Broken dental needle retrieval using a surgical navigation system: a case report and literature review

Surgical Removal of an Orthodontic Mini-Screw Displaced Into the Lateral Pharyngeal Space: A Case Report and Review of Pertinent Literature

Oral and maxillofacial surgeons are often faced with the clinical challenge of foreign body displacement into the perioral tissues and soft tissues of the head and neck. This mainly occurs either because of trauma or inadvertently during dental treatment. In addition to the maxillary sinus, iatrogenic foreign body displacement during dental treatment could happen into one of the 16 distinct fascial spaces of the head and neck region. Commonly displaced foreign bodies related to dental treatment include tooth roots or fragments, local anesthetic needles, implants and restorations. The clinical sequelae of a displaced foreign body depend on its size, shape, anatomic location and proximity to vital structures. Although patients may remain asymptomatic for a considerable amount of time, retained foreign bodies result in persistent pain, recurrent infection and scarring of soft tissue due to inflammation, all of which may complicate delayed retrieval. In addition to the history, imaging modalities such as plain radiographs and computed tomography (CT) help in locating the displaced foreign body and its subsequent retrieval. Surgical retrieval may be attempted through intraoral, transcervical and endoscopic approaches. Additionally, surgery may be aided by real-time imaging such as fluoroscopy. The present report aims to detail a case of inadvertent displacement of an orthodontic mini-screw, commonly used as a temporary anchorage device (TAD), into the lateral pharyngeal space, while attempting placement in the mandibular retromolar area. The case report also describes the surgical retrieval procedure of the TAD screw using an intraoral approach and with fluoroscopy guidance using C-Arm radiographic imaging. This case is reported along with the pertinent review of literature, as it not only explains a rare complication of orthodontic mini-screw placement but also details a modality to remove displaced foreign bodies from fascial spaces of the head and neck, which are otherwise directly inaccessible.

A Case of Broken Local Anesthetic Needle in the Pterygomandibular Space; Diagnostic Approaches and Surgical Management

Needle fracture during dental local anesthetic injections is a rare but significant, potentially serious complication. Various approaches for the location and removal of broken needles have been described; however, there are several difficulties and concerns related to the potential complications and critical anatomic challenges peculiar to the head and neck region. In this case, we describe the diagnostic approaches utilized in locating a broken needle that migrated in the pterygomandibular space following gag reflex, and sudden head movement of a middle-aged male patient. A meticulous diagnostic approach was employed to locate the needle utilizing CBCT scan, CT scan with contrast, and C-arm X-ray machine. The needle was successfully retrieved using an angled hemostat inserted through an oral incision, guided by a C-arm X-ray machine and ENT endoscopic instruments. While careful planning could prevent many complications that may arise during oral surgical procedures, inadvertent events leading to serious complications should be addressed using the appropriate and timely diagnostic techniques pre-and intra-operatively.

Observational and descriptive analysis of broken dental needles: a case series

PURPOSE

To discuss potential causes of broken dental needles during dental anesthesia and features of this complication, including the anatomical location of fragments in tissues, symptoms, complications, and therapeutic approaches.

METHODS

Twelve cases of broken dental needles occurring during dental anesthesia and subsequently referred to Hospital de Base do Distrito Federal, Brazil, between 1992 and 2019 were selected. In addition, similar cases reported in the literature over the past 50 years were reviewed.

RESULTS

Needle fractures occur most frequently during inferior alveolar nerve blocks and in younger patients. The leading cause is unexpected patient movement during the anesthetic procedure. The needle fragment is most commonly found in the pterygomandibular space or the deep spaces of the head and neck region. Needle migration is a particular concern; although rare, it is unpredictable and potentially life-threatening.

CONCLUSIONS

Needle fracture is an intraoperative complication which has the potential to cause severe patient damage. It is essential that practitioners have knowledge of this possible complication and understand the technical considerations for its prevention. The existing literature and the results of this case series analysis suggest that removal of the fractured needle fragment should be attempted as soon as possible.

Unexpected metallic foreign bodies on panoramic scans - a narrative review

BACKGROUND

The digital panoramic radiograph (orthopantomogram, OPG) is the standard radiographic technique for basic diagnostics in dental practice. A correctly taken image provides a good overview of teeth and jaw, whereas radiopaque foreign materials, e. g. metal, can obscure relevant findings.

