Vol. 119 No.

2 February 2015

Broken dental needle retrieval using a surgical navigation

system: a case report and literature review
Tim Yen Ting Lee, DDS, MD,a and Waleed Suliman Zaid, DDS, FRCD, MScb
Louisiana State University School of Dentistry, New Orleans, LA, USA

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. (Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119:e55-e59)

There has been a decrease in needle breakage incidents
since the introduction of exible alloy and disposable
hypodermic needle in the 1960s.1 Despite the decrease
in breakage events, needle fracture continues to be a
signicant complication in dentistry. Needle breakage
most often occurs during the administration of inferior
alveolar nerve blocks, and the needle fragment is
commonly dislodged in the pterygomandibular space.
The removal of broken needle in the pterygomandibular
space poses as a surgical challenge because of a com-
bination of difcult access, the close anatomic rela-
tionship to vital structures, and the small diameter of the
dental needle fragment. Recent developments in
computer-assisted surgery have brought signicant
changes to surgical approaches. The use of a surgical
navigation system is becoming more widespread and is
being applied to a range of surgeries, including ste-
reotactic biopsy, endoscopic sinus surgery, and foreign
body removal.2 We report a case of broken needle
retrieval in the pterygomandibular space using the
Medtronic surgical navigation system. This reports also
reviews the current techniques on broken needle
retrieval.
MATERIALS AND METHODS
A literature search was conducted in the following da-
tabases: 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,
a
Resident, Department of Oral and Maxillofacial Surgery, Louisiana
State University School of Dentistry, New Orleans, LA, USA.
b
Assistant Professor, Department of Oral and Maxillofacial Surgery,
Louisiana State University School of Dentistry, New Orleans, LA,
USA.
Received for publication Jun 17, 2014; returned for revision Aug 11,
2014; accepted for publication Aug 25, 2014.
2015 Elsevier Inc. All rights reserved.
2212-4403/$ - see front matter
http://dx.doi.org/10.1016/j.oooo.2014.08.019
and dental needle retrieval. Articles published after
1980 were reviewed. Seventeen articles that involved
broken dental needle retrieval were selected.
RESULTS
Based on titles and abstracts, 17 articles were selected,
which included 16 case reports and 1 review article. In
the articles reviewed, all patients reported clinical
symptoms secondary to retained broken needle. All
surgeons were able to successfully locate and remove
the needle fragments using various methods. Because
of needle migration into the lateral neck space, one
attempt to remove the needle fragment intraorally had
to be aborted and the needle was subsequently removed
transfacially.3 In all cases, preoperative imaging studies
were performed. More recently, there has been a shift to
use computed tomography (CT) scanning instead of
panoramic radiographs and plain lms to accurately
identify the position of the broken needle. For locali-
zation of the needle fragment, most authors favored the
use of reference needles and intraoperative radiographic
lms. However, some procedures took as long as 3
hours to complete.4 To reduce time spent on obtaining
intraoperative radiographs, 4 authors used intra-
operative C-arm uoroscopy instead of plain radio-
graphic lms.3,5-7 Recently, the use of intraoperative
cone beam CT scanning was reported.8 Gerbino also
described a case using CT-guided navigation for intra-
operative needle localization.9
CASE REPORT
An 18-year-old female patient was referred to the Department
of Oral and Maxillofacial Surgery at Louisiana State Uni-
versity Health Science with a chief complaint of oral pain.
One year before, she had been seen by a general dentist to
have 4 wisdom teeth extracted. During the administration of
inferior alveolar nerve block, a 27-gauge long needle was
fractured and trapped in the soft tissue. The dentist was unable
to retrieve the needle fragment at the time, and it was decided
to leave the needle fragment in its place. The patient was
observed for development of symptoms or needle migration.

e55
ORAL AND MAXILLOFACIAL SURGERY
e56 Lee and Zaid
Since the incident, although there was no limitation in
maximal incisal opening, the patient experienced persistent
pain that was exacerbated during mouth opening and closing.
