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Custom Mouthguards for Ortho Patients Dr. Ray Padilla, DDS

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Every semester, school kids of all ages eagerly join sports teams. But all of this truly laudable activity comes with a downside: a rise in orofacial injuries.

As a result, medical commissions and organizations now recognize the need for trauma dentists. From the International Olympic Committee's Medical Commission to the Academy for Sports Dentistry, dentists provide necessary information and insight on trauma treatment and prevention for world-class athletes.

However, while many pro-athletic teams have dentists on staff, few collegiate teams do. High schools and clubs are often "play at your own risk." Dental injuries—especially fractured teeth—are the most frequent oral/facial sports injury in the United States. And the related costs of an untreated avulsed tooth can run an estimated $10,000 to $15,000 over a patient's lifetime.

Cartoonists have long lampooned the stereotypical image of the hockey player with a few teeth missing, but our patients aren't laughing when it's their kid who made the hockey team—they're coming to us, their dentists, for counsel. They want to keep their children's teeth intact and they need to know the most effective (and cost-effective) way to do it.

Statistics on this quiet segment of dentistry not only reveal a deep need, especially at the local, non-professional level, but they also present an exciting opportunity. Sports dentistry can help prevent oral/facial injuries (fractured, avulsed or luxated teeth, as well as soft tissue injuries). Protective, properly-fitting mouthguards are recommended by both the AAD and AAPD to prevent sports injuries. Dentists can educate patients and meet this need.

Patients always have choices and it's our job to make sure they make the right decision for their budget and their need. The most critical aspect of this decision-making process is educating the patient.

Currently, our patients can choose three types of athletic mouthguards. Type 1 is a standard, off-the-shelf mouthguard that can be purchased from any sporting-goods store. There is no custom fit—the patient just sticks it in his or her mouth. Needless to say, the protection afforded is minimal and the level of discomfort means it's often left in the locker room. Type 2 is the "boil and bite" mouthguard—as the name implies, it is boiled first to soften the guard so it molds to the shape of the teeth. However, the material is unstable and studies have shown that this guard often does not offer a proper fit or adequate protection.

Research indicates that the best option for protecting a patient's mouth and teeth is Type 3—a custom-made, pressure-laminated mouthguard.

This mouthguard not only offers a comfortable, custom fit, it also allows for design modifications for orthodontically induced tooth movement and tooth eruptions. Clearly, cost is a consideration. Mouthguards created in a lab can run as much as $100 (or more) per mouthguard. Creating the appliance in-house by using a pressure thermoforming machine can decrease fabrication costs by up to 90 percent. It's a win-win for both the patient and the dentist—doing in-house fabrication slashes costs and adds another level of service for your patients.

Currently, two types of Type 3 mouthguards are available: vacuum-machine mouthguards and pressure-machine mouthguards. The vacuum type mouthguards are not recommended due to poor internal adaptation and poor fit. Prior to purchase, carefully review the differences between machines—focus especially on the internal adaptation for fit. The better the fit, the more effective the mouthguard.

Making a Type 3 Mouthguard
Step 1: Use a 3mm sheet of ethylene vinyl acetate material to see the adaptation. Remove the original model and pour stone into the ethylene vinyl acetate. Once the adaptation is clear, making a decision about whether to go with a newer vacuum machine or a state-of-the-art pressure machine will be more straightforward.

The dentist's next role is to decide whether to fabricate a custom-made mouthguard in the office or send it to a qualified laboratory. A key to trauma prevention is thickness and extensions. Minimal thickness should be labially, 2mm; and occlusally, 3mm.

A mouthguard is created specifically for the athlete, taking into account the athlete's age, what sport he or she is playing, and any trauma history. The recommended material used to create a mouthguard is ethylene vinyl acetate with a shore hardness of 80 through a four-step process: impression, fabrication, trimming and polishing, and placement/occlusal equilibration.

Step 2: As always, the better the impression at the outset, the better the appliance. The Accu-Dent System II multicolloid impression system allows the dentist to create casts both effectively and profitably. The impression gels, formulated in two different viscosities, give the dentist the flexibility to capture both soft tissue and hard tissue impressions. The light viscosity gel is applied using a syringe with a special tip—this allows for greater detail and eliminates air bubbles. (While ideal for mouthguards, this system also works well for partials, immediate dentures, orthodontics and splints.)

Step 3: After the impression is taken, immediately pour-up with a hard die stone, taking care to capture all vestibular borders. Don't bother with a large base; it will be removed at the trimming stage.

Step 4: Once the model is hard and set (this takes roughly 45 minutes), pencil in the highest margins of the vestibular border; at the model trimmer, remove excess stone carefully to this border. Including these vestibular borders will ensure the mouthguard has more retention, due to increased surface adaptation. This will also protect the alveolar bone from trauma.

Step 5: Now the model is trimmed and dry. Soak the model in orthodontic model soap for one hour. This will lubricate the model to allow for easy separation after fabrication. Dry the model and polish it with a dry towel. It is now ready for mouthguard fabrication.

