See

discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/278733325

Case Report: Fractured Needle in the

Pterygomandibular Space Following
Administration of an Inferior Dental...

Article in Dental update April 2015

DOI: 10.12968/denu.2015.42.3.270 Source: PubMed

CITATION READS

1 26

3 authors, including:

Edmund Bailey
Queen Mary, University of London
20 PUBLICATIONS 154 CITATIONS

SEE PROFILE

All content following this page was uploaded by Edmund Bailey on 03 May 2016.

The user has requested enhancement of the downloaded file.

 OralSurgery

Edmund Bailey

Jeethendra Rao and Alka Saksena

Case Report: Fractured Needle

in the Pterygomandibular Space
Following Administration of an
Inferior Dental Nerve Block
Abstract: Fortunately, needle fracture is a rare complication following the administration of dental local anaesthetic. We present a case of
needle fracture following administration of an inferior dental nerve block. The fractured needle was retrieved successfully under general
anaesthetic. We also provide some suggestions on how to prevent needle fracture, and advice on how to manage the situation should it
arise.
Clinical Relevance: Dental practitioners are the largest user group of local anaesthesia in the UK. It is important that practitioners are aware
of the risks to the patient of needle fracture, how to minimize the risk of this occurring and be aware of how to manage the situation should
it arise.
Dent Update 2015; 42: 270272

Fortunately, needle fracture is a rare disposable needles in the 1960s, along Case report
complication following the administration with improvements in metal alloys and
A 32-year-old medically well
of dental local anaesthetic injections.1 manufacturing processes, needle fracture
female attended her dentist for routine
Evidence seems to suggest that needle has become even less common.2 On
mandibular dental extractions, for which
fracture is more common when giving reviewing historical literature, we came
an inferior dental nerve block on the
an inferior dental nerve block than it is across a 1924 study by Blum,3 documenting
right-hand side was required. While using
with other dental infiltration and block 65 cases of broken needles over a 10-year
a disposable 23 mm 30 gauge dental
techniques. Since the introduction of period.
needle, and during administration of a
Needle fracture may occur due
second block, the needle fractured in the
to:
soft tissues and the dentist was unable to
Poor technique;
Edmund Bailey, MFDS, MOralSurg, visualize the fragment in order to retrieve
Patient movement during administration;
MPhil, Specialty Doctor in Oral Surgery, it. The proposed treatment was abandoned
Needle manufacturing faults.
University Dental Hospital of Manchester, and the patient was referred urgently to the
Jeethendra Rao, FRCS, MFDS, Locum maxillofacial department by her GDP. On
Consultant Maxillofacial Surgeon, Royal Needle selection presentation, the patient was somewhat
Blackburn Hospital and Alka Saksena, distressed by the situation. On examination,
Commonly used needles in
MSurgDent(UK), MFDS RCS(Eng), there was tenderness in the retromolar
dental practice in the UK include:4
MFGDP(UK), Consultant Oral Surgeon, region, trismus, but no sign of the needle.
23 mm (short) 30 gauge (narrow) for
University Dental Hospital of Manchester, Orthopantomogram and posterior-anterior
infiltration anaesthesia; and
Higher Cambridge Street, Manchester mandibular radiographs revealed a linear
35 mm (long) 27 gauge (wide) for
M156FH, UK. radio-opaque object with a bend, in the
regional block anaesthesia.
pterygomandibular space, representing
270 DentalUpdate April 2015
 OralSurgery

