American Journal of Emergency Medicine 31 (2013) 16291633

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

Original Contribution

Assisted head extension minimizes the frequency of dental contact with

laryngoscopic blade during tracheal intubation,,
Hyun Joo Kim, MD a, Jung-Man Lee, MD b, Jae-Hyon Bahk, MD b,
a
b

Department of Anesthesiology and Pain Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul 120-752, Republic of Korea
Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 110-744, Republic of Korea

a r t i c l e

i n f o

Article history:
Received 25 April 2013
Received in revised form 6 August 2013
Accepted 9 August 2013

a b s t r a c t
Objectives: We hypothesized that the assisted maintenance of head extension would reduce the frequency of
direct contact between the laryngoscope blade and the maxillary incisors during tracheal intubation.
Methods: Sixty-eight patients undergoing elective surgical procedures under general anesthesia were enrolled
in this prospective, randomized, controlled crossover study. A single experienced anesthesiologist performed
the simulated tracheal intubations with a classic Macintosh laryngoscope. After reaching the snifng position
during direct laryngoscopy, tracheal intubations with and without maintaining the head extension (by an
assistant) were simulated twice in each patient in random order. The occurrence of dental contact with the
laryngoscope blade was recorded during the simulated tracheal intubation. The distance between the
laryngoscopic blade and maxillary central incisors was assessed using a digital caliper. The angle of head
extension and the glottic view were also evaluated.
Results: The frequency of dental contact was lower with the assisted head extension than without it (25/68
[37%] vs 67/68 [99%], P b .001). The blade-to-tooth distance was longer with assistance than without it (1.8
1.9 [0-8] mm vs 0.0 0.1 [0-1] mm, P b .001). The angle of head extension was greater with assistance than
without it (26.6 5.8 [6.0-37.4] vs 19.9 5.4 [3.4-31.8], P b .001). No signicant difference was
observed between 2 simulated tracheal intubations with regard to the glottic views.
Conclusion: The assisted maintenance of head extension during the simulation of tracheal intubation reduced
the frequency of dental contact with the laryngoscopic blade without compromising the laryngoscopic views.
The results of this study suggest that assisted head extension during tracheal intubation may reduce the
possibility of unexpected dental injury.
2013 Elsevier Inc. All rights reserved.

1. Introduction
Tracheal intubation is a process that may result in dental damage
[1,2]. The mechanism of this damage is a substantial force that is
applied to the teeth by the laryngoscope blade when the clinician
uses the patient's upper teeth as a fulcrum for levering the
laryngoscope blade. The central maxillary incisors are, therefore,
the most involved teeth. Previous reports have suggested several
methods that use instruments for reducing dental injury such as
modied types of blades with lower ange heights [3-6], dental
shields [7,8], or attaching adhesive tape to the blade [9,10]. Of these
modications, a modied blade in which a ange is partially or
entirely removed appears to be the most effective method for
avoiding dental damage because it is the only method that can
increase the blade-to-tooth distance. However, this modied blade is

Grant: None.
Conicts of interest: None.
Registration of clinical trials: ClinicalTrials.gov (NCT01427348).
Corresponding author. Tel.: +82 2 2072 3108; fax: +82 2 747 5639.
E-mail address: bahkjh@snu.ac.kr (J.-H. Bahk).
0735-6757/$ see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajem.2013.08.019

not widely available and may be limited in its ability to displace the
tongue out of the line of sight.
Unanticipated dental injury occurs even when a tracheal intubation is performed by an experienced anesthesiologist or clinician
[11,12]. This injury may occur because of a disruption of the head
extension that occurs during tracheal intubation when the physician
releases the patient's head to grip the endotracheal tube. Although the
snifng position is properly established during direct laryngoscopy to
optimize the laryngeal view [13,14], the head extension is not
maintained during tracheal intubation because of the lifting force of
the laryngoscope blade on the tongue [15] and the absence of the
physician's hand supporting the patient's head. Therefore, maintaining head extension during tracheal intubation may reduce the
occurrence of direct contact between the maxillary incisors and
laryngoscope blade, thereby preventing unexpected dental injury.
However, no studies have investigated the effect of assisted head
extension on the occurrence of direct contact between the teeth and
the laryngoscope blade during tracheal intubation.
The goal of this study was to determine whether assisted
maintained head extension would reduce the frequency of dental
contact with the laryngoscope blade during tracheal intubation. We

