During
Dental Training Vs Number Of Years
In Practice
7. Sporting Activities For Which Dentist 7 5
Recommended Mouthguard Use

8. Reasons Reported By Dentist For Not 8 6


Recommending Mouthguards

9. Mouthguard Efficacy In Preventing 9 7


Orofacial Injuries

10. Mouthguard Utilization Rates In 10 8


Sports

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INTRODUCTION:

7KH ZRUG ³VSRUW´ GHULYHG IURP ROG FRPELQDWLRQ RI ZRUGV OLWHUDOO\

PHDQV³WRFDUU\DZD\IURPZRUN´6SRUt involves physical activity or skill carried out

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

interaction among participating individuals enables the release of uncontrolled strength

and exertion of harmful forces onto the opponent. These forces may also be tremendous

in extremely physical sporting activities like mountain biking, skateboarding and

rollerskating.3,4

Individuals competing in any type of organised and unorganised

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

participation in sporting activities may predispose the individuals to encounter an

injuring episode sometime or the other.2

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With passage of time there has been an increase in health

promotional activities in dentistry. These activities have focussed on several aspects,

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

prevention & management of dental/orofacial sports injury.2 Sport dentistry is a branch

which is closely related to Dental Traumatology. According to the International

Academy for Sports Dentistry the main goals of sports dentistry include prevention and

treatment of sports related dental/orofacial injuries, information collection, information

dissemination and promotion of research on the preventive procedures related to

injuries.2

Dental trauma which is a very prevalent orofacial injury in sport

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

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Mouthguards are religiously worn by athletes who recognize the need

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\

throughout the mouth there by reducing the chances of injury.14

Mouthguards were first introduced in 1913 to the sport of professional

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

is to increase player acceptance while concomitantly maintaining some standard of

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

hockey. However, regulation does not always equal compliance.15

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

mouthguard should be as thin as possible while still providing adequate protection,

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

protection may be compromised however, if the material is too thin in an attempt to

improve comfort.16-18

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Duhaime et al20 in a study comparing forces transmitted through

various mouthguard thicknesses concluded that the optimum mouthguard thickness was

approximately 4 mm for EVA material with a shore A hardness of 80.

The mouthguard is an effective device for the prevention from

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

use mouthguards or not.25 Therefore, it is necessary to grasp the thickness of the

mouthguard. There have been some reports investigating the thickness of

mouthguard.26-30

According to Westerman et al,20 the thickness of mouthguard

materials is directly related to energy absorption and inversely related to transmitted

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

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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

The thickness of the mouthguard influences on impact absorption and

the preventive effect against stomatognathic injury.34 Therefore, it is necessary to

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

frequency of injuries, prevention becomes the primary goal.39

Other mouthguard studies have attempted to compare force

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.

Now-a-days, the use of protective mouthguards as preventive

measures for persons participating in sports activities is being encouraged. There is

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

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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

Mouthguards usually are criticized by athletes due to communication

difficulties during the game, breathing problems and compromised aesthetics. However

these shortcomings could be reduced by customized fabrication of mouthguard. Airway

resistance however is also insignificantly shown to be increased by a custom-made

mouthguard.55,56,57 Athletes should not wear mouthguard which physically and

technologically do not offer a quality prevention against injury as seen in preformed

mouthguards. Athletes consider the custom-made mouthguard pleasant to wear both

during training session and when competing due to its technological properties and

appropriate design.2

American Academy Of Paediatrics (AAP) in 2001, published an

analysis of medical conditions affecting sports participation. According to this, health

care professional were asked to determine whether a child with a health condition

should or not participate in a particular sport. One way of determining this is by

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

In Collision Sports athletes purposely hit or collide with each other or

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

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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

Mountain Biking, Wrestling. In Limited-Contact Sports there is a contact with other

athletes or with inanimate objects is infrequent or inadvertent. However, some limited-

contact sports can be as dangerous as collision or contact sports. eg, Softball, Squash,

Skateboarding, Baseball, Basketball, Bicycling, Skating, Volleyball, Hockey, Cricket.

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

Likewise, Federation Dentaire International (FDI) categorizes

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

skating, Skateboarding and Mountain biking. Characteristics of high-risks sports are in

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

is static.59 It includes Basketball, Handball, Squash, Gymnastics, Parachuting and Water

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

probability of a fatal injury occurrence.59 It includes Badminton, Golf, Swimming,

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Running and Billiards. It includes sports in which rough contact between the players is

not allowed and in this risk of injury is less.60

Participation in sports makes a positive and powerful contribution to

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

anterior dentition play an important role in human relationships.61 The dental

professionals should make efforts to promote the use of mouthguard by informing

athletes of the possibilities of active prevention against injuries to dental/oral regions in

order to reduce their number.2 To increase acceptability and use adequately fitted

mouthguard should be fabricated and delivered by dental professionals as indicated in

the Academy for Sports Dentistry position statements.5 Infact subsequent care and

maintenance should also be accomplished by the dentist.2

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

attain excellence, for the development of skill, or some combination of these.1

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

athletic injuries and encouragement of research in prevention of such injuries." 62

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

periodontium. The study of dental trauma is called dental traumatology.63

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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

from sport activities.64

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

R Medical Attention: Refers to an assessment of a player's medical condition by a qualified

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"

must be replaced E\WKHWHUPLQRORJ\³SURSHUO\ILWWHGPRXWKJXDUG´

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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.

Krause P (1910)250 Carlos reported in the early 1910s, use of a reuseable

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

create his mouthguards.

Cohen A and Borish A (1958)251 documented that mouthguards were first

introduced by boxers in the 1920s and 1930s, also were used by gridiron

footballers, primarily as a result of pioneering work of a number of American

GHQWLVWV 7KH IRUPHU GHPRQVWUDWLQJ WKDW µWKH ZHDULQJ RI D SURSHUO\ ILWWHG

mouthguard DOO EXW HOLPLQDWHG PRXWK LQMXULHV LQ KLJK VFKRRO IRRWEDOOHUV¶

Mouthguards are not just effective in the prevention of dentoalveolar injuries.

Hickey J and Morris A (1967)254 found in their work on cadavers that

mouthguards reduced the intracranial pressure and hence the force of impact to

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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

mandibular fossa of the cranium as achieved by a mouthguard.

Francis KT and Brasher J (1991)19 reviewed the physiological effects of

wearing mouthguard and measured the ventilator gas exchange its effects of

wearing a mouthguard and found that the wearing of mouthguard did not

significantly change oxygen consumption while exercising at the lower work

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

post-season questionnaires. Approximately one half of the teams were supplied

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

teams reported a reduction in the incidence of oculofacial injuries compared

with comparison team respondents (p=0.04). There was no reported adverse

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.

Canadian Dental Hygienist Association (2005)61 CDHA position statement on

sports mouthguards research shows that orofacial injury in sport is prevalent and

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carries significant medical, financial, cognitive, psychological and social costs.

Reasearch also confirms that mouthguards can prevent orofacial injuries. The

CDHA therefore strongly recommends that dentist or dental hygienist play an

integral role in the prevention of orofacial injury in sport and promote properly

fitted mouthguards as an essential piece of protective equipment, in sports that

present a risk of orofacial injury at the recreational and competitive level, in both

at the time of practice and playing games.

Takeda T (2006)134 applied the exfoliation test and some treating techniques

and conditions that improve the adhesive strength on a laminated surface long

time to maintain stability of laminated type of mouthguards adequate strength

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.

Therefore, if laminated-type mouthguards were manufactured properly, it can be

used for a longer time and in a good condition.

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

participated in this investigation. There is some concern regarding the amount of

material thinning that occurs during the fabrication of custom fabricated

mouthguards. Alginate impressions from each subject were used to produce

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

production of a properly fitting mouthguard.

Tiwari U, Mishra V, Bhalla A, Singh N, Jain S, Garg H, et al (2011)52 Study

reported a unique experimental scheme, utilizing Fiber Bragg gratings (FBGs)

sensor as distributed strain sensors is proposed and investigated to estimate

impact absorption capability of custom-made mouthguard. Earlier investigations

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

flexibility for ease of bonding, self-referencing, and multiplexing capability of

using FBG sensors. Finite-element analysis was performed to simulate the stress

distribution due to impact on the mouthguard. The FBGs were fabricated by

exposing the core of photosensitive fiber to intense Ultra-Violet light through a

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

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shift for FBG bonded on the mouthguard, indicating that most of the impact

energy is absorbed by the mouthguard.

Mizuhashi F, Koide K, Takahashi M and Mizuhashi R (2012)256 Conducted

study, in which investigated the differences in the thickness of the mouthguard

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

the thickness of the mouthguard in clinical use.

Abe K, Takahashi H, Churei H, Iwasaki N and Ueno T (2013)224 evaluated

the effect of fiberglass reinforcement on the flexural and shock absorption

properties compared with conventional thermoplastic materials. Experimental

materials incorporating fiberglass cloth were used to develop a thin and

lightweight face guard (FG). Material was four commercial 3.2-mm and 1.6-mm

medical splint materials (Aquaplast, Polyform, Co-polymer, and Erkodur) and

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

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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

significantly lower than those of the commercial 3.2-mm specimens. These

results suggest that the thickness and weight of the FG can be reduced using the

experimental fiber-reinforced material.

Pae A, Yoo Ra, Noh K, Paek J and Kwon KR (2013)257 determined the effect

of stabilization splints and mouthguards on the athletic ability of professional

golfers. Eight professional golfers with a mean age of 20.5 were selected. These

participants performed four trials of 10 driver swings and 10 putts with or

without a stabilization splint (control group) or mouthguard. The drive distance,

club head speed, initial ball speed, and putting accuracy were compared and

analyzed before and after the application of equal bilateral molar occlusion.

