Degree or severity of the initial injury :
Hard and soft tissue involvement
Loss of a tooth/teeth
Bony fractures/root fractures
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.
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.
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.
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.
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.
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.
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.
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
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)
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.
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.
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.
Traumatized tooth that has become nonvital with or without loss of tooth structure.
Luxation: The effect on the tooth that tends to dislocate the tooth from the alveolus.
Teeth loss due to trauma.
Avulsion: The complete separation of a tooth from its alveolus by traumatic injury.
Fracture of root with or without loss of crown structure.
Displacement of a tooth without the fracture of crown or root.
Fracture of the crown en masse and its replacement.
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 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 . Tennery was the first to employ the acid-etch technique for the reattachment of a fragment to a vital tooth in 1978 . Andreasen et al. demonstrated a 25% retention rate of reattached coronal fragments after 7 years , while Calvalleri and German showed a 90% retention rate after 5 years .
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%) .
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 , while Farik et al. found that most fifth-generation bonding agents increased fracture resistance when used with an unfilled resin . 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 . Use of dual-cure resin cements has shown fracture resistance lower than fragments reattached with light-cured composite resins . 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.
Case 2: Restoration of a Fractured Anterior Tooth (Ellis Class II)
Case 3: Replacement of Lost/Missing Permanent Incisor in an Immature Arch