Needle breakage following inferior alveolar nerve block: implications and management

Observational and descriptive analysis of broken dental needles: a case series

PURPOSE

To discuss potential causes of broken dental needles during dental anesthesia and features of this complication, including the anatomical location of fragments in tissues, symptoms, complications, and therapeutic approaches.

METHODS

Twelve cases of broken dental needles occurring during dental anesthesia and subsequently referred to Hospital de Base do Distrito Federal, Brazil, between 1992 and 2019 were selected. In addition, similar cases reported in the literature over the past 50 years were reviewed.

RESULTS

Needle fractures occur most frequently during inferior alveolar nerve blocks and in younger patients. The leading cause is unexpected patient movement during the anesthetic procedure. The needle fragment is most commonly found in the pterygomandibular space or the deep spaces of the head and neck region. Needle migration is a particular concern; although rare, it is unpredictable and potentially life-threatening.

CONCLUSIONS

Needle fracture is an intraoperative complication which has the potential to cause severe patient damage. It is essential that practitioners have knowledge of this possible complication and understand the technical considerations for its prevention. The existing literature and the results of this case series analysis suggest that removal of the fractured needle fragment should be attempted as soon as possible.

Removal of a suture needle: a case report

Background

Foreign bodies may be embedded or left behind in the oral cavity during oral surgical procedure. The loss of instruments such as impression material, surgical gauze, and broken injection needles are commonly reported in the dental field. These complications are generally symptomatic and show signs of inflammation, pain, and purulent discharge. Accidental breakage of suture needles is a rare but potentially dangerous event.

Case presentation

In this report, we present one case of lost suture needle during the procedure of flap operation at local dental clinic and its successful removal under local/general anesthesia administration via CBCT with a help of two reference needles to localize the 6-0 nylon needle and consulting with the clinician.

Conclusion

CT scanning taken while mouth-closing may not be accurate with regard to real location measurement performed while mouth-opening. If so, other up-to-date radiographic devices and methods to retrieve a needle are recommended.

Physical, chemical, mechanical, and micromorphological characterization of dental needles

Background

In anesthetic techniques, touching bones can cause needle bending. Theoretically, a needle should support such deflection without fracturing. However, it is possible that a needle may fracture depending on the quality and type of needle used. This study evaluated the physical, chemical, and micromorphological characteristics of long and short dental anesthetic needles, as well as the mechanical properties of flexural load and bending resistance when needles are subjected to different bending angles.

Methods

Long and short needles (30G, Jets, Misawa, Selekto, Terumo, Unoject and 27G, Dencojet, Injex, Jets, Misawa, Procare, Setoject XL, Terumo) were evaluated. Scanning electron microscopy was used to evaluate the needle bevels and energy-dispersive X-ray spectroscopy was used for the chemical analysis of needle compositions. Flexural loading and bending strength assessments were performed using a universal testing machine by bending the needles (n = 5) to angles of 30°, 60°, or 90°, or until fracture occurred.

Results

The Injex 27G, Jets 27G, and Septoject XL 27G needles were all less than 30 mm in length. There were small percentage variations in the chemical compositions of the needles. Superior smoothness was observed for the Unoject 30G needle, which exhibited the highest fracture resistance at 60°. The Jets 30G needle exhibited greater resistance to fractures at 90°. The Procare 27G needle exhibited the highest load resistance to bending, followed by the Septoject XL 27G needle, and both needles were tied for the lowest fracture resistance. No needle fractured when bent to 30° or at less than three bends to 60° or 90°.

Conclusions

Greater needle resistance to bending increases the probability of early fracturing. Thinner and shorter needles are more resistant than longer and thicker needles. Performing a single bend does not result in any significant risk of fracture or obliterate the lumen, allowing for the continued passage of anesthetic liquid.

The retrieval of a surgical blade broken within the alveolar bone during minimally traumatic tooth extraction

Minimally traumatic tooth removal is the norm for removing teeth when a dental implant is planned at that site. The quantity of available bone is the primary requisite to place an implant. The initial use of a scalpel blade to widen the periodontal space followed by the use of luxators is one of the techniques that is being followed for atraumatic extraction. A case of accidental breakage of a number 11 scalpel blade while attempting tooth removal and the method adopted in removing this portion of the blade without further bone destruction is reported here. The authors have not found any previously published cases, reporting the breakage of a scalpel blade during the bone expansion procedure and its management.