When the bilateral molar occlusion was applied using a mouthguard or

stabilization splint, the club head speed and driving distance in the presence of

the oral appliances were significantly increased compared with those without the

presence of appliance (P < 0.05). When the mouthguards or stabilization splints

were adjusted it results in unilateral molar occlusion, the club head speed and

driving distance in the presence of the appliances were significantly decreased.

The initial ball speed and the putting accuracy were not affected by the use of

the appliances. No difference was observed in the effectiveness of the

stabilization splint and mouthguard when bilateral molar occlusion was

performed. The occlusion stability that results from stabilization splints and

ϯϵ



mouthguards is thought to increase the club head speed and driving distance in

professional golf players.

SPORT RELATED TRAUMA AND ITS MANAGEMENT :-

Sahlin Y (1990)73 evaluated sports accidents in childhood. 5-14 years old

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

reduced in number and severity by implementing mandatory use of protective

equipment such as helmets and mouthguard, provision of more skilled coaches,

increased practice in general training, leading to better body control, preventing

younger children from participating in technically advanced sporting activities

and doing further research to acquire more knowledge on the mechanisms of

injury according to age and technical skill.

Emshoff R, Schoning H and Rothler G (1997)76 assessed changes in the

incidence and causes of mandibular fractures occurring in Innsbruck, Austria

between 1984 and 1993 and concluded that sporting injuries were becoming

increasingly common. The high incidence of associated maxillofacial injuries

involved in skiing and cycling accidents suggested increasing need for

preventive and protective measures.

ϰϬ



Tesini DA and Soporowiski NJ (1999)66 reviewed the policy on prevention of

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

traumatic injuries are unavoidable, most can be prevented with helmets,

facemasks and mouthguard & have been shown to reduce both the frequency

and severity of dental and orofacial trauma.

Bastone EB, Freer TJ and McNamara JR (2000)68 reviewed the literature on

epidemiology of dental trauma with emphasis on etiology as well as the different

classifications currently used to report dental injuries. Type and dental locations

of traumatic injuries and possible preventive measures were also discussed.

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

permanent dentition. Accidents as a result of falls, sports, violence and road

traffic were also common causes of it. Most frequent type of injury was simple

crown fracture of maxillary central incisor in permanent dentition while injuries

to periodontal tissues were common in primary dentition. Knowledge of etiology

is important for planning preventive measures so by eliminating the cause, the

frequency of dental trauma could be reduced. Use of protective devices like

mouthguard and helmets while playing sport could avoid trauma. It was

concluded that traumatic injuries in children and adolescents were a common

problem and their prevalence has increased during the past few decades.

ϰϭ



AL - Malik M (2009)74 in a clinical study determined the occurrence, causes,

types and severity of oral trauma and the time elapsed until seeking dental care

in children seen in a hospital in Jeddah, Saudi Arabia. It included all cases of

oro-facial trauma for children aged 17 years and younger who presented at the

emergency and dental departments of the hospital during a 12-month period. In

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

paediatric traumatic oral injuries and this study helped us in improving

awareness regarding the oral injuries and importance of minimizing its

complication through educational programs.

Dua R and Sharma S (2012)69 performed an in vivo study to ascertain the

prevalence, causes and correlation of traumatic dental injuries among 7 to 12

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



playing (37. (QDPHOIUDFWXUHZDVPRVWSUHYDOHQW  ZLWK$QJOH¶VFODVV

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 ,

malocclusion exhibited greater risk factor for traumatic injuries.

AWARENESS, ATTITUDE AND USE OF MOUTHGUARD :-

Chapman P (1985)253 suggested that, the use of mouthguard should be

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

should make the wearing of mouthguards compulsory in all contact sports.

Chapman PJ (1985)110 reported that out of the 30 members of the 1984

Australian Rugby Union Touring Team (the Wallabies), 80% wore mouthguard

and of these, 75% believed that wearing mouthguard should be made

compulsory for Rugby players. 10 instances of orofacial injury were reported, in

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

participants in contact sports, even to those who are edentulous.

Peter D (2005)113 UHSRUWHGRQ³Athletic mouthguard, its indications, types, and

benefits´ that dental injuries are the most frequently incurred orofacial injuries

ϰϯ



from sports activities. The public is largely uninformed about the serious

consequences of sports trauma as well as methods of prevention. Trauma

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

consequences, perhaps as a defensive mechanism to protect psychologically

against the possibility of an injury. A survey by Karl reported that even in the

National Hockey League, only 51.6% of NHL players wear a mouthguard. It is

understandable that it may not be possible to force a professional athlete to wear

a mouthguard, but it is unfortunate that owners and the league administration do

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

can be attributed to the absence of a mouthguard or to improperly fabricated and

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.

Tulunoglu I and Zbek MO (2006)200 conducted a study to evaluated the

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

semi-professional or amateur boxers and tae kwon do participants in Turkey.

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



practitioners, and 89 (32.5%) were boxers. The participants answered a standard

questionnaire. All answers were evaluated and then statistical analyses were

performed. Of the total sample, 61 of the subjects (22.3%) suffered dental

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

do practitioners and 14 (25.9%) were boxers. Of the total sample of 274

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

authorities in Turkey should promote the use of mouthguards in contact sports

such as tae kwon do and boxing, which have a serious risk for dental and oral

soft tissue trauma and tooth loss.


66
AAPD Guidelines (2010) documented that the American Academy of

Pediatrics (AAP) recommended practitioners, to advise patients and their

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

training program with appropriate coaching, supervision, and safety measures in

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



Biazevic MGH, Crosato EM, Detoni A, Klotz R, De Souza ER and Queluz D

(2010) 260 evaluated the prevalence of orofacial injuries during practice of sports

and the use of mouthguard by university students in the southern region of

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

54.55%, swelling 23.72%, and dental fractures 16.21%. Among the

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

interviewed university students used individual protection measures to avoid

these injuries.

Azodo CC (2011)261 determined the prevalence of orofacial injuries among

EDVNHWEDOOSOD\HUVLQ%HQLQ&LW\1LJHULDDQGVXUYH\HGWKHDWKOHWHV¶DZDUHQHVV

attitude and use of mouthguards. Amongst basketball players in the Benin City

between November 2009 and January 2010. A self-administered questionnaire

elicited information on demography, the prevalence of oral and facial injuries,

distribution of site and cause of orofacial injuries, athletes knowledge, attitudes

and usage of mouthguard. The mean number of injuries in previous 12 months

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

injury was not significantly associated with demography, category, competition

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

mouthguard were mostly ignorance, non-availability and non-affordability.

Hence, concluded that the high prevalence of orofacial injury among basketball

players reported in this study justifies the need for multidisciplinary injury

prevention, interventional approach with emphasis on the rules of the games.

Takeda T, Ishigami K, Mishima O, Karaaswa K, Kurokawa K, Kajima T et

al (2011)260 The positive effects of wearing a mouthguard have been indicated

in various epidemiological surveys and experiments, and their usage appears to

be increasing in many sports. However, many preventable sports-related dental

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

ease of clinical application. This mouthguard consists of an outer and an inner

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

damage or treatment. The purpose of this article is to describe the method by

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.

Boffano P, Boffano M, Gallesio C, Roccia F, Cignetti R and Piana R

(2012)259 The prevention of dental injuries during full-contact sports such as

rugby is extremely important. Wearing a mouthguard can significantly reduce

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

Province of Turin, Italy completed a questionnaire about playing history, current

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

games. The most commonly reported problem associated with using a

mouthguard was the discomfort on speech, followed by difficulty in closing lips,

adversely affected breathing, adversely affected swallowing and slipping

sensation. A statistically significant association between patients <22 years 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

and coaches to promote the use of mouthguards would be extremely important

to reduce common complaints about these devices and increase their usage.

Duddy FA, Weissman J, Lee RA, Paranjpe A, Johnson J and Cohenca N

(2012)259 Prevention of traumatic dental injuries relies on the identification of

etiologic factors and the use of protective devices during contact sports.

Mouthguards are considered to be an effective and cost-efficient device aimed at

buffering the impacts or blows that might otherwise cause moderate to severe

dental and maxillofacial injuries. Interestingly, besides their role in preventing

injury, some authors claim that mouthguards can enhance athletic performance.

ϰϴ



So, through this study there is a comparison of two different types of

mouthguards on the athletic performance and strength of collegiate athletes.

Materials selected, eighteen college athletes ranging from 19 to 23 years

participated in this study, boil-and bite mouthguard and a custom-made

mouthguard (CM). So, the result came custom-made mouthguards had no

detrimental effect on athletic strength, performance and it is comfortable not

causing difficulty in breathing. So, the use of custom-made mouthguards should

be encouraged in contact sports as a protective measure, without concern for any

negative effect on the athletic performance of the athletes.

Ozbay G, Bakkal M, Abbasoglu Z, Demirel S, Kargul B, Welbury R et al

(2013)70 investigated that the frequency of dental injuries in pediatric handball

players, there habits with regard to mouthguard usage as well as their general

health knowledge about prevention of traumatic dental injuries. Concussion was

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

more knowledge and education considering the prevention of traumatic dental

injuries from their sports clubs and dentists.

Sigurdsson A (2013)82 documented an evidence based review of prevention of

dental injuries in which he gave historic review, protection devices, types of

mouthguards, in which it is clearly said that now the main focus has been on

making and promoting mouthguards. The foremost important is to investigate

the actual protection of mouthguards and faceguards. In addition more emphasis

ϰϵ



should be placed on the most constructive way to educate youngsters and

teenagers on how to avoid traumatic injuries to their teeth.

