- Email: [email protected]
RETRIEVAL OF A BROKEN NEEDLE IN THE PTERYGOMANDIBULAR SPACE
CLINICAL
PRACTICE CASE REPORT
RETRIEVAL OF A BROKEN NEEDLE IN THE PTERYGOMANDIBULAR SPACE ROY D. BEDROCK, M.S., D.M.D., M.D.; ANDREW SKIGEN, D.M.D.; M. FRANKLIN DOLWICK, D.M.D., PH.D.
Since the intro-
general dentist to A B S T R A C T duction of disposthe University of able dental neeBackground. Dental needle breakage can be a devastat- Florida School of dles in the early Dentistry’s ing experience for both practitioners and patients. The authors 1960s, the freDepartment of Oral describe the surgical management for localizing a broken dental quency of needle and Maxillofacial needle in the pterygomandibular space and how to prevent neebreakage has been Surgery for evaluadle breakage. minimal, comtion and removal of Case Description. The authors present the case of pared with the a 35-year-old man who had a chief complaint of pain and the abil- a 30-gauge long first quarter of needle that broke ity to feel a broken needle during mandibular movements after this century durreceiving an inferior alveolar nerve block from his general dentist during an inferior ing which time alveolar nerve before dental treatment. Surgical management involved localizrigid, inflexible, block. The dentist ing the broken needle using radiographs and removing the bronondisposable nee- ken needle under general anesthesia. and patient both dles were used. In stated that the paClinical Implications. Preventing needle break1924, Blum1 retient had moved his age is important, as it can be a traumatic experience for the paported 65 cases of head quickly when tient. Practitioners should establish the patient’s cooperation by broken needles in receiving the injecexplaining to him or her what to expect before injection. a 10-year period. tion. Practitioners also should routinely inspect dental needles before The occurrence The patient was administering injections and minimize the number of repeated of needle breakage healthy with no injections using the same needle. has decreased as a significant medical result of the development of stainless, flexible alhistory. He denied any current medication use loys used in modern, disposable dental needles.2 and had no drug allergies. Results of a physical Scientific advances in metallurgy and manufacexamination of the patient were essentially negaturing, as well as better training of dental practitive. The patient’s chief complaint was localized tioners in how to administer anesthetic also have pain to the left pterygomandibular region and the reduced breakage frequency.3 ability to feel the broken needle during mandibuThe removal of a broken dental needle that has lar movements. been lodged in the pterygomandibular space may To establish the general location of the broken be a difficult procedure. Therefore, a thorough unneedle, we took preoperative radiographs showing derstanding of this anatomical site and its conpanoramic, lateral skull and anterior-posterior tents is essential. skull views. The panoramic radiograph served as a standard guiding film to initially localize the REPORT OF A CASE broken needle. The lateral skull view helped us A 35-year-old male patient was referred by his determine the needle’s anterior-posterior location JADA, Vol. 130, May 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
685
CLINICAL PRACTICE
A B
Figure 1. Lateral skull radiograph showing the relationship of the broken needle (A) to the reference needle (B).
and also showed us its vertical relation to the teeth.4 The anterior-posterior view showed us the relationship of the needle in a medial and lateral relationship to the mandible. After we completely discussed the risks and benefits of removing the broken needle with the patient, we obtained his informed and written consent. The patient was taken to the operating room and placed under general anesthesia. The oral cavity was prepped and draped in the usual surgical manner. We placed a prop in the patient’s mouth and thoroughly examined the left pterygomandibular space for any signs of the needle. We inserted an 18-gauge reference needle in the left pterygomandibular space parallel to the occlusal plane of the dentition. We obtained lateral and anteriorposterior skull radiographs, which revealed that the 30gauge needle was inferior to and crossed over the 18-gauge needle distally near the posterior-medial surface of the mandible (Figure 1). We made a 4-centimeter inci686
Figure 2. Postoperative lateral skull radiograph. Note the absence of the broken needle.
