Dental trauma: restorative procedures using composite resin and mouthguards for prevention

AIM

The aim of this article is to describe a step-by-step protocol for emergency care of a patient with a dentoalveolar injury in the anterior region of the mouth as well as the fabrication of a mouthguard to prevent future trauma.

BACKGROUND

Dental trauma is one of the most serious oral health problems in active children and adolescents. Care of traumatized patients requires immediate initial emergency treatment followed by integrated procedures to restore damaged oral structures along with a subsequent trauma prevention strategy. Dentoalveolar injuries in the anterior region of the mouth are often characterized by tooth avulsion and coronal fracture. They are managed using procedures such as dental splinting, endodontic therapy with its unique characteristics, and restorative techniques to re-establish function and esthetics as well as protective mouthguards.

REPORT

A 16-year-old male presented with avulsion of his maxillary central incisors as a result of a direct, unintentional impact with an opponent during a basketball game. The teeth had been stored in physiological serum immediately following the injury and the patient received immediate care. On clinical examination, the right central incisor was fractured at the incisal third of the crown but no bone fractures were found. The teeth were reimplanted and splinted. The fractured right central incisor was restored following endodontic treatment and a mouthguard was fabricated for the patient.

SUMMARY

The dentist must be knowledgeable about the most efficient and suitable treatment for each traumatic scenario in order to provide appropriate care for dental injuries. Coordinated multi-disciplinary action is fundamental in the successful treatment of these injuries. The dental mouthguard is an effective device for protecting the teeth and supportive structures during physical activities and must be part of the protective equipment used by athletes. It is the responsibility of the dental professional to make parents, trainers, and athletic associations aware of the risks associated with physical activities without orofacial protection; this should encourage the proper use of all protective devices to prevent dentoalveolar injuries that compromise oral functions, esthetics, and increase the cost of healthcare.

The incidence and severity of dental trauma in intercollegiate athletes

BACKGROUND

The use of protective devices such as mouthguards during participation in contact sports may be effective in reducing the incidence or severity of dental injuries.

METHODS

Dental injuries reported to the athletic department at the University of Southern California, Los Angeles, were recorded from 1996 through 2005. The authors classified each injury and determined the severity of the injury. Severity was defined in relation to the treatment required and the prognosis of the teeth and supporting tissues involved.

RESULTS

Fifty-one traumatic dental injuries were reported. Basketball was the sport with the highest injury rate; it had an incidence rate (IR) of 10.6 injuries per 100 athlete-seasons among men, and an IR of 5.0 injuries per 100 athlete-seasons among women. The IR for men's basketball players was five times higher than that for football players for whom mouthguard use is mandatory.

CONCLUSIONS

Given the relatively high incidence of dental injury in basketball and the potential of mouthguard use to reduce the incidence and severity of the trauma, mandatory use of mouthguards among collegiate basketball players should be considered.

CLINICAL IMPLICATIONS

Dental professionals have a responsibility to educate patients and the public about the importance of using mouth-guard protection in contact sports.

Ankle injuries among United States high school sports athletes, 2005-2006

CONTEXT

Ankle injuries are the most common sport-related injuries. To date, no studies have been published that use national data to present a cross-sport, cross-sex analysis of ankle injuries among US high school athletes.

OBJECTIVE

To investigate the incidence rates of ankle injuries by sex, type of exposure, and sport.

DESIGN

Descriptive epidemiologic study.

SETTING

One hundred US high schools.

PATIENTS OR OTHER PARTICIPANTS

United States high school athletes.

MAIN OUTCOME MEASURE(S)

We reviewed ankle injury data collected over the 2005-2006 school year from a nationally representative sample obtained by High School RIO, an injury surveillance system. Specific sports studied were boys' football, boys' and girls' soccer, girls' volleyball, boys' and girls' basketball, boys' wrestling, boys' baseball, and girls' softball.

