Disclaimer: This article is intended solely for informational and educational purposes only. It does not constitute medical advice.
Dental injuries are a recognized complication of airway manipulation and instrumentation during general anesthesia and remain a significant source of patient morbidity and medicolegal claims. Reported incidence varies substantially because of differences in study design, injury definitions, and methods of postoperative examination. In a large retrospective series of 161,687 anesthetics, Newland et al. reported one dental injury per 2,073 anesthetics, whereas a prospective study involving systematic postoperative dental examination identified damage in 25% of 536 patients undergoing conventional direct laryngoscopy (Newland et al., 2007; Mourão et al., 2013). This discrepancy suggests that minor injuries, particularly enamel damage, may be under-recognized when detection depends on spontaneous reporting.
Direct laryngoscopy is a potential contributor to dental injuries, as contact between the rigid laryngoscope blade and the dentition can transmit considerable force to the anterior teeth, particularly when the maxillary incisors are inadvertently used as a fulcrum to improve the view of the airway. Difficult intubation, restricted mouth opening, limited cervical movement and prominent upper incisors may increase the force required during laryngoscopy. Repeated attempts further increase exposure to mechanical trauma (Gaudio et al., 2010). Nevertheless, injury is not confined to direct laryngoscopy. Christensen et al. identified dental injuries following management with supraglottic airway devices as well as Macintosh and video laryngoscopes, emphasizing that airway manipulation more broadly can place vulnerable teeth at risk (Christensen et al., 2019).
The maxillary incisors are consistently the most frequently affected teeth because of their anatomical position within the path of laryngoscope insertion. Injury patterns include enamel fractures, crown or root fractures, subluxation, luxation, and complete avulsion. Damage may also involve crowns, bridges, veneers, and other restorative work. In Newland et al.’s series, enamel fracture accounted for 32.1% of injuries and subluxation for 23.1%, while central maxillary incisors were injured most frequently. Christensen et al. similarly found fractures and subluxations to be the predominant injury types and demonstrated a marked concentration of injuries in the central maxillary incisors (Christensen et al., 2019).
Pre-existing dental disease is a major clinical consideration. Periodontal disease, mobile teeth, caries, previous restorative work and prostheses reduce the capacity of teeth to tolerate mechanical forces. Newland et al. found that patients with poor dentition or reconstructive work who also experienced moderately difficult or difficult intubation had approximately a 20-fold higher risk of dental injury than patients with good dentition and easy intubation (Newland et al., 2007). However, prospective data from Mourão et al. found that the number of intubation attempts and a reduced inter-incisor gap were associated with injury to specific anterior teeth, while several other proposed risk factors were not consistently significant (Mourão et al., 2013).
Prevention of dental injuries as a result of airway manipulation begins with careful preoperative assessment of both the airway and dentition. Clinicians should identify mobile or damaged teeth, periodontal disease, restorations and prosthetic work, document abnormalities clearly, and inform patients when substantial vulnerability is present. Airway technique should minimize dental contact and excessive levering, particularly during difficult or repeated laryngoscopy. Selected high-risk patients may benefit from dental protection, although such devices do not eliminate injury and can themselves present practical limitations. Accurate postoperative examination and prompt recognition are equally important, particularly when avulsion or fragmentation creates a potential aspiration risk. Detailed perioperative documentation serves not only clinical management but also communication and medicolegal review (Gaudio et al., 2011).
References
Christensen RE, Baekgaard JS, Rasmussen LS. Dental injuries in relation to general anaesthesia—A retrospective study. Acta Anaesthesiologica Scandinavica. 2019. https://doi.org/10.1111/aas.13378
Gaudio RM, Feltracco P, Barbieri S, et al. Traumatic dental injuries during anaesthesia: Part I: Clinical evaluation. Dental Traumatology. 2010;26:459–465. https://doi.org/10.1111/j.1600-9657.2010.00935.x
Gaudio RM, Barbieri S, Feltracco P, et al. Traumatic dental injuries during anaesthesia. Part II: Medico-legal evaluation and liability. Dental Traumatology. 2011;27:40–45. https://doi.org/10.1111/j.1600-9657.2010.00956.x
Mourão J, Neto J, Luís C, et al. Dental injury after conventional direct laryngoscopy: a prospective observational study. Anaesthesia. 2013;68:1059–1065. https://doi.org/10.1111/anae.12342
Newland MC, Ellis SJ, Peters KR, et al. Dental injury associated with anesthesia: a report of 161,687 anesthetics given over 14 years. Journal of Clinical Anesthesia. 2007;19:339–345. https://doi.org/10.1016/j.jclinane.2007.02.007