Читать книгу Management of Complications in Oral and Maxillofacial Surgery - Группа авторов - Страница 74

Instrument Breakage/Foreign Body Displacement

Оглавление

 Etiology: excessive force, inappropriate instrument use

 Management: immediate or delayed removal of foreign body, monitoring

The complexity of instruments utilized by the surgeon during third molar surgery can vary significantly based upon individual training, experience, and preferences. Nearly every surgeon has a preferred instrument for each situation, and, in many instances, the reliability and resiliency of those instruments may be taken for granted.

The structural failure of an instrument can lead to complications associated with foreign body displacement into the maxillary sinus, infratemporal fossa, sublingual space, airway, gastrointestinal tract, etc. One well‐documented, and avoidable, complication is local anesthetic needle breakage, usually occurring during an IAN block. In most instances, the clinician has bent the needle at the hub in order to allow for an easier approach to the medial aspect of the ascending ramus and mandibular foramen to ensure an adequate local anesthetic injection [42].

When instrument breakage does occur, the key is to locate the fractured portion of the instrument and assure that it is not violating, or could potentially violate, any surrounding critical structures (e.g., nerves, blood vessels). Once the location is ascertained, the surgeon should decide between two options: (i) leave the fractured piece in place and monitor for any migration or (ii) decide upon removal of the fractured instrument immediately or in a delayed fashion after fibrosis occurs.

Once the decision has been made to remove the retained foreign body, the safest method that will allow adequate access should be utilized. This often requires general anesthesia in an operating room setting. Since the fractured pieces are almost always small in size, the use of fluoroscopic or navigational guidance is often used. Blind exploration for a broken needle in the infratemporal fossa, or elsewhere, is not advised. On rare occasions, the assistance of either the neurosurgical or interventional neuroradiology teams may be required if potential vascular injury could occur during retrieval of the fracture instrument or needle [43] (Figure 2.11a–c) (Algorithm 2.6).


Fig. 2.10. (a) Panoramic image of biopsy proven left mandibular osteomyelitis demonstrating osteosclerosis, reactive periostitis, and “moth‐eaten” appearance to the bone. (b) Intraoperative appearance of the left mandible with reactive bone and advanced disease. (c) Following resection of the involved left mandible and reconstruction bone plate placement. (d) Surgical resection specimen with negative margins. (e) Postoperative panorex demonstrating a large continuity defect. (f) Secondary reconstruction with iliac crest three months after initial surgery and following completion of six weeks of IV antibiotics. (g) Iliac crest graft compressed and packed into syringes for delivery to the defect site. (h) Six months following secondary reconstruction demonstrating excellent graft take and restoration of continuity of the mandible.

Fig. 2.11. (a) Sagittal view CT demonstrating displacement of a 25‐gauge needle during posterior superior alveolar block with migration through foramen ovale and into the middle cranial fossa causing pain and intermittent facial numbness. Patient required a right pterional craniotomy for retrieval. (b) Coronal view of needle displacement through foramen ovale. (c) Axial view of needle displacement through foramen ovale.

Management of Complications in Oral and Maxillofacial Surgery

Подняться наверх