Considerations After Athletic Dental Trauma

The following list of factors should be considered:

1.
Degree or severity of the initial injury :
1. 1.
  
  Hard and soft tissue involvement
2. 2.
  
  Loss of a tooth/teeth
3. 3.
  
  Bony fractures/root fractures
2.

Risk for new trauma or reinjury to the affected site : Trauma to a previously damaged site is always a possibility. Depending on the severity of a subsequent injury, it could pose catastrophic consequences for the athlete. Proper risk vs reward assessment is prudent, especially in cases with concussions.
3.

Age of the athlete : The younger the athlete, the higher the potential for additional trauma and/or reinjury due to the number of years remaining to participate in the sport. At-risk younger athletes will require a guarded approach to definitive or long-term restorative solutions. Use of dental implants will be governed by level of physical maturity and other risk factors and is discussed later in this chapter.
4.

Continuation in the same sport as the initial trauma/participation in other sports : Participation in the same sport as the injury occurred or in multiple sports will influence restorative decision-making. Individuals identified as CPS (continuing to play sports) should receive special consideration when selecting both approach and materials.
5.

Level of competition : The speed and velocity of today’s athletic endeavors is rising meteorically. Athletes who continue their pursuits at the highest levels of sport may be placing themselves at risk levels above the norm, exposing themselves to higher frequency for dental trauma and possibly increased severity of the damage as a result.
6.

Option for use of protective equipment : It has been demonstrated that the use of protective equipment can reduce the risk and degree of injury. Wearing a properly fitted mouthguard—even in a non-mandated mouthguard sport—could produce unforeseen dividends for the athlete.
7.

Multidisciplinary approach to care : Consultation and collaboration with health professional colleagues is a vital factor for the successful long-term treatment of the athlete. Many times it becomes the role of the general dentist to be the coordinator or “quarterback” for the restorative team. This potentially includes all the dental specialties, physicians, athletic trainers, therapists, and other allies.
8.

Necessity for transitional restorations or prostheses : The injury may lend itself to a very succinct and defined treatment, such as a fractured incisor being repaired with a direct composite. However, in more complex cases, multiple appointments with numerous specialists over an extended period of time may necessitate the use of transitional restorations for the athlete. Both removal and fixed prostheses may be considered. Some of the other factors previously listed—such as age, level of competition, and reinjury risk assessment—also play a role in the need for transitional restorative options.
9.

Materials and techniques available: There are a multitude of direct and indirect materials and techniques for us to employ in the restoration of both soft and hard tissues. Consideration should be given to all the factors listed above when formulating a treatment plan and selecting the restorative path.

The list is not meant to be inclusive or exclusive in any manner but to simply serve as a guideline to begin the assessment of the athlete and a restorative treatment plan. It cannot be emphasized enough that any guidelines available to the profession as they relate to managing dental trauma are meant to be a template for good clinical judgment based on the specific circumstances present. Even though the practitioner may be faced with a time-sensitive treatment, it is imperative that the dentist provide the patient and/or guardian with a full disclosure of immediate and long-term outcomes so that an informed decision can be reached by the involved parties prior to initiating treatment.

6.2 Restorative Considerations

Once post-trauma stabilization is achieved, the next step is to complete the risk assessment for the athlete using decision-tree modeling to evaluate the path for restorative measures and develop a restorative treatment plan. The course of treatment may be classified in the one of the following ways:

Simple—completed in one or two appointments
Complex—requiring multiple appointments over a period of time
Multidisciplinary—utilizing the expertise of specialist colleagues to complete the restoration

Numerous options for restoring the athlete exist as a result of advances in dental materials. Ceramics, resins, fibers, and dental implants may all play a role in the decision-making process. Working closely with dental specialists plus other healthcare members such as athletic trainers, physicians, physical therapists, and others in both the planning and treatment phases can create a path to success. The treatment plan should be formulated from the scientific literature available and sound clinical judgment based on the specific circumstances present.

Conservative modalities should be paramount in formulating the treatment plan when the athlete will continue to play sports (CPS), especially at a high level; thus, some approaches which might be considered for the mainstream patient population may not be appropriate. Use of contemporary dental materials and techniques—such as direct composite resins and adhesive bonding—is ideal for restoring many sports-related injuries. Specifically, composite resins are key because they have the ability to restore only what is missing or damaged, easily accessible, have the ability to be repaired, and are the least costly of all tooth colored materials available to the dentist. Use of the Ellis classification of tooth fractures can be helpful in quantifying the restorative path for individual teeth using direct composite resins (Box “Ellis Classification (Tooth Fractures)”).

