Wednesday, December 18, 2013

Oral trauma in adolescent athletes: a study of mouth protectors

Tim McNutt, DDS, Sory W. Shannon, Jr., DMD, J. Timothy Wright, DDS, MD, Ronald A. Feinstein, MD
Pediatric Dentistry : September, 1989 – Volume 11, Number 3
Resident: Anna Abrahamian

Overview: Mouth guards have been proven to greatly reduce the number and severity  of traumatic oral injuries to participants in football and ice hockey, but their acceptance in most other sports has been almost non-existent.  The purpose of this study was to determine the extent of mouth protector use and the amount and type of oral trauma associated with and without mouth guard wear.  Interviews from 2,470 junior and senior high school football players were collected. Oral trauma, regardless of the sport during which the injury occurred, was evaluated. Prior to examination, each player/subject was also questioned about any history of loss of consciousness while participating in any sport.

Results: Of the 2,470 interviews conducted over the three-year period, there were 222 oral injuries noted (9% of all players suffered some form of oral injury). 64 (3%) reported LOC /concussion while participating in some form of sports activity. The total number of traumatic injuries occurring while not wearing a mouth guard was 167 (75% of the total injuries recorded). Of these 167, 40% of the injuries documented occurred during baseball and basketball AND while the players were not wearing a mouthguard. The total number of concussions or LOCs suffered by subjects/players not wearing a mouth protector was 36 (56% of the 64 LOCs/concussions).

Discussion: Participants not wearing mouth guards were almost 60 times more likely to sustain hard tissue trauma than those who did wear them.  Due to the diversity of sports that can produce oral trauma, it is recommended that mouth guards by warm by all individuals participating in contact and non-contact sports.  The results also indicate the need for mouthguards that have better soft tissue protection: in the athletes who suffered soft tissue laceration, 44% were wearing a mouth protector at the time of injury. Mouthguards with complete peri-oral coverage are commercially available and these offer increased protection by covering the extraoral lip and cheek.

Summary: Mouth guards function by: 1) spreading the force of impact over all the teeth covered by the mouth protector, 2) prevent traumatic contact between the maxillary and the mandibular teeth, 3) separate the soft tissue and the teeth (preventing soft tissue laceration/bruising), and 4) may help prevent concussions, cerebral hemorrhage, and possibly death, by separating the jaws and preventing the condyles from being displaced up and backwards against the glenoid fossa.

Assessment: Good article written by pediatric dental residents. Highlights how important it is for us to be involved in educating our patients and their families about using adequate oral protection during sports participation.

Custom Sports Mouthguard Modified for Orthodontic Patients and Children in the Transitional Dentition

Resident: Jeff Higbee
Article: Custom Sports Mouthguard Modified for Orthodontic Patients and Children in the Transitional Dentition
Journal: Pediatric Dentistry – 26:5, 2004
Author: Theodore P. Croll, DDS,  Cosmo R. Castaldi, DDS, MSD

 Purpose: To document fabrication of custom-formed protective mouthguards for a 10-year-old boy wearing fixed orthodontic appliances and a 9-year-old girl with a fixed palatal expander in place.


- Triple-layered ethyl vinyl acetate material (5 mm) makes for a sturdier and more protective mouthguard.
- One must consider, however, that if the bite is opened too much, there could be discomfort in the TMJ.
- The mouthguard’s posterior biting surface can be trimmed flat with an arbor band on the dental lathe to at least partially close the bite, according to the patient’s comfort.

Assessment: We will all have patients that need mouthguards that are in a changing mixed dentition or have dental appliances.  This gives good ideas for mouthguards fabrication for these patients.

