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REVIEW ARTICLE
Year : 2017  |  Volume : 17  |  Issue : 2  |  Page : 70-74

Traumatic orofacial injuries and its prevention


Department of Public Health Dentistry, Surendera Dental College and Research Institute, Sri Ganganagar, Rajasthan, India

Date of Web Publication6-Jun-2017

Correspondence Address:
Deeksha Gijwani
Department of Public Health Dentistry, Surendera Dental College and Research Institute, H.H Garden, Sri Ganganagar, Rajasthan
India
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DOI: 10.4103/sjsm.sjsm_3_17

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  Abstract 

Sports dentistry is one of the most recent and upcoming fields in dentistry. Its main focus is on the prevention and management of athletics-related orofacial injuries. Dental injuries are the most common type of orofacial injury sustained during participation in sports. The most significant aspect in preventing sports-related orofacial injuries is wearing basic protective devices such as properly fitting helmets, face masks, and/or mouthguards. Many athletes are not aware of the health implications of a traumatic injury to the mouth or of the potential for incurring severe head and orofacial injuries while playing. The dentist can play an imperative role in informing athletes, coaches, and patients about the importance of preventing orofacial injuries in sports. The aim of this paper is to increase professional awareness and interest for orientation toward sports dentistry.

Keywords: Dental injury, mouthguard, sports


How to cite this article:
Gijwani D, Singh S, Mathur A, Makkar DK. Traumatic orofacial injuries and its prevention. Saudi J Sports Med 2017;17:70-4

How to cite this URL:
Gijwani D, Singh S, Mathur A, Makkar DK. Traumatic orofacial injuries and its prevention. Saudi J Sports Med [serial online] 2017 [cited 2017 Aug 20];17:70-4. Available from: http://www.sjosm.org/text.asp?2017/17/2/70/207570


  Introduction Top


Dental injuries are the most common type of orofacial injury sustained during participation in sports [1] with the increased popularity of contact sports and encouragement to participate at an early age; the role of the dental profession in relation to prevention of dental and other orofacial sporting injuries has become more important.[2] Athletes, coaches, athletic directors, athletic trainers, parents, and members of the dental community should be aware of risks regarding dental trauma during sporting activities.[3] The common orofacial sports-related injuries include soft tissue injury, and hard tissue injury which includes those to the teeth and facial bones, such as tooth intrusions, luxation, crown and/or root fractures, complete avulsions, dental-facial fractures, abrasions, contusions, and lacerations.

Sports dentistry originated in 1980s,[4] yet there is increasing prevalence of sports-related injuries;[5] this could be due to the absence of any specialized training of the dentist. Hence, there is a felt need to make the dentist aware regarding various sports-related injuries its associated risk factors and their prevention and management.


  Various Sports-Related Injuries Top


Fractures

Fractures of the facial bones present more complex problem. The most frequent site of bony injury is the zygoma (cheekbone). Fractures of the zygoma account for approximately 10% of the maxillofacial fractures seen in sports injuries, occurring as a result of direct blunt trauma from a fall, elbow, or fist.[6] In a study by Linn and others, of the 319 patients treated for sports-related injuries, males proved to be more prone to zygomatic fractures than females because of the powerful physical contacts during sports.[7] Like the zygoma, the prominent shape and projection of the mandible cause it to frequently be traumatized. Approximately 10% of maxillofacial fractures from sporting activities occur in the mandible when the athlete strikes a hard surface, another player, or equipment.[8]

Temporomandibular joint injuries

Most blows to the mandible do not result in fractures, yet significant force can be transmitted to the temporomandibular disc and supporting structures that may result in permanent injury. In both mild and severe trauma, the condyle can be forced posteriorly to the extent that the retrodiscal tissues are compressed. Inflammation and edema results in forcing the mandibular condyle forward and down in acute malocclusion.