Ellis Classification (Tooth Fractures)

Ellis Class I

Enamel fracture: This level of injury includes crown fractures that extend through the enamel only. These teeth are usually nontender and without visible color change, but have rough edges.

Ellis Class II

Enamel and dentin fracture without pulp exposure: Injuries in this category are fractures that involve the enamel as well as the dentin layer. These teeth are typically tender to the touch and to air exposure. A yellow layer of dentin may be visible on examination.

Ellis Class III

Crown fracture with pulp exposure: These fractures involve the enamel, dentin, and pulp layers. These teeth are tender (similar to those in the Ellis II category) and have a visible area of pink, red, or even blood at the center of the tooth.

Ellis Class IV

Traumatized tooth that has become nonvital with or without loss of tooth structure.

Ellis Class V

Luxation: The effect on the tooth that tends to dislocate the tooth from the alveolus.
Teeth loss due to trauma.

Ellis Class VI

Avulsion: The complete separation of a tooth from its alveolus by traumatic injury.
Fracture of root with or without loss of crown structure.

Ellis Class VII

Displacement of a tooth without the fracture of crown or root.

Ellis Class VIII

Fracture of the crown en masse and its replacement.

Ellis Class IX

Fracture of deciduous teeth.

6.3 Case Reports

The following cases illustrate the use of composite resin materials to restore three commonly seen injuries: fractured anterior permanent tooth fragment and reattachment of the fractured segment, fractured anterior permanent tooth fragment without reattachment, and loss of a permanent incisor.

Case Study

Case 1: Reattachment of a Fractured Anterior Tooth Fragment (Ellis Class I or II)

The reattachment of a fractured anterior tooth segment can be the preferred option for managing coronal tooth trauma when the fragment is available and there is minimal or no compromise of the biologic width. This technique has a long-standing success rate and can provide excellent esthetics because it maintains the tooth’s original anatomic form, shade, and surface texture. In addition, the positive social and emotional effects to the patient of rebonding the fragment cannot be overlooked. Numerous reports are cited in the literature spanning four decades and justify its use in both vital and nonvital teeth [28–74]. The first reported case of a nonvital tooth reattachment was documented by Chosack et al. in 1964 and involved an endodontically treated fractured incisor and reattachment of the segment with the use of a post and core fitted to the fragment and then cemented into the tooth body [75]. Tennery was the first to employ the acid-etch technique for the reattachment of a fragment to a vital tooth in 1978 [76]. Andreasen et al. demonstrated a 25% retention rate of reattached coronal fragments after 7 years [77], while Calvalleri and German showed a 90% retention rate after 5 years [78].

Utilizing an acid-etch technique, contemporary dentin/enamel bonding agents and composite resins, the ability to bond a fractured tooth segment epitomizes the use of conservativeness and minimally invasive techniques. However, there are variables within the protocol which could influence the outcome such as preparation design, luting materials, and storage media of the fractured segment. One study compared the fracture strength of sound and restored anterior teeth using a resin composite and four reattachment techniques and concluded that fracture resistance results improved when an enamel bevel was applied prior to the adhesive system (95.8%), an internal groove was made (90.54%), or the composite was overcontoured on the facial (97.2%) in comparison to just bonding the fragment (37.09%) [79].

Use of various luting materials has been studied over the years, and the development of the enamel/dentin adhesives has led to their use as the system of choice for reattachment of tooth fragments. Andreasen et al. reported that the use of a dentin bonding agent with the acid-etch technique improved both fracture resistance and retention rate of the tooth fragment [36], while Farik et al. found that most fifth-generation bonding agents increased fracture resistance when used with an unfilled resin [80]. Almuammar and colleagues found that compomers produced higher bond strengths than resin-modified glass ionomer cements (RMGI), but neither could match those of composite resins when used as luting materials [81]. Use of dual-cure resin cements has shown fracture resistance lower than fragments reattached with light-cured composite resins [82]. Flowable and viscous composites with particle size classifications of hybrid, microhybird, microfilled, and nanofilled have all demonstrated the ability to serve as effective luting materials when used with adhesive systems.