Tuesday, December 17, 2013

Habitual biting of oral mucosa: A conservative treatment approach
Resident: Avani Khera

Chronic biting of the oral mucosa is a form of unintentional injury observed commonly on the buccal and labial mucosa/lateral surface of the tongue by children suffering from developmental and psychological problems. This injury in children is often short lived and tends to wane with time, however, periods of stress such as school exams, competition in sports, and other activities may aggravate the condition. In some individuals, habitual lip and cheek biting becomes a fixed neurosis and the frequency and severity of the biting behavior could be directly related to the stress experienced. Pediatric dentists are usually the first ones to diagnose such behavior in children or may be the ones consulted for the problem.  Possible treatment approaches include reconditioning the patient, oral appliances such as a mouth guard, extracting the offending teeth in extreme cases.

Case study:

8 year old boy presented with a cheek biting lesion on his buccal mucosa.  Impressions were taken and a soft mouth guard was fabricated from soft polyvinyl material (bioplast). Patient was reviewed every 2 months till 6 months and he presented with uneventful healing, with no recurrence. After 6 months, the appliance was discontinued. The patient was again recalled and reviewed 6 months after the discontinuation of appliance; the tissue remained healed.

Impression/discussion: I thought this article was interesting because it gave a different perspective on mouth guards (we typically think of them to help prevent from sports injuries or grinding).  Self mutilation is often a serious concern in the special needs population, and as pediatric dentists we are the first line providers in orofacial injuries to special needs children.  This prosthesis presents a conservative approach to treating trauma to the oral mucosa.

Monday, December 16, 2013

Policy on Prevention of Sports-related Orofacial Injuries

Resident: Hofelich
Year: 2013 revision

Key Points:

  • 10 year study of 3,385 craniomaxillofacial trauma cases reporting to an OS department found that 31.8 percent of injuries in children occurred during sports activities
  • children are most susceptible to sports-related oral injury between the ages 7-11 
  • baseball and basketball have been shown to have the highest incidence of sports-related dental injuries in children 7-17 yo  
  • baseball had the highest incidence within 7-12 year old age group, while basketball was the most frequent sport associated with dental injuries in the 13-17 year age group
  • Trampolines: when used recreationally, a significant number of head and neck injuries occurs, with head injuries most commonly a result of falls. The American Academy of Pediatrics (AAP) recommends practitioners 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 practitioners “should only endorse use of trampolines as part of a structured training program with appropriate coaching, supervision, and safety measures in place”.
  • The highest incidence of sports-related dental injuries has been shown in 15-18 year old males
  • majority of sport-related dental and orofacial injuries affect the upper lip, maxilla, and maxillary incisors
    • 50 -90% of dental injuries involve the maxillary incisors
    • mouthguard can protect the upper incisors, however, studies have shown that even with a mouthguard in place, up to 25% of dentoalveolar injuries still can occur
  • frequency of dental trauma is significantly higher for children with increased overjet and inadequate lip coverage
  • initiating preventive orthodontic treatment in early-to middle mixed dentition of patients with an overjet greater than 3mm has the potential to reduce the severity of traumatic injuries to permanent incisors
  • should consider the patient’s VDO, personal comfort, and breathing ability 
  • providing cushioning between the maxilla and mandible may reduce the incidence or severity of condylar displacement injuries as well as the potential for concussions
  • 2004 national fee survey, custom mouthguards ranged from $60 to $285.54 
    • In a study to determine the acceptance of the three types of mouthguards by 7-8 yo children playing soccer, only 24% of surveyed parents were willing to pay $25 for a custom mouthguard
    • when no cost was involved, 29% never wore the mouthguard, 32% wore it occasionally, 15.9% wore it initially but quit wearing it after one month, and only 23.2% wore the mouthguard when needed

The American Society for Testing and Materials (ASTM) classifies mouthguards by three categories44: 