Tooth intrusion

Tooth intrusion occurs when the tooth has been driven into the alveolar process due to an axially directed impact. This is the most severe form of displacement injury. Pulpal necrosis occurs in 96% of intrusive displacements and is more likely to occur in teeth with fully formed roots. Immature root development will usually mean spontaneous re-eruption. Mature root development will require repositioning, surgery, and splinting or orthodontic extrusion.

Tooth extrusion

The tooth is displaced partially out of the socket by the trauma. It is usually displaced palatally. Radiographically, the tooth appears dislocated and empty at the end of the socket.

Crown and root fractures

Crown fractures are the most common injury to the permanent dentition and may present in several different ways. The simplest form is crown infraction. This is a crazing of enamel without loss of tooth structure. It requires no treatment except adequate testing of pulpal vitality.[8] Fractures extending into the dentin are usually very sensitive to temperature and other stimuli. The most severe crown fracture results in the pulp being fully exposed and contaminated in a closed apex tooth or a horizontal impact may result in a root fracture.

Avulsion

Certainly, one of the most dramatic sports-related dental injuries is the complete avulsion of a tooth. Two to sixteen percent of all injuries involving the mouth result in an avulsed tooth. A tooth that is completely displaced from the socket may be replaced with varying degrees of success depending largely on the length of time the tooth is outside the socket.[9]


  Risk Factors for Sports Injuries Top


An essential component of any injury prevention program is an appreciation and understanding of the risk factors and determinants that can be predictive of these undesirable events. There are two broad categories of injury risk factors in sports. These are extrinsic risk factor and intrinsic risk factors:[10]

Extrinsic factor

Extrinsic risk factors are those potential predictors of injury that are independent of the individual. These are essentially the injury predictors that are related to the type of activity demanded by a particular sport. For example, the extrinsic factor of participation in running or jogging is more likely to produce a stress injury which is caused by engaging in contact sports such as boxing.[11]

Improper methods of preparing for competition, such as training mistakes, can also be significant extrinsic risk factors for sports injury. Other extrinsic factors include quality of the playing surface, status of the equipment to be used or worn, climatic conditions such as ice or rain, and the quality of supervision of the participants.[12]

Intrinsic factor

Intrinsic risk factors are the predisposing characteristics present in the individual sports participant. These are the biologic and psychosocial characteristics that may predispose a particular person to a particular kind of sports injury. A recent review of intrinsic risk factors as they relate to athletic injuries has been presented by Taimela et al.[10] The author presents convincing evidence that intrinsic factors play a significant role in the evolution of some sports injuries. They conclude that many potential intrinsic risk factors have received inadequate attention and that more studies are warranted to verify the overall significance of these factors to sports medicine and dentistry.[10]


  Prevention of Sports-Related Traumatic Orofacial Injuries Top


Promoting and using helmets, face masks, and mouthguards, etc., are required in some sports to reduce both the likelihood and the severity of sports-related traumatic injuries to the head, face, and mouth of an athlete. These are discussed as follows:

Helmets

These are designed to protect the skin of the scalp and ears from abrasions, contusions, and lacerations. They protect the bones of the skull from fractures and the brain and central nervous system from direct concussions, unconsciousness, cerebral hemorrhage, brain damage, paralysis, and death. During the decades between the 1920s through the early 1950s, the primary form of football headgear was the sturdy leather helmet. This type of helmet was constructed of various layers of leather stitched together for the protection of the skull, lateral aspects of the face, and ears of the athlete. A later modification was the placement of a protective rubber pad at the midline of the forehead region of the plastic helmet to prevent nasal pyramid lacerations caused by the helmet being driven into the soft tissues of the forehead during contact or collision. Another major advantage of the rigid plastic helmets allowed for the eventual placement of face masks to further protect the mouth and other facial structures.[13]