ϱϬ



INCIDENCE, SITE AND PREVALENCE OF DENTAL TRAUMA


FROM SPORTS:

A).Incidence & Prevalence:

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

main cause of dental injuries can be classified as falls(82%-primary,52%-permanent

teeth) collisions(8%), sporting activities(16%), violence(11.3%), and road traffic

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

introducing mandatory protective equipment. Popular sports such as baseball,

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

activities increases, so do the number of athletic dental injuries. Orofacial injuries

include soft tissue lacerations, chipped or avulsed teeth, and mandibular/maxillary

ϱϭ



fractures. Many of the published studies regarding dental injuries and participation in

sports are listed in table -1.

Sporting activities can be broadly classified as those which involve direct

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

the activity. (Dorney 1998)70

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

with regard to dental trauma experience.69

Many authors have reported different prevalence rates in different years.

(1) According to Age

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

any form of dental trauma.

(2) According to Sex

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

that 63.2% males and 36.4% females were affected.

(3) According to the Cause

One-third of all people suffering from dental trauma to do so during

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

24.2% using a sample size of 184.

(4) According to Sport Played

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

reported was fall (37.5%) during playing.

ϱϯ



(5) According to Tooth Involved

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

more than the girls.

Individuals participating in sports activities may be at risk for dentofacial

trauma. The literature indicates that the maxillary central incisors are injured more

frequently than any other teeth. (Table ± 2)

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

in 7% of the patients, the information was not reliable enough.69

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

distribution of sport-related mandibular fractures showed an increase from 28.6% to

34.5%.The major causative factor in sports-related mandibular fractures was skiing

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

skiing-related injuries, whereas in patients sustaining mandibular fractures caused by

soccer, mucosal lacerations, tooth luxations, and cerebral concussions were the only

associated injuries found.76

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

automobile accident.79 Biking topped the list of sports-related injuries, followed by

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

lack of conditioning, or insufficient warm up and stretching.77,78

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

resulted in 12% to 16% sport accident reported by martin et al in 1990. 83 Children

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

the sample groups. The results are shown in table - 4.

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



³7-]RQH´ERQHV WKHQRVHWKH]\JRPDDQGWKHPDQGLble). These injuries often occur in

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



PREDISPOSING FACTORS OF SPORTS INJURIES:

Sports activities involve the interplay of various factors which directly or

indirectly influence the tendency of children to sustain injuries.72

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

impact of the force influence the nature of trauma.

2. Player: Various attributes of the player influence the injuries sustained:

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.

b) Gender: Boys tend to sustain more injuries than girls.

c) Body size: It influences the ability of a player to maintain balance

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

of fracture seen in affected patients. No risk factor was found to be

significantly more prevalent, but Angle's Class II div 1 patients (21.9%)

experienced the maximum number of injuries. Children with such

malocclusion should be provided with protective devices. Use of

mouthguards must be considered even during active orthodontic therapy.

ϱϴ



Adolescents and younger children spend most of their time in

various sports activities. These sport endeavours involve unintentional

traumatic dental injuries which may be further affected by various

environmental determinants like human behaviour, material deprivation,

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

preschool and school-aged children, whereas physical leisure activities,

violent incidents and traffic accidents account for most TDIs among

adolescent.

e) Body growth: During period of growth spurts, the child adjusts to newly

learned skills in relation to the developing changes in the body.

f) State of mind: It effects the players level of concentration. Under stress his

mind may not anticipate the immediate risk.

g) Inherent personality factors: Emotionally stressed children are at a higher

frequency of injuries better.

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

of the players to sustain an injury.

a) Contact sports: Football, Hockey and Rugby are common contact sports with

a high risk of injury.

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

appropriate protective devices.

5. Referees and Umpires: They have an important role in identifying players who

intentionally cause injury to opponents. The referees and umpires should ensure

use of protective devices by the players.

6. Sports administrators: Sports organizations should identify those events which

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

playing field to identify rough patch or other areas.

8. Availability of orofacial and other protective equipment: Helmets, Facemasks

and Mouthguards should be available at low cost so that players can be

benefitted.

According to WHO, certain factors have been identified that could predispose a child

to oral and maxillofacial injuries.79

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

type of malocclusions, predisposing to dental trauma are:

ϲϬ



a) Increased over jet with protrusion of upper incisors and insufficient lip

closure

b) Angles class II div I

c) Angles class I type II

3. Children with cerebral palsy have high predilection to dental trauma

4. Epileptic patients present special problems

5. Dentinogenesis imperfect is an unusual dental condition with increased

susceptibility to trauma.79

ϲϭ



TYPE OF TRAUMATIC DENTAL INJURIES SECONDARY TO


SPORT:

Traumatic dental injury is moreover a public dental health problem


because of its frequency, occurrence at a young age, costs and treatment that may
FRQWLQXHIRUWKHUHVWRIWKHSDWLHQW¶VOLIH&KLOGUHQDQGDGROHVFHQWVSHQGDJUHDWGHDORI
time participating in numerous recreational and sport activities. 1/3rd of all preschool
children have suffered a traumatic dental injury involving the primary dentition, 1/4 th of
all school children and almost one third of adults have suffered a trauma to the
permanent dentition.84

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

1) Classification by Rabinowitch (1956)79

Rabinowitch has classified injuries to the primary teeth in the following way:

1. Fractures of the enamel or slightly into the dentin.

2. Fractures into the dentin.

3. Fractures into the pulp.

4. Fractures of the root.

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 I ± Simple fracture of the crown involving little or no dentin.

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 V: Teeth lost as a result of trauma.

Class VI: Fracture of the root with or without a loss of the crown structure.

Class VII: Displacement of a tooth without fracture of the crown or root.

Class VIII: Fracture of crown in masse and its replacement.

3) Andreason classification (1981)68,79,84,86,88,89,90,91

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.

Classification According To Trauma:

1. Injury to Hard dental tissue and Pulp.

2. Injury to Periodontal tissues.

3. Injury to Gingiva and Oral mucosa.

4. Injury to Supporting bone.

A).Injury To Hard Dental Tissue and Pulp:

ϲϯ


a. Crown Infraction: Incomplete fracture of the enamel

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

d.Uncomplicated Crown and Root fracture: A fracture involving


enamel,dentin,cementum, not exposing the pulp.

e. Complicated Crown and Root fracture: A fracture involving


enamel,dentin,cementum, and exposing the pulp.

f. Root fracture: A fracture involving enamel, dentin, cementum, and the pulp.

B). Injury to Periodontal Tissues:

a. Concussion: Injury without abnormal loosening or displacement but with marked


reaction to percussion.

b. Subluxation (loosening): Injury with abnormal loosening but without displacement of


the tooth or displacement of tooth into the alveolar bone.

c. Extrusive luxation: Partial displacement of tooth out of its socket

d. Lateral luxation: Displacement of tooth in a direction other than axially.

e. Exarticulation: Complete displacement of tooth out of its socket.

C. Injuries to The Supporting Bone:

a. Comminution of Alveolar socket: Cruising and compression of the alveolar socket.

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.

D. Injuries to Gingiva or Oral Mucosa:

a. Laceration of gingiva or oral mucosa: A shallow or deep wound in the mucosa


resulting from a tear and usually produced by a sharp object.

b. Contusion of gingiva or oral mucosa: A bruise usually produced by an impact from a


blunt object and not accompanied by a break of the continuity of the mucosa, causing
sub mucosal haemorrhage.

c. Abrasion of gingiva or oral mucosa: A superficial wound produced by rubbing or


scrapping of the mucosa leaving a raw bleeding surface.

4) Modification of Ellis classification by Mc Donald, Avery and Lynch (1983)79

This classification is a simpler and clearer version of the Ellis classification based
on the anatomic and morphological aspect of the anterior tooth.

Class 1: Simple fracture of the crown involving little or no dentin.

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.

Class 4: Loss of the entire crown.

5) Garcia-*RGR\¶VFODVVLILFDWLRQ  68,92,93,94

Is a numerically descriptive classification that holds good for the primary and
SHUPDQHQWWHHWK,WLVEDVHGRQ$QGHUVRQ¶VPRGLILHG:+2¶VFODVVLILFDWLRQ

Class 0 ± Enamel crack.

Class 1 ± Enamel fracture.

Class 2 ± Enamel-dentin fracture without pulp exposure.

ϲϱ


Class 3 ± Enamel-dentin fracture with pulp exposure.

Class 4 ± Enamel-dentin-cementum fracture without pulp exposure.

Class 5 ± Enamel-dentin-cementum fracture with pulp exposure.

Class 6 ± Root fracture.

Class 7 ± Concussion.

Class 8 ± Luxation.

Class 9 ± Lateral displacement.

Class 10 ± Intrusion.

Class 11 ± Extrusion.

Class 12 ± Avulsion.

