1

Oral Radiology in
linical and Laboratorial
Research in Dentistry

Removal of a broken dental needle in the

pterygomandibular space using an image
intensifier: two case reports
• Paulo Rogério Corrêa Couto Centro Universitário Tabosa de Almeida ASCES-UNITA, Caruaru, PE, Brazil 
• Rafael do Nascimento Silva Centro Universitário Tabosa de Almeida ASCES-UNITA, Caruaru, PE, Brazil 
• Rafael de Sousa Carvalho Sabóia Centro Universitário Tabosa de Almeida ASCES-UNITA, Caruaru, PE, Brazil 
• Airton Vieira Leite Segundo  Faculdade de Medicina do Sertão, Caruaru, PE, Brazil

| ABSTRACT | Introduction: Accidents and complications are elements that can occasionally be associated with
ABSTRACT
the procedures realized within work dentist environment. Among some accidents related to dental practice,
needle fracture during local anesthesia is noteworthy due to its rarity. Objective: This work seeks to report two
cases of removal of a broken dental needle in the pterygomandibular space using an image intensifier. Mate-
rial and Methods: In both cases, the accident happened during an inferior alveolar nerve block. The surgeons
requested image exams to locate the objects using general anesthesia. In the surgery, a transoral incision was
made to remove the broken needle from the pterygomandibular space, guided by an image intensifier. Results:
Both surgeries were a success. The broken needles were found quickly with the use of the image intensifier, and
no postoperative complications were observed. Conclusion: The correct assessment of fractured dental posi-
tion is essential for its removal. The use of the image intensifier has been showing advantages, such as offering
fast transoperative dynamic images and at different angles, thus providing opportunity for calmer surgery and
with less risk for the patient and the operator.

DESCRIPTORS | Needle; Fracture; Local anesthesia; Image.

| Remoção de agulha dentária quebrada no espaço pterigomandibular usando um intensificador de imagem:

RESUMO
relato de dois casos • Introdução: Acidentes e complicações são elementos que ocasionalmente podem estar associados a
procedimentos realizados em ambiente de trabalho odontológico. Dentre alguns acidentes relacionados à prática odontológi-
ca, a fratura por agulha durante a anestesia local destaca-se pela raridade. Objetivo: o presente estudo tem como objetivo
relatar dois casos de retirada de uma agulha dentária quebrada no espaço pterigomandibular com intensificador de imagem.
Material e Métodos: Em ambos os casos, o acidente ocorreu durante um bloqueio do nervo alveolar inferior. Os cirurgiões so-
licitaram exames de imagem para localizar os objetos por meio de anestesia geral. Na cirurgia, foi realizada uma incisão tran-
soral para retirada da agulha quebrada do espaço pterigomandibular, guiada por um intensificador de imagem. Resultados:
Ambas as cirurgias foram um sucesso. As agulhas quebradas foram encontradas rapidamente com o uso do intensificador de
imagem, sem complicações pós-operatórias. Conclusão: A correta avaliação da posição dentária fraturada é fundamental para
sua remoção. O uso do intensificador de imagem tem mostrado vantagens, como oferecer imagens dinâmicas transoperatórias
rápidas e em diferentes ângulos, trazendo assim uma oportunidade para cirurgias mais tranquilas e com menor risco para o
paciente e o operador.

| Agulha; Fratura; Anestesia local; Imagem.

DESCRITORES

AUTOR CORRESPONDENTE | • Paulo Rogério Corrêa Couto Centro Universitário Tabosa de Almeida

ASCES-UNITA  • Rua Laura Rabelo, 71 – Apto. 204A Caruaru, PE, Brazil 
• 55014-365  E-mail: [email protected]

• Received  May 09, 2021  • Accepted  June 25, 2021

• DOI:  http://dx.doi.org/10.11606/issn.2357-8041.clrd.2021.185532

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 Removal of a broken dental needle in the pterygomandibular space using an image intensifier: two case reports

INTRODUCTION providing analysis of the position of the broken

Accidents and complications are elements that needle at different angles, in addition to presenting
can, occasionally, be associated with the procedures its relation with the reference surgical instrument.6
performed by the dentist. They can occur during This work seeks to report the cases of two
trans-operative or postoperative procedures. Most of surgeries to remove a fractured needle using an
them can be bypassed promptly by the professional. image intensifier.
However, some cases can be very difficult for the
dentist to handle and too inconvenient for the patient. CASE REPORT
Thus, the specialty in Buccomaxillofacial Surgery and Case 1
Traumatology is the most involved in the management A 39-year-old male patient was referred to the
of patients who present these conditions. 1,2
Bucomaxillofacial Surgery and Traumatology Service
Among some accidents related to dental practice, of Hospital Regional do Agreste for removal of a
fracture dental needle during local anesthesia is broken needle in the pterygomandibular space on
noteworthy due to its rarity. Metal instruments used in the right side. During the anamnesis, the patient
clinical practice are susceptible to fatigue. Brokens needle reported that the accident occurred during the
usually occur during anesthetic infiltration. However, attempt to extract the dental element 48. After the
this kind of accident has become rare since the accident, the professional tried to remove the needle,
introduction of disposable needles that emerged at 1960s. 3
but it was unsuccessful.
Nowadays the needle tends to fracture, in most The clinical examination revealed a slight
cases, due to the choice of its size and caliber, growth volume in the region, with associated
inadequate technique, and due to the patient’s sudden painful symptoms. The patient also had trismus,
movements during the treatament. In addition, but there was no infection sign. Imaging exams were
factors involving the psychological condition and requested: face tomography with 3D reconstruction
the topography of the region to be anesthetized can and panoramic radiography (Figure 1), enabling the
also be determinants. 4
observation of an object of approximately 20 mm,
When a needle breaks, its removal may be simpler compatible with the size of a needle.
if a fragment part remains visible. However, surgical Knowing the position of the needle in the
removal of a broken needle during nerve block in pterygomandibular space and the difficulty in locating
the region that comprises the pterygomandibular it during the surgical procedure, it was decided to
space can be difficult due to its proximity to vital perform the surgery in a hospital environment,
anatomical structures in the area. When it is 3
under general anesthesia, with the use of an image
indicated, the removal of a broken needle must intensifier to assist in the trans-operative.
be realized in the safest possible way, avoiding An incision was made along the external oblique
unnecessary risks to the patient, especially if the line from the third molar lateral region to the first
broken needle is in close contact with important molar right side with delicate detachment of all
structures. Therefore, the assessment of its correct tissue, perpendicular to the needle plane, especially
position is imperative for its removal. 5
in the lingual region. After the detachment, the
Among the variety of techniques that exist to needle was not found. With the image intensifier,
locate foreign bodies in soft tissues, the image model Veradius Philips Medical Systems Nederland
intensifier has several advantages. It is a device that B.V, surgical images in region were obtained in the
offers images during the operation, in a fast way, operation, and the precise location of the needle