1630

H.J. Kim et al. / American Journal of Emergency Medicine 31 (2013) 16291633

hypothesized that head extension being maintained by an assistant

would reduce the frequency of contact between the blade and the
maxillary incisors during tracheal intubation without compromising
the laryngoscopic views.
2. Methods
2.1. Study design and setting
This prospective randomized controlled crossover study was
approved by the institutional review board of Seoul National
University Hospital (August 2011, H-1107-051-369) and registered
at ClinicalTrials.gov (NCT01427348). Each patient provided written
informed consent.

Herrsching, Germany) based on the patient's sex. Tracheal intubation

simulations were performed twice in each patient in random order:
both with (Fig. 1B) and without (Fig. 1C) the help of an assistant in
maintaining the head extension that was obtained in the snifng
position during direct laryngoscopy. A computer-generated randomly
numbered table was used to randomize the order in which the
patients underwent the 2 simulated tracheal intubations.
Each patient was placed in the supine position. An uncompressible
pillow 7 cm in height was placed under the occiput to elevate the head
and achieve neck exion [13,14]. The patient's head was extended by
the anesthesiologist's right hand at the atlanto-occipital joint to

2.2. Selection of participants

Between September and December of 2011, we enrolled 68
patients who had an American Society of Anesthesiologists physical
status of I or II and who were scheduled for elective surgical
procedures that required endotracheal intubation for general anesthesia at our hospital. The following exclusion criteria were applied:
an inability to participate because of a mental disability; the presence
of a cervical spine injury or pathology; the absence of teeth; the
presence of loose teeth, unstable crowns, bridgework, periodontitis, a
dental abscess, or anomalies of the craniofacial structure; a history of
difcult intubation; or patient refusal.
2.3. Methods and measurements
Preanesthetic assessments of the airways were made with patients
placed in the sitting position by an anesthesiologist who was not
involved in the direct laryngoscopy. The modied Mallampati
classication, mandibular protrusion test, thyromental distance,
hyomental distance, interincisor gap, and range of head/neck
movement were assessed. For the (modied) Mallampati classication [16], all patients were seated with their heads in the neutral
position and were asked to maximally protrude their tongue twice.
The classications were as follows: class 1, the soft palate, fauces,
uvula, and pillars were visible; class 2, the soft palate, fauces, and
uvula were visible; class 3, the soft palate and base of the uvula were
visible; and class 4, the soft palate was not visible. The lower jaw was
then protruded voluntarily for the mandibular protrusion test, which
classied the patients as follows: class 1, the mandibular incisors were
pulled forward beyond the maxillary incisors; class 2, the mandibular
incisors were in the same position as the maxillary incisors; and class
3, the mandibular incisors were not pulled forward toward the
maxillary incisors. When the patients fully opened their mouths, the
interincisor gap was measured using a digital caliper (Niigata Seiki Co,
Niigata, Japan). The thyromental distance and hyomental distance
were also measured using a digital caliper with the mouth closed and
the head fully extended. To measure the range of head and neck
movement, the head and neck were fully exed and extended while a
digital BevelBox (L.V. Level Co, Jiangsu, China) protractor was
positioned rmly on the patient's forehead.
Standard monitoring was initiated using a 3-lead electrocardiogram, blood pressure cuff, oxygen saturation by pulse oximetry, and
end-tidal fractions of carbon dioxide. Anesthesia induction was
initiated with intravenous propofol and remifentanil using the
target-controlled infusion technique (Orchestra Base Primea; Fresenius Vial, Paris, France) with target concentrations of 4 to 5 g mL 1
and 4 ng mL 1, respectively. Muscle paralysis was facilitated with
rocuronium (0.6 mg kg 1).
The direct laryngoscopies and tracheal intubations were all
performed by the same experienced anesthesiologist using a classic
Macintosh blade size 3 or 4 (Heine Optotechnik GmbH & Co KG,