Fractured Needle Removal With a 3-Dimensionally Printed Surgical Guide: A Case Report and Literature Review

Needle breakage is a rare complication of inferior alveolar nerve block anesthesia. This study proposes a new localization technique. We used a three-dimensionally printed surgical guide, supported by the lower dental arch to minimize the required surgical access. With this approach, the procedure could be performed with procedural sedation anesthesia.

Use of Intraoperative Biplanar Fluoroscopy for Minimally Invasive Retrieval of a Broken Dental Needle

This report describes a case of needle breakage during a left-sided inferior alveolar nerve block to perform restorative dentistry on a 56-year-old male patient. The needle was removed in conjunction with interventional neuroradiology using biplanar fluoroscopy.

[Medical solution to needle breakage during local anesthesia]

Needle breakage may be a damaging experience for both medical practitioners and patients. Medical literature provides numerous cases of dental practitioners being confronted with this problem. We have studied the clinical case of the patient L. at the Moscow State University of Medicine and Dentistry involving needle breakage during conductive anesthesia. We propose our medical approach to solving this issue alongside with a desirable course of action, providing additional recommendations and suggesting intraosseous anesthesia as a safer type of pain management.

Measurement of mandibular lingula location using cone-beam computed tomography and internal oblique ridge-guided inferior alveolar nerve block

Objectives

Inferior alveolar nerve block (IANB) is the most frequently used treatment for mandibular molars. Successful IANB requires insertion of the dental needle near the mandibular foramen. In this study, we aimed to analyze the anatomic location of the mandibular lingula and evaluate the effects of internal oblique ridge (IOR)-guided IANB.

Materials and Methods

The location of the mandibular lingula was measured using cone-beam computed tomography images of the mandibles obtained from 125 patients. We measured the distances from the occlusal plane to the lingula and from the IOR to the lingula in 250 mandibular rami. Based on the mean of these distances, alternative anesthesia was carried out on 300 patients, and the success rate of the technique was evaluated.

Results

The mean vertical distance was 8.85±2.59 mm, and the mean horizontal distance was 14.68±1.44 mm. The vertical (P<0.001) and the horizontal (P<0.05) distances showed significant differences between the sex groups. The success rate of the IOR-guided technique was 97.3%.

Conclusion

IANB-based location of mandibular lingula showed a high success rate. From this study, we concluded that analysis of the anatomic locations for mandibular lingula and IOR-guided IANB are useful for restorative and surgical dental procedures of the mandibular molars.

Is intraoperative navigation for needle breakage mandatory?: A case report

BACKGROUND AND OVERVIEW

Needle breakage when administering local anesthetic in the oral cavity can be of major concern to both the patient and the dentist. Intraoperative navigation has become the most popular advanced imaging technique.

CASE DESCRIPTION

In this report, the authors describe a case of needle breakage during inferior alveolar nerve block for a dental procedure. Using preoperative imaging, the authors located the needle and removed it while the patient was under general anesthesia. The authors review studies and case reports similar to the pre- and intraoperative imaging modalities presented in their report.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Preoperative 3-dimensional imaging is sufficient for establishing the exact location of the broken needle, especially in cases in which potential migration is unlikely.