sion along the external oblique ridge of the mandible and used a periosteal elevator to reflect the masseter and medial pterygoid musculature. During blunt dissection of the medial pterygoid muscle, we removed the broken 30-gauge needle. It was approximately 20 millimeters long. Postoperative radiographs
While there is still controversy as to whether or not to remove a broken dental needle, recognition, localization and documentation are of paramount importance. revealed that we had completely removed the needle (Figure 2). We copiously irrigated the surgical site with sterile saline solution and closed it, using 4-0 polyglactin 910 sutures. The patient tolerated the procedure well and was transported to the recovery room in sta-
ble condition. The patient’s postoperative course was unremarkable, and he was discharged the next morning. The mandibular branch of the trigeminal nerve was found to be intact postoperatively. DISCUSSION
While there is still controversy as to whether or not to remove a broken dental needle, recognition, localization and documentation are of paramount importance. In the 1950s, FraserMoodie5 and Aimes6 suggested removal, fearing that the needle might migrate toward large blood vessels in the head and neck. Brown and Meerkotter7 and Cawson8 felt that removal was not necessary unless the patient developed symptoms such as pain, infection, numbness and swelling. Today, however, removal is warranted not only because of the fear of needle migration but also because of the medicolegal considerations.9 Psychologically, patients are at ease knowing that the foreign body has been removed, and practitioners are relieved that the possibility of
JADA, Vol. 130, May 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
CLINICAL PRACTICE needle migration is no longer an issue. It behooves general practitioners and specialists to be familiar not only with the anatomy involved but also with how to confront this unfortunate situation should it occur. As with any dental or medical mishap, the practitioner should remain calm and advise the patient of the circumstance. He or she also should convey to the patient that although this is a rare occurrence, removing the broken needle is necessary to prevent any further complications. Immediate referral to an oral and maxillofacial surgeon is necessary, as is thorough and complete documentation of the events that led to the breakage. PREVENTION
Needle breakage during a routine inferior alveolar nerve block can be a devastating and depressing experience. Preventing this type of unfortunate event is of paramount importance. Before administering an injection, dental practitioners should first establish the patient’s cooperation by thoroughly explaining to him or her what to expect. Any sudden or unexpected movement by the patient during administration of the injection is considered to be a contributing factor to needle breakage.3 Examination of the needle before administering the injection should be standard practice among dental practitioners. If a practitioner notes any needle defects, he or she should discard
the needle. Repeated injections with the same needle should be minimized, as Dr. Bedrock was an needle fragiliassistant professor, Department of Oral ty and suscepand Maxillofacial tibility to Surgery, College of breakage with Dentistry, University repeated injec- of Florida, Gainesville, when this artitions has been cle was written. He 10 now is a clinical asdocumented. sistant professor, Short neeDepartment of Oral dles are inade- and Maxillofacial Surgery, School of quate when Dental Medicine, performing an Southern Illinois University; an attendinferior alveoing oral and maxillolar nerve facial surgeon, block. In 1961, Barnes-Jewish Medical Center, St. Archer11 sugLouis; and in private gested that no practice, St. Louis. Address reprint reneedle shorter quests to Dr. than 42 mm or Bedrock at 605 Old Ballas Road, Suite smaller than 110, St. Louis, Mo. 25 gauge 63141. should be used for nerve-blocking injections. Pietruszka and colleagues12 suggested that a 30-gauge needle should not be used for nerveblocking injections because it is the most narrow, least rigid needle available and also the most susceptible to breakage. We suggest using a 27-gauge, 35-mm long needle for inferior alveolar nerve blocks. We also recommend not penetrating the needle to its hub, as this is where the needle is the weakest and sight of the needle can be lost when it is buried to the hub. CONCLUSION
The management of a broken
Dr. Skigen is a resi-
Dr. Dolwick is a pro-
dent, Department of
fessor and director,
Oral and Maxillo-
Oral and Maxillo-
facial Surgery,
facial Surgery
College of Dentistry,
Residency Program,
University of Florida,
College of Dentistry,
Gainesville.