Fig. 1. Schematic diagram showing the positions of the head and neck during the
tracheal intubation simulation. A, Before direct laryngoscopy. B, During tracheal
intubation simulation with maintenance of head extension by an assistant, whereas the
anesthesiologist stops supporting the patient's head. C, During simulated tracheal
intubation without the maintenance of head extension by an assistant while the
anesthesiologist stops supporting the patient's head. Angle , the angle between the
forehead line and the horizontal line; distance D, the shortest distance between the tip
of the maxillary central incisors and the laryngoscopic blade; DP, digital protractor; FH,
force applied on the patient's head by the assistant's hand.

H.J. Kim et al. / American Journal of Emergency Medicine 31 (2013) 16291633

achieve the snifng position during direct laryngoscopy. The

anesthesiologist inserted the laryngoscope blade into the mouth
while maintaining the snifng position and keeping the blade along
the midline. The laryngoscope was lifted upward and forward along
the axis of the handle. After the best laryngeal view was obtained, the
assistant supported the patient's head (which was extended to the
same degree that the anesthesiologist initially performed). The
anesthesiologist stopped holding the head with her right hand and
simulated the condition of tracheal intubation while the laryngoscope
blade was kept in the same position in the mouth (Fig. 1B). The second
simulation of tracheal intubation was then performed. After achieving
the same snifng position during direct laryngoscopy, the anesthesiologist discontinued supporting the head, and the assistant did not
maintain head extension (Fig. 1C).
Another investigator who was not involved in the direct
laryngoscopy obtained 3 types of measurements, including the
blade-to-tooth distance, the glottis view, and the angle of the head
extension during the 2 simulated tracheal intubations. All measurements were obtained at the time point when the anesthesiologist
stopped supporting the head of the patient with or without the
assisted head extension. The blade-to-tooth distance was measured as
the shortest perpendicular distance from the tip of the maxillary
central incisor to the ange of the blade with a digital caliper. Under
optimal external laryngeal manipulation (thyroid cartilage pressure
was applied using the hand), the glottic view was classied using the
following grades according to the modied Cormack and Lehane
system [17-19]: grade 1, the whole glottis was visible; grade 2a, part
of the glottis was visible; grade 2b, only the arytenoids or posterior
parts of the vocal cords were visible; grade 3, only the epiglottis was
visible; and grade 4, neither the glottis nor the epiglottis was visible.
The angle of head extension was assessed as follows (Fig. 1). The angle
of head extension was measured with a digital protractor in each
condition (Figs. 1A-C). The angle of head extension with or without
assistance was calculated using the following formula: (Fig. 1B)
(Fig. 1A) or (Fig. 1C) (Fig. 1A). The difference between the head
extension angles with and without assistance was calculated as
follows: (Fig. 1B) (Fig. 1C). After all parameters were recorded,
the patient's trachea was intubated under the optimal external
laryngeal manipulation.
2.4. Analysis
The sample size was determined to detect a 15% difference
between patients with and without assisted maintenance of head
extension in the frequency of dental contact based on a previous
report [13] for a type 1 error of 0.05 and a power of 0.8. The power
analysis suggested that a minimum of 68 patients would be required.
The paired data on the frequency of dental contact according to the
presence of assistance were examined with McNemar test. The data
pairs for the angle of head extension and the blade-to-tooth distance
Table 1
Patient characteristics and preanesthetic airway assessments
Characteristics (n = 68)

Values

Age (y)
Sex (male/female)
Weight (kg)
Height (cm)
Body mass index (kg m2)
Modied Mallampati classication (1/2/3/4)
Mandibular protrusion test (1/2/3)
Interincisor gap (mm)
Thyromental distance (mm)
Hyomental distance (mm)
Head and neck movement ()

47 (13)
26/42
63.9 (12.3)
162.2 (8.4)
24.1 (3.3)
15/29/18/6
62/2/2
41.7 (5.7)
62.9 (9.1)
41.1. (7.9)
120.2 (15.6)

Data are presented as the means (SD) or numbers of patients.

