1. THE CLINICAL APPLICATION OF THE DENTAL MINIC ARM FOR THE REMOVAL OF BROKENINSTRUMENTS IN SOFT AND HARD TISSUE IN THEORAL AND MAXILLOFACIAL AREA

2. SOURCE Journal of Cranio-Maxillo-Facial Surgery2012;40: 572-578 3. AUTHORS Sung-Soo Park, Hoon-Joo Yang, Ui-Lyong Lee, Myung-Jin-Kim , Jong-Ho Lee et al Department of Oral and Maxillofacial Surgery, Schoolof Dentistry, Seoul National University, Republic ofKorea 4. INTRODUCTION Many kinds of broken instruments such as needles, probes,scalpels and catheters are reported to be left in patientsafter surgery. These parts should be removed as soon as possible toprevent further complications. However it is not easy to identify the exact location of theinstrument intraoperatively and a risk of damage exists forneighbouring nerves and vessels during removal 5. BROKEN INSTRUMENT RETRIEVAL Exact location not easy Maxillofacial area Changeable head position intraoperative Soft tissue traction intraoperative , swelling 6. The C-arm orthopaedic surgeryuseful intraoperativesafe way to detect metal materials removal maxillofacial not practical Large size 7. Fluroscopy C-arm Broken metal instruments Thorax , urological surgery Intrapulmonary abberant needle Symptomatic bone anchors Broken dialysis catheters 8. MATERIAL AND METHODS 8 patients 5M 3F Mean age 38.3+ 13.o years 8 broken instruments 4 dental anaesthetic needles 1 endodontic file 1 root picker 1 fissure bur 1 implant fixture 9. 5 cases soft tissue (pterygomandibular space) 1 paranasal sinus (subcutaneous) 2 cases hard tissue (mandible) 10. Guidance Dental mini C-arm (Dreamray 60F, DreamRayCo, Pusan, Republic of Korea.) Microfocus x ray tube 0.1-1.o mA current with a tubepotential of 60 kV Resolution 3.5 line pairs per mm 17 touch monitor and PC ,C arm, x ray generator,image sensor , foot pedal. 11. POSITIONING X ray sensor external surface of cheek Cone angles range of 50 (-25 to 25) coronal plane Patients head 650 horseshoe shape arc visual arc 12. SURGICAL TECHNIQUE 2% Lidocaine 1:100000 adrenaline Location identified mini C-arm Intraoral incision- buccal /lingual Mucoperiosteal flap Retracted to lingual pterygomandibular-lingual nerve 13. Blunt end haemostat turned around Superior-inferior anterio-posterior real time oriented 2 dimensional tracing anterio posterior / superiorinferior , sharp end of periosteal elevator- surgicaldissection mediolateral blunt haemostat 14. ENDODONTICFILEINF BORDERMANDIBLE 15. ROOT PICKERBUCCALMAND CANAL 16. BROKEN NEEDLEPTERYGOMANDIBULARSPACEKellys forceps 17. CLOSURE Removal confirmed-flouroscopy,OPG,visualization 4-0 vicryl Copious irrigation- hematoma Penrose drain- postoperative day 1 All instruments complete removal 18. POSTOPERATIVE Recovery uneventful except for two cases of lingualnerve parasthesia which reversed in few weeks. 19. DISCUSSION Several methods described broken needlepterygomandibular space Initial -2 plain radiographs different planes OPG PA view CT scans with 3D formatting more accurate position +relationshipDifficult correlate real position intraoperatively with CTsoft tissue intraoperative traction/swelling 20. Cone beam CT not adjustable intraoperative headposition Guide needles damage lingual, inferior alveolar nerves 2 dimensional tracing anterio posterior / superiorinferior sharp end of periosteal elevator- surgicaldissection mediolateral safe easy compared 3dimensional tracing guiding needles-movement/break 21. Critical geographic information-location inferioralveolar nerve superior inferior direction Negligible radiation exposure Lead garments/fixed barriers not needed 22. CONCLUSION Dental mini C-arm was beneficial in determining andconfining the location of broken object withintraoperative real time information, especially for softtissues Its small size is adequate for removing foreign bodiesfrom maxillofacial area and regarded as a safe andeasily controllable device. 23. CRITICAL APPRAISAL X ray radiation comparison C-arm and Mini C-arm Time factor involved Technique sensitive/operator dependent Cost Long term hazards 24. REFERENCES Athwal GS, Bueno Jr RA,Wolfe SW:Radiation exposurein hand surgery: mini versus standard C-arm.J HandSurg Am 30: 1310-1316,2005 Choi EH,Seo JY, Jung BY, Park W: Diplopia afterinferior alveolar nerve block anaesthesia: report of 2cases and literature review. Oral Surg Oral Med OralPathol Oral Radiol Endod 107:e21-e24,2009 Prasad R, Amstutz HC,Sparling EA:use of magnet toretrieve a broken scalpelblade. J Arthroplasty 15, 806-808,2000