University of Florida, Gainesville.
needle after an inferior alveolar nerve block should involve its immediate removal to prevent it from migrating among vital structures such as blood vessels, nerves, muscles and bones. This approach also is advocated to prevent medicolegal issues from arising. ■ 1. Blum T. Further observations with hypodermic needles broken during the administration of oral local anesthesia: a report of sixtyfive cases. Dent Cosmos 1924;66:322. 2. Stafne EC. Oral roentgenographic diagnosis. 3rd ed. Philadelphia: Saunders; 1969:283. 3. Crouse V. Migration of a broken anesthetic needle: report of a case. S C Dent J 1970;28(9):16-9. 4. Dudani IC. Broken needles following mandibular injections. J Indian Dent Assoc 1971;43(1):14-7. 5. Fraser-Moodie W. Recovery of broken needles. Br Dent J 1958;105:79. 6. Aimes ABP. Broken needles. Aust Dent J 1951;55:403. 7. Brown LJ, Meerkotter VA. An unusual experience with a broken needle. J Dent Assoc S Afr 1963;18:74. 8. Cawson RA. Essentials of dental surgery and pathology. 2nd ed. London: Churchill; 1968. 9. Marks RB, Carlton DM, McDonald S. Management of a broken needle in the pterygomandibular space: report of a case. JADA 1984;109(2):263-4. 10. Fitzpatrick B. The broken dental needle. Aust Dent J 1967;12:243-5. 11. Archer WH. Oral surgery: A step-bystep atlas of operative techniques. 3rd ed. Philadelphia: Saunders;1961:483. 12. Pietruszka JF, Hoffman D, McGivern BE Jr. A broken dental needle and its surgical removal: a case report. NY State Dent J 1986;52:28-31.
JADA, Vol. 130, May 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
687
PRACTICE CASE REPORT
RETRIEVAL OF A BROKEN NEEDLE IN THE PTERYGOMANDIBULAR SPACE ROY D. BEDROCK, M.S., D.M.D., M.D.; ANDREW SKIGEN, D.M.D.; M. FRANKLIN DOLWICK, D.M.D., PH.D.
Since the intro-
general dentist to A B S T R A C T duction of disposthe University of able dental neeBackground. Dental needle breakage can be a devastat- Florida School of dles in the early Dentistry’s ing experience for both practitioners and patients. The authors 1960s, the freDepartment of Oral describe the surgical management for localizing a broken dental quency of needle and Maxillofacial needle in the pterygomandibular space and how to prevent neebreakage has been Surgery for evaluadle breakage. minimal, comtion and removal of Case Description. The authors present the case of pared with the a 35-year-old man who had a chief complaint of pain and the abil- a 30-gauge long first quarter of needle that broke ity to feel a broken needle during mandibular movements after this century durreceiving an inferior alveolar nerve block from his general dentist during an inferior ing which time alveolar nerve before dental treatment. Surgical management involved localizrigid, inflexible, block. The dentist ing the broken needle using radiographs and removing the bronondisposable nee- ken needle under general anesthesia. and patient both dles were used. In stated that the paClinical Implications. Preventing needle break1924, Blum1 retient had moved his age is important, as it can be a traumatic experience for the paported 65 cases of head quickly when tient. Practitioners should establish the patient’s cooperation by broken needles in receiving the injecexplaining to him or her what to expect before injection. a 10-year period. tion. Practitioners also should routinely inspect dental needles before The occurrence The patient was administering injections and minimize the number of repeated of needle breakage healthy with no injections using the same needle. has decreased as a significant medical result of the development of stainless, flexible alhistory. He denied any current medication use loys used in modern, disposable dental needles.2 and had no drug allergies. Results of a physical Scientific advances in metallurgy and manufacexamination of the patient were essentially negaturing, as well as better training of dental practitive. The patient’s chief complaint was localized tioners in how to administer anesthetic also have pain to the left pterygomandibular region and the reduced breakage frequency.3 ability to feel the broken needle during mandibuThe removal of a broken dental needle that has lar movements. been lodged in the pterygomandibular space may To establish the general location of the broken be a difficult procedure. Therefore, a thorough unneedle, we took preoperative radiographs showing derstanding of this anatomical site and its conpanoramic, lateral skull and anterior-posterior tents is essential. skull views. The panoramic radiograph served as a standard guiding film to initially localize the REPORT OF A CASE broken needle. The lateral skull view helped us A 35-year-old male patient was referred by his determine the needle’s anterior-posterior location JADA, Vol. 130, May 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
685
CLINICAL PRACTICE
A B
Figure 1. Lateral skull radiograph showing the relationship of the broken needle (A) to the reference needle (B).