One year later the patient presented to our department for
evaluation. A panoramic radiograph conrmed the needle
fragment in the right pterygomandibular space (Figure 1).
Surgical exploration under general anesthesia was recom-
mended and the patient desired to proceed with the surgery. A
preoperative maxillofacial CT scan (1 mm slices) was per-
formed less than 1 week before the surgery date. The DICOM
data was uploaded to the Medtronic surgical navigation
workstation.
The Medronic AxiEM navigation used an electromagnetic-
based tracker system. After the patient was intubated, an
electromagnetic eld emitter device was mounted to the bed
rail next to the patients head. Next, a tracker device was
adhered to the patients mid-forehead. Patient registration was
performed next. We used a tracer registration probe to trace
out a series of points in the forehead, periorbital, and nasal
regions (Figure 2). Then the registration software matched the
previously traced points to their corresponding points on the
patients preoperative CT scan (Figure 3). After successful
patient registration, movement of the probe instrument cor-
responded to the same movement on the preoperative CT
scan, which was displayed on the workstation monitor. We
then veried the accuracy of the patient registration by
pointing the tip of the registration probe at various anatomic
landmarks, such as the anterior nasal spine, medial canthus,
and incisors, and ensuring that the software also pointed to the
corresponding positions on the preoperative CT scan. The
positional discrepancy was veried to be less than 1 mm.
The patient was then prepped and draped. The preoperative
CT scan indicated that the broken needle was above the lin-
gula and oriented superiorly toward the sigmoid notch. To
gain access, a 4 cm vertical incision along the ramus was
made. Subperiosteal dissection was carried out medially along
the ramus. The lingula and the inferior alveolar nerve were
identied. The broken needle could not be visualized or
palpated because it was trapped within the medial pterygoid
musculature. Next, we positioned the navigation probe until
the tip of the instrument was at the most anterior point of the
needle fragment on the preoperative CT scan (Figure 3). With
the navigation probe still in position, blunt dissection was
performed adjacent to the probe instrument. The tip of the
needle fragment was identied, and the broken needle was
removed with a hemostat (Figure 4 and Figure 5). Care was
taken to ensure that the inferior alveolar nerve was protected
during the dissection. No vital structures were injured. Inci-
sion was closed with 3-0 chromic sutures. Total intraoperative
time was less than 30 minutes. The patient was discharged
home on the same day, and there were no postoperative
complications.
DISCUSSION
There remains some debate regarding management of a
broken dental needle. Some advocate leaving the needle
fragment in place as long as the patient is asymptomatic.
Surgical exploration to retrieval needle fragment can
itself lead to additional neurologic and tissue injury.
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February 2015
Fig. 1. Dental panoramic radiograph illustrating the position
of the broken needle.
However, most believe that a broken needle should be
removed not only because of medicolegal implications
but also because of the risk of needle migration to
damage vital structures in the head and neck. For
instance, a needle in the pterygomandibular space may
migrate to the lateral pharyngeal space, where the sty-
loglossus muscle, the ascending pharyngeal artery, and
the external carotid artery are located.3 Rahman reported
a case where a needle fragment migrated from the
pterygomandibular space to the lateral neck within 2
weeks.10 Another reason to consider removing the nee-
dle fragment is the psychological effect on the patient
of having a sharp foreign object retained in the mouth.11
Initial investigations of a broken needle often involve
Panorex and plain radiographic lms taken at 90 degrees
to each other. Though plain lms are useful in approx-
imating the position of the needle, they cannot provide
accurate position of the needle relative to adjacent
structures. A preoperative CT scan is therefore invalu-
able before surgical exploration. Palpation of the soft
tissue should be avoided to prevent migration of needle
fragment. In the maxillary region, broken needles are
usually located in the molar area, where important
structures are rarely affected.