Another factor in a successful reattachment is adequate hydration of the tooth fragment prior to the procedure. Limited research has been done on this topic, but proper hydration is critical to maintaining the vitality and esthetic appearance of the tooth. Due to the hydrophilic nature of many of the dentinal adhesive systems, adequate hydration allows for quality bond strength values and improves the strength of the final restoration [57]. A variety of storage media have been evaluated ranging from tap water, saline, milk, egg albumin, 50% dextrose solution, and most recently coconut water. One study found that preservation of the tooth fragment in egg albumin or 50% dextrose resulted in higher bond strengths compared to tap water [62]. Sharmin and Thomas reported that saline-stored fragments gave higher fracture resistance than those kept in milk or dry [83], and Prabhakar et al. determined that dairy milk yielded the best adhesive results and egg white the poorest [70]. While there is little doubt that hydration plays an important role in the overall attachment result, further research is needed to fully understand the merits and benefits of each media (◘ Figs. 6.1, 6.2, 6.3, 6.4, 6.5, 6.6, 6.7, 6.8, 6.9, and 6.10).

../images/335190_1_En_6_Chapter/335190_1_En_6_Fig1_HTML.png — Fig. 6.1

A 12-year-old female presents with a fractured maxillary left central incisor as a result of a sports-related trauma (facial view)

../images/335190_1_En_6_Chapter/335190_1_En_6_Fig2_HTML.png — Fig. 6.2

A 12-year-old female presents with a fractured maxillary left central incisor as a result of a sports-related trauma (lingual view-mirror image)

../images/335190_1_En_6_Chapter/335190_1_En_6_Fig3_HTML.png — Fig. 6.3

The arch wire and bracket are removed to improve access. A 360° enamel bevel is prepared using a diamond bur

../images/335190_1_En_6_Chapter/335190_1_En_6_Fig4_HTML.png — Fig. 6.4

The fractured tooth segment was kept and stored in cow’s milk by the parent. The segment was rinsed with water and then carefully prepared with a similar 360° enamel bevel

../images/335190_1_En_6_Chapter/335190_1_En_6_Fig5_HTML.png — Fig. 6.5

The tooth was isolated with a specialized clear matrix prior to the bonding procedure

../images/335190_1_En_6_Chapter/335190_1_En_6_Fig6_HTML.png — Fig. 6.6

A total-etch technique was employed to both the tooth and the fragment for 15 s and then rinsed with a water spray and gently dried with air. A universal dentin bonding agent was applied to both the tooth and the segment according to manufacturer’s directions. The tooth segment was reattached to the tooth using a flowable composite and light cured with a LED source for 20 s from both the facial and lingual aspects

../images/335190_1_En_6_Chapter/335190_1_En_6_Fig7_HTML.png — Fig. 6.7

A total-etch technique was employed to both the tooth and the fragment for 15 s and then rinsed with a water spray and gently dried with air. A universal dentin bonding agent was applied to both the tooth and the segment according to manufacturer’s directions. The tooth segment was reattached to the tooth using a flowable composite and light cured with a LED source for 20 s from both the facial and lingual aspects

../images/335190_1_En_6_Chapter/335190_1_En_6_Fig8_HTML.jpg — Fig. 6.8

The restored tooth was smoothed and polished with 12-fluted, spiral-bladed carbides and abrasive impregnated silicone cups and points. Occlusion and excursive movements were evaluated

../images/335190_1_En_6_Chapter/335190_1_En_6_Fig9_HTML.png — Fig. 6.9

Final view of the reattached tooth fragment displaying excellent shade match due to the proper hydration of the fractured segment and enamel bevel (facial view)

../images/335190_1_En_6_Chapter/335190_1_En_6_Fig10_HTML.png — Fig. 6.10

Final view of the reattached tooth fragment (lingual view-mirror image)

Case Study

Case 2: Restoration of a Fractured Anterior Tooth (Ellis Class II)

In situations where the fracture tooth fragment is not reclaimed, it presents itself in multiple pieces or is simply unusable, the dentist is faced with the challenge of rebuilding what is lost using artificial materials. Composite resins offer the dentist the best overall solution to this esthetic and functional dilemma. The advancements made since Buonocore first conceived of bonding to enamel with the introduction of acid-etching [84] and Bowen’s historic work with resins [85] have been exponential. While the reattachment of the patient’s own tooth segment is the ideal dental material, resins offer the next best choice for a conservative restoration especially for an active athlete who may encounter another orofacial trauma. The use of modern composites coupled with contemporary bonding agents and matrices allows for great flexibility, and its documentation in the literature as a successful direct restorative is ubiquitous. Although the severity of the fracture (Ellis Classes I–III) plays a key role in the decision-making process of choosing a restorative material, direct resins can act as both a transitional and a permanent solution after an athletic trauma in all ages (◘ Figs. 6.11, 6.12, 6.13, and 6.14).