1631

Table 2
Frequency of dental contact, blade-to-tooth distance and head extension angle with/
without maintenance of head extension by an assistant during the tracheal intubation
simulation
Maintenance of head extension

Frequency of dental contact

Blade-to-tooth distance (mm)
Angle of head extension ()
The Cormack and Lehane grade
(1/2a/2b/3/4)

Not applied

Applied

67/68
0.0 (0.1), 0-1
19.9 (5.4), 3.4-31.8
35/23/9/1/0

25/68
b.001
1.8 (1.9), 0-8
b.001
26.6 (5.8), 6.0-37.4 b.001
35/26/6/1/0
1.000

Data are presented as the means (SD), range, or number of patients.

P b .05.

were compared between the patients with and without assisted

maintenance of head extension using the Wilcoxon signed rank test.
To compare the glottic view data between groups, we made 2 2
tables (grade 1 or 2a vs grade 2b, 3, or 4) [17,20] and used McNemar
test. The values from the preanesthetic airway assessments were
compared between patients in whom direct contact between the
laryngoscope blade and the teeth occurred and the patients in whom
such contact did not occur when the assistant maintained the head
extension. Fisher exact test or the Mann-Whitney U test was used
when appropriate. Data are presented as the means (SD) and range or
numbers of patients (percentages). SPSS for Windows version 18.0
(SPSS Inc, Chicago, IL) was used for statistical analysis. The results
were considered statistically signicant if P b .05.
3. Results
Patient characteristics including preanesthetic assessments of the
airways are shown in Table 1. The frequency of dental contact was
signicantly lower with assisted head extension than without it (P b
.001; Table 2). The preanesthetic airway assessments including the
modied Mallampati classication, the mandibular protrusion test,
the interincisor gap, the thyromental distance, the hyomental
distance, and/or the range of head/neck movement were not
signicantly different between the patients in whom dental contact
with the laryngoscope blade occurred and the patients in whom such
contact did not occur when the assistant maintained the maximum
head extension (Table 3). The same comparison was not applicable
when the head extension was not maintained by an assistant because
only one attempt was free of dental contact.
The blade-to-tooth distance increased with the maintenance of
head extension (P b .001) (Table 2 and Fig. 2). The angle of head
extension also increased in patients with maintenance (P b .001;
Table 2). The difference in the angles of head extension between
patients with and without maintenance was 6.6 (3.9). No signicant
difference in the glottic views was observed between the patients
with and without assisted maintenance of head extension (Table 2).

Table 3
Comparison of preanesthetic airway assessments between patients in whom dental
contact occurred and patients in whom dental contact did not occur when the assistant
maintained the head extension
Dental contact

Modied Mallampati classication (1/2/3/4)

Mandibular protrusion test (1/2/3)
Interincisor gap (mm)
Thyromental distance (mm)
Hyomental distance (mm)
Head and neck movement ()

Yes (n = 25)

No (n = 43)

4/13/6/2
22/2/1
42.6 (5.7)
62.7 (9.7)
40.6 (8.9)
123.6 (17.5)

11/16/12/4
42/0/1
41.2 (5.7)
63.0 (8.8)
41.4 (7.3)
118.3 (14.2)

The data are presented as the mean (SD) or number of patients.

.66
.25
.35
.99
.85
.29

1632

H.J. Kim et al. / American Journal of Emergency Medicine 31 (2013) 16291633

Fig. 2. Box and Whisker plots representing the blade-to-tooth distance. The box
represents the 25th to 75th percentile. The line inside the box represents the median.

