Anesthesia & Analgesia:
Technology, Computing, and Simulation: General Articles: Case Report
Quinn, Janet B. PhD; Schultheis, Lex W. MD, PhD; Schumacher, Gary E. DDS
ADAF Paffenbarger Research Center, Gaithersburg, Maryland, and Washington Hospital Center, Washington, D.C.
Supported, in part, by National Institutes of Health Grant DE14534, and the American Dental Association Foundation.
This work is an official contribution of the National Institute of Standards and Technology; not subject to copyright in the United States. Commercial products are identified to specify the experimental procedure, and does not imply endorsement by the authors or institutions supporting this work.
Accepted for publication September 3, 2004.
Address correspondence and reprint requests to Janet B. Quinn, ADAF Paffenbarger Research Center, Mailstop 8546, National Institute of Standards and Technology, Gaithersburg, MD 20899. Address e-mail to email@example.com.
Dental injuries are among the most numerous claims against anesthesia providers (1, 2); however, only 20% of such cases are described as “difficult intubations” (3). This questions the assumption that the application of large forces with the laryngoscope is the usual cause of injury. In this case report, a fractographic analysis of a retrieved tooth implicated postoperative chewing on an endotracheal tube as the probable cause of failure. To prevent this kind of dental trauma, protective tooth guards may be more effective if they are used postoperatively rather than only during the intubation procedure itself (4).
Several days after an atraumatic laryngoscopy, a 65-yr-old male (ASA physical status IV) discovered that his maxillary right canine tooth (#6) was broken in the root, just below the gingival margin. At the time of surgery, the patient’s oral condition was generally good, with some partially edentulous areas and serviceable restorations. Although many tooth fractures are assumed to initiate during intubation procedures (5,6), confirmatory analyses are rarely, if ever, done. The patient in this case, however, saved the broken tooth fragment, enabling a fractographic failure analysis.
Fractography is broadly defined as “means and methods for characterizing a fractured specimen or component” (7). This often involves examination of fracture surfaces to identify relevant features, such as fracture plane angles, which can determine the directions of the break forces. Fractography has been used for design and failure analyses in the aircraft (8–10) and automotive (11,12) industries, and more recently in biomedical applications (12–15). Fractographic analyses are generally most informative when applied to brittle fracture surfaces, where there is little or no deformation to obscure the original paths of the growing cracks. Teeth and some bone meet this criterion.
Figure 1a shows a view of the fracture surface of the broken canine tooth from the front, or labial direction. In Fig. 1b, the tooth fragment is rotated and angled to show the flattened incisal edge. Viewer orientation may be aided by noting that the discolored region on the right side of Fig. 1a is visible near the center of Fig. 1b. Some of the discoloration in this tooth was the result of restorative work that was not expected to influence the fracture path or strength (15).
Fractographic analysis indicated that the tooth fracture initiated from a combination of large bending and shear stresses at the root surface. Bending stresses can arise from the configuration shown in Fig. 2, where a remote force is applied to the crown while the embedded root resists the force. The highest bending stresses are at the approximate location indicated as the fracture initiation site in Fig. 2. These stresses tend to pull the specimen apart in tensile mode fracture at the root surface. The other side of the root is in compression. Because the root is firmly embedded, there is a shear component as well. Shear stresses result from tangential or sliding forces. In this case, a force as indicated in Figure 2 would not only cause the specimen to bend, but would also tend to “shear off” the specimen near the gingival margin.
The curvature as the crack proceeded from the root on the lingual side toward the occlusal and then toward the labial surface is expected in this type of mixed mode fracture. There is a small, thin ridge where the fracture changed direction at the labial root surface just above the enamel crown junction. This ridge is referred to as “compression curl” in fractography and is characteristic of bending failures (16).
To confirm the fractographic analysis and determine an approximate break load, an intact tooth with a root of similar size and shape was embedded in a configuration to simulate the natural tooth environment. The specimen was then loaded in a commercial testing machine (Instron Model 5500R, Canton, MA) until failure at 480 N (106 lb) resulted in fracture surfaces matching the original tooth. The break load of 480 N is typical for natural canine teeth (15). A more detailed fractographic analysis and description of the subsequent testing procedure is described in an engineering journal (17).
The break force from the lingual direction could only be applied by the laryngoscope if it were being withdrawn or levered from directly behind the right canine tooth more to the side of the mouth than the center. The approximate force magnitude of 480 N is high, more than half the weight of a normal person. This combination of force and direction is unlikely during a routine intubation procedure.
Also noteworthy is that the tooth fracture began at the root, in a location protected by the surrounding alveolar process. Thus, contact forces could not have directly initiated the critical crack, which started a distance away from the location of direct force contact (Fig. 2). Padding or otherwise softening the point of force application would not have averted fracture in this case.
A more reasonable explanation for the tooth fracture that is consistent with the fractographic findings is involuntary biting (bruxism) on the endotracheal tube. The flattened occlusal surface of the canine tooth, seen in Fig. 1b, is characteristic of a history of bruxism, confirmed from the patient’s dental records. Anxiety, such as may be associated with surgery, has also been linked with bruxism (18). Involuntary tooth grinding in the presence of an oral tube can concentrate biting forces to only a few teeth. Nocturnal total bite forces exceeding 800 N have been measured for bruxers (19) and this is far above the tolerance limit for individual anterior teeth (20).