and also showed us its vertical relation to the teeth.4 The anterior-posterior view showed us the relationship of the needle in a medial and lateral relationship to the mandible. After we completely discussed the risks and benefits of removing the broken needle with the patient, we obtained his informed and written consent. The patient was taken to the operating room and placed under general anesthesia. The oral cavity was prepped and draped in the usual surgical manner. We placed a prop in the patient’s mouth and thoroughly examined the left pterygomandibular space for any signs of the needle. We inserted an 18-gauge reference needle in the left pterygomandibular space parallel to the occlusal plane of the dentition. We obtained lateral and anteriorposterior skull radiographs, which revealed that the 30gauge needle was inferior to and crossed over the 18-gauge needle distally near the posterior-medial surface of the mandible (Figure 1). We made a 4-centimeter inci686
Figure 2. Postoperative lateral skull radiograph. Note the absence of the broken needle.
sion along the external oblique ridge of the mandible and used a periosteal elevator to reflect the masseter and medial pterygoid musculature. During blunt dissection of the medial pterygoid muscle, we removed the broken 30-gauge needle. It was approximately 20 millimeters long. Postoperative radiographs
While there is still controversy as to whether or not to remove a broken dental needle, recognition, localization and documentation are of paramount importance. revealed that we had completely removed the needle (Figure 2). We copiously irrigated the surgical site with sterile saline solution and closed it, using 4-0 polyglactin 910 sutures. The patient tolerated the procedure well and was transported to the recovery room in sta-
ble condition. The patient’s postoperative course was unremarkable, and he was discharged the next morning. The mandibular branch of the trigeminal nerve was found to be intact postoperatively. DISCUSSION
While there is still controversy as to whether or not to remove a broken dental needle, recognition, localization and documentation are of paramount importance. In the 1950s, FraserMoodie5 and Aimes6 suggested removal, fearing that the needle might migrate toward large blood vessels in the head and neck. Brown and Meerkotter7 and Cawson8 felt that removal was not necessary unless the patient developed symptoms such as pain, infection, numbness and swelling. Today, however, removal is warranted not only because of the fear of needle migration but also because of the medicolegal considerations.9 Psychologically, patients are at ease knowing that the foreign body has been removed, and practitioners are relieved that the possibility of
JADA, Vol. 130, May 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
CLINICAL PRACTICE needle migration is no longer an issue. It behooves general practitioners and specialists to be familiar not only with the anatomy involved but also with how to confront this unfortunate situation should it occur. As with any dental or medical mishap, the practitioner should remain calm and advise the patient of the circumstance. He or she also should convey to the patient that although this is a rare occurrence, removing the broken needle is necessary to prevent any further complications. Immediate referral to an oral and maxillofacial surgeon is necessary, as is thorough and complete documentation of the events that led to the breakage. PREVENTION