The frequencies of difcult laryngoscopy (modied Cormack and

Lehane grade 2b, 3, or 4) were as follows: 7 (10%) of the 68 attempts
with an assistant maintaining head extension and 10 (15%) of the 68
attempts without maintaining head extension. Tracheal intubations
under direct laryngoscopy were successful in all patients.
4. Discussion
This study showed that using an assistant to maintain head
extension decreased the frequency of dental contact with the
laryngoscopic blade during the simulation of tracheal intubation.
Our results showed that the angle of head extension was reduced
and that the frequency of dental contact increased to 99% during
tracheal intubation without supporting the patient's head. The
frequency of dental contact in this study is signicantly higher
compared with previous studies [3,21] because we measured the
blade-to-tooth distance at the moment when the anesthesiologist
stopped supporting the head extension to simulate a practical clinical
situation of tracheal intubation. To the best of our knowledge, this
study is the rst to investigate the high frequency of dental contact
with the laryngoscope blade when the angle of head extension
decreases because of the lifting force of the laryngoscope against the
tongue [15] during tracheal intubation. Therefore, the moment of
tracheal intubation should not be ignored, although the snifng
position is properly attained during direct laryngoscopy.
In our study, the frequency of dental contact decreased by 62%
when the head extension in the snifng position was maintained
continuously by an assistant during tracheal intubation. Previous
studies have reported that the frequency of dental contact was
reduced by 16% to 55% when using modied low-height Macintosh
blades [13,20]. Therefore, the assisted head extension is helpful in
avoiding dental contact during tracheal intubation. This simple
method requires no extra treatment costs and can be performed by
any clinician such as surgeons, nurses, or anesthesiologists in the
operation room.
Two crossover studies have demonstrated that a modied lowheight Macintosh blade reduces the frequency of dental contact from
20.3% to 4.1% or from 75% to 20% in patients [3,21]. In addition, greater
visibility of the larynx is achieved because the low-height ange
allows a higher degree of blade rotation without tooth contact.
However, this rotation maneuver using the laryngoscopic blade

compromises the space available for manipulating an endotracheal

tube, which may increase intubation difculty [15]. Furthermore, lowheight or absent anges may make it difcult to control the tongue,
thereby resulting in a narrow space for insertion of the endotracheal
tube. To reduce dental injury, several authors have recommended
using protective dental shields [7,8], which can reduce and distribute
loaded forces on the teeth. However, there is controversy regarding
the use of mouth guards because their thickness can cause them to
limit the view of the oral cavity during tracheal intubation. In addition,
a Macintosh blade with a strip of polyfoam or polyurethane sheeting
was shown to reduce the pressure on the teeth [9,10] but did not
increase the blade-to-tooth distance.
Our study has some limitations. First, all tracheal simulations
were conducted by a single unblinded anesthesiologist. The
practice of tracheal intubation in this study may not represent
that of average clinicians. However, any user bias was minimized
because the anesthesiologist aimed to obtain the best laryngeal
view, and rotating the laryngoscope blade toward the maxillary
incisors was not allowed. Second, the rst tracheal simulation may
have affected the results of the second simulation because of the
crossover design. However, the order of the 2 tracheal simulations
was randomized to overcome this limitation. Third, we could not
nd any signicant differences of preoperative airway assessments
in accordance with dental contact. It is thought that a combination
of risk factors for difcult laryngoscopy may contribute to dental
contact with the blade [3]. Further studies with larger samples are
needed to conrm this issue. Fourth, we did not measure the force
applied by the blade against the teeth. It is assumed that the force
applied on the teeth may be lower with head extension, although
the teeth still make contact with the laryngoscope blade. Additional
studies on this issue are warranted. Fifth, the clinical signicance of
the dental contact we demonstrated is unknown. However,
investigation of dental trauma as a primary outcome may be
challenging in randomized controlled trials [21]. Therefore, we
described the biomechanics of dental contact, which may lead to
dental injury during tracheal intubation.
In summary, we have shown that the assisted maintenance of head
extension during tracheal intubation reduced dental contact with the
laryngoscope blade without compromising laryngoscopic views.
Further study with larger numbers of patients is needed to clarify
the efcacy of the assisted head extension in preventing unexpected
dental injury during tracheal intubation.

