Surgical Retrieval of a Broken Local Anesthetic Needle in the Pterygomandibular Space Using CBCT and C-Arm Guidance
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThe manuscript addresses a clinically relevant topic and presents a technically interesting case. Although the work is not highly innovative, it may be of practical value for clinicians involved in the management of migrated dental implants and image-guided maxillary sinus surgery. I therefore consider the paper potentially suitable for publication after minor to moderate revision.
Novelty and clinical contribution:
Please clarify more explicitly in the Discussion what distinguishes this case from previously reported retrieval techniques (e.g., the combined use of CBCT and C-arm imaging, placement of radiopaque markers, or specific aspects of the surgical workflow).
Postoperative outcome:
Please consider adding information regarding the duration of postoperative follow-up, neurological status (e.g., lingual or inferior alveolar nerve function), and whether any postoperative imaging was performed.
Discussion structure:
The Discussion section could be made more concise by synthesizing the literature rather than summarizing individual reports sequentially, particularly when comparing different image-guided techniques.
Editorial points:
– Correct typographical errors in section headings (e.g., “Assessment”).
– Consider clarifying the fluoroscopic projections used intraoperatively.
The manuscript contains minor grammatical and typographical errors and shows inconsistent use of British and American spelling (e.g., “localise” vs. “localize”). A thorough language revision by a native English speaker is recommended.
“Obtaining a broken needle from the pterygomandibular space is a surgical challenge” → the word “is” is missing.
In the “Clinical Relevance” section, the term “obstetric” appears to be inappropriate for this clinical context and should be corrected.
Author Response
Response to Reviewer #1
We would like to sincerely thank the reviewer for the careful evaluation of our manuscript and for the constructive comments that helped us improve the clarity and quality of the paper. All suggestions were carefully considered and the manuscript has been revised accordingly. Detailed responses are provided below.
Comment 1 – Novelty and clinical contribution
Please clarify more explicitly in the Discussion what distinguishes this case from previously reported retrieval techniques (e.g., the combined use of CBCT and C-arm imaging, placement of radiopaque markers, or specific aspects of the surgical workflow).
Response
We thank the reviewer for this important suggestion. The Discussion section has been revised to more clearly highlight the clinical contribution of the present case. Specifically, we emphasized the combined use of preoperative CBCT planning and intraoperative C-arm fluoroscopy together with radiopaque reference markers, which allowed precise three-dimensional orientation and targeted dissection within the pterygomandibular space.
Changes in manuscript
Additional clarification has been included in the Discussion (Section 3.7) to emphasize how the combination of CBCT-based planning, intraoperative fluoroscopy, and radiopaque markers contributed to accurate localization and minimized unnecessary tissue dissection.
Comment 2 – Postoperative outcome
Please consider adding information regarding the duration of postoperative follow-up, neurological status (e.g., lingual or inferior alveolar nerve function), and whether any postoperative imaging was performed.
Response
We appreciate this valuable comment. Additional information regarding the postoperative course has been included in the Outcome and Follow-Up section. The duration of follow-up and the patient’s neurological status were clarified. The patient was followed clinically for one month and showed no signs of infection, trismus, or neurosensory deficit involving the lingual or inferior alveolar nerves.
Changes in manuscript
The Outcome and Follow-Up section (Section 2.6) has been revised to include information on postoperative clinical evolution and follow-up.
Comment 3 – Discussion structure
The Discussion section could be made more concise by synthesizing the literature rather than summarizing individual reports sequentially.
Response
We thank the reviewer for this helpful observation. The Discussion section has been revised to improve clarity and flow by synthesizing the literature and grouping findings from different studies rather than describing each report sequentially. This approach better highlights the main concepts regarding fractured needle management and image-guided retrieval techniques.
Changes in manuscript
The Discussion section has been edited and condensed to provide a clearer synthesis of the available literature.
Comment 4 – Editorial points
Correct typographical errors in section headings (e.g., “Assessment”).