Face masks

These are designed to protect the eyes, nose, nasal pyramid, zygomatic arches, and mouth from traumatic forces such as a fist, ball, puck, or stick directed toward the face. When used properly, face masks enhance player safety and reduce morbidity. Face masks are manufactured from plastic or rubber tubing or welded steel or aluminum of different diameters and are covered with a coating of vinyl plastisol. The earliest style of face mask introduced into football in the 1950s consisted of a contoured single bar. All styles of face masks provide varying degrees of protection to the maxilla horizontally from an extended finger, a clenched fist, a forearm, or a helmet directed, respectively, toward the eye nasal pyramid zygomatic region or the mandibular arch.[14]

The full cage face mask affords the greatest degree of overall facial protection and is generally preferred by defensive players to avoid injuries associated with line play and tackling. Offensive players such as quarterbacks, running backs, and wide receivers often select an intermediate style between the single bar and the full cage to provide adequate facial protection while minimizing the restriction on peripheral vision and thereby enabling visualization of a wider view of the playing field.[13]

Mouthguards or “gumshields”

These were originally developed in 1890 by Woolf Krause, a London dentist, as a means of protecting boxers from lip lacerations. Mouthguards also aid in reducing the likelihood of neck injuries, concussion, cerebral hemorrhage, unconsciousness, serious central nervous system damage, and death. Such injuries were a common and often disabling accompaniment of boxing contests in that era.[15] These gumshields were originally made from gutta percha and were held in place by clenching the teeth. By 1930s, mouthguards were part of the standard boxers' equipment and have remained so since that time.[16]

Classification of mouthguards

The American Society for Testing and Materials in Designation F697-80 (Reapproved 1986) established the classification for athletic mouthguards as follows.[16]

  • Type I: Stock mouthguards
  • Type II: Mouth-formed mouthguards
  • Type III: Custom-fabricated (over a dental cast) mouthguards.


This classification system is based on an ascending order of preference: Type I mouthguards are the least preferred, whereas Type III are the most preferred.

Stock mouthguards

Stock mouthguards are purchased over the counter by consumers from sporting goods stores. They are the least expensive of the three types of mouthguards available and come in a variety of styles and colors, with or without straps. They are ready to wear because one size is intended for all users; this is analogous to a situation that would attempt to fit all athletes into the same shoe size. Stock mouthguards are not adapted to the dentition of the athlete so that they must be held in place by biting the teeth together.

Mouth-formed mouthguards

Mouth-formed mouthguards are intermediate between the stock and custom-fabricated types. Mouth-formed mouthguards come in two varieties: Shell-lined and boil-and-bite.

The shell-lined variety is fabricated by placing freshly mixed ethyl methacrylate into a hard shell, which is then inserted into the athlete's mouth until the material sets. Although offering relatively good adaptation to the dental arch, this variety is often too bulky and uncomfortable as well as having an unpleasant odor and taste. In addition, for best results, the liner should be changed after each use. Consequently, the shell-lined variety is not favored by athletes.[17]

The thermoplastic boil-and-bite variety claims the largest share in today's marketplace. These mouthguards are fabricated by placing the mouthguard form into boiling water to soften the material. The softened material is then placed into the athlete's mouth, where it is molded with finger pressure as well as with facial and intraoral muscular movements to enhance adaptation to the hard and soft tissue structures of the mouth. After removal from the athlete's mouth, the mouthguard is placed into cold water until the shape is set firmly.

Boil-and-bite mouthguards come in a wide variety of styles and colors with or without strap attachments. They range in price from inexpensive to moderately expensive depending on the quality desired. Because there is such a wide variety of boil-and-bite mouthguards available on the market currently, directions for fabrication may vary. For best results, boil-and-bite mouthguards should be fabricated by a dentist according to the manufacturer's directions.

Custom-fabricated mouthguards

Custom-fabricated mouthguards are made professionally over a dental cast of the athlete's arch (maxillary arch for patients with Class I or Class II malocclusion; mandibular arch for patients with Class III malocclusion). Custom-fabricated mouthguards are considered superior to either stock or mouth-formed mouthguards. Because of their superior adaptation and retention, custom-fabricated mouthguards are believed to interfere least with breathing (oxygen exchange) and speech. Because of superior fit and comfort, they are more likely to be accepted by athletes.[18]

Custom-fabricated mouthguards are considered to be more protective because they conform more closely to the athlete's mouth, and the material thickness covering the critical occlusal table can be better controlled during laboratory fabrication.