6) Classification by Ulfohn (1985)79

This classification is evolved from a clinical endodontic point of view. He


classifies crown fractures into three simple cases:

A. Fracture of enamel.

B. Fracture of the crown with indirect pulp exposure through the dentin.

C. Fracture of the crown with direct pulp exposures.

7) Classification of dental trauma from prospective (incidence) studies:

1. Stockwel95 Fracture of enamel only


Fracture of crown involving enamel and dentine, but not the
pulp
Fracture of the crown with exposure of the pulp
Fracture of the root
Luxation of the tooth without fracture
Avulsion of the tooth

ϲϲ



Concussion without fracture,


Displacement or avulsion but loss of vitality during survey
period
Trauma to a previously traumatized tooth or further fracture,
Dislodgement or avulsion of the tooth

2.Perez et al.96 Intra-oral and/or extra-oral soft tissue injury


Presence or absence of fracture/displacement to teeth
Alveolar fracture
Crown fractures were analysed according to
Ellis classification system

3.Galea 97 Crown fractures without pulp exposure


Crown fractures with pulp exposure
Crown-root fractures
Root fractures
Subluxation
Subluxation with intrusion
Subluxation with extrusion
Luxation
Fracture of the alveolar socket
Dento-alveolar fracture
Fractures of the mandible/maxilla
Injuries to the soft tissues
Other injuries

4.Hamilton et al. 98 Fracture confined to enamel


Fracture involving dentine
Fracture with pulp exposed
Intrinsic discolouration
Abnormal mobility

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

6.Dearing 87 Fractures only

8) Classification of dental trauma from cross-sectional (prevalence) studies:-

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

2.Bijella et al.101 Crown fracture


Concussion
Subluxation
Subluxation with enamel fracture
Subluxation with lingual or labial displacement
Intrusion
Extrusion
Full displacement
Root fracture

ϲϴ

Crown-root fracture
Alveolar bone fracture

3.Burton et al.102 Fracture involving dentine and/or pulp


Devitalization
Avulsion

4.Forsberg and Tedestam103


Enamel fracture
Enamel-dentine fracture
Fracture involving pulp
Root fracture
Luxation, subluxation
Ex-articulation
Discolouring

5.Zerman and Cavalleri104


Fracture of enamel, including enamel chipping
Fracture of enamel-dentine without pulpal involvement
Fracture of enamel-dentine with pulpal involvement
Fracture of root
Crown-root fracture with pulpal involvement
Concussion
Subluxation
Intrusive luxation
Extrusive luxation
Lateral luxation
Avulsion

ϲϵ


6.Hunter et al.105 Fracture


Discolouration
Absence of any maxillary incisor teeth

7.Burden106 Fracture (enamel)


Fracture (enamel and dentine)
Fracture (involving pulp)
Discolouration
Other restoration

ϳϬ



PREVENTION OF SPORT INJURIES:

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

engage in these endeavours.1

With increasing participation, increases the chance of injuries related to

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

weighed against any possibility of dental/oral injuries during participation in sports.

There should be an informed decision if participating in any sport or recreational

activity.1 (Figure - 2)

Sports related traumatic dental injuries are preventable, by the use of

properly fitted, protective athletic equipment.77 Currently different athletic equipment

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

the concept of a mouth guard was initiated in the sport of boxing.109

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

x Mouthguards or Gum shields were originally developed in 1890 by Woolf

Krause , a London dentist, as a means of protecting boxers from lacerations.

These gum shields were originally made from gutta percha and were held in

place by clenching the teeth.108

x Mouthguard are regarded as being essential for protection of the orofacial region

in all contact sports by Chapman in 1983, Walkden in 1981, and Hughston in

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

device gained importance particularly in boxing.65

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

it was used by gridiron Footballers, as a result of the pioneering work by number

of American dentists including Cohen & Borish and after that Cathcart , the

IRUPHU   KDG GHPRQVWUDWHG WKDW µWKH ZHDULQJ RI D SURSHUO\ ILWWHG 0RXWKJXDUG

eliminate the mouth injuries in High-VFKRROIRRWEDOOHUV¶111

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

x In 1947, a Los Angeles dentist, made a breakthrough by using transparent

acrylic resin tRIRUPDQDFU\OLFVSOLQW´109


x
In the 1948 issue of the Journal of the American Dental Association, the

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

guard for athletes. 109

x In the 1950s, the American Dental Association (ADA) began conducting

research on mouth guards and soon promoted to the public.109

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

extremely far-sighted piece of Legislation.111

x Since 1962,various organizations related to sports athletics made regulations

which enforces mandatory use of mouthguard among its participations.65

x The National Collegiate Athletic Association (NCAA) followed suit in 1973 and

made mouth guards mandatory in college football. Since the introduction of the

mouth guard, the number of dental injuries has decreased dramatically.109

ϳϯ



Sports Which Need Mouthguards: 109 (Table ± 5)

The ADA recommends mouth guards be used in

Acrobatics Ice Skating Water polo

Basketball Inline Skating Weight Lifting

Bicycling Lacrosse Wrestling

Boxing Martial Arts Volleyball

Equestrian Events Racquetball Squash

Extreme Sports Rugby Surfing

Field Hockey Shot putting Soccer

Football Skateboarding Softball

Gymnastics Skiing Skydiving

Handball Snowboarding Judo & Karate

The American Academy of Pediatric Dentistry (AAPD, 2012) recognizes

the prevalence of sports-UHODWHGRURIDFLDOLQMXULHVLQRXUQDWLRQ¶V\RXWKDQGWKHQHHGIRU

prevention. This policy is intended to educate dental professionals, health care

providers, and educational and athletic personnel on the prevention of sports-related

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

activities. Study conducted by Maestrello CL, Mourino AP and Farrington FH indicated

dentists attitude towards mouthguard protection. (Table - 6 (A),(B),(C), 7, 8)

1. Continuation of preventive practices instituted in youth, high school and college

football, lacrosse, field hockey, and ice hockey.

2. For youth participating in organized baseball and softball activities, an ASTM-

certified face protector is required (according to the playing rules of the sport).

3. Mandating the use of properly-fitted mouthguard in other organized sports

activities that carry risk of orofacial injury.

4. Prior to initiating practices for a sporting season, coaches/ administrators of

organized sports consult a dentist with expertise in orofacial injuries for

recommendations for immediate management of sports-related injuries (e.g. avulsed

teeth).

5. Continuation of research in development of a comfortable, efficacious, and cost-

effective sports mouthguard to facilitate more widespread use of this proven protective

device.

6. Dentists of all specialties, including pediatric and general dentists, provide

education to parents and patients regarding prevention of orofacial injuries as part of the

anticipatory guidance discussed during dental visits.

7. Dentists should prescribe, fabricate, or provide an appropriate referral for

mouthguard protection for patients at increased risk for orofacial trauma.

ϳϱ


8. That third party payors realized the benefits of mouthguards for the prevention and

protection from orofacial sports-related injuries and, furthermore, encourages them to

improve access to these services.

9. The ASD and the International Association of Dental Traumatology be consulted as

valuable resources for the professions and public.66

Protective Equipment For The Prevention Of Craniofacial And Intraoral Sports

Related Traumatic Dental Injuries:

Preventive management should be done, after risk assessment of dental

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

Preventive solutions for orofacial injuries are:112

- Routine checkups should be done for any physical or mental condition that might

cause an unexpected problem during athletic event.

- Completion of any ongoing dental treatment e.g. orthodontic treatment should be done

for correction of proclined anterior teeth.

- Use of preventive devices like mouthguard, helmets and face masks should be done

under professional guidance.112

The protective devices for prevention of orofacial trauma are:

1) Mouthguard (Figure ± 3)

2) Helmet (Figure ± 3 D)

ϳϲ



3) Facemasks/faceguard (Figure ± 3 E)

These can be used alone or in conjunction with one another.

1) Mouthguard

According to Dorland Medical Dictionary (2000) it is defined as a

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

during contact sports.1

According to the American Society For Testing And Material (ASTM)

mouthguard is a resilient device or appliance placed inside the mouth to reduce mouth

injuries, particularly to the teeth and surrounding structures.65

In 1913,moXWK SURWHFWRUV ZHUH LQLWLDOO\ LQWURGXFHG DV WKH %R[HU¶V

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

use of mouthguards among its participants.65

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

a mouthguard could have a significant preventive role.113 The Academy of Sports

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,

parachuting, horseback riding, rugby, racquetball, skiing, soccer, squash, surfing,

skateboarding, shot putt, skydiving, trampoline, tennis, volleyball, wrestling, weight

lifting and water polo.65

Wearing an appropriately designed and made mouthguard while

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

teeth with a properly fitted mouthguard.65

A protective mouthguard should be comfortable yet tight fitting, allows

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

the jaws from any dislocations and fractures.65

Characteristics Of An Ideal Mouthguard1 (Figure ± 4)

The ideal mouthguard has several characteristics. These are as follows.

(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

and strain on the oral structures.

(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

prognathism). It should be removable and taken in and out easily.

(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

mouthguard should be odourless and tasteless to maximize its acceptability by the

athlete.

(4) Fabrication ± The custom-made mouthguards should be fabricated easily with

limited chair time and lab time. The cost must be reasonable for acceptance by the

athlete.

Functions Of Mouthguards: 113

Textbook and Color Atlas of Traumatic Injuries to the Teeth, Andreasen and

Andreasen list 8 basic mouthguard functions:

(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

direct frontal blows while redistributing the forces of impact.

(3) Opposing teeth are protected from seismic contact with each other.

(4) The mandible is afforded elastic, recuperative support that can prevent fracture or

damage to the unsupported angle of the lower jaw.

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

base of the skull, resulting in concussion.

(6) Mouthguards can provide positive reinforcement in the prevention of neck injuries.

(7) Mouthguards provide a psychologic benefit to athletes. Findings suggest athletes

feel more confident and aggressive when they have the proper protection.

(8) Mouthguards fill edentulous spaces and thereby help support adjacent teeth. This

allows removable prostheses to be taken out during athletic competition.

Types Of Mouthguards

The American Society for Testing and Materials(ASTM), the ASD,the National

Collegiate Athletics Association(NCAA), and the American Dental Association(ADA)

gave three categories for athletic mouthguard.1

Classification of Mouthguards

The ASTM in Designation : F697-80 (Reapproved 1986) established the classification

system for athletic mouthguards as follows:1

Type I: Ready Made or Stock Mouthguard (Figure -3 A) - They are brought over-

the-counter and designed to be used without further modification. It is a preformed

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

to large), with little-to-no retention or adaptability to hard and soft tissues.