Needle breakage during a routine inferior alveolar nerve block can be a devastating and depressing experience. Preventing this type of unfortunate event is of paramount importance. Before administering an injection, dental practitioners should first establish the patient’s cooperation by thoroughly explaining to him or her what to expect. Any sudden or unexpected movement by the patient during administration of the injection is considered to be a contributing factor to needle breakage.3 Examination of the needle before administering the injection should be standard practice among dental practitioners. If a practitioner notes any needle defects, he or she should discard
the needle. Repeated injections with the same needle should be minimized, as Dr. Bedrock was an needle fragiliassistant professor, Department of Oral ty and suscepand Maxillofacial tibility to Surgery, College of breakage with Dentistry, University repeated injec- of Florida, Gainesville, when this artitions has been cle was written. He 10 now is a clinical asdocumented. sistant professor, Short neeDepartment of Oral dles are inade- and Maxillofacial Surgery, School of quate when Dental Medicine, performing an Southern Illinois University; an attendinferior alveoing oral and maxillolar nerve facial surgeon, block. In 1961, Barnes-Jewish Medical Center, St. Archer11 sugLouis; and in private gested that no practice, St. Louis. Address reprint reneedle shorter quests to Dr. than 42 mm or Bedrock at 605 Old Ballas Road, Suite smaller than 110, St. Louis, Mo. 25 gauge 63141. should be used for nerve-blocking injections. Pietruszka and colleagues12 suggested that a 30-gauge needle should not be used for nerveblocking injections because it is the most narrow, least rigid needle available and also the most susceptible to breakage. We suggest using a 27-gauge, 35-mm long needle for inferior alveolar nerve blocks. We also recommend not penetrating the needle to its hub, as this is where the needle is the weakest and sight of the needle can be lost when it is buried to the hub. CONCLUSION
The management of a broken
Dr. Skigen is a resi-
Dr. Dolwick is a pro-
dent, Department of
fessor and director,
Oral and Maxillo-
Oral and Maxillo-
facial Surgery,
facial Surgery
College of Dentistry,
Residency Program,
University of Florida,
College of Dentistry,
Gainesville.
University of Florida, Gainesville.
needle after an inferior alveolar nerve block should involve its immediate removal to prevent it from migrating among vital structures such as blood vessels, nerves, muscles and bones. This approach also is advocated to prevent medicolegal issues from arising. ■ 1. Blum T. Further observations with hypodermic needles broken during the administration of oral local anesthesia: a report of sixtyfive cases. Dent Cosmos 1924;66:322. 2. Stafne EC. Oral roentgenographic diagnosis. 3rd ed. Philadelphia: Saunders; 1969:283. 3. Crouse V. Migration of a broken anesthetic needle: report of a case. S C Dent J 1970;28(9):16-9. 4. Dudani IC. Broken needles following mandibular injections. J Indian Dent Assoc 1971;43(1):14-7. 5. Fraser-Moodie W. Recovery of broken needles. Br Dent J 1958;105:79. 6. Aimes ABP. Broken needles. Aust Dent J 1951;55:403. 7. Brown LJ, Meerkotter VA. An unusual experience with a broken needle. J Dent Assoc S Afr 1963;18:74. 8. Cawson RA. Essentials of dental surgery and pathology. 2nd ed. London: Churchill; 1968. 9. Marks RB, Carlton DM, McDonald S. Management of a broken needle in the pterygomandibular space: report of a case. JADA 1984;109(2):263-4. 10. Fitzpatrick B. The broken dental needle. Aust Dent J 1967;12:243-5. 11. Archer WH. Oral surgery: A step-bystep atlas of operative techniques. 3rd ed. Philadelphia: Saunders;1961:483. 12. Pietruszka JF, Hoffman D, McGivern BE Jr. A broken dental needle and its surgical removal: a case report. NY State Dent J 1986;52:28-31.
JADA, Vol. 130, May 1999 Copyright ©1998-2001 American Dental Association. All rights reserved.
687