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DrAnil's picture
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Under Armour Performance Mouthwear
Bite Tech

All too often, dental practitioners see teenagers or adults with their front teeth broken. In most cases, this is the result of a sports-related mishap and totally avoidable. While direct hard- object trauma injuries (such as baseball bat or hockey stick impact) do occur, it is far more common to see tooth fractures as a result as the jaws suddenly coming together too hard, too fast, and with great force. This can occur in any contact sport (and many noncontact activities, as well). Furthermore, as many athletes know from experience, closing the jaw can actually help you to perform better. In both ancient and recent times, leather bite straps enhanced performance in both sport and battle. Bite Tech’s Under Armour Performance Mouthwear is designed to protect against inadvertent sudden closure as well as enhancing performance levels. Training and competition often cause the jaw to clench, compressing the temporomandibular joint (TMJ). This triggers the release of hormones that can produce stress, fatigue and distraction. Under Armour’s Performance Mouthwear appliance prevents the teeth from clenching; it pivots the jaw forward to alleviate pressure on the TMJ, eliminating energy-draining clenching. Independent university studies indicate that mouthguards can increase strength, endurance, and speed reaction time. A custom-designed mouthguard reduces athletic stress, reduces impact, and allows individuals to play better, stronger, and longer. The custom-fitted Under Armour appliances are far more precise than the typical pharmacy or supermarket boil-and-bite over-the-counter products. Under Armour Performance Mouthwear is an innovative provider of high-quality, scientifically designed, lab-fabricated appliances that offer maximum interocclusal and lateral protection for the teeth while enhancing performance ability. For more information, visit bitetech.com.
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drmithila's picture
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Mouthwear

 

 

The use and efficacy of mouthguards for the prevention of traumatic athletic injuries to the teeth and oral soft tissues as well as in the prevention of concussions should indicate to the athletic community the importance of this piece of protective equipment. By comparison to other athletic equipment, mouthguards are quite inexpensive. The underlying theme is to emphasize that for maximum comfort and protection, every athlete should possess a properly fitted mouthguard fabricated exclusively for the individual by a dentist. The materials and standard techniques used for the fabrication of stock, mouth-formed, and custom-made protectors are described. The characteristics that an ideal mouthguard should possess suggest that custom-formed mouthguards are superior in quality to either the stock or mouth-formed types, although the custom-formed types are more expensive and require the services of a dentist. The development of new dental materials has provided dentists with the opportunity to explore new techniques for the fabrication of custom-made mouthguards. New techniques for photopolymerized urethane diacrylate lipguards and mouthguards have been developed as have adaptations for those athletes who wear fixed orthodontic appliances and those who are partially edentulous. Proper cleaning and storage of all types of mouthguards can prolong the length of service of these protective appliances.

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drmithila's picture
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Mouthwear

 The ASTM (American Society for Testing and Materials) defined athletic mouthguard as a resilient device or appliance placed inside the mouth (or inside and outside) to reduce mouth injuries particularly to the teeth and surrounding structures.