Avaliação da deformação de agulhas gengivais e análise fractal

Resumo Introdução A fratura da agulha na anestesia odontológica é rara, mas sua ocorrência tem sérias complicações e deve ser evitada. Objetivo O objetivo deste estudo foi avaliar a deformação de agulhas dentárias após a aplicação de forças de compressão. Material e método Agulhas das marcas Dencojet e Septoject XL nos calibres 27G e 30G (quatro grupos) foram dobradas em dois sentidos opostos em máquina de ensaio mecânico DL200 - EMIC, com base na ISO 7885:2010. A resistência à compressão das agulhas foi medida em cada dobra. Ao final, foi realizada inspeção visual em uma lupa EK3ST em aumento de 40×, para análise da integridade das agulhas. Resultado As agulhas de calibre 30G não apresentaram diferenças significativas entre elas. As agulhas de maior calibre (27G) apresentaram diferenças no primeiro (p = 0,0001) e no segundo dobramento (p = 0,0016). As agulhas Septoject XL 27G demonstraram ser muito menos flexíveis, fornecendo valores mais altos de resistência à dobra. No grupo Septoject XL 30G, 70% das agulhas fraturaram próximo ao canhão. Todas as amostras do grupo Septoject XL 27G apresentaram fraturas após a segunda dobra. Conclusão Todas as agulhas gengivais testadas apresentaram comportamento aceitável, mesmo quando submetidas a situações críticas. As agulhas Dencojet 27G demonstraram ser mais flexíveis quando dobradas. Todas as agulhas Septoject XL 27G fraturaram após a segunda dobra. Não é aconselhável dobrar as agulhas dentárias.

Displacement of a Broken Dental Injection Needle Into the Perivertebral Space

Dental injection needle breakage is an uncommon problem in dental practice. Displacement of the broken fragment into anatomical spaces is, on the other hand, a serious complication that occurs most commonly during inferior alveolar nerve blocks as a result of material wear, incorrect application of the anesthesia technique, or sudden movement of the patient during injection. Further complications such as infection, trismus, and nerve paralysis may exacerbate the condition and, if not treated adequately, life-threatening conditions may develop over time as the fragment dislodges deeper in soft tissues. Clinical symptoms of the patient, as well as the findings gathered from detailed physical examination and radiographic evaluation, are important factors to consider before performing an exploratory surgery. Removal of a broken needle may be troublesome due to its proximity to vital anatomic structures. Multislice computed tomography is a reliable imaging modality that provides accurate information to pinpoint the exact location of the needle fragment.This report describes a case of needle breakage occurred during inferior alveolar nerve block which was performed to extract a third molar tooth and the migration of the broken fragment from the right mandibular ramus area into the perivertebral space, with special emphasis on the surgical retrieval technique with multiplanar computed tomography imaging guidance.

Radiographic and computed tomography monitoring of a fractured needle fragment in the mandibular branch

Some complications can arise with the usage of local anesthesia for dental procedures, including the fracture of needles in the patient. This is a rare incident, usually caused by the patient's sudden movements during anesthetic block. Its complications are not common, but can include pain, trismus, inflammation in the region, difficulty in swallowing, and migration of the object, which is the least common but has the ability to cause more serious damage to the patient. This report describes a case in which, after the fracture of the anesthetic needle used during alveolar nerve block for exodontia of the left mandibular third molar, the fragment moved significantly in the first 2 months, before stabilizing after the third month of radiographic monitoring.

A novel case of a broken dental anesthetic needle transecting the right internal carotid artery

BACKGROUND AND OVERVIEW

Although dental anesthetic needle fractures remain an uncommon occurrence, there is a lack of consensus on the management of the treatment of this complication. Complications could include trismus, dysphagia, or infection that may lead to more deleterious results.

CASE DESCRIPTION

In this case study, a 47-year-old man underwent a routine dental extraction at a private office. During administration of the inferior alveolar nerve block, a dental anesthetic needle fractured. The general dental practitioner dismissed the patient and reassured him that no retrieval of the needle was needed. Several weeks later, the patient sought care for severe, acute pain and dysphagia. Traditional retrieval techniques were unsuccessful, and the authors consulted the neurosurgery team. The patient underwent endovascular surgery with digital subtraction angiography for retrieval of the needle from the right internal carotid artery.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Most authors in the literature agree that proper technique and equipment are paramount in avoiding fractures of dental anesthetic needles. Although needle fracture is a rare complication, immediate referral and retrieval of the broken needle by an appropriately trained surgeon is essential for optimal outcomes. This case demonstrates an example of a broken needle that migrated and transected the internal carotid artery at the jugular foramen. All dental practitioners must be cognizant of the potentially serious complications associated with a retained broken needle.

