© 2007 Nature Publishing Group PRACTICE Needle breakage following inferior alveolar nerve block: implications and management M. Ethunandan, 1 A. L. Tran, 2 R. Anand, 3 J. Bowden, 4 M. T. Seal 5 and P. A. Brennan 6 Needle breakage following inferior alveolar nerve block is a rare complication in current dental practice. We report a case of delayed retrieval of a broken needle with the use of modern imaging modalities. In addition, possible causes of needle breakage and preventative measures, indications and timing of removal, localisation techniques and surgical approaches are discussed. INTRODUCTION The current use of disposable needles made of modern alloys has signifi- cantly decreased the incidence of needle breakage during administration of local anaesthesia for dental treatment. 1-3 This complication, however, continues to be reported infrequently and is thought to be due to poor practice, unexpected patient movement and needle manufac- turing defects. 1-8 Needle breakage has most frequently been reported in rela- tion to an inferior alveolar nerve block and the literature has mainly concen- trated on elaborate needle localisation techniques. 1-8 We report the manage- ment of a patient with a broken needle in the pterygomandibular space and discuss the possible causes and pre- ventative measures, the indications and timing of removal, modern modalities of localisation and a technique for needle retrieval. We also give advice for appro- priate referral and documentation. CASE REPORT A 45-year-old male was referred by his dentist to the maxillofacial depart- ment for management of a broken 25 mm, 30-gauge dental needle in the right pterygomandibular space. This occurred following the administration of a right inferior alveolar nerve block, for the removal of the lower right second molar tooth. The needle had fractured at the hub and was not clinically visible or palpable. On presentation, the patient had no pain, dysphagia or right inferior alveolar nerve paraesthesia. Dental panoramic, postero-anterior mandible and lateral cephalometric radiographs were taken which con- firmed the presence of the needle in the pterygomandibular space (Fig. 1). A computed tomogram (Siemens Somatom Volume Zoom 4), with axial (Fig. 2) and reformatted 3D volume rendered (Fig. 3) images was also obtained which demon- strated the needle to be present immedi- ately adjacent to the medial aspect of the ramus of the mandible and just below the lingula. In view of the lack of significant symptoms, the patient did not want intervention, but understood the pos- sible risk of needle migration if left in situ. Six months later, the patient com- plained of persistent discomfort in the mouth and therefore requested removal of the needle. A further dental pano- ramic radiograph taken at this time did not demonstrate any significant altera- tion in needle position. At operation under general anaesthe- sia, a vertical incision was made along the ascending ramus, which extended to the external oblique ridge, allowing an avascular subperiosteal plane to be estab- lished in the medial aspect of the mandi- ble. The lingula, lingual and inferior dental nerves were visualised and pro- tected. Following careful blunt dissec- tion through the periosteum, the broken needle was identified supra-periosteally in the same location as demonstrated in the CT scan and retrieved. The wound was closed using resorbable sutures. The patient made an uneventful recovery. DISCUSSION Needle breakage during administration of an inferior alveolar nerve block is a rare event in modern dental practice and 1* Specialist Registrar, 2 Senior House Officer, 3 Specialist Registrar, 4 Specialist Registrar, 5 Consultant, 6 Professor of Surgery/Consultant, Oral & Maxillofacial Surgery, Queen Alexandra Hospital, Portsmouth, PO6 3LY *Correspondence to: Mr Madanagopalan Ethunandan Email: mgethu@hotmail.com Refereed Paper Accepted 27 July 2006 DOI: 10.1038/bdj.2007.272 © British Dental Journal 2007; 202: 395-397 BRITISH DENTAL JOURNAL VOLUME 202 NO. 7 APR 14 2007 395 • Serves as a reminder of a rare complication. • Outlines points to prevent such a complication. • Describes current management. • Illustrates the dentist’s role following the event. IN BRIEF