METHODS

A literature review on unexpected metallic foreign bodies in OPG was performed to determine the spectrum of metallic foreign bodies that may cause radiopaque areas on panoramic radiographs in routine clinical use.

RESULTS AND CONCLUSION

A total of 37 different unexpected metallic foreign bodies were found. They can be categorized as jewelry, clothing, personal protective equipment, medical devices, iatrogenic foreign bodies, and rare incidental findings. Radiopaque foreign materials in the OPG are often relatively easy to recognize as artifacts because of their location, and they are avoidable in most cases. If unclear, a three-dimensional radiograph was helpful for determining the location. Radiopaque areas caused by foreign bodies can lead to misinterpretation or partial or complete non-evaluability and should therefore be avoided.

KEY POINTS

· The OPG is the standard radiograph for dentists, oral surgeons, and oral and maxillofacial surgeons.. · Foreign bodies made of metal can lead to non-evaluability of panoramic radiographs. Based on a review of the literature and exemplary radiographs, this article provides an overview of rare but typical metallic foreign bodies in OPG, thus addressing the problem of the subfield of radiography by making radiologists more familiar with these images.. · The spectrum of unexpected metallic foreign bodies includes unremoved earrings with the typical ghost images on the contralateral side, piercings, hearing aids, acupuncture needles, rare iatrogenic foreign bodies, incidental findings in infants in the nose and external auditory canal, vascular clips after surgical interventions, and ritual subcutaneous foreign materials..

CITATION FORMAT

· Brauer HU, Bartols A, Hellmann D et al. Unexpected metallic foreign bodies on panoramic scans - a narrative review. Fortschr Röntgenstr 2023; 195: 809 - 818.

Robust H-K Curvature Map Matching for Patient-to-CT Registration in Neurosurgical Navigation Systems

Image-to-patient registration is a coordinate system matching process between real patients and medical images to actively utilize medical images such as computed tomography (CT) during surgery. This paper mainly deals with a markerless method utilizing scan data of patients and 3D data from CT images. The 3D surface data of the patient are registered to CT data using computer-based optimization methods such as iterative closest point (ICP) algorithms. However, if a proper initial location is not set up, the conventional ICP algorithm has the disadvantages that it takes a long converging time and also suffers from the local minimum problem during the process. We propose an automatic and robust 3D data registration method that can accurately find a proper initial location for the ICP algorithm using curvature matching. The proposed method finds and extracts the matching area for 3D registration by converting 3D CT data and 3D scan data to 2D curvature images and by performing curvature matching between them. Curvature features have characteristics that are robust to translation, rotation, and even some deformation. The proposed image-to-patient registration is implemented with the precise 3D registration of the extracted partial 3D CT data and the patient's scan data using the ICP algorithm.

Needle Removal in the Deep Maxillofacial Region Assisted by Computerized Navigation Technique and Digital Guiding Plate

Retention of foreign bodies frequently happened in the region of oral and maxillofacial. In very rare cases, the positions of the foreign objects moved with the movement of muscles in the oral and maxillofacial regions. Precise locations of moving objects and minimally invasive surgeries pose a great challenge to surgeons. The case of a 44-year-old female patient diagnosed with retention of the fractured needle is reported in this study. A digital guide plate was manufactured to locate the precise position of the fractured needle and preoperatively mimic the surgery processes. The computerized navigation system guided us to make an incision and precisely target the fractured needle during the surgery. Combing the technologies of the digital guiding plate and navigation system, removing the moving foreign bodies becomes objective, time-saving, and minimally invasive.

Preliminary Study of the Treatment Strategy for Retaining Traumatic Foreign Bodies Involving the Carotid Artery

PURPOSE

Craniomaxillofacial trauma is usually accompanied by indwelling foreign bodies, and some of those are close to the carotid artery, which increases the risks and difficulties of surgical treatment. The introduction of interventional radiology combined with image-guided surgical navigation may be a good solution for precise surgery to remove foreign bodies.

