Dental and oral trauma in sports A. Khayampour, DDS, MSc, OMFS

Oral tissue trauma %50 of facial trauma occurs in mouth and teeth Low Speed elbows & fists soft tissue lacerations & contusions High Speed balls, pucks, sticks Bone / tooth fractures

Intraoral laceration Treated much like skin lacerations Irrigation with saline, reapproximation with absorbable sutures Avoid secondary healing, esp. in tongue

Lip laceration Compression of lip on teeth Look for associated dental and other hard tissue injury

Lip laceration

Lip laceration Mucosal only lacerations heal well without sutures Deep or through & through lacerations require layered repair Vermillion border: approximate border FIRST, then repair remainder

Tongue laceration Irrigate, remove foreign bodies Repair muscle with 3-0 resorbable; if deeper than 5mm Repair mucosa if still necessary, resorbable is fine Check for hematoma and sweeling: consider corticosteroids

Gingival trauma Consider suturing free gingiva Attached gingiva does not need suturing; consider secondary healing

Dental trauma Infraction Enamel fracture Enamel- dentin fracture( uncomplicated crown fracture) Enamel- dentin- pulp fracture( complicated crown fracture) Crown- root fracture without pulp exposure Crown root fracture with pulp exposure Root fracture

Periodontal trauma Alveolar fracture Concussion Subluxation Extrusive luxation Lateral luxation Intrusive luxation avulsion

infraction Enamel cracks Usually asymptomatic In case of marked infraction etching and sealing is required

Uncomplicated crown fracture Loss of tooth structure without involving pulp Glass ionomer for emergency treatment, composite resin for definitive cure

Complicated crown fracture Loss of tooth fracture with pulp exposure Pulp capping/ partial pulpotomy/ RCT

Crown-root fracture without pulp exposure Loss of tooth structure: enamel, dentin and cementum

Crown- root fracture with pulp exposure Consider RCT and check for fracture line under the gingiva

concussion An injury to tooth supporting structures without mobility or displacement but with pain in percussion Soft diet, monitor for 1 year

subluxation Increased mobility without displacement, gingival sulcus bleeding No treatment, if mobility is too much Consider splinting for 2 weeks

extrusion Partial displacement of tooth out of it’s socket Repositioning and 2 weeks splinting

Lateral luxation Tooth displacement other than axially Usually with labial or lingual bone fracture Repositioning and 4 weeks splinting

intrusion Displacement of the tooth into alveolar bone Treatment is determined by intrusion severity and open/ close apex of the tooth Surgical repositioning is used in more than 7 mm intrusion in close apex, otherwise spontaneous or orthodonthic repositioning is used

avulsion Complete displacement of tooth out of it’s socket Treatment: Find the tooth and pick it up by the crown Wash the tooth for 10 seconds and replace it If immediate replacement is not possible store the tooth in milk, hanks storage medium or saline It can be stored in mouth or saliva

avulsion Splinting is used for up to 2 weeks if closed apex and extraoral time is less than 60 minutes Antibiotic therapy is needed for 7- 10 days with doxycycline RCT is performed 7- 10 days after initializing of splint If extraoral time is more than 60 minutes perform RCT prior to tooth replacement and remove PDL with gauze and splinting is used for up to 4 weeks

avulsion In open apex defer RCT until signs of necrosis are seen. Tetracycline is contraindicated in less than 12 years of age and instead amoxicillin or penicillin are used. Splinting is used for 1- 2 weeks in open apex

avulsion A very important note is the storage medium for avulsed tooth: Milk, saliva, hanks solution, green tea are considered suitable Never use water or saline. Some literature suggest saliva is not a good medium because of microbial contamination. Remember the 60 minutes extraoral golden time.

Primary teeth Primary avulsed teeth should not be reinserted. Intruded primary teeth are allowed to re erupt In primary dentition every effort is made to preserve the permanent teeth, even with primary teeth sacrificing.

Prevention of oral injuries

Mouth guards Mouth guard use is mandatory for football, ice hockey, lacrosse, field hockey, and boxing. Several states have passed regulations mandating mouth guards for soccer, basketball, and wrestling

Mouth guards 1. Mouth guards help to protect the teeth and soft tissues of the mouth from injury. 2. The better the fit, the more protection offered. 3. Mouth guard use may reduce the risk or severity of a concussion.

Types of mouth guards There are 3 types of mouth guards: 1. Stock. 2. Mouth-formed, or “boil-and-bite.” 3. Custom fit.

Stock mouth guards These pre-formed, over-the-counter, ready-to-wear mouth guards are generally the least comfortable and, therefore, the least likely to be worn. Because of poor fit, they also offer the least protection and require constant biting down to stay in place.

Boil and bite mouth guards Made of thermoplastic material that conforms to the shape of the teeth after being placed in hot water, these mouth guards are commercially available and the most common type used by athletes. They vary in fit, comfort, and protection.

Custom fit mouth guards This type of mouth guard must be made by a dentist for the individual. It is the most expensive, but also offers the most protection and comfort. Custom mouth guards are preferred by dentists and usually preferred by athletes because of their increased comfort, wear-ability, and retention, as well as ease of speaking when worn. This type of mouth guard is particularly important for adolescents with orthodontic appliances.

Recommendations The American Academy of Pediatric Dentistry (AAPD) recommends properly fitted mouth guards for all children participating in organized and unorganized contact and collision sports. The AAPD supports mandated for use of athletic mouthguards in any sporting activity containing a risk of orofacial injury.

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