the needle fragment (Figures 1 and 2). The

patient was admitted for exploration of the
pterygomandibular space for removal of the
needle under a general anaesthetic. The risk
of damage to the inferior dental and lingual
nerves was discussed with the patient and
consent was gained.
During surgery, a retromolar
incision medial to the ascending ramus
was made, followed by superficial blunt
dissection of the pterygomandibular space
in order to minimize risk of damage to
the mandibular division of the trigeminal
nerve and associated blood vessels (Figure
3). The retrieved needle was noted to be
bent (Figure 4). The patient was discharged
later the same day and made an uneventful Figure 1. Horizontal section through the pterygomandibular space above the mandibular foramen.
recovery. At 3 week review, the patient
was found to have no labial or lingual
paraesthesia and her trismus had almost
fully resolved. for the surgeon undertaking retrieval of dental nerve block,1-3, 5, 8-12 with the majority of
the fractured needle. Ultrasound-guided these involving short needles. Short needles
retrieval of foreign bodies can also be
Discussion used,7 the advantages of this real-time
Different imaging modalities procedure and the use of small instruments
have been suggested when locating minimize bleeding time and avoid injury to a
needles embedded in the soft tissues: a surrounding structures. Patient compliance
stereotactic technique5 using an image is enhanced by the fact that the procedure
intensifier and standard venepuncture has little or no aesthetic impact. This would
needles as reference points can be used. not be appropriate in this case as the
Images are quickly available (compared foreign body (the needle) was impacted
to intra-operative radiographs) and can deep in the soft tissues, the examples used
be viewed immediately. Image intensifiers in the study by Callegari et al7 are retained
are usually readily available owing to their in the soft tissue underneath the skin.
common use in orthopaedic surgery. Image Needle fracture in tissues is an
intensifiers are electronic devices used uncommon but devastating event for both
to produce a fluoroscopic image with a the patient and clinician. In the literature
low-radiation exposure. A beam of x-rays there are several examples of this occurring
passing through the patient is converted following the administration of an inferior
into a pattern of electrons in a vacuum
tube. The electrons are accelerated and
concentrated onto a small fluorescent b
screen, where they present a bright image,
which is generally displayed on a video
monitor.6 However, in this case, plain
radiographs adequately aided the retrieval.
Ethunandan et al discuss the difficulties
encountered in location of the fractured
needle when only plain radiographs
are utilized.1 Cone Beam Computerized
Tomography (CBCT) or conventional
Computerized Tomography (CT) imaging
provides the precise location of the needle
within the pterygomandibular space
in the coronal, sagittal and transverse
planes. It also provides a 3-dimensional Figure 2. (a) Posterior/anterior view of the mandible and (b) an orthopantomogram showing needle
reformatted image and can be invaluable location.