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,

the stock mouthguard is considered by many to be less protective. Such mouthguards

are no longer widely available.114

Type II Mouth: Formed or Boil-and-Bite Mouthguards (Figure -3 B) ± are available

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.

2) The boil-and-bite mouthguard which is manufactured typically as a standard tray of

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

Type III: Custom-Made Mouthguard (Figure -3 C) ± They are custom made on a

PRGHO RI WKH SDWLHQW¶V PRXWK ,W LV DYDLODEOH LQ VHYHUDO W\SHV LV LQGLYLGXDOO\ GHVLJQHG

and form-fitted in a dental office or made in the professional laboratory. Although

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

adaptability to orthodontic appliances.114

The simplest of these is a vacuum formed guard made from a single layer

of polyvinyl acetate-polyethylene. More complex designs incorporate sandwiching of

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

transmitted forces during impact, a material thickness of 4 to 5 mm is best suited.114

Materials Used For Mouthguards Includes114

The most commonly used materials for mouthguard are:

(1) Polyvinyl-acetate-polyethylene or ethylene vinyl acetate (EVA) copolymer

(2) Polyvinylchloride

(3) Polyurethane

(4) Latex rubber

(5) polyurethane

Latex rubber, a popular material used in early mouthguards is not in use

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

acrylic resin and polyurethane are less widely used.114

It is a readymade or custom made device which is fabricated in such a way

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

absorbing property which is used to fabricate mouthguard.112

Mouthguards typically are designed to fit over occlusal surfaces of the

maxillary teeth and gingivae. Class III occlusion may require mouthguard placement on

the mandibular arch.114

ϴϮ

x
Use Of mouthguard should be encouraged in all contact Sports, as the most

important value of the mouthguard is the concussion-saving effect following

Impact to the mandible. This fact alone should make the wearing of mouthguard

FRPSXOVRU\LQ DOOFRQWDFW 6SRUWV¶ ,Q DGGLWLRQ +LFNH\ 0RUULV IRXQGLQ WKHLU

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

condyle and the mandibular fossa of the cranium.111

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

removable partial dentures. It aids in reducing neck injuries, concussion,

cerebral hemorrhage, unconsciousness, serious central nervous system damage,

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

the entire temporal region.111

x Number of reviews of epidemiological and laboratory studies showed that

mouthguard reduces orofacial injuries.264 Mouthguard unequivocally reduce

hard and soft oral tissue injuries, jaw fracture, neck injuries. Some studies

documented that substantial impact that mouthguard have on reducing sports

related orofacial trauma.262 Some more studies showed that mouthgaurd are

effective in preventing dental injuries.263 (Table ± 9)

ϴϯ


Design, Construction, and Materials Issues

A. Occlusal contact:-

In 2004, Takeda et al.115 studied different occlusal conditions of a two-

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

achieved if an impression of the opposing arch is made. Only the pressure-laminated

mouthguard (not the one-layered vacuum-type mouthguards) permit sufficient occlusal

thickness to be created.

B. Thickness:-

In 2005, Waked and Caputo116 noted that an interocclusal space at

physiologic rest position is 2 to 4 mm from tooth contact. They therefore recommend a

mouthguard with a thickness greater than 3 mm so the arches are adequately separated.

These researchers conducted a study with 10 vacuum-formed and 10 pressure-laminated

mouthguards. The pressure-laminated mouthguard produced material thicknesses

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

thicker mouthguard that fits the interocclusal space better.

C. Design at different angles:-

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

of the second molars.

b. Thickness should be 3 mm on the labial aspects, 2 mm on the occlusal

aspect, and 1 mm on the palatal aspect.

c. The palatal flange should extend about 10 mm above the gingival

margin.

d. The labial flange should extend to within 2 mm of the vestibular

reflection.

e. The edge of the labial flange should be rounded in cross-section whereas

the palatal edge should be tapered.

f. When a maxillary guard is constructed, it should be articulated against

the matching mandibular model for optimum comfort.

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

tolerate guards that extend to the third molars.119

ϴϱ


D. Rebound and thickness testing:-

Guevara et al.120 conducted a study in 2001 comparing 19 vacuum-formed

mouthguards with 10 mouth-formed mouthguards. They found that the vacuum-formed

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

in making the vacuum-formed mouthguard to ensure that adequate thickness of material

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

achieved the standard of at least 50% rebound, established as a minimum requirement

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

Westerman et al.122 conducted two studies of the inclusion of air or gas

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

inclusion.123 This study examined results of simulated impact on two types of

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

throughout the polymer.

The researchers found that the foaming agent did not produce statistically

significant improvements in the impact performance, measured by improvements in

energy absorption, and reductions in transmitted forces of the EVA material.

E. Types of arch casts:-

Generally, single-arch mouthguards are fabricated for the maxillary teeth.

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

teeth.123 However, athlete compliance may be low, due to a lack of comfort.

The American Society for Testing and Materials (ASTM) recommends that

mouthguards for individuals with a class I or II malocclusion should be constructed

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

leaves this area unprotected.

F. Material and comfort:-

In 2001, Brionnet et al.128 conducted a study with 48 male rugby players

aged
129-133
who provided feedback on the comfort of acrylic resin and silicone rubber

custom-made bimaxillary mouthguards. Overall, players found the mouthguards quite

ϴϳ



comfortable and reported no difference in responses to the two types of mouthguard

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.

Fabricating A Custom-Fitted Mouthguard114

Formation of a professionally fitted custom mouthguard typically consists of five

standard steps:

(1) 0DNLQJDQLPSUHVVLRQRIWKHSDWLHQW¶VDUFK W\SLFDOO\WKHPD[LOODU\ IRUZKLFKWKH

mouthguard will be made (an impression of the opposing arch and a bite

registration are taken only if occlusal adjustments are to be made with an

articulated cast). The impression should include all remaining teeth (except

erupting third molars), the gingival (up to the mucolabial fold), labial frenulum,

complete palate, full vestibular extensions and borders. (Figure ± 5 A, B)

(2) Pouring a high-VWUHQJWKVWRQHPRGHORIWKHSDWLHQW¶VXSSHUWHHWK )LJXUH± 5 C)

(3) Forming one or more sheets of thermoplastic material (such as ethylene vinyl

acetate, polyvinyl chloride, polyvinyl acetate, natural rubber, soft acrylic resin or

other material) on the stone model.

(4) Seating the mouthguard with proper occlusal balance and equilibration.

(5) Final trimming of excess material from the mouthguard.114

Two common fabrication methods for custom mouthguards are:

(1) Vacuum formation, in which a single layer of copolymer material is used.

ϴϴ

(2) Pressure lamination, which combines heat and high pressure to laminate multiple

layers of copolymer material.

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

made mouthguard, it should be offered to patients.

Improvement In Mouthguards

It is desirable to use an appropriate mouthguard that has maximal effect in

preventing injuries in the orofacial area, especially in contact sports. Today, the use of

mouthguards is increasing. Boil-and-bite mouthguards are made from a thermoplastic

material that is immersed in hot water and then formed in the mouth using the fingers,

tongue, and biting pressure.138 Most players use boil-and-bite-type mouthguards

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

preventive ability, etc. Therefore, it is strongly desirable to use a mouthguard that is

custom-made.134

A major complication that seems to arise during the fitting of boil-and-bite

mouthguards is that a significant amount of thinning (between 70±90%) occurs at the

occlusal surface135 as a result of excessive or uncontrolled exertion of biting pressure.

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

on boil and-bite appliances for protection.136,137

ϴϵ


In contrast, custom-made mouthguards are not easily produced. To obtain

DFXVWRPILWDGHQWLVWPXVWWDNHDQLPSUHVVLRQRIWKHDWKOHWH¶VGHQWDODUFK W\SLFDOO\WKH

maxillary teeth) and fabricate the mouthguard from a stone or plaster model of the

dentition. Although custom-made mouthguards are by far the most expensive to

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

Custom mouthguards can be either vacuum formed or pressure-formed

over a stone or plaster cast model of the dentition.136,138 Vacuum-formed mouthguards

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,

the shape of vacuum-formed mouthguards is typically short-lived.136 Once the shape of

a mouthguard is lost, so too is fit, retention and comfort. An additional shortcoming of

vacuum formed mouthguards is related to the irregular distribution of mouthguard

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.

Alternatively, mouthguards can be pressure formed using high heat and

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

benefit of pressure-formed mouthguards is that they may be laminated (i.e. multi-

ϵϬ



layered). The advantage of fusing or laminating sheets of mouthguard material together

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.

Even though custom-made mouthguards are generally accepted as the best

available product on the market, there is still some concern regarding the amount of

thinning that results during the fabrication process.

Park et al.135 reported that in the course of manufacturing custom-made

mouthguards, there was an average decrease in material thickness of 25±50%. It is

unclear if this thinning is merely a consequence of the fabrication process

(thermoforming effect) or perhaps related to other factors such as jaw size. Thus,

conducted study evaluated the contribution that various size characteristics of the

maxillary dental arch as well as the height

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

Nowadays, vacuumed-type mouthguards are mostly used. In this type, it

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

manufactured. On the other hand, laminated-type mouthguards have higher shock

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

injuries often occur. Hence, the application of laminated-type mouthguards133,158-161 is

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

method of the laminated-type mouthguard should be improved. Therefore, some reliable

methods to reduce failures are necessary. Furthermore, it is necessary to control the

thickness of the mouthguard after fabrication by reducing the heating time.134

Using a mouthguard material of the EVA type, studied examined not only

adhesive strength on the laminated surface but also some methods of promoting

adhesive ability by means of a de-lamination test.134

Two pieces of mouthguard materials (3 mm thickness) were laminated

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,

was applied to the laminate surface with a writing brush.134

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.

