Guidelines for the Fabrication, Use and

Maintenance of Sports Mouthguards

Fifth Edition 2022

Guidelines for the fabrication, use and maintenance of sports mouthguard

Acknowledgments

Principal Editors
Dr Brett Dorney
Professor Martin Tyas AM

Substantial assistance in the preparation and development of earlier editions of these Guidelines was provided by:
Dr Brian Bishop
Mr John Kenyon-Smith
Associate Professor Paul McCrory
Dr Helen Cornwell

The Australian Dental Association wishes to express its gratitude for their efforts in the publication of these Guidelines.
Published by the Australian Dental Association PO Box 520, St Leonards, NSW 1590, Australia
© Australian Dental Association 2022
All rights are reserved. No part of this work may be reproduced or copied in any form or by any means, electronic or
mechanical, including photocopying, without the written permission of the publisher.
ISBN: 978-0-646-90228-9

Page 2 | Fabrication, Use and Maintenance of Sports Mouthguards

Contents

Foreword 4
Introduction 5
Types of mouthguards 6
Wearing of mouthguards 6
Benefits of mouthguards 7
General design principles 7
General principles for materials 8
Integrity of materials 8
Advice on use and maintenance 8
Appendix A 9
References 12

Fabrication, Use and Maintenance of Sports Mouthguards | Page 3

Foreword

The purpose of a sports mouthguard is to reduce the

stresses and absorb the energy generated by impact to the
teeth in order to prevent or minimise consequent injury to
the teeth and associated structures while participating in
sporting activities. Although most mouthguards are made
for sporting activities, they are also useful in other situations,
e.g., for people with epilepsy who may fall or fit and damage
their teeth; or during intubation for a general anaesthetic.
Attempts to develop a standard for sports mouthguards
have been unsuccessful due to a number of factors. Principal
among these is that sports mouthguards are custom-
made devices, i.e., are made for individual wearers, and
consequently the finished product is subject to inherent
variations in the fabrication process. In addition, the
characteristics required of the raw materials to prevent injury
are not well documented.
Therefore, these Guidelines have been developed as
an alternative to a standard, and represent a consensus
on state-of-the-art procedures for sports mouthguard
fabrication, use and maintenance.

Page 4 | Fabrication, Use and Maintenance of Sports Mouthguards

Introduction

Several recent systematic reviews1, 2 have looked at the One study provided evidence to suggest a protective effect
clinical efficacy of mouthguards in the prevention of sporting of mouthguard use on concussion severity as measured by
injuries. The search strategies revealed over 2,250 citations time loss from unrestricted participation, however it did not
for mouthguards and head injury. Comparison of published measure individual mouthguard exposure and therefore
studies is difficult given the variability in research designs, could not provide a measure of relative risk.11
selection bias, definition of injury, mouthguard types, Three cohort studies12-14 found no significant difference
measurements used to assess mouthguard exposure and between concussion rates, and one additional study
injury, risk compensation and the variety of sports assessed examined concussion rates between football players wearing
which have differing head injury risk. custom-made versus non-custom mouthguards and thus did
not examine risk differences between users and non-users.15
Biomechanical studies have suggested a protective role of
mouthguard use in reducing sporting impact-related forces Only one randomised controlled trial (RCT) has been
to the head.3, 4 Two papers have been universally cited in the conducted in this area, which assessed head and orofacial
concussion prevention literature to support mouthguard use injury rates in Australian Rules football using two study arms
as an effective means of preventing concussion, however (custom laminated mouthguard versus usual mouthguard
both of these papers are methodologically limited.3, 5 behaviours).16 The authors stated that the study was
Hickey et al.3 revealed a reduction in the amplitude of bone underpowered to determine injury risk for orofacial injury
deformation and intracranial pressure by approximately 50 and there was no report of concussion rates for each study
per cent with the use of a mouthguard, whereas Takeda et arm. Thus, the true association between mouthguard use
al.4 showed that mouthguard use significantly decreased and concussion risk could not be ascertained. At the same
the distortion of the mandibular bone and the acceleration time, there is evidence to support the use of mouthguards
of the head compared with no mouthguard use. Stenger for orofacial and dental injury protection.17 Such findings
et al.6 also recommended mouthguards based on their justify the use of mouthguards and facial protection in
anecdotal experience of mouthguard use in US collegiate collision sports as a means to reduce injuries, but at this
football. While biologically plausible, particularly with regard time cannot be advocated specifically for concussion risk
to orofacial injury, detailed concussive impact biomechanical reduction.
studies show that mandibular impact accounts for a small
Future studies must not only be methodologically rigorous
percentage of all concussive injuries and this may be why
and statistically powered but must address the different
few prospective studies demonstrate a role for mouthguards
types of mouthguard on the market and their relative
in prevention of brain injury.7
efficacy in reducing or preventing injury.18, 19
However, recent laboratory research8 showed that
This document provides guidance on the fabrication of
mouthguards can reduce distortion to the mandible and the
sports mouthguards and includes information to be given
acceleration of the head from the same blow, and therefore
to users of mouthguards on their use and maintenance.
may have the potential to prevent mandibular bone fractures
Appendix A gives guidance on the methods of fabrication
and concussion. The proven benefit of a mouthguard is
of custom-made maxillary mouthguards and bimaxillary
the dissipation of the forces delivered to the maxilla, skull
mouthguards
and temporomandibular joint complex when the mandible
receives a blow.9 There is also stabilisation of the skull
through increased neck muscle activity by clenching on the
mouthguard, as well as a benefit from the altered position of
the condyle in the fossa.10
Numerous studies on mouthguard efficacy include cross-
sectional surveys, case reports, case series and retrospective
studies, and these have shown conflicting results. There
were five prospective cohort studies that assessed the
relation between mouthguard use and concussion rates.