April 2015 DentalUpdate 271

 OralSurgery

space (Figure 1) include the mandibular Conclusion

division of the trigeminal nerve and inferior Needle fracture during inferior
alveolar artery and vein. Contents of the dental block administration is rare but
lateral pharyngeal space include the carotid continues to be reported in the dental
artery and branches together with the literature. By use of a careful technique and
9th (glossopharyngeal), 10th (vagus) and the following of manufacturers instructions,
12th (hypoglosssal) cranial nerves. Deep dental local anaesthetic needle fractures can
infratemporal contents include the pterygoid be minimized. Following fracture of a dental
plexus, which communicates with the needle, prompt retrieval in a specialist oral
cavernous sinus and ophthalmic veins, the and maxillofacial department is required
Figure 3. Intra-operative view of needle retrieval
interior maxillary artery and vein and the to minimize risk of developing serious
via supraperiosteal incision at the antero-medial
aspect of the ramus of the mandible.
mandibular division of the trigeminal nerve. complications.
The patient must be advised of the inherent
risks associated with surgical intervention of
Acknowledgements
these spaces and consequences of spread
The authors would like to thank Mr K Sanders,
of infection and/or damage to the blood
Consultant in OMFS, as the patient was
vessels and nerves which are present.14
admitted under his care.
To reduce the risk of needle
fractures it is recommended that:
Needles should conform to European References
standards and be CE certified;
1. Ethunandan M, Tran AL, Anand R, Bowden J, Seal MT,
Figure 4. The needle following retrieval. Only long (35 mm) needles are used for
Brennan PA. Needle breakage following inferior alveolar
inferior dental nerve blocks;
nerve block: implications and management. Br Dent J.
Needles should not be manipulated prior
2007; 202: 395397.
to use, by bending or breaking;
are more prone to fracture when used for 2. Bedrock RD, Skigen A, Dolwick MF. Retrieval of a broken
When giving local anaesthetic injections,
inferior dental nerve blocks as they have to needle in the pterygomandibular space. J Am Dent Assoc
needles should not be subject to extreme
be inserted to the hub (where the needle 1999; 130: 685687.
or repeated movements, nor should they be
attaches to the thread) to provide adequate 3. Blum T. Further observations with hypodermic needles
inserted to the hub;
anaesthesia. It is known that needles are broken during the administration of oral local anesthesia:
Needles should be replaced after every
at their weakest at the hub.4 Manipulation a report of sixtyfive cases. Dent Cosmos 1924; 66: 322.
use, due to needle point damage. Disposal
of the needle by bending it mid shaft can 4. Robinson PD, Pitt Ford TR, McDonald F. Local Anaesthesia in
would also avoid the risk of needle stick
potentially generate forces that can weaken Dentistry. Oxford: Wright, 2000.
sharps injury.
it at the hub. We were unable to find any 5. Thompson M, Wright S, Cheng LHH, Starr D. Locating
examples of needle fracture relating to other broken dental needles. Int J Oral Maxillofac Surg 2003; 32:
dental anaesthetic injections. In several of 622624.
these cases, the needle fracture occurred on Management 6. Mosbys Medical Dictionary 8th edn. Oxford: Elsevier, 2009.
the second or subsequent administration of Upon realizing that a needle has 7. Callegari L et al. Ultrasound-guided removal of foreign
local anaesthesia.8,12 This would imply that fractured, the dentist should immediately bodies: personal experience. Eur Radiol 2009; 19(5):
the needle might be weakened on re-use. attempt retrieval with a fine mosquito/ 12731279.
In a study examining long needles used in haemostatic clip if the needle is visible. If 8. Shah A, Mehta N, Von Arx DP, Derrick P. Fracture of a dental
single inferior dental nerve blocks, scanning the needle cannot be retrieved, the patient needle during administration of an inferior alveolar nerve
electron microscopy revealed 95% had needle should be informed, advised of the clinical block. Dent Update 2009; 36: 2025.
tip damage.9 The study advised that needles risks of leaving the needle in situ and 9. Rout PGJ, Saksena A, Fisher SE. An investigation of the
are replaced after each injection, as per the referred to the nearest oral and maxillofacial effect on 27-gauge needle tips following a single local
manufacturers guidance.13 surgery unit for further investigation and anaesthetic injection. Dental Update 2003; 30: 370374.
Needle fracture should be dealt management. Following appropriate 10. Sen P, Waith C, Clarke S. Fractured dental needle at the
with promptly to reduce pain and to avoid radiographic imaging and patient consent, base of skull. J Cranio-Maxillofac Surg 2006; 34: (Suppl S1):
risk of wound infection and swelling, which the patient should undergo surgical 136137.
may inhibit its retrieval. There is also the exploration and retrieval of the fractured 11. Nezafati S, Shahi S. Removal of broken dental needle using
possibility of migration of the needle into needle under general anaesthesia. Retrieval mobile digital C-arm. J Oral Sci 2008; 50(3): 351353.
other spaces such as the peritonsillar space should be performed as soon as possible to 12. Pogrel MA. Broken local anaesthetic needles.
medially, infratemporal fossa and skull prevent complications, such as migration of J Am Dent Assoc 2009; 140 (12): 15171522.
base superiorly,10 parotid gland and lateral the needle,1,10 tissue space infection, and also 13. Directions for Use. Septodont Septoject. Revised July
pharyngeal space posteriorly, and sublingual to prevent the pain and discomfort caused 2009.
and submandibular spaces inferiorly. by having a needle imbedded in the soft 14. Hupp JR, Ellis E, Tucker MR. Contemporary Oral and
Contents of the pterygomandibular tissues.1 Maxillofacial Surgery 5th edn. Oxford: Mosby Elsevier, 2008.

272 DentalUpdate April 2015

View publication stats