Ultrafilm-soft was used to eliminate the adhesive surface. As for direct

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

influence of colour was examined as to whether it was clear, neon-yellow, neon-green,

white and black. The influence of water sorption was examined by facilitating water

VRUSWLRQ DW  DQG ¶& IRU D PRQWK 7KH FRORXU DQG ZDWHU VRUSWLRQ SDUDPHWHUV ZHUH

examined at a heating time of 165 s, which showed good adhesive ability after

considering the influence of heating time.134

Dorney, Padilla and co-workers158,159 used Drufomat in manufacturing

laminated-type mouthguards, which facilitated lamination by using high pressure (6

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

telephone number, team logo, favourite sticker, etc.

Padilla and co-workers,159 when comparing the pressure-laminated type

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

and coworkers160 reported the manufacture of a mouthguard of the bi-maxillary type.

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.

In Japan, Takeda and co-workers161 reported a fundamental way of

manufacturing an improved laminated-type mouthguard. Generally, mouthguard

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

co-workers162 reported the following: as a result of measuring the change in the

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

laminate-type mouthguards are manufactured by fusing some sheets of mouthguard

materials together. Sometimes they are damaged on the adhesive surface by saliva,

occlusal force, change of temperature, etc. Therefore, it is desirable that laminate-type

mouthguards are fused with sufficient strength during manufacture.134

The Factors that Influences Adhesion134

There are three methods for adhering plastics together: adhesion by

heating, adhesion by solvent (adhesion by melting the surface) and adhesion by bonding

agent.163 Adhesion by heating and adhesion by solvent are applied to thermoplastics,

which are softened by heating. Adhesion by a bonding agent is applied to thermosetting

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

factors or techniques affect the adhesion.

This mechanism is performed by the system of Drufomat, primarily, and

by other methods in the manufacture of laminated-type mouthguards. Thus, many

factors also seem to influence adhesion of mouthguard materials. 164

Steps Of Fabrication Of Mouthguard222

There are 4 parts to the fabrication of custom- made mouthguards they are:-

1.Impression

2.Fabrication

3.Trimming and Polishing

4.Placement and Occlusal Equilibration

Modern Technique For Mouthguard Construction165

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

extension of the mouthguard. (Figure ± 5 C)

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

placed on the sample platform. (Figure ± 5 D, E)

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

-5 H) As an alternative to reheating, a solvent may be applied to help adhere the

subsequent layer.

5). While still in the heated state, the assembly is placed again on the sample platform

and another 2 mm layer adapted as before.

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

tried in the mouth and adjusted for fit and occlusion.(Figure ± 5 k)

There have been markedly demonstrated improvements in mouthguard construction in

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

resolve a significant oral injury.

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



devices suggested which include enhancement of athletic performance and the

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

benefits of optimally constructed mouthguards in the prevention and reduction of sports

injuries.222

Care For Mouthguards: It includes:109

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 A soft toothbrush can be used to remove saliva and debris. (Figure ± 6 C)

x Keep the mouth guard in a well-ventilated plastic storage box when not in use.

The box should have several holes in it. (Figure ± 6 D)

x 'RQRWOHDYHWKHPRXWKJXDUGLQGLUHFWVXQOLJKW LQDFORVHGFDURULQWKHFDU¶V

glove box. Heat can damage it.

x Ensure your mouth guard is in good condition before each use.

x Ask your dentist to inspect your mouth guard at every dental check-up.

x Replace the mouth guard if it is damaged.

x 5HSODFHDFKLOG¶VPRXWKJXDUGHYHU\WRPRQWKVHYHQLILWDSSHDUVWREHLQ

good condition. Growth and new teeth can alter the fit.

x 5HSODFHDQDGXOW¶VPRXWKJXDUGDIWHUGHQWDOWUHDWPHQWRUWRRWKORVV2WKHUZLVHLW

should last for several years.

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)

The most desirable qualities of a mouthguard are protection, retention,

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

made for any patient whereas the mouth formed cannot.223

Fibber Bragg Grating Sensor for Measurement of Impact Absorption Capability165

Shock absorbing capability can be broadly defined as the reduction in the

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

of the commonly used measures is the initial rebound of a pendulum or a dropped

weight which directly impacts the mouthguard material.

The degree of rebound is a marker of the amount of impact force absorbed,

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

measurements of the performance characteristics of mouthguards, impact tests should

ϵϴ



be conducted on custom- mDGHPRXWKJXDUGVFRQVWUXFWHGGLUHFWO\RQWR D µVWDQGDUGL]HG

MDZ¶

The shock absorption ability of mouthguards has been researched using

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

absorption ability of mouthguards.167 Fibber Bragg Grating sensor is a new breed of

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

some unique advantages, like long-term stability, immunity to electromagnetic

interference, and compatibility with medical and dental composite materials, 173 they are

increasingly being used to study strain changes in dental research studies.

The shock absorption ability is proportional to the thickness174 of the

mouthguard. It is also necessary to maintain adequate thickness on the occlusal surface

to establish suitable occlusion and protect from the impact of force applied on the

mandible.166 The vacuumed-type mouthguards most commonly

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

forces after it has been manufactured. Conversely, laminated-type mouthguards have

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

injuries often occur.

Hence, the application of laminated-type mouthguards is considered to be

necessary from the standpoint of safety and comfort.175

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

mouthguards shock absorption capacity because of the differences of dissipation of

striking force.

Grading System Of The Protection Offered By Various Types Of Mouthguard 178

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

recommended to sportsmen and women by their dentists. This type of mouthguard

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



asphyxiation. Sportsmen should be actively discouraged from wearing such a

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

mouthguards should not be worn.182The wearing of a properly183 designed and fitted

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

characteristics of a thermo-formed material.187To make athletes participating in contact

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

of mouthguard and their protection capabilities has been developed.

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



comparative studies of the various types of mouthguard and mouthguard materials.

However, typical tests on the material do not really reveal the ideal properties being

sought in a mouthguard material. Tests on mouthguards placed on a model or on the


185
maxilla of a cadaver by Hickey et al may give a clearer indication of the protection

offered by the mouthguard and the mouthguard material.

Hoffmann et al188 studied the mechanical and physical properties of several

commercially available mouthguards. Mouthguards were fitted onto a specially made

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

rigidity of the mouthguard.

Oikarinen et al189FRPSDUHG WKH ³JXDUGLQJ FDSDFLW\´ RI VHYHUDO PRXWK

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.

To determine the effect of mouthguards on pressure changes and bone

deformation within the skull, Hickey et al185 constructed an impact producing

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

protection capabilities of mouthguards as regards concussion.

Kim and Mathieu190 studied the lamination of mouthguards using finite

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

was a significant effect on stress distribution, which effect could be increased by

controlling the ratios of modulus and volume fractions of the top and bottom layers.

A visco-elastic polyurethane, Sorbothane, used in orthopaedic and sports

applications because of its shock absorbing properties, was tested by Bulsara and

Matthew191 as an intermediate layer between two layers of EVA. A piezo-electric

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

force of impact from a blow to the teeth and jaws.

In an attempt to develop a standard test procedure for mouthguard

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

jawbone on which mouthguards were to be tested. Different projectiles at various

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

any mouthguard fitting the standard model they had made.

Westerman et al194 used an impact test rig similar to a Charpy or Izod

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

of the material and that a small reduction in thickness of 1 mm resulted in an increase in

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

air cells within an EVA copolymer mouthguard material produced a reduction in

transmitted forces when the impact was less than 10 KN.

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

the individual mouthguards.

Physical and mechanical tests were employed to examine the basic

properties of 57 different mouthguard products by Going et al196 in 1974. As well as

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

underlying tooth structure.

Mouthguard Proposal

ϭϬϰ



It is proposed that mouthguards should have a composite laminate

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

slowly than a single material system.186 Combinations of compliant/rigid materials

could be built up in a multi-layered composite system with materials and layer

thicknesses being adapted according to particular requirements.

Distribution of force impacting on mouthguard with outer layers made of EVA.

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

in reduced impact force and increased displacement. The mouthguard manufacturing

process, therefore, may compromise the performance of EVA as a protective device, the

increased displacement being a real cause for concern.187

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,

are easily dislodged, and may present a choking hazard.

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

be reduced sufficiently to compromise the already limited protection.

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

have been moved, worn down, or restored.

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

concussion. However, it must be correctly made and conform to certain guidelines in

relation to thickness and coverage of the dentition;

The following criteria should apply to mouthguards used in contact sports197:

ϭϬϲ

1. They should enclose the maxillary teeth to the distal surface of the second

molars.

2. Thickness should be 3 mm on the labial aspects, 2 mm on the occlusal aspect,

and 1 mm on the palatal aspect.

3. The labial flange should extend to within 2 mm of the vestibular reflection.

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

palatal edge should be tapered.

6. When a maxillary guard is constructed it should be articulated against the

matching mandibular model for optimum comfort.

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.

A mouthguard conforming to the above guidelines will provide maximum

protection against oral trauma such as broken or avulsed teeth, soft tissue lacerations,

and concussion. However, mouthguard materials, whilst effective, could be improved.

The ideal mouthguard material is composed of a polyvinyl acetate-polyethylene mixture

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

recommended for mouthguards.198

ϭϬϳ


Three areas that can be developed to improve custom made mouthguards:

GRADE - 7:- Improved materials that are better at absorbing repeated impacts and

transfer less energy to the teeth, jaws, and brain.

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

protected and the risk of repeated concussion negated.

GRADE - 9:- An effective, instrumented, test for mouthguards is required so that new

mouthguards can be tested.199 This test must be instrumented so that a quantifiable

index of protection can be developed.

GRADE - 10:- By combining items 1±3 above, we can obtain the ultimate

mouthguard.