The IASD (International Academy for Sports Dentistry)  statement on “A Properly Fitted Mouthguard ”. In this statement, the IASD adopted the ASTM operational definition for a mouthguard. The IASD statement goes further to state that the single word "mouthguard" must be replaced by the terminology “properly fitted mouthguard”.
Mechanisms of protection:
Hickey et al., 1967conducted a study on an intact male cadaver to determine the effect of mouthguards on pressure changes and bone deformation within the skull after a blow to the chin. Results indicated that both intracranial pressure and bone deformation were reduced when mouthguards were in place; thus, a new importance was given to this mean of protection in contact sports beyond that of preventing injury to the oral tissues.
Moreover, De Wet, 1981, found that almost one of ten unprotected boys was concussed, and this at primary school level. He also reported that one boy even had two episodes of concussion without attracting special attention.
Josell and Abrames, 1982, reported that by separating the soft tissue and the teeth, the mouthguard might prevent laceration and bruising of the lips and cheeks during impact. Also, they stated that mouthguards would cushion and distribute the impact during a direct frontal blow, which might otherwise cause fracture or dislocation of anterior teeth. Mouthguards may prevent the teeth in opposing arch from traumatic contact, which could fracture the teeth or damage their supporting structures. They also reported that mouthguards might help prevent 43 concussions, cerebral hemorrhage, and possibly death, by separating the jaws, thus preventing the condyles from being displaced up and backward against the wall of the glenoid fossa.
Oikarenin et al., 1993, compared the guarding capacities of mouthguards and concluded that intra-oral mouthguards not only protect the teeth, but they also prevent soft tissue lacerations as direct contact with the oral mucosa and teeth is prevented and that the intracranial pressure in indirect trauma is reduced.
Mueller et al., 1996, found that several mechanisms contributed to the decreased incidence of oral trauma with mouthguard use: First, Mouthguards separated the teeth from the soft tissues, thereby preventing lacerations and bruising during impact. Second, they cushioned opposing teeth and structures. Third, they cushioned and distributed the impact and prevent superior and posterior displacement of the condyles.They concluded that these might help in the prevention of concussions, cerebral hemorrhage, neck injuries, and possible death.
Barth et al., 2000, studied management of sports related concussions and found that properly fitted mouthguards produced a separation between the head of the condyle and the base of the skull and this increased distance would be necessary to reduce acceleration, reducing the force of impact during a blow and thus reducing the impact of those forces on the brain and reducing trauma. Additionally, the cushionquality of the mouthguard itself allows for an easing or reducing of the acceleration of the blow, similar to the padding in a boxer’s gloves or protective headgear. This dampening effect should also reduce the ultimate force brought to bear on the brain.

 

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drmithila's picture
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Mouthwear

  to summarize the functions of mouthguards:

1)    They spread the force of the blow over all the teeth that are covered by the mouthguard.
2)    They stop violent contact of the upper  & lower teeth.
3)    They keep the lips away from the malaligned teeth protecting the lips, the teeth and an orthodontic treatment.
4)    They hold the jaws apart:
a) acting as shock absorbers.
b) preventing upward & backward displacement of the condyles in their fossae.
So, they reduce the incidence of concussion from a blow to the chin.
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drmithila's picture
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Mouthwear

 Types of mouthguards:

I. Stock Mouthguards:
The stock mouthguards, available at most sporting good stores, come in limited sizes (usually small, medium, and large), least expensive but the least protective. As they cannot be prepared to mimic the mouth, they fit poorly, bulky, interfere with talking and breathing and can be held in place only when the jaws are closed.Some athletes try to make it more comfortable by cutting parts of their stock mouthguard that further reduces the required retention and protection. Unfortunately, these are still the most commonly used mouthguards on the market of many developing countries.
Ranalli, 1991, consider stock mouthguards to be potentially hazardous and should not be recommended.
Stock Mouthguard
II. Mouth Formed Mouthguards:
Presently, most mouthguards sold worldwide are of this type. They are available in limited sizes and are of two subtypes: the shell-liner and the thermoplastic.
 
a) The shell-liner type: consists of a preformed outer shell of polyvinyl chloride that fits loosely over the maxillary dentition. The liner is made of a plasticized acrylic gel or a silicon rubber. This mixture is placed in the player’s mouth, permitted to mold to the teeth, and then thermoset or chemoset. Because the outer shell is a stock tray resembling the stock mouthguards in size, they are also bulky and interfere with breathing and talking.
Heintz, 1968, and Bureau of Health Education and Audiovisual Services, and Council on Dental Materials, Instruments, and Equipment, 1984, found that by repeated biting on the shell liner mouthguards the liner material crept or spread, resulting in decrease in retention. Moreover, as the material is continually exposed to oral fluids, the plasticizers are leached out causing the liner to become hard. This in turn further reduces the protective properties of these mouthguards.
 
