CLINICAL SCIENCES: Clinical Investigations
Ice hockey is one of the most popular sports in Finland. There are almost 60,000 licensed players (1) in the Finnish Ice Hockey Association and over 3 million spectators follow the games annually (Finnish population about 5 million). Ice hockey as a sport is considered potentially dangerous, because the game involves hard contacts, collisions, and a fast-moving puck (11).
Of all ice-hockey–related injuries, 39.4% are head or face injuries. Upper and lower limbs are concerned in 17.6% and 31.6% of the injuries (12). The amount of dental injuries is 11.5% of all ice-hockey–related injuries. Hit by a stick is the most common reason for dental or facial injuries (10) and accounts for 54% of facial trauma. The players are more commonly injured during games than during practice (10). The mean age of injured players is 21.4 yr even though 70% of the players are younger than 18 yr old. In Finland, players younger than 18 yr of age are obliged to wear a full cage face mask, which has decreased the number of facial injuries significantly (10).
Dental injuries are permanent, and they often also cause complications later in life. The most common late complications are root resorption, periapical lesion, pulpal obliteration, and loss of vitality (3). These may also lead to loss of the injured tooth.
The purpose of this study was to determine the incidence, cause, and nature of maxillofacial and dental injuries in ice hockey games and in training and also to evaluate the use and the effect of dental or facial guards.
MATERIALS AND METHODS
The subjects included 479 male players injured during ice hockey game or training. The mean age of the players was 24.3 yr (SD ± 6.9) and the range from 11 to 53 yr. The material was gathered from the insurance company (Pohjola) that had all the ice hockey players’ licenses (MSP) during the years 1991 and 1992, excluding the licenses of The Finnish Ice Hockey League. The information used in this study is based 1) on the notification of accidents made by the injured player or his club and 2) on the insurance notification and the medical reports issued by doctors and dentists who treated the injured players. The material covers all ice-hockey–related dental and facial (nasal and malar fractures excluded) hard-tissue injuries in 1991 and 1992, excluding dental and facial injuries of players in the Finnish Hockey League. There are about 250 ice hockey players in the Finnish Hockey League.
The figures were analyzed by using standard statistical tests based on the assumption of normality. The representativeness and comprehensiveness of the figures are assured by the need for all players to have a license, which includes insurance against accidents during matches and training.
Incidence of dental and facial ice hockey injuries during games and training.
During the study’s 2 years, a total of 479 ice hockey players were injured. The number of separate dental injuries was 650. In these injuries, a total of 915 teeth were damaged. The most common trauma was diagnosed as a noncomplicated crown fracture that occurred in 283 injuries (of 43.5% dental or maxillofacial injuries); 189 (66.8%) occurred during games and 94 (33.2%) during training. In six players, the injury was diagnosed as a maxillofacial fracture, and all of these injuries occurred during games. Of all the 915 damaged teeth, 458 (50%) were upper central incisors. In 344 (37.8%) cases, the damaged teeth were other incisors (upper lateral incisors, lower central incisors and lower lateral incisors). The different diagnoses of dental and maxillofacial injuries are listed in Table 1.
Causes of dental and facial injuries.
The main cause of injury in games and training was a blow from the stick (48.9% of players). The stick caused 52.7% of game and 40.3% of training dental injuries. The ice hockey stick caused a total of 444 tooth injuries in 323 accidents of different diagnoses. Noncomplicated crown fracture was diagnosed due to the stick 138 times. Figure 1 shows the causes of injury in games and training sessions.
Wearing of guard and its influence on injuries.
Some kind of a dental or facial guard was worn only by 10% of the injured players. The guards were either mouth guards (7 players), chin guards (2 players), face masks (31 players), or visors (6 players). Of all injured players, 4.8% were younger than 18 yr of age, and 56.1% of them were reported to have worn a facial guard. In 1991 and 1992, the number of under-18-yr-old license holders was 62%. Of all injured ice hockey players, 40.9% belonged to the age group 18–24. In this age group, only 11.2% wore a facial guard. Figures 2 and 3 describe the use of guards during games and practice in relation to the age of the players.
The material used in this study may be considered comprehensive because in Finland all ice hockey players are obliged to have a license. One of the shortcomings is that the material does not contain players who have not been injured. Wearing of a guard by such players is not known. In addition, minor injuries such as microfractures of teeth are not always reported to the insurance company, even though these injuries may cause complications later.