Mouthguards differ and wearers need to be aware of their various

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

could wear a mouthguard in their chosen team colour. (Figure ± 7)

A grading system for sports mouthguards, indicating the risks associated

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

of oral trauma in contact sports.178 (Figure ± 8)

Attitude, Awareness, utilization rates and behavioural aspects of players towards

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

prominent in soccer, basketball, hockey, and boxing.201-203 In contrast to some sports,

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

extend the use of mouthguards in many other sports.202,205

Study conducted by Meadow D and Needleman H in 1984 and indicated

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

representation of seasonal trauma distribution is shown in figure ± 10.

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

been dramatically reduced by the use of these devices.206 (Figure ± 9)

A study conducted by Tulunoglu I200 indicated that only boxers were

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

trauma. Education on the effectiveness of properly fitted mouthguards for injury

prevention, information on the risk of injury, and availability of more comfort can lead

to the development of more positive attitudes and increase its usage.200

Heintz207 and Chapman208 confirmed that properly fabricated, custom-fitted

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

energy, quickly stopping the vibration of the maxillary teeth.113

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

Although approximately 40 years of research shows the benefits of mouthguards, the

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



or skateboarding.211 The utilization rate and behavioural aspects of mouthguards are

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

requirements in sports, lack of knowledge about the protective qualities of mouthguards,

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

not require mouthguard use.

3OD\HUV¶ DWWLWXGHV WRZDUGV PRXWKJXDUGV GHSHQG RQ DHVWKHWLFV DQG WKH

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

decrease if they were fitted with custom-fabricated mouthguards. Rules do not

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

rugby players said that mouthguards were unnecessary.216

2WKHUIDFWRUVWKDWLQFUHDVHWKHDWKOHWH¶VOLNHOLKRRGRIZHDULQJDPRXWKJXDUG

include starting to wear a mouthguard at an early age,213 a previous injury, and player

position.

Rugby player and basketball players214 studied indicated that mouthguards

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

Two studies showed that promoting injury-prevention material had little

impact on whether or not a player wore a mouthguard. Cornwell et al. 214 2003 in

Australia conducted a study of 496 basketball players. They measured mouthguard

wearing prior to and following a promotional intervention. Baseline mouthguard use

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



Ferrari and Medeiros in 2002218 surveyed 204 professional and semi-

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

compared with passively reading prevention material.

Further research is needed in the area of developing prevention material

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

on whether or not players wear mouthguards.

&RDFKHV¶DWWLWXGHVWRZDUGVPRXWKJXDUGXVHDUHDOVRDQLPSRUWDQWIDFWRULQ

LQIOXHQFLQJSOD\HUV¶FRPSOLDQFH8QOLNHRIILFLDOVFRDFKHV DUH SUHVHQWZLWKWKHSOD\HUV

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

patterns of behaviour that should be carried forward into competition.

A number of studies show that coachHVKDYHWKHPRVWLQIOXHQFHRQSOD\HUV¶

attitudes about mouthguards.213 Ranalli and Lancaster129 in 1995 conducted a survey of

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

school athletic coaches in sports that do not mandate mouthguard use.

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

if they detected a mouthguard infraction.

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

three fourths of parents had received no information on mouthguards and injury.

There was a lack of perceived need for mouthguards in sports such as

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



always promoting or enforcing mouthguard use. These barriers to prevention may be

addressed with educational information about orofacial injuries and the benefits of

mouthguards which targets players, officials, coaches and parents. One of the

educatiRQDOSURJUDP¶VJRDOVVKRXOGEHWRFKDQJHDWKOHWHVSDUHQWVEHKDYLRXUVRWKDWLWLV

proactive instead of reactive.61

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,

concussion, unconsciousness, cerebral haemorrhage, brain damage, paralysis, and death.

Organised sports at the amateur level that mandate the use of helmets

during practice and in competition. Helmets are recommended in football, baseball,

cycling, ice hockey, lacrosse, rugby, soccer and skiing/snowboarding, etc. 1

Two basic types of soft protective helmet linings are available:

- 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

inflatable bladder to enhance protection.112

3)Face Mask: 112

Facemasks are designed to protect against facial injuries to the mouth,

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,

baseball, softball, basketball, football, etc.1

Maxillofacial traumatic injuries sometimes occur in contact sports such as

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

injury, and the effectiveness of faceguards has been widely recognised.230-240

A faceguard is required to fulfil the following three requirements: 233

1) To protect the player from re-injury (protection ability),

2) To not hurt other players (safety),

3) 7RQRWQDUURZWKHSOD\HU¶VILHOGRIYLVLRQ PDLQWDLQWKHSHUIRUPDQFH 

Typically thermoplastic resin have been used as the faceguard material.

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

than those that use high moulding temperature thermoplastic resin.242

ϭϭϲ

Previous research on the impact absorption properties of faceguards and

mouthgurads243-246 explained about combination of hard thermoplastic material and soft

cushioning material can provide remarkable shock absorption properties.

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.

To solve this problem a reduction in the thickness of the hard

thermoplastic material was attempted by reinforcing the conventional thermoplastic

material with fibreglass. Thermoplastic material that are reinforced with fibreglass are

widely known as fibber-reinforced plastic (FRP) materials.224

ϭϭϳ


FACTS FROM THE NATIONAL YOUTH SPORTS FOUNDATION FOR

SAFETY:-66

(1) An athlete is 60 times more likely to sustain damage to the teeth when not wearing a

protective mouthguard. Mouthguards and faceguards prevent an estimated 200,000 high

school and college football injuries.

(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.

Approximately one third of all dental injuries are sports related.

(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

of thousands of dollars per individual.

(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,

lacrosse, martial arts, racquetball, roller hockey, rugby, shot-putting, skateboarding,

skiing, skydiving, soccer, squash, surfing, volleyball, water polo, weight lifting, and

wrestling. There are newer sports such as rollerblading, mountain biking, and

skateboarding, or sports such as racquetball and gymnastics, in which wearing a

ϭϭϴ

mouthguard may prove beneficial. With their increased participation in sports, female

athletes need the protection through mouthguard.

POSITION STATEMENTS OF VARIOUS HEALTH ORGANIZATIONS:-61

A number of associations and organizations consider orofacial injury to be

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

Canadian organizations with position statements on mouthguards.

‡ 7KH&DQDGLDQ$FDGHP\RI6SRUW0HGLFLQHKDVDSRVLWLRQVWDWement on head injuries

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.

‡ 7KH&DQDGLDQ'HQWDO$VVRFLDWLRQKDVDSRVLWLRQVWatement that encourages dentists to

counsel clients about orofacial protection and encourages organized activities to develop

safety protocols to minimize the risk of orofacial injury.

‡ 6HYHUDOSURIHVVLRQDOKHDOWKRUJDQL]DWLRQVKDYHUHFRPPHQGHGWKHXVHRf mouthguards

in a variety of contact sports at all levels of competition, both organized and

unorganized. These organizations include the American Medical Association and the

American Academy of Paediatrics.

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

practices and games.

‡ 7KH $FDGHP\ RI *HQHUDO 'HQWLVWU\ LQ WKH 8QLWHG 6WDWHV UHFRPPHQGV ³WKDW SOD\HUV

participating in basketball, softball, wrestling, soccer, lacrosse, rugby, in-line-skating

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

sponsoring organizations that all participants in contact sports be required to wear

TXDOLW\ILWWHGSURWHFWLYHPRXWKJXDUGV´

‡7KH$PHULFDQ'HQWDO$VVRFLDWLRQ $'$ UHFRJQL]HVWKHSUHYHQWLYHYDOXHRIRURIDFLDO

protectors (such as mouthguards, face shields and helmets)and endorses the use of

orofacial protectors by all participants in recreational and sports activities with a

significant risk of injury, all levels of competition including practice sessions, physical

education and intramural programs.

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



MANAGEMENT OF SPORT INJURIES:


According to Scott J et al in 1996, dental injuries are the commonest

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

participation in sports carries a considerable risk for sustaining injuries. Type of

orofacial injuries commonly observed in sports include injuries to dentition, namely

fractured or avulsed teeth and injuries to the periodontium. Due to direct impact on

jaws, injuries resulting in dislocation or fracture of jaws may be incurred.112

One interesting aspect of high risk sporting activities is the protective

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.

The management of sport injuries is carried out in two ways:

1. Preventive management

2. Therapeutic management

As discussed about preventive management of sport dentistry. Any

deviation in the respiratory, cardiac, or vascular function in the athlete must be attended

to and may include initiation of cardiopulmonary, respiration, haemorrhage control, and

prevention of shock. Therapeutic Management of Oral and Dental Injuries include: 112

a) Soft Tissue Injuries

b) Hard Tissue Injuries

i) Le Fort Fracture I, II, III

ϭϮϮ



ii) Mandibular Fractures

iii) Mandibular Dislocations

iv) Tooth Fractures

v) Tooth Luxations

vi) Tooth Avulsions

vii) Infraction

viii) Concussion

ix) Subluxation

a) Soft Tissue Injuries 112: Management priorities include controlling hemorrhage

and cleaning the wound from foreign materials to permit visibility of the region.

Injury to underlying tissues and structures must be determined as well to permit

proper management of the entire region.

Fractures to the zygomatic, maxillary, and mandibular regions should

be ruled out based on the mechanism of the injury, clinical findings, and in some cases

radiographs are required ,once the athlete is transported to a medical facility.