b) The thermoplastic type (boil and bite mouthguards): made from thermoplastic copolymer of polyvinyl acetate-ploy ethylene, immersed in boiling water for about 45 seconds, dipped in cold water for a few seconds and formed in the mouth by using finger, tongue, and biting pressure.
Woodmansey, 1999, added that because these mouth guards are formed at near-body temperatures, it has been reported that they can readily distort and wear through. Moreover, these mouthguards often lack proper thicknesses and extensions. So, they do not cover the needed area with the appropriate thickness on the posterior teeth leading to lesser protection and retention. Moreover, athletes usually try to alter thicknesses and extensions to get more comfort that further reduces the required retention and protection. In one reported incident in Australia, a boil-and-bite mouth guard dislodged from the teeth and impacted in an athlete’s oropharynx.
 
Mouth Formed Mouthguard
Tawfik and Moselhy, 2001, as many other researchers all over the world found that Custom Mouthguards are still superior to the Stock and Mouth Formed Mouthguards because they have a better fit and retention, thickness, comfort, life span and ease of breathing and talking.
For about 17 years of experience dealing with athletes and athletic injuries, I found that Stock and Mouth Formed Mouthguards do not provide the expected comfort and injury protection that Custom Made Mouthguards do.  Additionally, most of the athletic community believe that mouthguards are uncomfortable, unretentive, bulky, interfere with talking and breathing and introduce gagging simply because most mouthguards worn are of the Stock and Mouth Formed Mouthguards and the majority of athletes do not wear Custom Made Mouthguards provided by the dentist.
So, as a sports dentist, I do not recommend both Stock and Mouth Formed Mouthguards to my patients and athletic teams. 
III. Custom Made Mouthguards:
As they are made by the dentist, they are the most expensive, but are the best from the standpoint of fit, retention, comfort, and ease of speech. This type is fabricated on a cast of athlete maxillary dentition and surrounding tissues. Before fabrication of the Custom Made Mouthguard, your dentist will address medical and dental history, conduct thorough oral and para-oral examination and may conduct other investigations as taking necessary x-rays. Many factors should be considered before the Custom Mouthguard fabrication because they may affect the mouthguard fabrication technique and design. These may include general and personal factors as:
  •           Type of sport and level of competition being played.
  •           Position of the player e.g. goalkeeper, wing, ...etc. Moreover, famous athletes usually are more vulnerable to sports injuries due to intentional or unintentional tough play of opponents.
  •           Previous history of dento-facial injuries or concussion thus needing additional protection in any specific area.
  •       Age of the athlete as young athletes at the mixed dentition period (approximately 6-12 years old) should be supplied with mouthguard that provide adequate space for the developing jaw and the erupting teeth or sometimes mouthguard replacement.
  •          Sex of the athlete as females practicing sports are less prone to vigorous injuries than males. Additionally, females usually like some feminine touches added to their mouthguards.
  •           Type of occlusion as some athletes close their teeth in a way that need the fabrication of mouthguard on their lower jaw instead of the upper jaw or even the fabrication of what is called Bimaxillary Mouthguard on both jaws.
  •        Athletes who are under orthodontic treatment need special technique for mouthguard fabrication and recurrent replacements primary to protect their teeth and soft tissues (e.g. lips and cheek) from laceration or abrasions by either the orthodontic bands and/or wires and secondary to protect the orthodontic treatment itself.
  •        Athletes presented with cavities, impacted teeth as canines, missing teeth and/or removable or fixed prosthesis would have special professional attention.
  •          Mouthguard colors should be picked in harmony with the athletes complexion, colors of his/her hair and eyes ...etc. Moreover, it may carry names, team logo or country flag.
  •          Athletes’ desires as some sportsmen like some colors that emotionally affect their performance or their opponents’ performance.
 These are some important factors that only the well-experienced sports dentist would consider before fabrication of Custom Made Mouthguard to any athlete.
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drmithila's picture
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Mouthwear

Four out of five children in Ireland may have dental problems at some point soon.