RESULTS

An estimated 326 396 ankle injuries occurred nationally in 2005-2006, yielding an injury rate of 5.23 ankle injuries per 10 000 athlete-exposures. Ankle injuries occurred at a significantly higher rate during competition (9.35 per 10 000 athlete-exposures) than during practice (3.63) (risk ratio = 2.58; 95% confidence interval = 2.26, 2.94; P < .001). Boys' basketball had the highest rate of ankle injury (7.74 per 10 000 athlete-exposures), followed by girls' basketball (6.93) and boys' football (6.52). In all sports except girls' volleyball, rates of ankle injury were higher in competition than in practice. Overall, most ankle injuries were diagnosed as ligament sprains with incomplete tears (83.4%). Ankle injuries most commonly caused athletes to miss less than 7 days of activity (51.7%), followed by 7 to 21 days of activity loss (33.9%) and more than 22 days of activity loss (10.5%).

CONCLUSIONS

Sports that combine jumping in close proximity to other players and swift changes of direction while running are most often associated with ankle injuries. Future research on ankle injuries is needed to drive the development and implementation of more effective preventive interventions.

Epidemiology of lower extremity injuries among U.S. high school athletes

OBJECTIVES

Despite the health benefits of organized sports, high school athletes are at risk for lower extremity sports-related injuries (LESRIs). The authors documented the epidemiology of LESRIs among U.S. high school athletes.

METHODS

Via two-stage sampling, 100 U.S. high schools were randomly selected. During the 2005 school year, LESRIs in nine sports were reported: boys' baseball, football, and wrestling; girls' softball and volleyball; and boys' and girls' basketball and soccer. The authors calculated rates as the ratio of LESRIs to the number of athlete exposures. National estimates were generated by assigning injuries a sample weight based on the inverse probability of the school's selection into the study.

RESULTS

Among high school athletes in 2005, 2,298 of 4,350 injuries (52.8%) were LESRIs. This represents an estimated 807,222 LESRIs in U.S. high school athletes in nine sports (1.33/1,000 athlete exposures). Football had the highest LESRI rate for boys (2.01/1,000) and soccer the highest for girls (1.59/1,000). Leading diagnoses were sprains (50%), strains (17%), contusions (12%), and fractures (5%). The ankle (40%), knee (25%), and thigh (14%) were most frequently injured. Fractures occurred most often in the ankle (42%), lower leg (29%), or foot (18%). Girls with ligamentous knee injuries required surgery twice as often as boys (67% vs. 35%; p < 0.01). Girls had 1.5 times the proportion of season-ending LESRIs of boys (12.5% vs. 8%; p < 0.01).

CONCLUSIONS

While LESRIs occur commonly in high school athletes, team- and gender-specific patterns exist. Emergency department staff will likely encounter such injuries. To optimize prevention strategies, ongoing surveillance is needed.

Ankle sprain injuries: a 2-year prospective cohort study in female Greek professional basketball players

CONTEXT

Ankle sprains are a common basketball injury. Therefore, examination of risk factors for injury in female professional basketball players is worthwhile.

OBJECTIVE

To examine rates of ankle sprains, associated time missed from participation, and risk factors for injury during 2 consecutive seasons.

DESIGN

Prospective cohort study.

SETTING

Eighteen professional basketball facilities.

PATIENTS OR OTHER PARTICIPANTS

We observed 204 players from 18 female professional basketball teams for 2 consecutive seasons during a 2-year period.

MAIN OUTCOME MEASURE(S)

Using questionnaires, we recorded the incidence of ankle sprains, participation time missed, and mechanisms of injury in games and practice sessions. Potential risk factors, such as age, body mass, height, training experience, and history of ankle sprain, were examined using multivariate logistic regression.

RESULTS

Fifty of the 204 participants sustained ankle injuries; injuries included 32 ankle sprains, which translated to an ankle sprain rate of 1.12 per 1000 hours of exposure to injury. The 32 players missed 224.4 training and game sessions and an average of 7.01 sessions per injury. Most injuries occurred in the key area of the basketball court and were the result of contact. Injury rates during games were higher than injury rates during practice sessions. Centers, followed by guards and forwards, had the highest rate of injury. Players who did not wear an external ankle support had an odds ratio of 2.481 for sustaining an ankle sprain.

CONCLUSIONS

Female professional basketball athletes who did not wear an external ankle support, who played in the key area, or who functioned as centers had a higher risk for ankle sprain than did other players.