Several intraoperative techniques for localizing
broken needle in pterygomandibular space have been
described. Thompson described the use of a stereotactic
technique using 2 19-gauge venipuncture needles. Two
reference needles are positioned sequentially until the
2 needles meet radiographically at the broken needle
fragment. Blunt dissection is then carried down 1 or the
other venipuncture needle until the tip of the broken
needle fragment is encountered. Others have reported
successes with similar technique.12 However, intra-
operative plain radiographic lms are often difcult
to obtain and are time consuming. Furthermore, it can
be difcult to discriminate between small changes in
position on the plain radiographs. Nezafati and Shahi
reported using C-arm digital uoroscopy to provide
rapid radiography without disturbing the reference
needles.5 However, as with plain lms, uoroscopy
only shows image in 2 dimensions and is unable to
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Volume 119, Number 2
Fig. 2. Patient registration with the tracer probe.
Fig. 3. Intraoperative navigation helped position the tip of the probe next to the needle fragment.
provide an accurate position of the fragment needle in a
3-dimensional space. One must review images in
different directions in order to precisely locate the
needle in a space.
Intraoperative ultrasound imaging has been suggested
to localize foreign bodies in the neck.13 However,
ultrasound device does not provide precise position
CASE REPORT
Lee and Zaid e57
and its use in a small oral cavity is limited by the size of
the ultrasound device.
Some advocate the use of a metal detector to localize
fractured needle.14 A metal detector operates by
measuring the change in the induction of a search coil.
The tones emitted change with proximity to a nearby
metal. A metal detector can distinguish between
ORAL AND MAXILLOFACIAL SURGERY
e58 Lee and Zaid
Fig. 4. Locating the needle fragment within the pter-
ygomandibular space.
Fig. 5. Retrieved broken dental needle.
different types metals, such as dental amalgam and
dental needle. However, the disadvantage of using a
metal detector is that it is not readily available and the
detector probe must be small enough to use intraorally.
Johansson and Krekmanov described the use of an
electromagnet to remove broken instruments.15 How-
ever, an electromagnet can no longer be used to locate a
dental needle because iron has been eliminated from the
stainless steel alloy in modern needles.
Surgical navigation systems provide an accurate
means of localizing needle fragments. Image-guided
navigation systems from different vendors work in
comparable ways. Each navigation system contains a
computer workstation, a display system, a tracking
system, and a set of surgical instrumentations. The
Medtronic AxiEMs tracking system uses electromag-
netism to detect positional changes. Other navigation
systems use infrared or optical tracking for positioning.
In an optics-based system, an overhead infrared unit
emits invisible light. The infrared light is then reected
back by the specialized reective instruments to an
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February 2015
overhead camera, allowing the position of the in-
struments to be tracked. For an optics-based navigation
system, a line of sight must be maintained during
tracking. Operating room setup must be adjusted to
minimize optical interference. An electromagnet-based
navigation system does not have a line-of-sight prob-
lem. However, certain metallic or ferromagnetic in-
struments can interfere with the navigation system and
must be kept more than 10 cm away when the tracker is
being used.16
All surgical navigation systems are known to have
errors of less than 1 mm.17 Nevertheless, it is important
to consider that oral soft tissues are pliable. The position
of a broken needle within the pterygomandibular soft
tissue may shift depending on the degree of mouth
opening or mandibular position. In the present case
the preoperative CT scan was taken with the patient in
full occlusion. Intraoperatively, the patients mouth
remained open at a maximal incisal opening of 40 mm.
We were, however, able to use the navigation system
to successfully locate the broken needle. Gerbino
described the use of a customized intermaxillary splint
that xed the mandible against the maxilla in the same
dened open position during the initial CT scan and
during the operation.9 This method would further
improve the accuracy of intraoperative navigation.
Another factor that could have inuenced the accuracy
of the intraoperative navigation was that the preopera-
tive CT scan was completed several days before the
surgery, which may have allowed for migration of the
needle. Therefore, it is important to minimize the time
between the preoperative CT scan and the actual
surgery.