1. Type I – Custom-fabricated mouthguards are produced on a dental model of the patient’s mouth by either the vacuum-forming or heat-pressure lamination technique. The ASTM recommends that for maxixmum protection, cushioning, and retention, the mouthguard should cover all teeth in at least one arch, customarily the maxillary arch, less the third molar. A mandibular mouthguard is recommended for individuals with a Class III malocclusion. The custom-fabricated type is superior in retention, protection, and comfort. When this type is not available, the mouth-formed mouthguard is preferable to the stock or preformed mouthguard.
2. Type II – Mouth-formed, also known as “boil-and-bite”, mouthguards are made from a thermoplastic material adapted to the mouth by finger, tongue, and biting pressure after immersing the appliance in hot water. Available commercially at department and sporting good stores, these are the most commonly used among athletes but vary greatly in protection, retention, comfort, and cost.
3. Type III – Stock mouthguards are purchased over-the-counter. They are designed for use without any modification and must be held in place by clenching the teeth together to provide a protective benefit. Clenching a stock mouthguard in place can interfere with breathing and speaking and, for this reason, stock mouthguards are considered by many to be less protective. Despite these shortcomings, the stock mouthguard could be the only option possible for patients with particular clinical presentations (ex: use of orthodontic brackets and appliances, periods of rapidly changing occlusion during mixed dentition)

Assessment: We should be recommending mouthguards more in the clinic, however, the parents might not be interested in having one made if they have to pay for it out of pocket. Good points were made in the article that should help when having the discussion with the parents about the importance of wearing a mouthguard. 

Parental Attitudes Toward Mouthuards

Resident: Mackenzie Craik

Article: Parental Attitudes Toward Mouthguards

Author: Nadia Diab, DMD Arthur P. Mourino, DDS, MSD

Journal: Pediatric Dentistry--19:8, 1997.

Methods: An 11-item, one-page questionnaire was mailed to 1800 parents chosen at random in the Henrico County, VA public school system. Parents were asked questions such as "who should be responsible for mouthguard wear?, what sports should require mouthguards?, and has [their] child ever sustained an oral or facial injury?"

Results: The parental responses indicate that mouthguard enforcement is the responsibility of both parents and coaches. Of the total injuries reported, 19% were sustained in basketball, 17% in baseball, and 11% in soccer. Despite these high injury rates, however, there was a lack of perceived need for mouthguard use in these sports. When asked which sports should require a mouthguard rule, the sports that generated the most responses were, in decreasing order, football, boxing, ice hockey, wrestling, field hockey, and karate. Parents were more likely to require mouthguards for their sons than daughters, and more likely to require them for their children who participated in a mandatory mouthguard sport, a contact sport, or who had been previously injured.

Conclusions: The authors conclude that because parents view themselves as equally responsible as coaches for maintaining mouthguard use, both groups should be targeted and approached as a possible source for the recommendation of mandatory mouthguard rules in basketball, baseball, and soccer.

Assessment: I found it interesting that parents are more likely to require their sons to where mouthguards than they are for their daughters, and also the fact that they don't feel that mouthguards are as important for such sports as basketball, baseball, and soccer when in all actuality this is where the highest percentage of total sports related injuries come from.

Effect of wearing mouthguards on the physical performance of soccer and futsal players: a randomized cross-over study

Resident: Derek Nobrega
Title: Effect of wearing mouthguards on the physical performance of soccer and futsal players: a randomized cross-over study
Authors: Collares, K., Correa, M. B., Silva, I. C. M. d., Hallal, P. C. and Demarco, F. F.
Journal: Dental Traumatology. doi: 10.1111/edt.12040

Purpose: The aim of this study was to assess the influence of custom-fit mouthguards on the aerobic performance of soccer and futsal players under 17.

Forty players from 3 Brazilian clubs participated in the study. The athletes' aerobic performance was assessed through the 20-meter shuttle-run test. All athletes performed two tests with and without mouthguard. Two outcome variables were analyzed: (1) the total distance covered in the test, and (2) the maximum oxygen uptake (VO2 max). A questionnaire assessing the level of acceptance of mouthguards considering different parameters was administered to the athletes before the delivery of the mouthguards and after 2 weeks of use.