Step 6: This is a positive pressure, not (suck down) vacuum. All three machines that are available for this process must be connected to a compressor. They are: Druformat by Dreve (Unna, Germany, distributed by Raintree Essix, LLC), the Erkopress by Erkodent (Pfalzgrafenweiler, Germany, distributed by Glidewell Laboratories) and the Biostar by Scheu Dental (Iserlohn, Germany, distributed by Great Lakes Orthodontics). This example uses the Druformat.

Because the ethylene vinyl acetate shrinks approximately 30 to 40 percent during fabrication, two 3mm sheets are laminated together to form a 3mm to 4mm mouthguard. It's important to do this process in separate steps to ensure the incisal and occlusal surfaces are manufactured to the correct thickness.

Step 7: Power up the machine and turn on the heater switch, then place a sheet of the ethylene vinyl acetate in the disc positioning ring. Place the trimmed model (with marked extensions) on the tray table, slightly off center toward the lingual.

Step 8: Now place the clamping ring over the ethylene vinyl acetate sheet to lock its position.

Step 9: Place the heater into position over the model, allowing the ethylene vinyl acetate material to soften to a malleable consistency.

Step 10: The ethylene vinyl acetate material will soften and slump until it touches the model. Now the first layer is ready to pressure thermoform.

Step 11: The white button that activates the pressure is located on the upper left side of the Druformat. When the heater is removed from the ethylene vinyl acetate material, this button must be pressed at the same time. The pressure chamber will drop over the model and pressurize the ethylene vinyl acetate, securing it to the model.

When the thermoprocess has begun, a light will illuminate, signaling that your hands can be removed from the machine. Do not remove your hands prior to the light signal, as pressure will not be maintained.

Step 12: Allow the ethylene vinyl acetate to cool for a minimum of 10 to 15 minutes before removing it from the pressure chamber. Removing it prematurely may distort the mouthguard.

Step 13: Once the ethylene vinyl acetate has cooled, depress the white button until the pressure indicator light shuts off and the pressure has released in the chamber. Push the heater lever slowly toward the cylinder. The pressure cylinder will then rise.

Step 14: Remove the ethylene vinyl acetate from the disc positioning ring and allow it to cool completely to room temperature. The first layer is now complete.

Step 15: Trim any excess material with a hot knife. Do not trim excessively: the lingual borders should be trimmed 1mm from the teeth, and follow the penciled mucosal borders for the labial border trim. The distal of the first molar is the minimal extension.

Step 16: Attach any identification labels and logos using any label machine (10 point maximum font size).

Step 17: Now create the second layer for the mouthguard. Place a clear 3mm sheet of ethylene vinyl acetate in the disc positioning ring. Place the model with its first layer on the positioning tray slightly off-center toward the lingual. Now repeat steps eight through 13. The clear second layer will become malleable. It must become hot enough to droop heavily over the first layer. If it is not hot enough, complete lamination will not occur and the mouthguard will separate.

Activate the pressure chamber and allow the model to cool for 15 minutes while still under pressure.

Repeat steps 12-16.

Step 18: Remove the clamping ring and allow the mouthguard to cool to room temperature. This eliminates any chance of distortion and guarantees a tight fit.

Step 19: Repeat steps 15-16, trimming the second layer of ethylene vinyl acetate to the proper extensions.

Step 20: Check the internal lingual extensions and mark with a pen, 1mm from the teeth.

Step 21: Trim excess material lingually to the marked extensions, using a Dedico stone acrylic bur. Next, place the mouthguard back on the model and feather-finish the margins for comfort lingually, bucally and labially. Remove any interferences with muscle attachments. Finishing and thinning the lingual extensions is critical to providing comfort and ease in speaking.

Step 22: Trim and smooth the mouthguard to desired thickness, using Essix Scotch wheels. Relieve all frenum attachments with a lisco disc.

Step 23: Place final finish and polish.

Step 24: The custom-made pressure-laminated mouthguard is finished.

Step 25: Next, fit the mouthguard to the patient. Make sure the fit is precise and the patient finds it comfortable. As always with any dental appliance, adjustments may be necessary. A balanced occlusion must be present—this is critical. Warm the posterior occlusal surface of the mouthguard, being extremely careful not to distort it, and place the mouthguard in the patient's mouth. Ask the patient to bite down carefully; all posterior teeth should occlude. The patient must not bite down excessively, as the occlusal separation of 3mm to 4mm must be maintained to ensure proper absorption of impact energy.

This pressure-laminated mouthguard is the best possible protection for both new and experienced athletes. The precise fit reduces the potential of injury and leads to increased compliance. In short, if it fits and it's comfortable, the athlete will wear it—and can focus on the joy of the game.


Dr. Ray Padilla is on faculty at the UCLA School of Dentistry and maintains a private practice in Manhattan Beach, California. His involvement in sports dentistry includes the 1984 Los Angeles Summer Olympic Games and Dental Commissioner for World Cup Soccer 1994, 1999, and 2003. He is the Team Dentist for UCLA Athletics, the Los Angeles Galaxy Major League Soccer Team, and U.S. Soccer. Dr. Padilla has published many articles on mouthguards, trauma treatment and prevention and organized www.sportsdentistry.com. An international speaker, he has lectured in Australia, Greece, Japan, Switzerland, Germany, Canada, Spain, Mexico, United Arab Emirates and numerous USA venues.
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