PATIENTS AND METHODS

Four patients were included in the study. All patients underwent digital subtraction angiography and enhanced computed tomography before surgery. The patients were divided into 3 categories (A, B, and C) according to the presence of carotid artery damage and its positional relationship with the foreign body, and 3 corresponding treatment strategies were developed. Treatments were completed using interventional radiology and surgical navigation systems.

RESULTS

All foreign bodies were completely removed, except for 1 remaining in the jugular foramen in a patient. The prognosis of all patients was good, and no systemic complications occurred.

CONCLUSION

The combined interventional radiology and surgical navigation method proposed in this study is an effective method to improve the accuracy and safety of foreign body removal surgery.

Analysis of retrieval of dental implants displaced into ectopic locations between 2015–2017 and 2018–2020: scoping review of literature

Purpose: This study aimed to evaluate differences in 10 items of treatment details in patient regarding cases between 2015–2017 (EP) and 2018–2020 (LP) from scoping literature review of displaced dental implant (DDI) retrievals. Materials and methods: PubMed, Google Scholar, and ScienceDirect were searched using key words including “displaced,” “retrieved,” “migrated,” or “accidental" dental implants. Treatment details were analyzed for the differences between EP and LP in 92 cases from 32 articles published in 13 countries. Statistical significance was evaluated using the Mann-Whitney U-test, Fisher’s exact test, and Pearson’s correlation analysis. Results: In the comparison between EP and LP, there was no significant difference in the number of publication countries (11 vs. 10), number of published articles (17 vs. 15), distributions of cases (50 vs. 42), mean age of patients (55.9 ± 1.8 years vs. 55.3 ± 2.5 years), male-female distribution (31/19 vs. 24/18), and distribution of displacement into the maxillary sinus and other regions (46/4 vs. 34/8), and no significant difference in the Pearson’s correlation between publication years and the number of articles. DDI retrievals utilized intraoral and endoscopic surgeries (61.2% and 82.5%), transoral and transnasal approaches (93.8% and 81.8%), and local and general anesthesia (64.7% and 76.3%) during EP and LP, respectively. Moreover, significant differences were observed in all distributions between the two factors (30/19 vs. 7/33 cases, 30/2 vs. 6/27 cases and 2/12 vs. 9/29 cases) in EP and LP, respectively (P < 0.01). Conclusions: These results suggest that most DDI retrievals in otorhinolaryngology since 2018 have been mostly performed using transnasal endoscopic approaches under general anesthesia.

Removal of a suture needle: a case report

Background

Foreign bodies may be embedded or left behind in the oral cavity during oral surgical procedure. The loss of instruments such as impression material, surgical gauze, and broken injection needles are commonly reported in the dental field. These complications are generally symptomatic and show signs of inflammation, pain, and purulent discharge. Accidental breakage of suture needles is a rare but potentially dangerous event.

Case presentation

In this report, we present one case of lost suture needle during the procedure of flap operation at local dental clinic and its successful removal under local/general anesthesia administration via CBCT with a help of two reference needles to localize the 6-0 nylon needle and consulting with the clinician.

Conclusion

CT scanning taken while mouth-closing may not be accurate with regard to real location measurement performed while mouth-opening. If so, other up-to-date radiographic devices and methods to retrieve a needle are recommended.

Role of Navigation in Oral and Maxillofacial Surgery: A Surgeon's Perspectives

Surgeries related to the maxillofacial area deal with an intricate network of anatomical structures. With the complexity of the vital structures, it necessitates a surgical team to respect each anatomical boundary. In the past, there was an exceptionally high number of cases with surgical errors. These errors were not because of flaws in the surgeon’s skills or techniques but owing to lack of resources. Visualisation is one of the key factors that determines the precision of any surgical outcome. Advances in surgical planning have led to the introduction of a “Navigation” system that helps surgeons to see more, know more and ultimately do more for their patients. The usefulness of the navigation system in oral surgeries has been indicated by its surgical applications in craniomaxillofacial trauma, orthognathic surgeries, head and neck pathological resections, complex skull base surgeries and surgery involving temporomandibular joint. A vast majority of research literature has suggested remarkable improvement in surgical outcomes under the guidance of 3d planning and navigation. However, with such an inordinate advancement, financial expenses and a gradual learning curve are always a constraining factor in surgical navigation. This article overviews indication of navigation in craniofacial surgeries with a focus on applied aspect, planning and solution to the future problem.