An en bloc avulsion fracture of tibial tuberosity and Gerdy's tubercle in an adolescent basketball player: a case report

We report a case of en bloc avulsion fracture of tibial tuberosity and Gerdy's tubercle, which has never been reported. A 14-year-old boy suffered from an acute pain in his left knee during running just before a jump. Simple radiographs showed an avulsion of the tibial tuberosity. On CT scans, the fractured fragment was attached not only to patellar tendon but also to iliotibial band (ITB) via Gerdy's tubercle. MRI evaluation revealed no intra-articular associated pathology. Open reduction and internal fixation with three cannulated screws were performed under lateral parapatellar approach to expose both the tibial tuberosity with patellar tendon and Gerdy's tubercle with ITB. At postoperative 1 year, he could walk, run, squat, and complained of no difficulty in activities on daily living with full range-of-motion of the knee. Radiographs showed well-healed fracture in situ. Gradually, he returned to sports activity. We believe that the injury was caused by the dynamic pull of quadriceps muscle via patellar tendon onto tibial tuberosity and the mostly static pull of ITB onto Gerdy's tubercle, both of which took a part in the fracture of the anterolateral portion of the unfused epiphysis of proximal tibia. The pes anserinus attaching on the anteromedial metaphysis of proximal tibia might exert the opposing deforming force. Preoperative planning including the determination of the extent of fracture and recognition of concomitant injury is a prerequisite for appropriate treatment.

Descriptive epidemiology of collegiate men's basketball injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2003-2004

OBJECTIVE

To review 16 years of National Collegiate Athletic Association (NCAA) injury surveillance data for men's basketball and identify potential areas for injury prevention initiatives.

BACKGROUND

Collegiate men's basketball is a contact sport in which numerous anatomical structures are susceptible to both acute and overuse injuries. To date, no comprehensive reporting of injury patterns in NCAA men's basketball has been published.

MAIN RESULTS

The overall rate of injury was 9.9 per 1000 athlete-exposures for games and 4.3 per 1000 athlete-exposures for practices. Approximately 60% of all injuries were to the lower extremity, with ankle ligament sprains being the most common injury overall and knee internal derangements being the most common injury causing athletes to miss more than 10 days of participation. A trend of increasing incidence of injuries to the head and face was noted over the 16-year span of the study, which may be related to an observed increase in physical contact in men's basketball over the past 2 decades.

RECOMMENDATIONS

These results provide the most comprehensive description of injury patterns in NCAA men's basketball to date. Many of the most common injuries seen in men's basketball, such as ankle ligament sprains and knee internal derangements, may be at least partially preventable with interventions such as taping and bracing and neuromuscular training. However, randomized controlled trials assessing the efficacy of such preventive measures among collegiate men's basketball players are clearly lacking. The increase in head and facial injuries may indicate that officials need to assess the increased tolerance for physical contact in men's basketball seen over the past 2 decades.

Descriptive epidemiology of collegiate women's basketball injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2003-2004

OBJECTIVE

To review 16 years of National Collegiate Athletic Association (NCAA) injury surveillance data for women's basketball and to identify potential areas for injury prevention initiatives.

BACKGROUND

The number of colleges participating in women's college basketball has grown over the past 25 years. The Injury Surveillance System (ISS) has enabled the NCAA to collect and report injury trends over an extended period of time. This has allowed certified athletic trainers and coaches to be more informed regarding injuries and to adjust training regimens to reduce the risk of injury. It also has encouraged administrators to make rule changes that attempt to reduce the risk of injury.

MAIN RESULTS

From 1988-1989 through 2003-2004, 12.4% of schools across Divisions I, II, and III that sponsor varsity women's basketball programs participated in annual ISS data collection. Game and practice injury rates exhibited significant decreases over the study period. The rate of injury in a game situation was almost 2 times higher than in a practice (7.68 versus 3.99 injuries per 1000 athlete-exposures, rate ratio = 1.9, 95% confidence interval = 1.9, 2.0). Preseason-practice injury rates were more than twice as high as regular-season practice injury rates (6.75 versus 2.84 injuries per 1000 athlete-exposures, rate ratio = 2.4, 95% confidence interval = 2.2, 2.4). More than 60% of all game and practice injuries were to the lower extremity, with the most common game injuries being ankle ligament sprains, knee injuries (internal derangements and patellar conditions), and concussions. In practices, ankle ligament sprains, knee injuries (internal derangements and patellar conditions), upper leg muscle-tendon strains, and concussions were the most common injuries.

