The document discusses the use of a dental mini C-arm to locate and remove broken instruments from soft and hard tissues in the oral and maxillofacial area. It describes 8 cases where the mini C-arm was used successfully to locate various broken instruments like needles and files for safe removal. The mini C-arm provided real-time intraoperative imaging at a low radiation exposure and was beneficial for determining the location of broken objects, especially in soft tissues. It allows for 2D tracing of instruments which is safer than using needles as guides. The mini C-arm is concluded to be a safe and easily controllable device for removing foreign bodies from the maxillofacial area.

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