There’s something particularly horrifying about dental injuries. Maybe it’s the thought of what your own mouth would look like minus a few teeth, or the sheer in-your-face nature of the injuries. You can’t see a torn ACL, but you can see a pool of blood littered with teeth. Sidney Crosby, a habitual mouthguard-wearer and owner of a (formerly) beautiful smile horrified a nation Saturday when he took a puck in the mouth at the expense of several teeth and his jaw. This week we’ll have a quick refresher on how jaw injuries are treated, and explore the options for hockey teeth.
The good news on Crosby is there’s been no signs of any concussion-like symptoms. The bad news is a fractured jaw is a disgusting piece of work. The other good news is that while Crosby did have surgery, he didn’t have his jaw wired shut, so he shouldn’t have any of the problems a wired jaw brings like weight loss and a stinky mouth.
A Broken Jaw Refresher
When Patrick Eaves broke his jaw in November of 2011, I wrote about it. Just in case you’re too
lazy busy to read it, here’s a reminder of the treatment choices for broken jaws (specifically the mandible aka lower jaw):
- Nothing: If the fracture is fairly minor and non-displaced (meaning the ends of the bone haven’t moved away from one another) and the surrounding muscles aren’t pulling them out of alignment, you may get away with just a soft diet and doctor’s orders to take it easy on your face. No big yawns, crunchy food, or facepunches.
- Mandibulomaxillary fixation (MMF): This is the grossest of all the options, and involves not opening your mouth for about six weeks. This is good for nondisplaced fractures, or for fractures so severe that there’s not enough contiguous bone to plate back together. What you’ll get is metal bars held onto your teeth with wires, then the upper and lower jaws are held together with more wires or strong elastics linking those bars. The problems with MMF are the obvious ones – you can’t eat solids, you can’t brush 2/3 of your tooth surfaces, and if you barf there’s not an easy exit for the vomit. MMF also makes breathing a chore, so workouts usually end up being minimal at best.
- Open reduction and internal fixation (ORIF): This is what Crosby had done – surgery to plate the jaw back together. This is usually followed up by about a month of MMF, but somehow Crosby got lucky and didn’t require it. Detroit’s Brad Stuart had the same procedure in January of 2011 for two non-displaced fractures, wasn’t wired, and was out only six weeks. The idea that Crosby could be back for the playoffs isn’t actually completely insane.
Fun With Teeth
When the puck broke Crosby’s jaw, it also knocked out several teeth. Before you decide that mouthguards are a complete waste of time, consider the fact that not wearing one puts you at about twice the risk of tooth or oral soft tissue damage. Consider also that no mouthguard is going to completely protect you against a Brooks Orpik slapper in the mouth. The point with protective equipment isn’t that it prevents every single injury, it’s that it reduces the amount of damage or the incidence of injury.
Teeth are complex little critters, with layers of strong outer enamel, softer dentin, and seriously ouchy pulp (where the blood and nerves live). What are the options for lost or damaged teeth? Depends on what exactly the injury is, and what your dental cosmetic goals are.
Chipped Teeth: This is the least horrible dental injury, and often the solution is to do absolutely nothing. There are three classes of dental fracture (which is the fancy name for a chipped tooth):
- Ellis Class I – The only thing damaged is the enamel. If you don’t care that you’re a little snaggly, you may choose to do nothing.
- Ellis Class II – The enamel and dentin are damaged, which exposes you to an increased likelihood of decay. It also hurts. You’ll be hot and cold sensitive, and generally miserable. The short-term solution is dental cement to cover the defect, then a cosmetic repair.
- Ellis Class III – This sucker goes right to the pulp. You’ll be hating life. Everything (including air) hurts. You’ll need dental cement to cover the defect, and you’re probably looking at a root canal.
Avulsed Teeth: An avulsed tooth is one that’s been knocked out whole. Incredibly enough, avulsed teeth can often be put back in place. The tooth can be stored in milk, saline, or the patient’s mouth until they can get to a hospital (where hopefully there’s a dentist on staff) and have it stuck back in the socket. A dental splint (essentially temporary braces) is applied to hold the tooth in place, and with any luck it settles back in and does just fine. Obviously not every tooth survives this sort of thing, and the longer the tooth is out the less likely it is to be reimplantable. Take-home lesson: Next time you do something stupid and knock a tooth out, put it in your mouth and get your sober pal to take you to the ER. Pro tip: DO NOT swallow the tooth on the way there. A trip through the GI tract won’t help the odds of the tooth going back in the socket.
Tooth Luxation: Teeth get knocked loose fairly frequently. A tooth that’s barely moving generally doesn’t need any treatment outside of a soft diet and some ibuprofen. A tooth that’s partially out of the socket or on a crazy angle can sometimes be put back into place and splinted, much like an avulsion. A badly impacted tooth (meaning it’s been shoved down into the socket) often comes with a broken socket, and with an interruption to the tooth’s blood supply. While those teeth can sometimes be repositioned and splinted, they’re likely to need a root canal, and the splint will stay on for one or two months.
Teeth that are just flat gone: Sometimes you don’t have time to get your teeth pushed back into their sockets. Maybe two months of temporary dental splinting wasn’t convenient for your job. Maybe you swallowed the tooth that got knocked out. Maybe it was just easier to pull the broken-off root and worry about the gaping holes later. While a gaping maw isn’t a big deal during a game, it’s nice to have a full set of teeth for the purposes of eating and speaking. There’s a few options for filling the gaps, but they’re neither cheap nor easy.
- Implant: Implants are titanium screws that are drilled into the jaw, and later fitted with a fake tooth. Titanium has the advantage of being good at osseointegration, meaning bone will integrate with the metal. The implant is usually given some time to integrate with the bone before the tooth is fitted – as much as six months – but research has started to suggest that immediate installation of a new tooth may in fact be feasible. Not only can implants hold single teeth, they can serve as anchors for larger prosthetics, meaning that someone missing several teeth in a row may have an implant on either side of the gap that supports a bridge. The problem with implants is that they really need gentle handling during the integration period, because any movement is going to spell disaster. Having delicate teeth that can’t tolerate any movement isn’t the most convenient situation mid-NHL season.
- Bridge (aka partial): A bridge is a dental prosthetic that’s anchored to surrounding teeth (or implants) instead of into the jaw itself. Some clever technician makes a replica of your missing tooth, and it’s mounted to a framework that’s cemented to the remaining teeth on either side of your gap. Bridges, of course, are breakable (much like teeth), and may not be feasible if you’re expecting to get hit in the face on any sort of a regular basis.
- Removable bridge: This is the way a lot of hockey players choose to replace their missing teeth. They can wear the teeth when they’re off the ice, then take them out when they play to keep from reliving the original injury in a spectacularly expensive way every time a puck hits them in the mouth.
Do-it-yourself dentistry: In 2010 Washington’s Eric Belanger took an (accidental) stick in the face courtesy of Montreal’s Marc-Andre Bergeron during game 5 of their playoff series. Belanger ended up losing a total of nine teeth, one of which he pulled out himself while on the bench. He had some work done by Washington’s team dentist during the game – namely stitches to repair his lip, and a preliminary root canal. YES. A root canal during a hockey game. He came back to finish the game, which Washington lost. Happily we’re all winners because from that incident we gained this horrific video of Belanger pulling his own tooth. Enjoy.