Key Points
- Mouthguards did not influence the aerobic performance of the players, considering both the total distance covered in the tests and the VO2 max.
- Stability was the parameter with the highest acceptance.
- Communication had the lowest level of acceptance considering all parameters assessed.
- Levels of acceptance regarding breathing and communication increased after mouthguards usage.
- Only 10% of the players reported receiving recommendations to use mouthguards while playing soccer or futsal.
- None of the participants reported having used mouthguards before.
- The use of custom-fit mouthguards does not affect the aerobic performance of soccer and futsal U-17 players.
- Future studies should focus on the development of appliances with maximum protection and minimum influence on communication.


Interesting article on the use of mouthguards in a sport not commonly associated with mouthguard use. Despite the benefits, mouthguard use in soccer is low, especially among professional athletes who younger players imitate. I believe if a few well-known soccer players began wearing mouthguards, as NBA players do, more younger children will wear them. That being said, despite fracturing a tooth playing soccer when I was younger, I did not wear a mouthguard following the injury, and currently do not wear one when I play soccer.

Wednesday, December 11, 2013

Management of space problems in the primary and mixed dentitions

Management of space problems in the primary and mixed dentitions
Resident: Hofelich
Authors: Ngan et al
Journal: JADA
Year: 1999

Intro: Crowding and irregularity are the most common components of malocclusion in dental patients. Study done in the 1960s found that 40% of children age 6-11yo and 85% of teens age 12-17 yo have crowding of youths.

Crowding Definition:
simple- "disharmony between the size of the teeth and the space available in the alveolus with no skeletal, muscular, or occlusal functional features", most frequently associated with Class I malocclusion
complex-"crowding caused by skeletal imbalance, abnormal lip and tongue functioning, and/or occlusal dysfunction as well as disharmony between the sizes of the teeth and the available space"
Etiology: unknown

Most favorable sequence of eruption to obtain a normal molar relationship according to Lo and Moyers:
Maxilla: first molar, central incisor, lateral incisor, first premolar, second premolar, canine, second molar  
Mandible:first molar, central incisor, lateral incisor, canine, first premolar, second premolar, second molar

Conventional space analysis (canine space analysis)
-space available is estimated by measuring the arch perimeter from the mesial contact of the permanent first molar from one side of the dental arch to the mesial contact of the permanent first molar on the opposite side of the dental arch
-space required is summation of the mesiodistal widths of the erupted mandibular permanent incisors and the estimated widths of the unerupted permanent canines and premolars

Tanka and Johnston analysis
-take 1/2 of the mesiodistal widths of the four lower incisors and adding 10.5mm which is equal to the estimated width of the mandibular canines and premolars in one quadrant
-1/2 of the mesiodistal widths of the four lower incisors and adding 11mm equals the estimated width of the maxillary canine and premolar in one quadrant

Cases of mild crowding
-early loss of primary tooth most commonly attributed to caries

premature loss of primary canines- usually a result of large permanent incisors and ectopic eruption, usually accompanied by a lateral shift resulting in a midline discrepancy

early loss of primary molars- can cause distal drifting of the primary canine if the loss occurs during the active eruption of the permanent lateral incisors, reduction in arch length

ectopically erupted permanent first molars- under the distal surface of the primary second molars causing pathological resorption of the roots, leads to loss of arch length, self correction occurs in 66% of cases

Cases of moderate crowding
-usually the result of lack of space or loss of space
-regain space by distalization
-easier to regain space in maxilla because of the increased anchorage by the palate

Cases of severe crowding
-expansion in maxillary arch
-cases of 5-9 mm of space deficiency, most will need extraction of permanent teeth to preserve facial esthetics and integrity of supporting soft tissue

Cases of extremely severe crowding: space shortage of 10 mm or greater
-consider serial extraction
guidelines for serial extraction: absence of skeletal discrepancies, large (>10mm) arch-length deficiency, normal overbite, class I malocclusion, commitment on the practioner's part to finishing the case

Recommended timing of referring patients with crowding to orthodontists for tx is in the late mixed-dentition stage of development.

Assessment: Good overview of crowding and space preservation. Nice to know while doing hygiene checks when considering the appropriate time to refer to an orthodontist.

Early treatment of palatally erupting maxillary canines by extraction of the primary canines.