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 Couto PRC • Silva RN • Sabóia RSC • Leite Segundo AV

was determined (Figure 2). With the support

of a curved Halstead forceps, the needle was
located and clamped, being removed, without
major complications. Soon after the procedure, a
radiographic control was made (Figure 3), in which
the presence of the radiopaque object was no longer
observed. Complications, such as hemorrhage,
infection, or paraesthesia were not observed.
Currently, the patient is under post-operative follow-
up for 90 days, with no functional complaints.
FIGURE 3 | Postoperative panoramic radiography showing the
removal of the broken needle.

Case 2
A 24-year-old male patient was referred to the
Oral and Maxillofacial Surgery service of the HRA
to do an evaluation of the broken anesthetic needle
location and eventual necessity for removal. The
accident occurred during anesthetic technique for
blocking the left inferior alveolar nerve.
On clinical examination, the patient reported
pain and discomfort in the region. Cone beam
computed tomography was requested to locate
the needle, and the sections showed a hyperdense
fragment of approximately 20 mm, located in the
FIGURE 1 | Preoperative panoramic radiograph showing the left pterygomandibular space (Figure 4).
broken needle.
Due to persistent discomfort, it was decided to
remove the needle under general anesthesia with
nasotracheal intubation.
During the procedure, the mouth was maintained
open and stabilized. A jelco number 18 was inserted
into the soft tissues to assist the broken needle
location. Images of the region were obtained using
the Veradius Philips Medical Systems Nederland B.V.
After spatial location of the fragment, an
incision of approximately 4 cm was made in the
buccal mucosa, in the retromolar region, and then
a dissection, following the path of the positioned
needle. After direct visualization, the needle was
removed. The area was sutured with 4.0 resorbable
FIGURE 2 | Trans-operative image of the needle (image intensifier). thread, following the hemostatic handling and

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 Removal of a broken dental needle in the pterygomandibular space using an image intensifier: two case reports

irrigation w ith saline solution. The patient the application of anesthetic injections in the oral
reacted well, with a satisfactory evolution and was cavity, the incidence of this accident has decreased
discharged the next day. significantly.1 The literature reports several ways to
After the procedure, a control radiograph (Figure minimize this accident, such as: guiding the patient
5) was taken, in which the presence of the radiopaque not to move during the puncture, not using short
object was no longer observed. The patient is needles for inferior alveolar block in adults, not
currently under post-operative follow-up for 90 days, bending the needles before inserting them in the
with no functional complaints. tissue, not inserting the needle body completely to
the soft tissue calotte and not using 30-gauge needles
for inferior alveolar block in adults or children,
giving preference to 27-gauge needles.7
Due to the anxiety and fear that dental treatment
causes in a group of people and relating the needs
of each case, minimal sedation can be used to avoid
disorders during the application of anesthesia, such as
sudden movements, and to avoid fractures, especially
in infant patients and people with special needs.3
Many authors indicate the immediate removal
of the broken needle, due to the risk that migration
could cause injury to noble structures such as
vessels and nerves, which could cause dysesthesias,
FIGURE 4 | Tomography showing the presence of a broken needle
on the left side. paresthesias and hemorrhages, as well as to the
psychological benefits to the patient. 4 On the other
hand, other authors suggest that this procedure
should not be realized when there are no painful
symptoms, when taking into consideration the
trauma and the complexity of its removal, and
because there is the suggestion that the fragment
will be surrounded by fibrous tissue. Even so, there
are patients who show too much concern about
the needle present, even without symptoms. The
main indications for removing the fragment in the
case reports in question were the pain and trismus
generated by the local inflammatory response, in
FIGURE 5 | Postoperative panoramic radiograph showing the
absence of the broken needle. addition to the psychological changes of the patients
and the risk of injury to adjacent noble structures.8,9
Among the regions of the oral cavity, the
DISCUSSION maxilla is the least incident. 4 In contrast, the
Surgical treatment of broken dental needles pterygomandibular space is the most affected local
is a very discussed issue in the literature. Since by broken needles in techniques to block the inferior
the introduction of the disposable needles, for alveolar nerve and the mandibular nerve. This space

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 Couto PRC • Silva RN • Sabóia RSC • Leite Segundo AV

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