References
[1] Newland MC, Ellis SJ, Peters KR, et al. Dental injury associated with anesthesia: a
report of 161,687 anesthetics given over 14 years. J Clin Anesth 2007;19:33945.
[2] Yasny JS. Perioperative dental considerations for the anesthesiologist. Anesth
Analg 2009;108:156473.
[3] Lee J, Choi JH, Lee YK, et al. The Callander laryngoscope blade modication is
associated with a decreased risk of dental contact. Can J Anaesth 2004;51:1814.
[4] Bizzarri DV, Giuffrida JG. Improved laryngoscope blade designed for ease of
manipulation and reduction of trauma. Anesth Analg 1958;37:2312.
[5] Callander CC, Thomas J. Modication of Macintosh laryngoscope for difcult
intubation. Anaesthesia 1987;42:6712.
[6] Ibler M. Modication of Macintosh laryngoscope blade. Anesthesiology
1983;58:200.
[7] Brosnan C, Radford P. The effect of a toothguard on the difculty of intubation.
Anaesthesia 1997;52:10114.
[8] Monaca E, Fock N, Doehn M, et al. The effectiveness of preformed tooth protectors
during endotracheal intubation: an upper jaw model. Anesth Analg 2007;105:
132632.
[9] Lisman SR, Shepherd NJ, Rosenberg M. A modied laryngoscope blade for dental
protection. Anesthesiology 1981;55:190.
[10] Ghabash MB, Matta MS, Mehanna CB. Prevention of dental trauma during
endotracheal intubation. Anesth Analg 1997;84:2301.
[11] Gaudio RM, Feltracco P, Barbieri S, et al. Traumatic dental injuries during
anaesthesia: part I: clinical evaluation. Dent Traumatol 2010;26:45965.
[12] Vogel J, Stbinger S, Kaufmann M, et al. Dental injuries resulting from tracheal
intubationa retrospective study. Dent Traumatol 2009;25:737.
[13] El-Orbany M, Woehlck H, Salem MR. Head and neck position for direct
laryngoscopy. Anesth Analg 2011;113:1039.

H.J. Kim et al. / American Journal of Emergency Medicine 31 (2013) 16291633

[14] Takenaka I, Aoyama K, Iwagaki T, et al. The snifng position provides greater
occipito-atlanto-axial angulation than simple head extension: a radiological
study. Can J Anaesth 2007;54:12933.
[15] Bucx MJ, Snijders CJ, ven der Vegt MH, et al. Reshaping the Macintosh blade using
biomechanical modelling. A prospective comparative study in patients. Anaesthesia 1997;52:6627.
[16] Samsoon GL, Young JR. Difcult tracheal intubation: a retrospective study.
Anaesthesia 1987;42:48790.
[17] Yentis SM, Lee DJ. Evaluation of an improved scoring system for the grading of
direct laryngoscopy. Anaesthesia 1998;53:10414.

1633

[18] Koh LK, Kong CE, Ip-Yam PC. The modied Cormack-Lehane score for the grading
of direct laryngoscopy: evaluation in the Asian population. Anaesth Intensive Care
2002;30:4851.
[19] Cormack RS, Lehane J. Difcult tracheal intubation in obstetrics. Anaesthesia
1984;39:110511.
[20] Lee A, Fan LT, Gin T, et al. A systematic review (meta-analysis) of the accuracy of the
Mallampati tests to predict the difcult airway. Anesth Analg 2006;102:186778.
[21] Kimberger O, Fischer L, Plank C, et al. Lower ange modication improves
performance of the Macintosh, but not the Miller laryngoscope blade. Can J Anesth
2006;53:595601.

Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.