That’s because they don’t wear any kind of mouthguards while playing contact sports. There were 505 children questioned as part of this study. About 95 percent of the children ages 9 to 13 play a sport and about two-thirds play between one and three sports.

Only 22 percent of these children wore mouthguards, according to the Journal of the Irish Dental Association.

Among rugby players, 60 percent did wear some type of mouthguard. The problem stems from the fact that mouthguards aren’t required equipment in many of the leagues in Ireland.

Some of the other reasons that they aren’t worn by most young athletes in Ireland are the costs and lack of knowledge about the importance of mouthguards. As a result, 10 percent of the children had some type of dental injury in the last year and more than half of these problems impacted their teeth. Nearly three-quarters of these injuries necessitated some type of dentist to treat the injury within two hours after the injury occurs.

Mouthguards have been proven to lower the risk for dental injury. They also limit the force from a blow to the face that may otherwise result in other health problems.

 

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Since the lower jaw forms a bilateral joint with the base of the skull at the glenoid fossa, blows to this mobile jaw may drive the jaw up and back, creating a transfer of energy from the lower jaw to the temporomandibular joint (TMJ) and base of the skull. Dr. Robert Cantu4 stated that blows to the chin, which acts as a lever, produce maximal forces. This fact has long been known in boxing, where the prime target for the opposing combatants has always been the chin. Stewart and Witzig19 have estimated that in athletes, over 90% of concussions resulting in unconsciousness are the result of blows to the lower jaw.

Although boxing serves as a prime example of the effects of direct blows to the lower jaw, even athletes wearing face shields and helmets are at risk of TMJ and traumatic brain injury from lower jaw impacts. Tim Walilko at the Wayne State School of Medicine demonstrated that the impact of a hockey puck traveling at 64 mph into a face shield is capable of creating enough energy transfer (shield - chin rest - lower jaw - TMJ - basal skull ) to create a 20% likelihood of mTBI.20

Standard National Operating Committee on Standards in Athletic Equipment (NOCSAE) football helmet drop test studies21 have shown that impact to the football helmet faceguard can displace the helmet and pull on the chin strap, causing a similar transfer of energy exceeding the pass/fail criteria set for helmets themselves.21,22 The ability of standard design mouthguards to protect against concussion has long been an area of debate. Barth has pointed out the theoretical and mathematical basis for a role of mouthguards in protecting the brain during lower jaw impacts if the mouthguard is fitted to provide vertical separation between the condyle and glenoid fossa. He also pointed out that the protective effect is limited to blows of a vertical nature only.23 Blows with a horizontal component are still capable of driving the lower jaw posteriorly, imparting impact energy at the TMJ area.17

Unfortunately, most blows to the lower jaw in sports arrive from the front and side,24-26 and carry a significant component of horizontal force. Additionally, little protection is available if the jaw is open during impact.27 Without the ability to lock the lower jaw into position, standard design mouthguards are capable of providing only unidimensional protection (Figure 4).

A prime determinant of the effectiveness of an appliance in reducing the risk of brain injury is the ability of the appliance to prevent displacement of the lower jaw during lower jaw impacts from any direction. When considering risk reduction for TMJ and brain injury in sports, we must begin to distinguish between the uni-dimensional protection afforded by standard design mouthguards and the multidimensional support provided by a new class of intraoral guard known as jaw joint protectors (Figure 5).
INTRAORAL GUARDS TO REDUCE LOWER JAW IMPACT TRAUMA

Classification of Mouthguards in Sports

Types of athletic mouthguards have traditionally been classified based on fabrication or design, as follows27:

(1) Classification by fabrication.
Stock mouthguard cannot be custom sized and should not be used
Boil and bite can be custom sized by molding when soft after boiling
Custom made dentist prescribed and laboratory fabricated mouthguards.

(2) Classification by design.
Single-arch design covers only one arch of teeth (usually the maxillary)
Dual-arch design covers both the maxillary and mandibular arches.