Fabrication, Use and Maintenance of Sports Mouthguards | Page 5

Types of mouthguards Wearing of mouthguards

A mouthguard is a protective device worn in the upper jaw Custom-made mouthguards (formed on a cast of the
and sometimes the lower jaw, to reduce injuries to the teeth, wearer’s jaws) are the most acceptable. Mouth-formed and
jaws and associated soft tissues. Types include: stock mouthguards have disadvantages with respect to
possible lack of retention, single-tooth contact, inadequate
Custom-made mouthguard thickness, lack of retention and often rapid material
Custom-made mouthguards are formed on a cast of the deterioration with a consequent risk of injury. Critical for
upper jaw, sometimes in conjunction with a cast of the injury prevention, the mouthguard should have an ideal
lower jaw, to obtain even occlusal contact and are produced thickness after fabrication of 3 mm, and provide an occlusal
using appropriate materials. surface balanced to the mandibular teeth.

Bimaxillary mouthguards Provision of professionally fitted, custom-made mouthguards

for people involved in contact sports, and recognition of the
Worn on the upper and lower jaws with a passage for ‘injury-prone dentition’ are important in injury prevention.
breathing in the anterior, this type of mouthguard could be
considered for players in boxing, martial arts and contact Consideration should be given to wearing mouthguards in
sports who desire a different type of protection. They require all sporting activities (including training) in which there is
a period of adaptation in order to be tolerated. risk of trauma to the teeth and associated structures. Such
activities include stick and ball sports, all football codes,
Laminated mouthguard contact martial arts and where close physical contact could
These offer flexibility in design and construction. Ethyl reasonably be expected, e.g., water polo, basketball
vinyl acetate (EVA) blanks of different Shore hardness and and netball.
thicknesses can be laminated together to provide increased At what age should mouthguard wear commence?
protection.
Dental injuries are relatively common in children and their
Mouth-formed mouthguard effects can be catastrophic to the developing dentition.
Also known as a ‘boil and bite’ mouthguard, this type is Good habits for use of protective equipment are maximised
purchased ‘over-the-counter’ from outlets such as sports by their early introduction. Wearing custom-made
shops. It is softened in hot water and then formed in the mouthguards should commence as soon as children start
mouth by finger, tongue and biting pressure. participating in organised contact sport.

Such mouthguards fit poorly, are difficult to wear, thin The mouthguard can be constructed of two layers of EVA,
out dramatically, provide poor protection, are difficult pressure laminated together; the base layer 3 mm thick, and
to adapt to the mouth’s anatomy, may be dislodged the outer layer 2 mm thick. Custom-made professionally
during use with a consequential risk of airway fitted mouthguards should be considered as a part of
obstruction20 and are therefore not recommended. children’s sporting team uniform.