Assessment of the oral cavity should include ruling out tooth, tongue,

vascular and nerve involvement before closure of the superficial lacerations is

performed.

b) Hard Tissue Injuries:

i) Le Fort Fracture I, II, III:

ϭϮϯ



These are relatively uncommon in sports. Immediate attention is

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

complete neurologic examination should be performed to assess the degree of

concussion that has occurred and the athlete should be treated for shock and transported

to a hospital.

ii) Mandibular Fractures:

Mandibular fractures are relatively common sports-related facial

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

mandible. Immediate management include ensuring an appropriate airway because of

the potential for respiratory compromise with mandibular pathology. This should

include stabilization of the fracture site, assessment for potential concussion, and

treatment for shock. Stabilization of the mandibular fracture is easily accomplished

using a circumferential compression bandage known as a Barton bandage. Consistent

with most injuries resulting from direct trauma to the head, the athlete will likely

experience a degree of concussion that must be monitored because of the risk of

intracranial haemorrhage. Finally, pain and haemorrhage may induce shock and every

effort to prevent this insidious state should occur.

iii) Mandibular Dislocations:

Optimally, management of a dislocations is immediate reduction.

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.

iv) Tooth Fractures:

Fractures to the crown of the tooth can occur either independently or

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

be accomplished by gentle biting on a towel or handkerchief during transport. If the

tooth is mal aligned or displaced, gentle realignment should be attempted using finger

pressure, followed by similar stabilization techniques during transport. In case tooth

turns non vital, it needs endodontic treatment.112

A sequel of sports-related traumatic dental injuries is often fracture of

the tooth crown. When fracture occurs, a complete evaluation of the injury should be

done so that appropriate management can be implemented.

The Fracture of Crown is as follows: 248

A).Crown Fracture ± Uncomplicated

B).Crown Fracture ± Complicated

C).Crown/Root Fracture

D).Root Fracture

A). CROWN FRACTURE ± UNCOMPLICATED

ϭϮϱ



Definition: An enamel fracture or an enamel-dentin fracture that does not involve

the pulp.

Diagnosis: Clinical and/or radiographic findings reveal a loss of tooth structure

confined to the enamel or to both the enamel and dentin.

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

lost tooth structures can be restored.

B). CROWN FRACTURE ± COMPLICATED

Definition: An enamel-dentin fracture with pulp exposure.

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

pulpotomy and pulpectomy /root canal therapy.

C). CROWN/ROOT FRACTURE

Definition: An enamel, dentin, and cementum fracture with or without pulp

exposure.

Diagnosis: Clinical findings usually reveal a mobile coronal fragment attached to

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

teeth and in a direction usually perpendicular to the central radiographic beam in

permanent teeth. While radiographic demonstration often is difficult, root fractures can

only be diagnosed radiographically.

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

the succedaneous tooth.

‡ 3HUPDQHQW WHHWK 7KH HPHUJHncy treatment objective is to stabilize the coronal

fragment. Definitive treatment alternatives are to remove the coronal fragment followed

by a supragingival restoration or necessary gingivectomy; osteotomy; or surgical or

orthodontic extrusion to prepare for restoration. If the pulp is exposed, pulpal treatment

alternatives are pulp capping, pulpotomy, and root canal treatment.

D). ROOT FRACTURE

Definition: A dentin and cementum fracture involving the pulp.

Diagnosis: Clinical findings reveal a mobile coronal fragment attached to the

gingiva that may be displaced. Radiographic findings may reveal 1 or more radiolucent

lines that separate the tooth fragments in horizontal fractures. Multiple radiographic

exposures at different angulations may be required for diagnosis. A root fracture in a

primary tooth may be obscured by a succedaneous tooth.

Treatment objectives: To reposition as soon as possible and then to stabilize the

coronal fragment in its anatomically correct position to optimize healing of the

ϭϮϳ



periodontal ligament and neurovascular supply, while maintaining aesthetic and

functional integrity.

‡3ULPDU\WHHWK7UHDWPHQW DOWHUQDWLYHV LQFOXGHH[WUDFWLRQRIFRURQDO IUDJPHQWZLWKRXW

insisting on removing apical fragment or observation.

‡3HUPDQHQWWHHWK5HSRVLWLRQDQGVWDELOL]HWKHFRURQDOIUDJPHQW

v). Tooth luxations: Refers to a tooth that has been displaced in one of three positions,-

Extrusive, Lateral, or Intrusive.112

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

of the alveolar socket.

Diagnosis: Clinical findings reveal that the tooth appears to be shortened or, in

severe cases, it may appear missing.

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

apically and the periodontal ligament space is not continuous.

Treatment objectives:

‡3ULPDU\WHHWK([WUDFWLRQLVLQGLFDWHGZKHQWKHDSH[LVGLVSODFHGWRZDUGWKH

permanent tooth germ.

‡ 3HUPDQHQW teeth: To reposition passively or actively and stabilize the tooth in its

anatomically correct position to optimize healing of the periodontal ligament and

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

periodontal ligament usually is torn.

Diagnosis: Clinical findings reveal that the tooth appears elongated and is mobile.

Radiographic findings reveal an increased periodontal ligament space apically.

Treatment objectives:

‡ 3ULPDU\WHHWKUHSRVLWLRQDQGDOORZIRUKHDOLQJ

If the treatment decision is to reposition and stabilize, splint for 1 to 2 weeks.

‡ 3HUPDQHQWWHHWKWRUHSRVLWLRQDVVRRQDVSRVVLEOH and then to stabilize the tooth in its

anatomically correct position to optimize healing of the periodontal ligament and

neurovascular supply while maintaining esthetic and functional integrity.

C). LATERAL LUXATION

Definition: Displacement of the tooth in a direction other than axially. The

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


reveal an increase in periodontal ligament space and displacement of apex toward or

though the labial bone plate.

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

anatomically correct position to optimize healing of the periodontal ligament and

neurovascular supply, while maintaining esthetic and functional integrity. Repositioning

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

weeks may be needed with breakdown of marginal bone.

vi). Tooth avulsions112 : Acute management of an avulsed tooth should include

immediate reimplantation, which is essential to maintain vitality of the tooth and its

structural components. Immediate reimplantation and avoidance of excessive trauma to

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

nylon splinting or an acid ± etched composite with a stabilizing wire.

ϭϯϬ



vii). Infraction

Definition: Incomplete fracture (crack) of the enamel without loss of tooth

structure.

Diagnosis: normal gross anatomic and radiographic appearance; craze lines

apparent, especially with trans-illumination

Treatment objectives: to maintain structural integrity and pulp vitality..

viii). Concussion

Definition: Injury to the tooth-supporting structures without abnormal loosening

or displacement of the tooth.

Diagnosis: Because the periodontal ligament absorbs the injury and is inflamed,

clinical findings reveal a tooth tender to pressure and percussion without mobility,

displacement, or sulcular bleeding. Radiographic abnormalities are not expected.

Treatment objectives: to optimize healing of the periodontal ligament and

maintain pulp vitality.

ix). Subluxation

Definition: injury to tooth-supporting structures with abnormal loosening but

without tooth displacement.

Diagnosis: Because the periodontal ligament attempts to absorb the injury,

clinical findings reveal a mobile tooth without displacement that may or may not have

sulcular bleeding. Radiographic abnormalities are not expected.

ϭϯϭ



Treatment objectives: to optimize healing of the periodontal ligament and

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:

One of the emerging branches of dentistry is Sports Dentistry and

research as is an ongoing process in this branch too.

Sports Dentistry as defined by the International Academy for Sports

Dentistry involves the prevention and treatment of orofacial athletic injuries and related

oral diseases, as well as collection and dissemination of information on dental athletic

injuries and the encouragement of research in the prevention of such injuries.1

Sport dentistry is the prevention and treatment of dental and facial

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

about sport related dental trauma/injuries.1

The common sports-related dental injuries are fractures of crown, root,

concussion, subluxation, extrusive, intrusive and lateral luxation, avulsion, fractures of

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

x Mandatory usage of protective equipments such as helmet, chin guard,

mouthguard

x In general training, there will be increased practice, which leads to better body

control mainly young children.

x Participation in technically advanced sporting activities should be avoided for

younger children.

ϭϯϯ



x There should be provision of skilled coaches

x To acquire more knowledge regarding sports injury and prevention.

Research shows that orofacial injury in sport is preventable and carries

significant medical, financial, cognitive, psychological, and social costs. Research also

confirms that mouthguard can prevent orofacial injuries.61 The most important aspect in

preventing these injuries is wearing basic protective devices such as properly-fitting

mouthguard and headgears like helmets and facemasks while playing.77

When talk about population of India tremendous efforts should be taken

in terms of creating an awareness about various protective device which can be reduces

the chance and incidence of traumatic dental injuries.65 There is a significant

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

There is a evidence indicating that mouthguard can make sport safer by

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

articulated against the mandibular model.61

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

mouthguards, fitting procedures are accomplished in a number of sitting with custom

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,

the unwillingness to adopt a mandatory mouthguard rule. Most often professionally

involved athletes complain about discomfort, poor retention, inappropriate fit and cost.2

Education on the effectiveness of properly fitted mouthguard, for injury prevention,

information on the risk of injury, and availability of more comfort can lead to the

development of more positive attitudes and increase its usage.200

First, greater use of mouthguards in all contact sports needs to be

promoted. The cost of mouthguard fabricated by oral health professionals is extremely

low compared with the medical, financial, cognitive, psychological and social

consequences associated with orofacial injuries. Second, a multidisciplinary approach is

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

develop an approach for expanding regulations regarding mouthguard use in sports. 61

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

The dentist can play an imperative role in informing athletes, coaches

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

As there is growth in sports participation and world of sports is also

expanding fast, as a professional we should show our responsibility towards promoting

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

recognize, treat, and prevent conditions in larger community of sports.66

ϭϯϲ



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mouthguard protection. Pediatr Dent. 1999;21(6):340-6.

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