../images/335190_1_En_6_Chapter/335190_1_En_6_Fig11_HTML.jpg — Fig. 6.11

A female adult presented from the hospital emergency room after a bicycling accident. A wire trauma splint had been placed and numerous enamel/dentin fractures covered with a glass ionomer material. Endodontic therapy had been initiated on the maxillary right central incisor

../images/335190_1_En_6_Chapter/335190_1_En_6_Fig12_HTML.png — Fig. 6.12

Numerous enamel/dentin fractures covered with a glass ionomer material. Endodontic therapy had been initiated on the maxillary right central incisor (lingual view-mirror image)

../images/335190_1_En_6_Chapter/335190_1_En_6_Fig13_HTML.png — Fig. 6.13

After administration of local anesthesia, the glass ionomer material was removed with a rotary instrument and the fractured areas assessed (Ellis I and II). An enamel bevel was placed with a diamond bur and each tooth isolated with a specialize clear matrix. A total-etch technique and a universal bonding agent were used along with a microhybrid direct composite material to restore the fractured teeth

../images/335190_1_En_6_Chapter/335190_1_En_6_Fig14_HTML.png — Fig. 6.14

Final image of the restored maxillary anteriors after finishing and polishing

Case Study

Case 3: Replacement of Lost/Missing Permanent Incisor in an Immature Arch

Diagnosis and timely treatment are important in saving a traumatized tooth, especially in the anterior segment of the arch. Yet with all best efforts to save and restore a damaged tooth, the concept of inevitable tooth loss is a reality. There is minimal research on the “best treatment” option for an active athlete in restoring a lost tooth or even multiple teeth. Common sense guidelines based on existing research should be evaluated to determine recommendations for our active athletes. There are a variety of replacement options for missing teeth including removable appliances (partials, flippers, or Essix tooth maintainers) and fixed appliances (resin-based, metal-based, and ceramic-based bonded bridges, cantilever, and conventional bridges). Traditional bridgework in the young athlete may be contraindicated and can result in loss of vitality of abutment teeth, while removable prostheses can lead to significant plaque accumulation and self-image concerns with esthetics [86–88]. All have been used throughout history with various levels of success and have been the only available options to our patients and patient-athletes prior to the advent of root-formed dental implants. However, one option which has demonstrated to be an excellent transitional restoration for the active athlete is the use of fiber reinforcement and composite to fabricate a bonded bridge. Fiber reinforcement has been present in dentistry for many years and appears in several forms. Uses span from splints for traumatized or periodontally involved teeth, fiber-based posts, orthodontic retainers, and reinforcement of indirect provisional restorations. Various materials lend themselves to the use in a fiber-based modality and can include polyethylene, glass, quartz, nylon, and Kevlar^™ to name a few. The fabrication of a fiber-reinforced composite bridge has been successfully documented in the literature in both direct and indirect applications and extends itself to use in trauma-related cases, as well as congenitally missing teeth [89–106]. The definitive work on a direct fabrication method was reported and enhanced by Belvedere [107, 108]. The fiber-reinforced composite bridge has lent itself to be a conservative alternative for a missing anterior tooth instead of more invasive options, such as traditional fixed prostheses or dental implants. It may be an especially good choice for the athlete who is still growing (where an implant may be contraindicated) or the active athlete who may run the risk of more extensive damage should they experience a subsequent trauma to the same site (◘ Figs. 6.15, 6.16, 6.17, 6.18, 6.19, 6.20, 6.21, 6.22, 6.23, 6.24, 6.25, 6.26, 6.27, 6.28, 6.29, 6.30, 6.31, 6.32, 6.33, 6.34, 6.35, 6.36, 6.37, 6.38, 6.39, 6.40, and 6.41).