Case Report: Fractured Needle in the Pterygomandibular Space Following Administration of an Inferior Dental Nerve Block

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.

A basic review on the inferior alveolar nerve block techniques

The inferior alveolar nerve block is the most common injection technique used in dentistry and many modifications of the conventional nerve block have been recently described in the literature. Selecting the best technique by the dentist or surgeon depends on many factors including the success rate and complications related to the selected technique. Dentists should be aware of the available current modifications of the inferior alveolar nerve block techniques in order to effectively choose between these modifications. Some operators may encounter difficulty in identifying the anatomical landmarks which are useful in applying the inferior alveolar nerve block and rely instead on assumptions as to where the needle should be positioned. Such assumptions can lead to failure and the failure rate of inferior alveolar nerve block has been reported to be 20-25% which is considered very high. In this basic review, the anatomical details of the inferior alveolar nerve will be given together with a description of its both conventional and modified blocking techniques; in addition, an overview of the complications which may result from the application of this important technique will be mentioned.

Broken dental needle retrieval using a surgical navigation system: a case report and literature review

This paper reports a case of fractured needle retrieval in the pterygomandibular space using the Medtronic surgical navigation system. Current literature on needle fracture and retrieval in the oral cavity was also reviewed. A literature search was conducted in the following databases: PubMed, MDConsult, The Cochrane Library, and Google. A variety of keywords were used, including "needle fracture," "broken dental needle," "needle injuries in dentistry," "foreign body retrieval," and "dental needle retrieval." Articles published after 1980 were reviewed. Seventeen articles that involved broken dental needle retrieval were selected.

Unique migration of a dental needle into the parapharyngeal space: successful removal by an intraoral approach and simulation for tracking visibility in X-ray fluoroscopy

OBJECTIVES

The first objective was to describe a novel case of migration of a broken dental needle into the parapharyngeal space. The second was to address the importance of simulation elucidating visualization of such a thin needle under X-ray fluoroscopy.

METHODS

Clinical case records (including computed tomography [CT] and surgical approaches) were reviewed, and a simulation experiment using a head phantom was conducted using the same settings applied intraoperatively.

RESULTS

A 36-year-old man was referred after failure to locate a broken 31-G dental needle. Computed tomography revealed migration of the needle into the parapharyngeal space. Intraoperative X-ray fluoroscopy failed to identify the needle, so a steel wire was applied as a reference during X-ray to locate the foreign body. The needle was successfully removed using an intraoral approach with tonsillectomy under surgical microscopy. The simulation showed that the dental needle was able to be identified only after applying an appropriate compensating filter, contrasting with the steel wire.

CONCLUSION

Meticulous preoperative simulation regarding visual identification of dental needle foreign bodies is mandatory. Intraoperative radiography and an intraoral approach with tonsillectomy under surgical microscopy offer benefits for accessing the parapharyngeal space, specifically for cases medial to the great vessels.

Intermuscular pterygoid-temporal abscess following inferior alveolar nerve block anesthesia-A computer tomography based navigated surgical intervention: Case report and review

Inferior alveolar nerve block (IANB) anesthesia is a common local anesthetic procedure. Although IANB anesthesia is known for its safety, complications can still occur. Today immediately or delayed occurring disorders following IANB anesthesia and their treatment are well-recognized. We present a case of a patient who developed a symptomatic abscess in the pterygoid region as a result of several inferior alveolar nerve injections. Clinical symptoms included diffuse pain, reduced mouth opening and jaw's hypomobility and were persistent under a first step conservative treatment. Since image-based navigated interventions have gained in importance and are used for various procedures a navigated surgical intervention was initiated as a second step therapy. Thus precise, atraumatic surgical intervention was performed by an optical tracking system in a difficult anatomical region. A symptomatic abscess was treated by a computed tomography-based navigated surgical intervention at our department. Advantages and disadvantages of this treatment strategy are evaluated.