Early treatment of palatally erupting maxillary canines by extraction of the primary canines.
Sune Ericson and Juir Kurol, Jonkoping, Sweden
European Journal of Orthodontics Issue 10: 1998.
Resident: Margaret Cannon

Introduction/Purpose: The maxillary canine is the second most commonly impacted tooth, behind third molars.  It effects approximately 2% of the population. Of these patients, 85% are palatally impacted, 15% are buccally impacted. A thorough search of the previous literature showed “sporatic” case reports where extractions of the primary canine had favorable results upon eruption of the permanent canine.  No systematic longitudinal study to evaluate the effect of primary canine extraction on the palatally deflected path of eruption of maxillary canines has been carried out. Therefore, the goal of this study was evaluate the effect of extraction of the primary canine on palatally erupting max canines.
Method: 46 consecutive ectopic palatally placed maxillary canines were studied. 14 boys and 21 girls between the ages of 10 and 13 were referred for treament. The position of the canines were carefully determined in three planes; the frontal plane, the transverse, and the sagittal. Primary canines were extracted immediately after discovery of the position of the permanent canines. In 4 of the 46 cases the lateral incisors already showed root resorption.  All cases had good dental arches and no space deficiency was registered after measuring with sliding calipers.

- 36 of the 46 ectopic canines showed normalization of the path of eruption and later clinically correct position at the final control.
- 23 of the 36 normal final results showed improved position by 6 months of these 23, 9 had already normalized by 6 months.
- Of the 46 canines, 22 overlapped the adjacent lateral incisor by more than half the root of the lateral, 14 of these normalized. Of the 24 that overlapped the root of the lateral by less than half, 22 normalized.
- Complete normalization occurred in 78% of canines in relation to their previous lingual position.
- 10 of the 46 canines showed no change or an impaired position.
- No new cases of resorption were recorded throughout the study. Of the 4 cases noted at the start of the study, 2 normalized, 1 had no change and the last has an impaired position.
- Dentical follicle exceeded 3mm in 13 cases and varied between 1 and 5 mm for the 46 canines.  No association could be made between the size of the follicle and the cases that did not improve.

Assessment: I thought this was very useful for interceptive ortho, which we will all have the possibility of doing in practice. It also provides a preventive strategy which could lower the chance of surgical exposures and also lower the cost of phase II ortho in the future. Simple things like extractions of primary canines can build your report with parents and patients as it could be the difference in a simple ortho case that we keep in house of a complex one that we refer out. 

AAPD Handbook Chapter 10 - Growth and Development/Management of the Developing Occlusion

Resident: Anna Abrahamian

Types of Bone Formation
Bone growth occurs in osteogenic areas under tension (not pressure)
-       Intramembranous (more modifiable in context of dento-facial orthopedics)
o    bone formed at periosteal and sutural surfaces
o   facial bones (maxilla, body of mandible)
o    cranial vault
-       Endochondral (less modifiable)
o   growth from cartilaginous precursors (cranial base and condyle of mandible)

Growth of Facial Components
Cranial Vault – remodeling occurs on inner and outer surfaces of bone to allow for expanding neurocranium
Cranial Base – spheno-occipital synchondroses is the principal growth cartilage
Maxilla – growth occurs through balanced apposition and resorption; apposition of bone is “up and back” against the cranial base with growth expressed downward and forward
Mandible – condyle grows by apposition (similar to epiphyseal plates of long bones); apposition along posterior border ramus, resorption along anterior border, “up and back” growth expressed downward and forward.

Facial Growth Patterns
Female growth spurt starts at approximately 10.5 to 11 years and is complete by about 13.5 to 14 years.
Male growth spurt starts at approximately 12.5 to 13.5 years and is complete by about 17 to 18 years.

Dimensional Craniofacial Growth
Facial height is 70% complete by age 3 and 90% complete prior to adolescent growth spurt.
Width: shows least amount of change of any facial dimension
Depth: (A-P) is the longest growing facial dimension.