RECOMMENDATIONS

Appropriate preseason conditioning and an emphasis on proper training may reduce the risk of injury and can optimize performance. As both player size and the speed of the women's game continue to increase, basketball's evolution from a finesse sport to a high-risk contact sport also will continue. The rates of concussions and other high-energy trauma injuries likely will increase. The NCAA ISS is an excellent tool for identifying new risk factors that may affect injury rates and for developing consistent injury definitions in order to improve the research and provide a source of clinically relevant data.

Prolonged immobilization in abduction and neutral rotation for a first-episode anterior shoulder dislocation

STUDY DESIGN

Case report.

BACKGROUND

Patients who sustain first-episode anterior glenohumeral dislocations are at risk to develop chronic glenohumeral instability. Current treatment options after an initial anterior glenohumeral dislocation include immediate surgery, delayed surgery, or conservative interventions such as immobilization and strengthening exercises. Duration of immobilization is variable among formal studies. Recent research suggests that typical immobilization positions may not allow adequate healing and in fact may promote glenohumeral joint instability.

CASE DESCRIPTION

The patient was a 19-year-old male who sustained a first-episode anterior glenohumeral dislocation during athletic activity. Physical therapy management included a longer-than-typical period of immobilization and protected activity to allow for more complete healing. The shoulder abduction and neutral rotation immobilization position used with this patient may increase healing of structures that influence stability of the shoulder

OUTCOMES

At 13 weeks after the dislocation, the patient had full active and passive range of motion, near normal strength, and no complaints of pain or instability. At a 20-month follow-up the patient had resumed full activities of daily living including recreational sports without symptoms of instability.

DISCUSSION

Conservative intervention options for first-episode anterior shoulder dislocations need further study. Immobilization and protected activity periods should be adequate to allow for complete healing. The optimal positions for immobilization should be determined and implemented.

[Chronic ankle instability in sports -- a review for sports physicians]

Chronic ankle instability represents a typical sports injury which can mostly be seen in basketball, soccer, orienteering and other high risk sports. 20 to 40 % of the acute ankle sprains develop into chronic ankle instability. From a sports orthopaedic point of view, chronic ankle instability can be subdivided into a lateral, medial or a combination of both so called rotational ankle instability. From a pathophysiological point of view, chronic ankle instability can be either mechanical with a structural ligament lesion or functional with loss of the neuromuscular control. For the sports physician, the chronic ankle instability is a difficult entity as the diagnosis is usually complex and the therapy usually surgical. This review on chronic ankle instability addresses pathomechanism, diagnostics, indications for conservative and surgical treatments, and possible long-term sequelae, as ligamentous osteoarthritis.

Traumatic proximal tibiofibular joint dislocation treated by open reduction and temporary fixation: a case report

Isolated dislocations of the proximal tibiofibular joint are a rare condition. Missed diagnosis can lead to chronic knee pain and disability. Early recognition should be followed by immediate closed reduction or open reduction and joint transfixation. We present a young athlete with this injury which was treated successfully by open reduction.

Lower-extremity overuse injury and use of foot orthotic devices in women's basketball

One hundred thirty-two female basketball players were observed for lower-extremity overuse injury between 1993 and 2004. Athletes studied between 1993 and 1996 did not receive foot orthotic devices and composed the control group. The treatment group comprised athletes studied between 1996 and 2004. Athletes in the treatment group were given a foot orthotic device before participation in basketball. Data analysis included lower-extremity overuse injury rates and the effect of foot orthotic devices on lower-extremity overuse injury rates by means of an incidence density ratio. The control group had a lower-extremity overuse injury rate of 5.37 per 1,000 exposures, and the treatment group had a rate of 6.44 per 1,000 exposures. The incidence density ratio was not significant (P = .44). This study rejects the concept that foot orthotic devices may assist in prevention of lower-extremity overuse injury in female basketball players.

[Sports injuries of temporomandibular joints and oral muscles in basketball players]

All sporting activities have an associated risk of orofacial injuries due to falls, collisions with players, devices, and hard surfaces. Many authors have reported about incidence of orofacial injuries during sports activities. Flanders and Bhat concluded that 34% of all injuries in basketball are orofacial injuries, while orofacial injuries account for only 0.07% of all injuries in American football.