C-arm fluoroscopy: a reliable modality for retrieval of foreign bodies in the maxillofacial region

The anatomic complexity of the maxillofacial region makes the retrieval of foreign bodies a daunting task for the maxillofacial Surgeon. Moreover the inability of 2-dimensional imaging to precisely locate foreign bodies makes it challenging. The anatomic proximity of critical structures and esthetic considerations limits the access and thus poses a greater challenge for the surgeon in cases of foreign body retrieval. Hereby we propose a simple technique and a case report to support, the retrieval of small (<5 mm greatest dimension) objects from the maxillofacial region. The present technique uses a 2 dimensional mobile C arm Fluoroscopy and a needle triangulation method to precisely locate a loosened miniplate screw in the mandibular angle region.

Needle in the external auditory canal: an unusual complication of inferior alveolar nerve block

Inferior alveolar nerve block is used to anesthetize the ipsilateral mandible. The most commonly used technique is one in which the anesthetic is injected directly into the pterygomandibular space, by an intraoral approach. The fracture of the needle, although uncommon, can lead to potentially serious complications. The needle is usually found in the pterygomandibular space, although it can migrate and damage adjacent structures, with variable consequences. The authors report an unusual case of a fractured needle, migrating to the external auditory canal, as a result of an inferior alveolar nerve block.

Removal of a broken needle using three-dimensional computed tomography: a case report

Inferior alveolar nerve block obtained maximum anesthetic effect using a small dose of local anesthetic agent, which also has low a complication incidence. Complications of an inferior alveolar nerve block include direct nerve damage, bleeding, trismus, temporary facial nerve palsy, and etc. Among them, the major iatrogenic complication is dental needle fracture. A fragment that disappears into the soft tissue would be hard to remove, giving rise to a legal problem. A 31-year-old woman was referred for the removal of a broken needle, following an inferior alveolar nerve block. Management involved the removal of the needle under local anesthesia with pre- and peri-operative computed tomography scans.

[Head and neck cellulitis caused by a broken anesthesia needle]

INTRODUCTION

Third molar extraction is one of the most common surgical procedures in oral and maxillofacial surgery. Infectious complications can be estimated at 3.6% after local anesthesia.

OBSERVATION

A 39-year-old female patient, presenting with important swelling of the face and neck after extraction of teeth 28 and 38 after local anesthesia. Clinical and radiographic data led to the diagnosis of facial cellulitis due to a foreign body on the sub angulo-mandibular region. Drainage under general anesthesia was performed and a fragment of anesthesia needle was removed. One month after surgery, the patient was considered cured.

DISCUSSION

Breaking an anesthesia needle is a rare accident, which can occur during oral surgery under local anesthesia. Respecting the rules of good practice is essential in preventing this type of complication, especially since forensic rules for dental and oral surgery are becoming stricter.

Long buccal nerve block: a previously unreported complication

Although local anesthetic injections are commonly used in dental practice, the complex neurovascular anatomy of the face can present the practitioner with unexpected complications. Several reports document adverse events related to inferior dental blocks (IDBs), whereas long buccal nerve blocks are usually performed without incident. We describe a previously unreported complication of a long buccal nerve block involving blanching, pain, and paresthesia specifically within the infraorbital arterial territory of the face. We had previously reported an identical event resulting from an IDB. We discuss the facial vascular relationships that might explain this complication and how to manage it.

The clinical application of the dental mini C-arm for the removal of broken instruments in soft and hard tissue in the oral and maxillofacial area

Many kinds of broken instruments, such as needles, probes, scalpels and catheters, are reported to be left in patients after surgery. These parts should be removed as soon as possible to prevent further complications. However, it is not easy to identify the exact location of the instrument intraoperatively, and a risk of damage exists for neighbouring nerves or vessels during the removal. The C-arm used in orthopaedic surgery, is seen as a useful and safe way to detect metal materials intraoperatively. However, its application for removal of broken instruments in the oral and maxillofacial area is not practical because of its large size. In our experiences with the removal of eight broken instruments in the oral and maxillofacial area, the newly developed dental mini C-arm was useful in finding broken instruments in soft tissue (five cases) and in paranasal sinus (one case), because it gives real time in situ information. This is important, because the position of the broken instrument can be changed due to traction of the soft tissue or swelling. The dental mini C-arm was less helpful in finding broken instruments in soft tissues compared to hard tissues (two cases) as the position of instruments did not change.