Mouth-formed “shell-liner” guards, which have a rigid Patients undergoing orthodontic treatment should be
outer layer and a soft thermoplastic inner layer, are also provided with custom-made mouthguards.
not recommended as the hard outer layer may amplify
impact force and cause injury. 20 Biocompatibility
Stock mouthguard Mouthguard material should not constitute a biological or
toxicological hazard with respect to infection or irritation
Another “off-the-shelf” variety, these mouthguards consist
of normal oral mucosa, and should not contain elements or
of a curved trough of plastics or rubber and are worn
components toxic to oral tissues.
without modification or adaptation. Such mouthguards fit
poorly, are difficult to wear, provide poor protection,
may be dislodged during use with a consequential risk NOTE: Further guidance may be found in ISO 7405,
of airway obstruction20 and are not recommended. Dentistry—Preclinical evaluation of biocompatibility of
medical devices used in dentistry—Test methods for dental
materials and ISO 10993-1, Biological evaluation of medical
devices, Part 1: Evaluation and testing.

Page 6 | Fabrication, Use and Maintenance of Sports Mouthguards

Benefits of mouthguards General design principles

The benefits of wearing a sports mouthguard include The general design principles for sports mouthguards are:
reducing: • For sports where high occlusal loads are to be expected,
• the risk of injury to the maxillary and mandibular the mouthguard should enclose the maxillary teeth,
anterior teeth. preferably to the distal surface of the second molar.
• damage to the posterior teeth of either jaw following For these design requirements a mandibular model will
a traumatic closure of the mandible. be necessary to obtain an even occlusal contact.
• intraoral and perioral lacerations. • For standard club sports, enclosing the maxillary teeth to
• tongue damage at impact. the distal surface of the first molar is usually sufficient.

• fracture of the body of the mandible and the • In the mixed dentition, the mouthguard should extend
mandibular condyles. to the distal surface of the maxillary first molar.

• damage to the temporomandibular joint. • The approximate material thickness should be 2-3 mm on
the labial aspect, 3 mm on the occlusal aspect and 2 mm
on the palatal aspect.
• The labial flange should extend to within 2 mm of the
vestibular reflection.
• The palatal flange should extend about 10 mm above
the gingival margin.
• The edge of the labial flange should be rounded in
cross-section.
• The edge of the palatal flange should be tapered in
cross-section.
• On closing the mouth, there should be even contact
between the mouthguard’s occlusal surface and the
lower teeth.
• For laminated mouthguards, improved impact force
dispersion occurs when an airspace is created over the
anterior teeth.8
• Mouthguards should not be designed and constructed
with hard inserts sandwiched between laminations. 22
• Mouthguards should be thoroughly inspected prior
to being issued to ensure adequate thickness, resilience
and minimum pressure on the soft tissues.

Fabrication, Use and Maintenance of Sports Mouthguards | Page 7

General principles Advice on use and
for materials maintainance
The general principles for mouthguard materials are: Patients fitted with sports mouthguards should be advised
on the use and maintenance of their appliance. This advice
• Easy to manipulate.
should include:
• Resistant to damage from heat
• Wear only a professionally fitted, custom-made
• Sufficient elastic modulus to reduce stress beneath mouthguard with an even occlusal contact.
material at point of impact.
• Wear your mouthguard at training, practice and during
• Sufficient rigidity to distribute forces over a large the game.
area of the dentition.
• Rinse your mouthguard before and after use.
• Sufficient toughness to resist cutting by biting.
• Wash your mouthguard only with soap and in cold
• Resistant to fracture under sudden impact. or lukewarm water.
• Resistant to water absorption in order to prevent • Clean the inner surface after wearing with a soft
tainting by mouth fluids. toothbrush.
• Able to withstand normal cleaning compounds. • Do not let others use your mouthguard; it is
custom-made and so can only be used by you.
• Resistant to low pH.
• Store your mouthguard in a clean, rigid and ventilated
• Tasteless and odourless.
plastic container.
• Keep your mouthguard away from sunlight and heat.

