Application of Mini-C Arm in Oral & Maxillofacial Surgery

1. 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

2. SOURCE
 Journal of Cranio-Maxillo-Facial Surgery
2012;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, School
of Dentistry, Seoul National University, Republic of
Korea

4. INTRODUCTION
 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 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 surgery
useful intraoperative
safe way to detect metal materials
 removal maxillofacial
 not practical
 Large size

9.  Fluroscopy C-arm
 Broken metal instruments
 Thorax , urological surgery
 Intrapulmonary abberant needle
 Symptomatic bone anchors
 Broken dialysis catheters

10. 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

11.  5 cases soft tissue (pterygomandibular space)
 1 paranasal sinus (subcutaneous)
 2 cases hard tissue (mandible)

12. Guidance –Dental mini C-arm (Dreamray 60F, DreamRay
Co, Pusan, Republic of Korea.)
 Microfocus x ray tube 0.1-1.o mA current with a tube
potential of 60 kV
 Resolution 3.5 line pairs per mm
 17” touch monitor and PC ,C arm, x ray generator,
image sensor , foot pedal.

15. POSITIONING
 X ray sensor external surface of cheek
 Cone angles range of 50⁰ (-25 to 25) coronal plane
 Patients head 650
 horseshoe shape arc –visual arc

16. SURGICAL TECHNIQUE
 2% Lidocaine 1:100000 adrenaline
 Location identified mini C-arm
 Intraoral incision- buccal /lingual
 Mucoperiosteal flap
 Retracted to lingual pterygomandibular-lingual nerve

17.  Blunt end haemostat turned around
 Superior-inferior anterio-posterior real time oriented
 2 dimensional tracing anterio posterior / superior
inferior , sharp end of periosteal elevator- surgical
dissection mediolateral blunt haemostat

18. ENDODONTIC
FILE
INF BORDER
MANDIBLE

19. ROOT PICKER
BUCCAL
MAND CANAL

20. BROKEN NEEDLE
PTERYGOMANDIBULAR
SPACE
Kellys forceps

21. CLOSURE
 Removal confirmed-flouroscopy,OPG,visualization
 4-0 vicryl
 Copious irrigation- hematoma
 Penrose drain- postoperative day 1
 All instruments complete removal

22. POSTOPERATIVE
 Recovery uneventful except for two cases of lingual
nerve parasthesia which reversed in few weeks.

23. DISCUSSION
 Several methods described broken needle
pterygomandibular space
 Initial -2 plain radiographs different planes OPG PA view
 CT scans with 3D formatting more accurate position +
relationship
Difficult correlate real position intraoperatively with CT
soft tissue –intraoperative traction/swelling

24.  Cone beam CT not adjustable intraoperative head
position
 Guide needles damage lingual, inferior alveolar nerves
 2 dimensional tracing anterio posterior / superior
inferior sharp end of periosteal elevator- surgical
dissection mediolateral safe easy compared 3
dimensional tracing guiding needles-movement/break

25.  Critical geographic information-location inferior
alveolar nerve –superior inferior direction
 Negligible radiation exposure
 Lead garments/fixed barriers not needed

27. CONCLUSION
 Dental mini C-arm was beneficial in determining and
confining the location of broken object with
intraoperative real time information, especially for soft
tissues
 Its small size is adequate for removing foreign bodies
from maxillofacial area and regarded as a safe and
easily controllable device.

28. CRITICAL APPRAISAL
 X ray radiation comparison C-arm and Mini C-arm
 Time factor involved
 Technique sensitive/operator dependent
 Cost
 Long term hazards

29. REFERENCES
 Athwal GS, Bueno Jr RA,Wolfe SW:Radiation exposure
in hand surgery: mini versus standard C-arm.J Hand
Surg Am 30: 1310-1316,2005
 Choi EH,Seo JY, Jung BY, Park W: Diplopia after
inferior alveolar nerve block anaesthesia: report of 2
cases and literature review. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 107:e21-e24,2009
 Prasad R, Amstutz HC,Sparling EA:use of magnet to
retrieve a broken scalpelblade. J Arthroplasty 15, 806-
808,2000