Physical, chemical, mechanical, and micromorphological characterization of dental needles

Background

In anesthetic techniques, touching bones can cause needle bending. Theoretically, a needle should support such deflection without fracturing. However, it is possible that a needle may fracture depending on the quality and type of needle used. This study evaluated the physical, chemical, and micromorphological characteristics of long and short dental anesthetic needles, as well as the mechanical properties of flexural load and bending resistance when needles are subjected to different bending angles.

Methods

Long and short needles (30G, Jets, Misawa, Selekto, Terumo, Unoject and 27G, Dencojet, Injex, Jets, Misawa, Procare, Setoject XL, Terumo) were evaluated. Scanning electron microscopy was used to evaluate the needle bevels and energy-dispersive X-ray spectroscopy was used for the chemical analysis of needle compositions. Flexural loading and bending strength assessments were performed using a universal testing machine by bending the needles (n = 5) to angles of 30°, 60°, or 90°, or until fracture occurred.

Results

The Injex 27G, Jets 27G, and Septoject XL 27G needles were all less than 30 mm in length. There were small percentage variations in the chemical compositions of the needles. Superior smoothness was observed for the Unoject 30G needle, which exhibited the highest fracture resistance at 60°. The Jets 30G needle exhibited greater resistance to fractures at 90°. The Procare 27G needle exhibited the highest load resistance to bending, followed by the Septoject XL 27G needle, and both needles were tied for the lowest fracture resistance. No needle fractured when bent to 30° or at less than three bends to 60° or 90°.

Conclusions

Greater needle resistance to bending increases the probability of early fracturing. Thinner and shorter needles are more resistant than longer and thicker needles. Performing a single bend does not result in any significant risk of fracture or obliterate the lumen, allowing for the continued passage of anesthetic liquid.

The retrieval of a surgical blade broken within the alveolar bone during minimally traumatic tooth extraction

Minimally traumatic tooth removal is the norm for removing teeth when a dental implant is planned at that site. The quantity of available bone is the primary requisite to place an implant. The initial use of a scalpel blade to widen the periodontal space followed by the use of luxators is one of the techniques that is being followed for atraumatic extraction. A case of accidental breakage of a number 11 scalpel blade while attempting tooth removal and the method adopted in removing this portion of the blade without further bone destruction is reported here. The authors have not found any previously published cases, reporting the breakage of a scalpel blade during the bone expansion procedure and its management.

Fractured Needle Removal With a 3-Dimensionally Printed Surgical Guide: A Case Report and Literature Review

Needle breakage is a rare complication of inferior alveolar nerve block anesthesia. This study proposes a new localization technique. We used a three-dimensionally printed surgical guide, supported by the lower dental arch to minimize the required surgical access. With this approach, the procedure could be performed with procedural sedation anesthesia.

[Medical solution to needle breakage during local anesthesia]

Needle breakage may be a damaging experience for both medical practitioners and patients. Medical literature provides numerous cases of dental practitioners being confronted with this problem. We have studied the clinical case of the patient L. at the Moscow State University of Medicine and Dentistry involving needle breakage during conductive anesthesia. We propose our medical approach to solving this issue alongside with a desirable course of action, providing additional recommendations and suggesting intraosseous anesthesia as a safer type of pain management.

Computer-assisted navigation for removal of the foreign body in the lower jaw with a mandible reference frame: A case report

RATIONALE

In surgery of the lower jaw, the application of computer-assisted navigation is complicated and challenging due to the mobile nature of the mandible. In this study, we presented a computer-assisted navigation surgery for removal of the foreign body in the lower jaw with a mandible reference frame, basing on the strategy that the mandible is independent as an entity.

PATIENT CONCERNS

A 41-year-old male patient, identified as having a broken fissure bur that displaced into the mandibular lingual soft tissue, was referred to our department. The fissure bur broke accidentally and then displaced into the soft tissue when the patient underwent extraction of the left mandibular impacted third molar.

DIAGNOSIS

A metallic foreign body in the left lower jaw, confirmed by orthopantomography.

INTERVENTIONS

A computer-assisted navigation surgery with a customized mandible reference frame.