Integrity of materials • Examine your mouthguard regularly for signs of

deterioration, and replace if it is split or if the resilience,
fit or bite have changed.
Currently, the required mechanical properties of
mouthguards are not well defined. The following • Have your mouthguard checked for signs of wear,
deterioration or reduction in fit as part of your routine
properties21 are recommended:
dental review, or at least annually, by your dental
• Hardness, Shore ‘A’ at 37 °C practitioner.
» liner 40 to 60
• Contact your dental practitioner if your mouthguard
» shell 55 to 85
becomes loose, too tight or causes you any discomfort.
» mouthguard specific EVA blanks, 80-95
• Do not expose your mouthguard to petroleum and
• Water absorption at 37 °C: < 0.5% w/w
petroleum products, cleaning agents, paints, adhesives
• Impact test at room temperature: ≥ 70% and similar chemicals. It may be damaged and rendered
of impact absorbed ineffective, without the damage being visible to you.
• Tear strength at 37 °C: ≥ 200 N/cm. • Consider regular replacement of mouthguards in children
whose mouths are growing, and deciduous teeth are
being lost and replaced by permanent teeth.

Page 8 | Fabrication, Use and Maintenance of Sports Mouthguards

Appendix A - Fabrication of custom-made mouthguards

Examination and impressions 5. Allow the model and thermoformed EVA blank to cool
for mouthguards thoroughly (normally 15 minutes), trim the periphery
to the outline with an electric knife or hot scalpel. (A
Mouthguards should be constructed following a number 11 scalpel in a metal handle produces the best
thorough clinical examination, including radiographs and cleanest outline). Only extend the mouthguard to the
where appropriate. Mouthguard design should take into distal surface of the upper first molars, unless upper and
lower models are needed for even occlusal contact.
consideration previously traumatised teeth and areas where
tooth eruption is expected. 0. Shape and smooth the periphery using abrasive wheels.
1. Finish with a soft polishing disk or mounted silicone
The occlusal pattern, soft and hard tissue pathology and the point.
temporomandibular joint should also be assessed.
2. Adjust the mouthguard to provide even contact between
its occlusal surface and the lower teeth on closure of
Impressions should be taken by a suitably trained dental the mandible.
professional and where necessary a registration of the
occlusion should be made. For orthodontic patients, wax can NOTE: TThis adjustment can be made in the mouth after
be used to block out orthodontic brackets, bands and wires first softening the occlusal surface preferably with a hot
during impression taking, and plaster or light-curing resin air pen or a small flame; or using articulated casts in the
can be used on the cast to block out brackets, bands and laboratory or at the chairside. The laboratory method allows
wires still visible after the initial impressions. It is unlikely that better control of the final thickness of the mouthguard and
a custom-made mouthguard will interfere with orthodontic there is no risk of burning the patient. Only very experienced
tooth movement, however regular review of the mouthguard operators should use the direct heat technique.
fit should be undertaken during the treatment period.
Laminated Mouthguard

A.1. Maxillary mouthguards The following procedure is a recommended method for the
fabrication of a laminated custom-made mouthguard:
Custom-made mouthguards may be fabricated using either 1. Prepare a gypsum cast of the wearer’s upper jaw to the
pressure-forming or vacuum-forming machines. Each type full depth of the sulcus and the hard tissue landmarks of
of machine has advantages and disadvantages. Particular the lower jaw.
features which are important are infra-red heating of the
2. Outline the periphery of the mouthguard on the upper
blank and full forming power (pressure or vacuum) should
cast with a marking pencil. (This outline is only useful
be achieved at the end of the heating cycle. when using either clear or semi-clear EVA mouthguard
blanks. Opaque colours such as black and white
Single-Layer Mouthguards completely mask the pencilled outline). (Additional steps
are required to add an airspace over the labial surface of
The following procedure is a recommended method for the the anterior teeth: soak the gypsum cast in water for 5
fabrication of a single-layer custom-made mouthguard: minutes; dry; add a 1 – 2 mm thick layer of plaster over
1. 
Prepare a gypsum cast of the wearer’s upper jaw and the anterior teeth [canine to canine]; allow to set).
preferably also the lower jaw. 3. Cover the model with a water-based separator or a
2. 
Outline the periphery of the mouthguard on the upper polyethylene high-shine foil.
cast with a marking pencil. (This outline is only useful 4. Heat a 3 mm EVA mouthguard blank by following the
when using clear or semi-clear EVA blanks. Opaque manufacturer’s instructions.
colours such as black and white will completely mask
the pencilled outline). 5. Thermoform and allow to cool (normally 15 minutes).
3. 
Coat the model with a water-based separator or a 6. Trim the periphery to the outline with an electric knife
polyethylene high-shine foil. or a hot scalpel. (A number 11 scalpel in a metal handle
produces a cleaner more anatomical outline).
4. Form the mouthguard from either a 3 or 4 mm thick EVA
mouthguard blank, using a vacuum or pressure machine. 7. Degrease the first layer and the bonding surface of
the second mouthguard foil with an isopropyl alcohol
solution or roughen the bonding surface of the first EVA
blank with trimming wheels. Note that this step is critical
if using a coloured EVA blank as the second layer.