Meticulous infection control practices are essential both in the dental operatory for impression taking and in the laboratory for mouthguard fabrication. Before taking an alginate impression, the mouth should be examined thoroughly and all necessary dental treatment completed. The mouth should be cleansed with a prophylaxis or thorough toothbrushing, flossing, and mouth rinsing before the impression is made.[19]


  Management of Sports-Related Traumatic Orofacial Injuries Top


Treatment for an avulsed tooth

  1. Primary tooth:
    • The primary avulsed tooth is generally not reimplanted – to avoid injury to the developing permanent tooth bud
  2. Permanent tooth:
    • Place the tooth in saliva, saline, milk, and Hank's balanced salt solution
    • Root canal treatment can be carried out before replantation or later.


Treatment tooth fracture (infraction, Ellis Class I, II, or III)

  1. Primary tooth:
    • Treatment options for an enamel-dentin crown fracture with pulpal exposure in the primary dentition include: direct pulp capping, Cvek pulpotomy, cervical-depth pulpotomy, pulpectomy, or extraction
  2. Permanent tooth:
    • Treatment for a case of enamel infraction consists of sealing the cracks – using any enamel adhesive system
    • For an Ellis Class I dental fracture, dental care involves removing the sharp edges to prevent injury to the soft tissues of the mouth. Alternatively, the fracture may be restored with composite material
    • For an Ellis Class II fracture, the dentin should be coated with a protective covering, such as a RMGI or Fuji IX cement – as an interim measure
    • For an Ellis Class III complex fracture of the permanent tooth, a direct pulp cap may be performed
    • For an exposure larger than 2 mm, a Cvek pulpotomy may be performed.


Treatment of tooth pushed up (dental intrusion)

  1. Primary tooth:
    • Allow the primary tooth to spontaneously erupt over a 2–3 months period as long as the developing permanent tooth bud has not been injured
    • Extraction of the intruded tooth will prevent further damage or hypoplasia to the adult tooth bud
  2. Permanent tooth:
  3. Current management strategies for intruded permanent incisors include: surgical reduction (immediate repositioning), repositioning with traction (active repositioning), and waiting for the tooth to return to it preinjury position (passive repositioning)
  4. Incisors that have been intruded beyond 6 mm should be immediately repositioned (surgically) to their normal position – followed by root canal treatment. Root canal treatment is recommended in permanent teeth with complete root development.


Treatment of root fracture (apical, mid-root and cervical)

  1. Primary tooth:
    • As long as no abscess or excessive mobility occurs, the primary tooth with a fractured root can simply be monitored for health
    • For coronal third fractures in primary teeth, the coronal third is extracted, leaving the apical portion of the root to resorb normally
  2. Permanent tooth:
    • The most important factor in the success and treatment of a horizontal root fracture is the immediate reduction of the fractured segments and complete immobilization of the coronal segment
    • Treatment for horizontal root fractures consists of rigid fixation (immobilization) in an attempt to get the cementum and dentin to heal.



  Conclusion Top


Sports dentistry encompasses a wide range of preventive and treatment modalities of oral/facial athletic injuries and related oral diseases and their manifestations. The pediatric dentist must possess a sound clinical working knowledge regarding sports-related orofacial injuries and the various methods of prevention. Preventive programmers should include information regarding sports-related orofacial injuries, preventive measures such as helmets and mouthguards, and their management, resulting in better awareness of the general population. It is also our responsibility to identify, educate, and provide the athletes preventive measures such as mouthguards.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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16.
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17.
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Abstract
Introduction
Various Sports-R...
Risk Factors for...
Prevention of Sp...
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