AIM, METHODS AND EXAMINEES

The aim of this investigation was to identify the incidence, type and severity of temporomandibular joint injuries, stiffness and pain in oral muscles, and pain during opening and closure of the mouth while playing basketball. The sample consisted of 195 basketball players, 135 professionals and 60 non-professionals. They filled out the questionnaire individually with help of the researchers.

RESULTS

The data received by the survey revealed a total of 350 temporomandibular joint injuries and/or pain, oral muscles stiffness and pain during opening and closure of the mouth during basketball career. The incidence of injuries was higher in professional 72.6% (254) than in non-professional players 27.4% (96). Twenty-four professional and 9 non-professional players reported pain or oral muscles stiffness, while 58 professional and 15 non-professional players reported pain during opening and closing the mouth. Only 1 non-professional player and 6 professional players reported injuries of the temporomandibular joint. All basketball players who were injured during their career had more than one injury. During career, professional players reported pain while opening and closing of the mouth more often than non-professional players, on the average 1.3 and 0.9 times, respectively. Pain or oral muscles stiffness during basketball career was reported 0.6 times on the average by non-professional players, as compared to 0.5 times by professional players. Non-professional players reported 5.2% injuries of temporomandibular joints during their career, while professional players only 3.2%. With regard to positions in the team, most injuries of temporomandibular joints, stiffness and pain in oral muscles were reported by forwards, on the average 2.33 incidents. Centers were the second most frequently injured group with an average of 1.96 incidents, followed by point guards with 1.74, power forwards with 1.62 and guards with 1.55 incidents.

CONCLUSION

Only 2 basketball players (1%) frequently used a mouthguard and 93.3% of them never even tried to wear a mouthguard. Implementation of mandatory mouthguard usage in sports, such as basketball, would decrease such a large number of sports injuries. Mouthguards would absorb the force of impact and consequently stiffness and pain in oral muscles so that injuries of temporomandibular joints would be reduced or even avoided. Such a low percentage of mouthguard use in basketball players reflects poor awareness and education of both athletes and coaches, as well as an insufficient role of dentists in sports medicine and education.

Injury prevention and performance enhancement: a training program for basketball

The purpose of this investigation was to determine the effectiveness of a training program for basketball. Effectiveness in this case was determined by the program's ability to decrease the rate of injury and to increase athletic performance on the basketball court. The search for a program to help prevent serious knee ligament injuries has resulted in a plyometric type of training program. The first stage began eight weeks before basketball season, the second three days before the season started. Upon completion of the second testing session, both male and female participants had improved in all tests administered. This shows that a supervised, scientifically developed program consisting of sports-specific material can result in an increase in sports performance. There were no injuries reported during the training period or during the season lending credence to the fact that a program of this type can result in injury reduction.

Biomechanical analysis of anterior cruciate ligament injury mechanisms: three-dimensional motion reconstruction from video sequences

BACKGROUND

Methods for analyzing the mechanisms of injuries in sports from video sequences of injury situations are so far limited to a simple visual inspection, which has shown poor accuracy.

PURPOSE

To investigate whether a new model-based image-matching technique could successfully be applied to estimate kinematic characteristics of three typical anterior cruciate ligament (ACL) injury situations.

METHODS

A four-camera basketballvideo, a three-camera European team handball video and a single-camera downhill skiing video were imported into the program Poser 4, where a skeleton model and a model of the surroundings were matched to the background image frame by frame. When the match was considered satisfactory, joint angles as well as velocity and acceleration of the center of mass were calculated using Matlab.

RESULTS

In the basketball and handball matchings, the skeleton and surrounding models were successfully matched to the background through all frames in all camera angles. Detailed time courses for joint kinematics and ground reaction force were obtained, while less information could be acquired from the single-view skiing accident.

CONCLUSION

The model-based image matching technique can be used to extract kinematic characteristics from videotapes of actual ACL injuries, and may provide valuable information on the mechanisms for ACL injuries in sports.

Case of the month: Right coronary artery dissection following sports-related blunt trauma

Coronary artery dissection is a rare life-threatening complication resulting from blunt traumatic injury. Most cases of coronary artery injury, including dissection, involve the left anterior descending artery given its anatomical location relative to the impact. Right coronary artery (RCA) dissection secondary to blunt trauma is a particularly unusual occurrence, and has not previously been reported in the emergency medicine literature. We present a case of RCA dissection following low impact sport-related blunt chest trauma and discuss the pathophysiology, risk factors, diagnosis and current treatment options.