Fabrication, Use and Maintenance of Sports Mouthguards | Page 9

8. H
 eat the blank using a machine with infra-red heating A.2. Bimaxillary mouthguards
that develops full forming power before the end of the
heating cycle, follow the manufacturer’s instructions for The following procedure is a recommended method for the
thermoforming the second 3 mm EVA blank. fabrication of bimaxillary mouthguards:
9. O
 nce the thermoformed EVA blank and model have 1. 
Take alginate impressions of both arches.
completely cooled, cut out the second layer following
the mouthguard design of the first blank. 2. Make up a pair of four stacked tongue blades and secure
each pair with a piece of sticky tape at both ends.
10. Shape and trim the periphery with abrasive wheels in
a straight handpiece. 3. Check the vertical incisal opening by placing each stack
11. Finish with a soft polishing disk, mounted silicone point, along the line of the lower posterior teeth on each side,
a hot air pen or commercial polishing solvents designed up to and including the second molars, and ask the
for this purpose. patient to close the mouth. This should provide an incisal
opening of 10-11 mm. If the opening is more than 12
12. Adjust the mouthguard either on an articulator or in mm, remove a blade from each stack.
the mouth to provide even contact between its occlusal
surface and the lower teeth on closure of the mandible. 4. Mix up a golf ball sized amount of putty-type silicone
13. The standard custom built pressure thermoformed impression material, divide into two equal parts and roll
mouthguard is constructed from two layers of clear each into a finger-like shape. Adapt each piece around
3 mm thick ethyl vinyl acetate mouthguard blanks. one end of each stack, extending about one-third of the
length of the top and bottom blades, and flatten out so
NOTE: This adjustment can be made in the mouth after first that the material is not too bulky to fit into the mouth.
softening the occlusal surface preferably with a hot air pen
5. F rom closed centric, ask the patient to open wide and
or a small flame. The laboratory method using articulated
curl the tongue backwards. Insert the stacks between
maxillary and mandibular models allows better control of
the posterior teeth and tell the patient to close into the
the final thickness of the mouthguard and there is no risk of
material until the teeth contact the stacks. Maintain
burning the patient. Only very experienced operators should
this position until the material hardens. Do not ask the
use the direct heat technique.
patient to curl the tongue back as far as possible, as this
could put the mandible into a retruded position. This
Coloured pressure-laminated mouthguard step should be practised a few times before mixing the
Follow steps 1 to 3 for laminated mouthguards. material to ensure that there is no protrusion or lateral
deviation when the bite is being taken. To help patients
1. Heat a clear 2 mm thick EVA mouthguard blank relax and thus avoid an incorrect record, also ask them
following manufacturer’s instructions.
do this step with their eyes closed.
2. Allow to cool; cut back following the mouthguard
periphery design. 6. Mark each stack left or right.

3. Thermoform a coloured 3 mm EVA blank as the 7. Pour up the alginate impressions in high-strength
second layer. gypsum.