A NEW CLASSIFICATION FOR INTRAORAL SPORTS APPLIANCES

If we are to consider an expanded role of intraoral appliances in reducing the risk of concussion, traumatic brain injury, and jaw joint injury, we need to begin considering appliances based on classification by function, as follows:

(1) Mouthguard an intraoral appliance designed to protect the teeth and the oral tissues.

(2) Jaw joint protector (or brain injury risk-reducing appliance) an intraoral appliance designed to protect the teeth and oral tissues and the jaw joint and associated basal skull surface and brain during lower jaw impacts.

APPLIANCE DESIGN REQUIREMENTS FOR MINIMIZATION OF CONCUSSION RISK

An intraoral appliance designed to protect the brain and jaw joint should have the following features:

(1) It must prevent posterior and superior displacement of the lower jaw during impact, by fixing the mandible into position. This can only be accomplished by a dual-arch appliance.17

(2) The appliance must exhibit rigidity and resistance to deformation during lower jaw impact and during clenching (a normal and beneficial physiological response of athletes during maximal performance).27

(3) An appliance must fit properly. Compliance of wear is dependent on comfort, and comfort is dependent on fit. Proper fit is also required in order to provide retention. Only a properly retained mouthguard can be relied upon to be properly positioned at the time of impact.27,28

(4) The appliance must provide for adequate breathing during clenching.28,29 Prevention of lower jaw displacement during impacts is possible only when the mandibular dentition is firmly seated within the appliance. Therefore, an airway opening is of the utmost importance in order to allow both mouth and nasal breathing.

AN INTRAORAL APPLIANCE TO REDUCE THE RISK OF CONCUSSION

The limitations of single-arch appliances during lower jaw impact have also been recognized by athletes and dental professionals. Boxers have utilized numerous dual-arch dentist-fabricated appliances in the past, and various manufacturers (Everlast, Shock Doc) have had versions of dual-arch appliances meant to address lower jaw impact. Control of anteroposterior positioning of the mandible to create a horizontal separation of the TMJ and skull was not specifically addressed by these appliances. Compliance of wear by athletes is limited when breathing is compromised28,29 or when an airway breathing space is not incorporated or inadequate.

Dr. E. Williams designed an appliance to address the issue of lower jaw impacts and repetitive trauma in boxers. The appliance was designed to overcome previous limitations of dual-arch appliances, and is now utilized and endorsed by most major boxing, martial arts, and contact sport organizations. It is marketed as a jaw joint protector (Brain-Pad, WIPSS Products Inc). The appliance can be boil- and bite-fitted by dentists, athletes, or parents for general application, although custom fit by dental professionals may be recommended in cases of malocclusion, orthodontic therapy, or other special circumstances.

The Brain-Pad is fabricated with the following features to address the specific problem of energy transfer to the basal skull area during lower jaw impact:

(1) Dual-arch design with upper and lower bite channels to lock and hold the lower jaw into a down and forward position, creating a multidimensional safety space in the jaw joint area.

(2) Frontal airway space allows mouth breathing and speech while clenching the teeth. Dual material design allows for thermoplastic fitting as well as rigidity to maintain the airway space.

(3) A protective lower lingual flange guard minimizes posterior displacement of the mandible during impact.

(4) Down and forward mandibular positioning increases the airway space to optimize breathing during maximal exertion.

Impact to the lower jaw is transmitted to the appliance, which locks the lower jaw in position, and thus the forces are dissipated through the appliance into the maxillary arch. The risk reduction capacity of the Brain-Pad was evaluated by Voigt Hodgson at the Wayne State School of Medicine.22 In standard NOSCAE drop tests, the Brain-Pad design provided significant protection in the TMJ basal skull area, while standard design custom or boil and bite mouthguards did not meet the pass/fail criteria

The increase in bulk of a dual-arch appliance may be an initial concern for athletes accustomed to standard single-arch designs, but even younger athletes quickly adapt to the appliance. The Brain-Pad is not recommended for patients with class III malocclusion.

 

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