Rapid chondrolysis after arthroscopic partial lateral meniscectomy in athletes: a case report

We present a patient with a severe chondrolysis after arthroscopic partial lateral meniscectomy in a 17-year-old high school basketball player. This is a rare but severe complication after arthroscopic partial lateral meniscectomy. At 7 months after the first operation, a second-look arthroscopy showed numerous cartilaginous debris floating in the knee and a high-grade cartilage damage on the lateral compartment of the tibia. This unexpected complication and a consideration of its etiology are shown.

Star Excursion Balance Test as a predictor of lower extremity injury in high school basketball players

STUDY DESIGN

Prospective cohort.

OBJECTIVE

To determine if Star Excursion Balance Test (SEBT) reach distance was associated with risk of lower extremity injury among high school basketball players.

BACKGROUND

Although balance has been proposed as a risk factor for sports-related injury, few researchers have used a dynamic balance test to examine this relationship.

METHODS AND MEASURES

Prior to the 2004 basketball season, the anterior, posteromedial, and posterolateral SEBT reach distances and limb lengths of 235 high school basketball players were measured bilaterally. The Athletic Health Care System Daily Injury Report was used to document time loss injuries. After normalizing for lower limb length, each reach distance, right/left reach distance difference, and composite reach distance were examined using odds ratio and logistic regression analyses.

RESULTS

The reliability of the SEBT components ranged from 0.82 to 0.87 (ICC3,1) and was 0.99 for the measurement of limb length. Logistic regression models indicated that players with an anterior right/left reach distance difference greater than 4 cm were 2.5 times more likely to sustain a lower extremity injury (P<.05). Girls with a composite reach distance less than 94.0% of their limb length were 6.5 times more likely to have a lower extremity injury (P<.05).

CONCLUSIONS

We found components of the SEBT to be reliable and predictive measures of lower extremity injury in high school basketball players. Our results suggest that the SEBT can be incorporated into preparticipation physical examinations to identify basketball players who are at increased risk for injury.

Fifth metatarsal stress fractures in elite basketball players: evaluation of forces acting on the fifth metatarsal

Our hypothesis in this study was that significant forces act on the fifth metatarsal during certain maneuvers commonly performed while playing basketball and that medial arch support influences these forces. Eleven male collegiate basketball players participated in this study. Electronic pressure sensors capable of dynamic readings were inserted into the players' shoes, and surface electromyographic (EMG) electrodes were placed over the peroneus longus and brevis muscles. The players performed 3 common maneuvers postulated to place maximal stress on the fifth metatarsal. The maneuvers were performed in a standard basketball shoe, then in a shoe with an orthosis supporting the arch. During each of these maneuvers, EMG activity of the ankle everters was recorded, along with maximal force, total work, and time elapsed beneath the fifth metatarsal.

Stress fractures of the femur after ACL reconstruction with transfemoral fixation

The ACL reconstruction with hamstring tendons has become increasingly popular, in part because it is assumed that the complication rate associated with the technique and their severity are lower than with patellar tendon. Two cases of stress reaction of the medial supracondylar area of the femur after ACL reconstruction with hamstring tendons using BioTransfix (Arthrex, Naples, FL, USA) devices for fixation within femur are presented. Both patients were professional athletes (one soccer and one basketball player), and it is hypothesized that the accelerated rehabilitation program used might have represented a risk factor for stress fractures when associated with the guide pin exit hole in the medial femoral cortex. To our knowledge, no such cases have been published to date, but it is important to consider this possibility if an unexplained pain arises in the rehabilitation process of an ACL reconstruction using transfemoral fixation.

Simultaneous rupture of the patellar tendon and the anterior cruciate ligament: a case report and literature review

We report a case of simultaneous rupture of the patellar tendon and the anterior cruciate ligament. This condition was rarely reported in the literature and clinical diagnosis can be difficult. It is frequently associated with injuries of other knee structures. The preferred treatment is immediate primary repair of the patellar tendon and delayed reconstruction of the anterior cruciate ligament.