OUTCOMES

The broken bur was removed successfully. Satisfactory wound healing and mouth opening was achieved, without postoperative complications.

LESSONS

Surgeons should be alert to the presence of broken bur in the lower jaw and avoid its displacement into deep facial space, and computer-assisted navigation with a mandible reference frame is recommended for removal of the foreign body in the lower jaw.

Optical surgical navigation-assisted removal of a foreign body using a splint to simplify the registration process: a case report

Background

Oral and maxillofacial surgeons often encounter foreign objects within the human body. Despite the visual identification of foreign objects via imaging techniques, the accurate determination of their position in the maxillofacial area can be challenging. The clinical application of a navigation system can solve this issue. This system provides a useful guide for a safer and more accurate surgical technique by accurately determining the location of the lesion in real time during the surgery. However, complications with regard to registration may be encountered. We describe a navigation system that simplifies registration using a dental splint with embedded reference points for foreign body removal in the maxilla.

Case presentation

A 78-year-old Japanese woman was referred with the chief complaint of pain in the left upper molar region. We found the symptoms to be associated with a foreign body in the maxilla and decided to remove it. A minimally invasive treatment procedure was desirable. However, the lesion was in contact with the maxillary sinus, and it was difficult to pinpoint its position because of the absence of an anatomical landmark. Therefore, we decided to use a navigation system. In order to simplify registration, a dental splint with embedded reference points was created. The registration could be reliably performed before surgery using an optical navigation system that facilitates the process, using splints with embedded reference points. Following preoperative registration, the splint with the reference frame was placed in the patient’s mouth, and the accuracy of the navigation was confirmed. The position with respect to the maxillary sinus was precisely identified followed by the removal of the surrounding bone and excision of the lesion. Therefore, the surgery could be accurately performed without perforating the maxillary sinus. In addition, owing to preoperative registration, the operative time could be shortened. After the surgical procedure, the patient’s symptoms disappeared.

Conclusions

The procedure was performed in a precise, minimally invasive manner. Furthermore, the operative time was reduced by the simplified registration process, wherein a splint was embedded with reference points. This technique may prove useful for performing maxillofacial surgical procedures.

Avaliação da deformação de agulhas gengivais e análise fractal

Resumo Introdução A fratura da agulha na anestesia odontológica é rara, mas sua ocorrência tem sérias complicações e deve ser evitada. Objetivo O objetivo deste estudo foi avaliar a deformação de agulhas dentárias após a aplicação de forças de compressão. Material e método Agulhas das marcas Dencojet e Septoject XL nos calibres 27G e 30G (quatro grupos) foram dobradas em dois sentidos opostos em máquina de ensaio mecânico DL200 - EMIC, com base na ISO 7885:2010. A resistência à compressão das agulhas foi medida em cada dobra. Ao final, foi realizada inspeção visual em uma lupa EK3ST em aumento de 40×, para análise da integridade das agulhas. Resultado As agulhas de calibre 30G não apresentaram diferenças significativas entre elas. As agulhas de maior calibre (27G) apresentaram diferenças no primeiro (p = 0,0001) e no segundo dobramento (p = 0,0016). As agulhas Septoject XL 27G demonstraram ser muito menos flexíveis, fornecendo valores mais altos de resistência à dobra. No grupo Septoject XL 30G, 70% das agulhas fraturaram próximo ao canhão. Todas as amostras do grupo Septoject XL 27G apresentaram fraturas após a segunda dobra. Conclusão Todas as agulhas gengivais testadas apresentaram comportamento aceitável, mesmo quando submetidas a situações críticas. As agulhas Dencojet 27G demonstraram ser mais flexíveis quando dobradas. Todas as agulhas Septoject XL 27G fraturaram após a segunda dobra. Não é aconselhável dobrar as agulhas dentárias.

[Needle fractures during mandibular block: prevention and emergency care algorithm]

Cases of dental needle fracture during mandibular block were studied in the last 10 years. Despite dental anesthesia development, the cases of needle fracture occur regularly in the world practice. Some of these complications has iatrogenic nature while others may be attributed to independent reasons like patients' sharp movement and needle manufacturing defect. In most of the cases the needle migrates to surrounding anatomical spaces making operative removing a challenging task. Subsequent surgical removing of a foreign body has severe consequences to patient in the form of a large operating injury, long-term disability and functional limitations. The article presents an algorithm for prevention and emergency care for a patient with dental needle fracture during mandibular block.