CONCLUSIONS
The small diameter and dimension of dental needles
make retrieving a broken needle a challenging task. In
addition, needle fragments often cannot be palpated
intraoperatively. From our experience, image-guided
surgical navigation systems provide an accurate alter-
native in localizing broken needles. Compared with the
other localizing modalities, the use of surgical naviga-
tion systems can help decrease intraoperative time,
minimize dissection, and reduce postoperative recovery
time. In addition, the patient is not subjected to any
intraoperative radiation exposure.
REFERENCES
1. Ethunandan M, Tran AL, Anand R, Bowden J. Needle breakage
following inferior alveolar nerve block: Implications and
management. Br Dent J. 2007;202:395-397.
2. Siessegger M, Mischkowski RA, Schneider BT. Image guided
surgical navigation for removal of foreign bodies in the head and
neck. J Craniomaxillofac Surg. 2001;29:321-325.
3. Altay MA, Jee-Hyun Lyu D, Collette D, et al. Transcervical
migration of a broken dental needle: A case report and literature
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Volume 119, Number 2
review. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014;118:
e161-e165.
4. Pogrel MA. Broken local anesthetic needles: A case series of 16
patients, with recommendations. J Am Dent Assoc. 2009;140:
1517-1522.
5. Nezafati S, Shahi S. Removal of broken dental needle using
mobile digital C-arm. J Oral Sci. 2008;50:351-353.
6. Rifkind JB. Management of a broken needle in the
pterygomandibular space following a Vazirani-Akinosi block:
Case report. J Can Dent Assoc. 2011;77:b64.
7. Brucoli M, Deandreis M, Arcuri F, Benech A. Management
of a needle breakage during third molar extraction with
C-ARM digital uoroscope. J Craniofac Surg. 2012;23:
1583-1584.
8. Kim JH, Moon SY. Removal of a broken needle using three-
dimensional computed tomography: A case report. J Korean
Assoc Oral Maxillofac Surg. 2013;39:251-253.
9. Gerbino G, Zavattero E, Berrone M. Management of needle
breakage using intra-operative navigation following inferior
alveolar nerve block. J Oral Maxillofac Surg. 2013;71:
1819-1824.
10. Rahman N, Clarke M, Stassen L. Case report: Management of
broken dental needles in practice. J Ir Dent Assoc. 2013;59:
241-245.
11. Marks RB, Carlton DM, McDonald S. Management of a broken
needle in the pterygomandibular space: Report of case. J Am Dent
Assoc. 1984;109:263-264.
CASE REPORT
Lee and Zaid e59
12. Bedrock RD, Skigen A, Dolwick MF. Retrieval of a broken
needle in the pterygomandibular space. J Am Dent Assoc.
1999;130:685-687.
13. Abe K, Nakamatsu K, Beppu K, Ariji E, Oka M. Use of intra-
operative ultrasonography to detect a small foreign body in the
soft tissue of the upper lip. Br Dent J. 1994;177:292-294.
14. Moore UJ, Fanibunda K, Gross MJ. The use of a metal detector
for localisation of a metallic foreign body in the oor of the
mouth. Br J Oral Maxillofac Surg. 1993;31:191-192.
15. Johansson B, Krekmanov L. Fragment of broken instrument
removed from eld of operation by an electromagnet. Br J Oral
Maxillofac Surg. 1987;25:265-266.
16. Stevens F, Conditt MA, Kulkarni N, Ismaily SK. Minimizing
electromagnetic interference from surgical instruments on
electromagnetic surgical navigation. Clin Orthop Relat Res.
2010;468:2244-2250.
17. Song EK, Seon JK, Park SJ, Yoon TR. Accuracy of navigation:
A comparative study of infrared optical and electromagnetic
navigation. Orthopedics. 2008;31.
Reprint requests:
Tim Yen Ting Lee, DDS, MD
837 Martin Behrman Ave
Metairie
LA 70005
Tim.y.t.lee@gmail.com