An Audit of the Use of Intra-Septal Local Anaesthesia in a Dental Practice in the South of England

Aim

The aim of this audit was to evaluate the efficacy, when used by the author, of the intra-septal local anaesthetic technique for cavity preparation in mandibular molar and premolar teeth.

Methods

One hundred and thirteen consecutive patients who required local anaesthesia (LA) for cavity preparation in lower molar and premolar teeth in a general dental practice took part in the audit sample. Articaine 4%, with1:100,000 adrenaline (epinephrine), was administered using the intra-septal technique. Visual analogue scales (VAS) were used to record pain experienced on injection and the quality of anaesthesia obtained. Any side-effects reported were recorded. The standards set were that at least 70% should find the administration of the LA pain-free and that at least 80% should experience no pain during cavity preparation.

Results

Sixty-nine (62%) patients reported the injection technique to be completely pain-free and a further 23 (20%) reported very minor pain on injection. Eighty (71%) patients reported pain-free treatment and 18 (16%) experienced very minor pain during treatment. No side-effects were reported. Patients aged under 40 years and those who had cavities prepared in first premolar teeth appeared more likely to experience pain during cavity preparation.

Conclusion

The intra-septal injection technique requires no specialist equipment, is easily administered, rapid in onset and provides a level of anaesthesia equivalent to that produced by an inferior dental nerve block and with fewer side-effects. The injection is relatively painless to administer.

Needle breakage: incidence and prevention

Since the introduction of nonreusable, stainless steel dental local anesthetic needles, needle breakage has become an extremely rare complication of dental local anesthetic injections. But although rare, dental needle breakage can, and does, occur. Review of the literature and personal experience brings into focus several commonalities which, when avoided, can minimize the risk of needle breakage with the fragment being retained from occurring.

Needle breakage during local anesthesia in the oral cavity--a retrospective of the last 50 years with guidelines for treatment and prevention

Needle breakage in the oral cavity after local anesthesia is a common complication with possible serious complications of injuring vital structures. There are different possible reasons for needle breakage, with a main focus on preventable mistakes in treatment. In this study, an analysis of literature of the last 50 years as well as own cases has been performed to renew knowledge and prevention and therapy strategies for this serious complication. A systematic, multilingual review of medical literature from 1900 until today was conducted and information was evaluated systematically. In the majority of cases needle fracture happened during inferior alveolar nerve block. It is mainly a problem due to inadequate technique or the use of too thin needles for the performance of inferior alveolar nerve block. Different arguments about possible therapy strategies and methods exist. Basically, if a hypodermic needle fractures, it should be removed surgically under general anesthesia. To localize the fragment, use of either multi-plane X-rays or fluoroscopy with at least two reference needles in place or, if possible, of three-dimensional CT scans is recommended. This article shows, that despite progression in material, needle fracture is still an existing, preventable problem, if some basic rules are followed.

Broken local anesthetic needles: a case series of 16 patients, with recommendations

BACKGROUND

Local anesthetic needle fractures occur rarely. Since reports are uncommon, the mechanism and optimal treatment remain controversial.

METHODS

The author reviewed 16 cases of needle fracture that were reported during a 25-year period in one academic institution.

RESULTS

Of 16 needle fractures, 15 occurred in connection with an inferior alveolar nerve block, and one occurred in connection with a posterior superior alveolar block. Of the 16 fractures, 13 involved a 30-gauge needle. Five of the patients involved were younger than 10 years. The oldest patient was 28 years old. In all cases, a surgeon retrieved the needle, often with radiological guidance, while the patient was under general anesthesia in an operating room.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Most needle fractures occur during the administration of inferior alveolar nerve blocks, often with 30-gauge needles and in children who are reported to have moved suddenly and violently as the dentist gave the injection. Dentists should avoid burying any needle up to the hub (so as to ensure the possibility of immediately retrieving the needle intraorally), avoid using 30-gauge needles to administer inferior alveolar nerve blocks and avoid bending the needle before inserting it.