4. Allow to cool; cut back following the initial outline 8. Form upper and lower mouthguards, extending each
established by the initial 2 mm clear blank. (This outline to include the second molars in each quadrant.
is visible even if the second layer is an opaque colour).
9. Smooth and trim both mouthguards.
Using fine abrasive polishers to remove the polished
surface of the coloured second layer blank. (A clear 10. Build up the occlusal surfaces of the lower first molars
second layer EVA blank does not require this step). with plaster to cusp height to resemble a small dome.
5. Thermoform using manufacturer’s instructions the third (This is to enhance retention of the lower mouthguard
layer using either a 2 or 3 mm thick EVA blank. by a suction cup effect). Do not extend the plaster onto
other surfaces.
6. Allow to cool, cut back the third layer to the already
established outline and articulate maxillary and
mandibular models to balance the occlusion, as
described in point 12 for laminated mouthguards.

Page 10 | Fabrication, Use and Maintenance of Sports Mouthguards

Method for joining using a standard flask Method for joining without a flask
The following procedure is a recommended method for The following procedure is a recommended method for
joining using a standard flask: joining without using a flask:
1. Trim the lower mouthguard to expose one-third of the 1. T rim the lower mouthguard to expose one-third of the
crown of the six lower anterior teeth on both the labial crown of the six lower anterior teeth on both the labial
and lingual aspects. and lingual aspects.
2. Relieve the silicone on the tongue-blade stack bite record 2. Using the bite record, set up the models on an
in the region of the lower first molars. articulator.
3. Place upper and lower casts into the occlusal silicone 3. Degrease the surfaces to be bonded with an isopropyl
impression on the stack, and mount the casts on a alcohol solution.
plasterless articulator.
4. Build up blocks of mouthguard material that extend
4. Paint the inside surface of each mouthguard and both distally from the distal of the canine teeth on the lower
dental arches with separating medium. mouthguard. (Use either excess mouthguard material
that has been formed into a roll and apply heat from a
5. Place the mouthguards on the casts and wax-up the join
hot air pen, or apply mouthguard material through a
on each side with casting wax. (The joins should extend
glue gun).
distally from the distal of the canine teeth and should be
slightly concave on both inner and outer surfaces). 5. Trim the added material.
6. Remove the casts and the waxed-up unit from the 6. Degrease the surfaces to be bonded with an isopropyl
articulator and invest in an extra-large flask. alcohol solution.
7. When the plaster has set, open the flask and lift out the 7. Heat the surfaces to be bonded of both mouthguards
wax joins with a small wax spatula. (Do not immerse the with a hot air pen.
flask in hot water to soften the wax before opening the
8. Press both heated mouthguards together.
flask, and do not use hot water to remove wax remnants
from the casts). 9. T rim the added material and chamfer and trim the
peripheries with a fine cross-cut tungsten carbide bur.
8. Remove any remaining wax film by wiping the surfaces of
the moulds with a proprietary wax solvent. 10. Finish with a soft polishing disk or mounted
silicone point.
9. Heat half a mouthguard blank to a soft, pliable
consistency either over a flame, or in a microwave oven 11. Scrub the models with water to remove any residual
at a low power for approximately 4 minutes. separator; replace the mouthguard on the models
and create a high shine with a hot air pen.
10. Pack the material into the moulds, shut the flask and
tighten in a clamp until the flask is approximately 2 mm Method using mould injection
open. Excess material will be extruded as the clamp
Mould injection involves a technique using elastomeric
is tightened.
acrylic resin and an injection flask.† The mouthguard is totally
11. Immerse the flask in water at 80-85 °C for 15 minutes, waxed-up for this method and there is minimal final cleaning
then tighten the clamp further. If the flask closes fully, and polishing required, compared to the methods of joining
set it aside for cooling. if not, re-immerse the flask in the using a standard flask.
water for 5 minutes and tighten the clamp again. If the
flask now closes fully, set it aside for cooling; if not,
re-immerse for another 5 minutes and retighten.
12. Bench-cool the flask for approximately 4 hours before
deflasking. (Attempts to accelerate cooling may affect
the material).
* Examples include ‘Zoff’ and ‘Remove’ (Smith & Nephew Pty, North
13. Clean the mouthguard and give a final polish using Ryde, NSW www.smith-nephew.com/australia), are available from
eucalyptus oil or dipropylene glycol.* pharmacies. † Available from Ivoclar Vivadent, Noble Park, Victoria
www.ivoclarvivadent.com.au

Fabrication, Use and Maintenance of Sports Mouthguards | Page 11

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