The use of mouthguards to avoid dental trauma associated with anesthesia has been reported to range from helpful (21) to totally ineffective (22). Because most such studies focus on dental protection only during the intubation procedure itself, a significant incidence of tooth fracture during the recovery period might explain the mixed results. Also, it should be mentioned that dental injuries from Guedel oral airways are a recognized problem (23) that have been attributed to the concentration of biting forces on a few front teeth (24).
In conclusion, this study suggests that some tooth fractures attributed to the intubation procedure might actually be the result of biting on the endotracheal tube during the recovery period. Because bruxers comprise an estimated population fraction of 4.4% (25) and some drugs list bruxism as a side effect (26), the use of prudent precautions such as postoperative mouthguards or shields may reduce the potential for bruxism-related dental injury.
1. Warner ME, Benenfield SM, Warner MA, et al.: Perianesthetic dental injuries: Frequency, outcomes, & risk factors. Anesthesiology 1999;90:1302–5.
2. Owen H, Wadell-Smith I: Dental trauma associated with anaesthesia. Anaesth Intensive Care 200;28:133–45.
3. Tolan TF, Westerfield S, Irvine D, Clark T. Dental injuries in anesthesia: Incidence and preventive strategies. ASA Meeting Abstracts 2000:A1133.
4. Tolan TF, Westerfield S. Dental injuries in anesthesia: frequency, causes, and preventive strategies. Presented at the ASA annual meeting, Las Vegas, NV, October 2004. ASA meeting Abstracts 2004:A1256.
5. Lockhart PB, Feldban EV, Gabel RA, et al. Dental complications during and after tracheal intubation. J Am Dent Assoc 1986;112:480–3.
6. Ho AMH, Hewitt G. Warning devices for prevention of dental injury during laryngoscopy: Preliminary report. J Clin Monitor Comp 2000;16:269–72.
7. ASTM C 1145–01. Standard terminology of advanced ceramics. West Conshohocken, PA: ASTM, vol. 15.01.
8. Whittaker AJ, Taylor R, Tawil H. Thermal transport properties of carbon-carbon fibre composites. II. Microstructural characterization. Proc R Soc London 1990;A430:167–97.
9. Fuller ER, Freiman SW Jr, Quinn JB, et al. Fracture mechanics approach to the design of glass aircraft windows: A case study. Window and Dome Technologies and Materials IV, SPIE 1994;2286:419–30.
10. Peel CJ, Jones A. Analysis of failures in aircraft structures. Met Mater 1990;6:496–502.
11. Danzer R, Hangl M, Paar R. How to design with brittle materials against edge flaking. Sixth International Symposium on Ceramic Materials for Engines. Tokyo: Japan Fine Ceramics Association, 1997:658–62.
12. Frechette V. Failure analysis of brittle materials. In: Advances in ceramics. Westerville, OH: American Ceramics Society, 1990: 28.
13. Morrell R, Byrne WP, Murray M. Fractography of ceramic femoral heads. Ceramic Transactions 2001;122:253–66.
14. Oberholzer TG, Rossouw RJ. Unusual fracture of a mandibular second premolar: A case report. Quintessence Int 2001;32:299–302.
15. Ho HHW, Chu FCS, Stokes AN. Fracture behavior of human mandibular incisors following endodontic treatment and porcelain veneer restoration. Int J Prosthod 2001;14:260–4.
16. ASTM C 1322–02. Standard practice for fractography and characterization of fracture origins in advanced ceramics. West Conshohocken, PA: ASTM, vol. 15.01.
17. Quinn JB, Schultheis LW. Failure analysis of a broken tooth. JFAP 2004;4:41–6.
18. Pingitore G, Chrobak V, Petrie J. The social and psychological factors of bruxism. J Prosth Dent 1991;65:443–6.
19. Nishigawa K, Bando E, Nakano M: Quantitative study of bite force during sleep associated bruxism. J Oral Rehab 2001;28:485–91.
20. Misch C. Implant dentistry. St. Louis: Mosby, 1999.
21. Skeie A, Schwartz O. Traumatic injuries of the teeth in connection with general anaesthesia and the effect of use of mouthguards. Endod Dent Traumatol 1999;15:33–6.
22. Nakahashi K, Yamamoto K, Tsuzuki M, et al. Effect of teeth protector on dental injuries during general anesthesia [in Japanese]. Masui 2003;52:26–31.
23. Vogel C. Dental injuries during general anaesthesia and their forensic consequences. Anaesthesist 1979;28:347–9.
24. Star EG. Damage of teeth by oral airways [in German]. Prakt Anaesth 1976;11:347–8.
25. Ohayon MM, Li KK, Guilleminault C. Risk factors for sleep bruxism in the general population. Chest 2001;119:53–61.
26. Romanelli F, Adler DA, Bungay KM. Possible paroxetine-induced bruxism. Ann Pharmacother 1996;30:1246–8.