There are only few detailed studies on dental injuries among ice hockey players. This study revealed that a noncomplicated crown fracture is by far the most common dental injury among ice hockey players. Even though a great number of dental injuries related to ice hockey are not serious, they are usually permanent and therefore may cause complications later in life. The result that almost 70% of players are injured during games and about 30% during training is in accordance with other studies (12,10,4).
One of the most important observations in this study was that the injuries caused by a blow from a stick were more than 3 times as frequent during games as during training. The result supports the idea that sticks are also used as weapons during ice hockey games.
The number of injured players that were reported to have worn facial guards when injured can be considered minor, as only 10% of all injured players used a facial guard. Several studies have shown that facial guards reduce the number of injuries (10,7,8,9). In Finland, all players younger than 18 are obliged to use a full cage face mask (2). The low number of young players wearing full cage face mask indicates that this rule is not always followed. The number of injuries increased after the age of 18. This is surprising because most of the players are younger than 18. This increase may partly be explained by the fact that players grow stronger and use rougher tactics as they become older. Mölsä et al. (6) observed that the number of injuries is still larger in the league and that the referees only give penalties in 9% of the instances of injury. In the Finnish Ice Hockey League, the players are not allowed to use full cage face masks, to keep up the image of the game and also to leave the responsibility for the injuries to the players. Murray and Livingston (5) in their review article claim that good guards even encourage the players to use rough tactics. However, leaving the responsibility to the players has not been very successful, at least according to the statistics on injuries.
The results of the present study emphasize the role of guards to prevent injuries. The most frequent injury, a noncomplicated crown fracture, could be easily prevented by the proper use of dental or facial guards. It is therefore concluded that if rough play is allowed in ice hockey games, then it is essential to develop better guards than before and the players need to be obliged to use them.
The authors thank Mika Hairo for his assistance in the data handling and Professor Seppo Sarna for his help in the statistical analysis.
Address for correspondence: Harri Lahti, Department of Oral and Maxillofacial Surgery, University of Helsinki, Mannerheimintie 172, P.O. Box 41, 00014 University of Helsinki, Finland; E-mail: Harri.A.Lahti@helsinki.fi.
1. Finnish Ice Hockey Association Register, 1998–1999.
2. Finnish Ice Hockey Association, Competition Rules.
3. Häyrinen-Immonen, R., J. Sane, K. Perkki, M. Malmström. A six-year follow-up study of sport related dental injuries in children and adolescents. Endodont. Dent. Traumatol. 6: 208–212, 1990.
4. Kujala, U., S. Taimela, I. Antti-Poika, S. Orava, R. Tuominen, and P. Myllynen. Acute injuries in soccer, ice hockey, volleyball, basketball, judo, and karate. Br. Med. J. 311: 1465–1468, 1995.
5. Murray, T. M., and L. A. Livingston. Hockey helmets, face masks, and injurious behavior: a review. Pediatrics 95: 419–421, 1995.
6. Mölsä, J., O. Airaksinen, O. Näsman, and I. Torstila. Ice hockey injuries in Finland. Am. J. Sports Med. 25: 495–499, 1997.
7. Pashby, T. J. Eye injuries in Canadian hockey: phase II. Can. Med. Assoc. J. 117: 670–678, 1977.
8. Pashby, T. J. Eye injuries in Canadian hockey: phase III. Older players now at most risk. Can. Med. Assoc. J. 121: 643–644, 1979.
9. Rontal, E., M. Rontal, K. Wilson, and B. Cram. Facial injuries in hockey players. Laryngoscope 87: 884–894, 1977.
10. Sane, J., P. Ylipaavalniemi, and H. Leppänen. Maxillofacial and dental ice hockey injuries. Med. Sci. Sports Exerc. 20: 202–207, 1988.
11. Sim, F. H., W. T. Simonet, L. J. Melton, and T. A. Lehn. Ice hockey injuries. Am. J. Sports Med. 15: 30–40, 1987.
12. Tegner, Y., and R. Lorenzon. Ice hockey injuries. Br. J. Sport Med. 25: 87–89, 1991.
Keywords:©2002The American College of Sports Medicine
MAXILLOFACIAL INJURY; FACE TRAUMA; MOUTH GUARD; INJURY PREVENTION