Application of computer-assisted navigation systems in oral and maxillofacial surgery

The oral and maxillofacial region has a complicated anatomy with critical contiguous organs, including the brain, eyes, vital teeth, and complex networks of nerves and blood vessels. Therefore, advances in basic scientific research within the field of intraoperative oral and maxillofacial surgery have enabled the introduction of the features of these techniques into routine clinical practice to ensure safe and reliable surgery. A navigation system provides a useful guide for safer and more accurate complex in oral and maxillofacial surgery. The effectiveness of a navigation system for oral and maxillofacial surgery has been indicated by clinical applications in maxillofacial trauma surgery including complex midfacial fractures and orbital trauma reconstruction, foreign body removal, complex dentoalveolar surgery, skull base surgery including surgery of the temporomandibular joint (TMJ), and orthognathic surgery. However, some fundamental issues remain involving the mobility of the mandible and difficulty in updating images intraoperatively. This report presents an overview and feasible applications of available navigation systems with a focus on the clinical feasibility of the application of navigation systems in the field of oral and maxillofacial surgery and solutions to current problems.

Displacement of a Broken Dental Injection Needle Into the Perivertebral Space

Dental injection needle breakage is an uncommon problem in dental practice. Displacement of the broken fragment into anatomical spaces is, on the other hand, a serious complication that occurs most commonly during inferior alveolar nerve blocks as a result of material wear, incorrect application of the anesthesia technique, or sudden movement of the patient during injection. Further complications such as infection, trismus, and nerve paralysis may exacerbate the condition and, if not treated adequately, life-threatening conditions may develop over time as the fragment dislodges deeper in soft tissues. Clinical symptoms of the patient, as well as the findings gathered from detailed physical examination and radiographic evaluation, are important factors to consider before performing an exploratory surgery. Removal of a broken needle may be troublesome due to its proximity to vital anatomic structures. Multislice computed tomography is a reliable imaging modality that provides accurate information to pinpoint the exact location of the needle fragment.This report describes a case of needle breakage occurred during inferior alveolar nerve block which was performed to extract a third molar tooth and the migration of the broken fragment from the right mandibular ramus area into the perivertebral space, with special emphasis on the surgical retrieval technique with multiplanar computed tomography imaging guidance.

Removal of a fractured needle during inferior alveolar nerve block: two case reports

The inferior alveolar nerve block is the most common method of local anesthesia for intraoral surgery at the posterior mandibular region. However, unexpected complications may occur when administering the local anesthesia. One of these uncommon complications is the fracture of the needle. If the injection needle is broken during the surgery, it should be removed immediately. However, this is one of the most difficult procedures. In this report, we present two cases of needle fracture during the procedure, and its successful removal under general/local anesthesia administration.

Retrieval of a Broken Dental Needle Close to the Facial Artery After Cervical Migration

Use of imaging tools like digital C-arm, tridimensional tomography, and navigational surgery has proven its value to the surgical removal of broken needles. A 32-year-old patient was referred for evaluation of a fractured needle during inferior alveolar nerve block attempt few days before. The patient complained of a pricking sensation at the injured area while moving the neck. A contrasted computed tomography was performed for further evaluation of the needle toward the vascular network of the neck, showing a close location by the left facial artery, parallel to the styloid process of the temporal bone. The needle was then released from the underlying tissues and retrieved. Although considered a rare intercurrence, there are still reports of breaking needles during dental anesthesia. Such reports are almost always related to inferior alveolar nerve blocks, associated with the use of short, thin needles, and after multiple bending movements before the insertion of the needle in the tissues. Accurate image examinations such as contrasted computed tomography are of great importance for planning the surgical removal, especially in patients of migration next to important vessels of the neck.

The surgical retrieval of a broken dental needle: A case report

One complication related to local anesthesia in the dental clinic is a broken needle. Although rare, a broken needle may be difficult to retrieve. Dental radiographs and 3D CT have been used in the past to confirm the location of a broken needle. We present the case of a broken needle, which was successfully removed using a careful, microscopic approach.