Lateral Cephalometrics
See pages 121-123 for normal values of these diagnostic references

Primary Dentition Occlusion
Approximately 2/3 of primary dentition exhibit generalized spacing (Baume Type I) while 1/3 are non-spaced (Baume Type II); spacing is related to basal arch size rather than tooth mass  differences
Primary spacing affects crowding outcome predictors into the mixed dentition: spacing 3-6mm (no transitional crowding), spacing less than 3mm (20% with incisor crowding), no spacing (50% with incisor crowding), crowded primary teeth (100% with incisor crowding).

Molar Terminal Plane Relationships
Mesial step:  usually results in Cl I permanent molar relationships (15% incidence)
Flush terminal plane: majority “shift” to Cl I molar, significant number stay end-on or “shift to full Cl II (75% incidence)
Distal step: usually results in full Cl II, some shift to end-on Cl II

Ideal Primary Dentition Occlusion
- Flush terminal plane or mesial step molar with class I canines
- Generalized spacing including primate spaces
- 2mm overjet and 2mm overbite


Posterior Crossbites in the Primary Dentition
Basic treatment includes maxillary expansion. Appliances include: fixed rapid palatal expanders (Haas, Hyrax - >90% success), fixed archwire expanders (w-arch, quad helix - >90% success, and removable appliances (Schwartz plate - 70% success)

Anterior Crossbites in the Primary Dentition
Pseudo-Class III: incisal and canine interference produces anterior shift of mandible on closure
True Class III: retruded maxilla, prognathic mandible, retroclined lower incisors

Non-nutritive Digit Sucking Habits
50% of children with NNS habit will discontinue between 24-28 months of age. Persistent habit may result in anterior openbite, distorted incisor eruption, increased overjet, proclined upper incisors, linguoversion of lower incisors, posterior crossbite with constricted maxilla, possibly class II relation. Consider intervention prior to eruption of permanent anterior teeth approximating age 5 to 6 years.
Recommendations: “gentle persuasion” first; cribs, rakes, “bluegrass appliance” to “help” child quit.

Leeway Space
Refers to size differential between primary C-D-E segment and permanent 3-4-5 – allows for late mesial shift of first molars when seconday primary molars exfoliate and permanent first molars move mesially
Approx 0.9mm per quadrant  in upper arch
Approx 1.7mm per quadrant in lower arch

Ectopic Eruption (Of First Permanent Molars)
Incidence: 2-3% in maxillary arch, rare in lower arch
2/3 self-correct, so watchful waiting is often a legitimate approach. However, ectopic teeth will rarely self-correct after dental age of 7. Eruption of a lower first molar to the level of occlusal plane suggests treatment intervention.
Treatmenr options – brass ligature, elastic separators, Humphrey appliance (distalization spring), Haltermann appliance (elastic to bonded button).

Maxillary Canine Eruptive Displacement
Labial and palatal malpositioning of permanent canines is often associated with atypical resorption of permanent incisors. 
Early recognition is key at approx 10-12years by palpation and radiographic evaluation
If displaced permanent canine overlap of adjacent lateral incisor is not beyond midline long axis of the lateral, chances of canine normal repositioning after primary canine extraction 85-90%. If canine overlap beyond lateral incisor long axis, successful repositioning approximately 60%.

Ankylosed Teeth
Lower first primary molars most commonly affected (than upper 1st primary molars, lower 2nd primary molars, and upper second primary molars); can also occur secondary to traumatized primary and permanent anterior teeth.
Static retention results in clinical “submersion,” supraeruption of opposing teeth, and tipping of adjacent teeth (space loss).
Management: Monitor early on – can build up with composite or SSC to maintain M-D and occlusal dimensions, eventual treatment may often involve extraction.

Class II (Retrusive Mandible) -> Functional appliances
Class II (Protrusive Maxilla) -> Cervical pull headgear , High-pull headgear
Class III (Protrusive Mandible) -> Chin-cup therapy (success not documented by long-term studies)

Class III (Retrusive Maxilla) -> Extra-oral reverse-pull headgear (facemask)