Response
Thank you for pointing this out. All section headings have been reviewed and corrected where necessary.
Changes in manuscript
The section title “Diagnostic Assessment” has been revised and typographical errors have been corrected throughout the manuscript.
Comment
Consider clarifying the fluoroscopic projections used intraoperatively.
Response
We appreciate this suggestion. Additional clarification regarding the use of intraoperative fluoroscopy has been included in the surgical procedure description.
Changes in manuscript
The description of C-arm fluoroscopy guidance in Section 2.5 (Surgical Procedure) has been expanded to clarify how fluoroscopic views were obtained during surgery to guide dissection.
Comment 5 – English language and grammar
The manuscript contains minor grammatical and typographical errors and shows inconsistent use of British and American spelling.
Response
We thank the reviewer for highlighting this issue. The manuscript has undergone a thorough language revision to correct grammatical errors and ensure consistent spelling and terminology throughout the text.
Comment
“Obtaining a broken needle from the pterygomandibular space is a surgical challenge” → the word “is” is missing.
Response
Thank you for identifying this typographical error. The sentence has been corrected in the revised manuscript.
Comment
In the “Clinical Relevance” section, the term “obstetric” appears to be inappropriate for this clinical context.
Response
We thank the reviewer for pointing out this mistake. The term “obstetric” was incorrectly used and has been corrected to “maxillofacial region” in order to accurately reflect the clinical context.
Changes in manuscript
The corrected wording appears in Section 2.7 (Clinical Relevance).
Concluding Statement
We once again thank the reviewer for the constructive comments and suggestions. The revisions made in response to these remarks have improved the clarity, scientific rigor, and clinical relevance of the manuscript.
Reviewer 2 Report
Comments and Suggestions for AuthorsThe manuscript is highly interesting and addresses a clinically relevant and uncommon complication in dental practice. The topic is well chosen and has direct applicability for clinicians, particularly oral and maxillofacial surgeons, given the increasing use of advanced imaging and intraoperative guidance techniques.
It would be advisable to further emphasize that, in dentistry, the use of local anesthetic injections, and therefore dental needles, is routine and extensive, as a wide range of diagnostic, restorative, surgical, and endodontic procedures depend on local anesthesia. Highlighting this context would help underscore the clinical relevance of the reported complication and its potential implications for everyday dental practice.
In the Materials and Methods section, please ensure that comprehensive technical details are provided. Specifically, the type of anesthesia administered, the needle characteristics (gauge, length, and type), and all equipment, reagents, and materials used during diagnosis and surgical retrieval should be clearly specified, including brand name, model, and country of origin, in accordance with standard reporting guidelines.
Additionally, it would be important to explicitly state the time interval between needle fracture and surgical retrieval. This information is clinically relevant, as it may influence the degree of tissue reaction, migration risk, surgical difficulty, and overall patient management.
Author Response
Response to Reviewer #2
We would like to thank the reviewer for the positive evaluation of our manuscript and for the constructive comments that helped improve its clarity and methodological completeness. All suggestions were carefully considered, and the manuscript has been revised accordingly. Detailed responses are provided below.
Comment 1 – Clinical context of local anesthesia in dentistry
It would be advisable to further emphasize that, in dentistry, the use of local anesthetic injections, and therefore dental needles, is routine and extensive…
Response
We thank the reviewer for this valuable suggestion. We agree that emphasizing the routine use of local anesthesia in dentistry better highlights the clinical relevance of the reported complication. The Introduction has been revised to provide additional context regarding the widespread use of local anesthetic injections across diagnostic, restorative, surgical, and endodontic procedures in dental practice.
Changes in manuscript
Additional explanatory sentences have been added in the Introduction section to emphasize the frequency and clinical importance of local anesthesia in dental procedures.
Comment 2 – Technical details in Materials and Methods
Please ensure that comprehensive technical details are provided regarding anesthesia, needle characteristics, and equipment used.
Response
We appreciate this important comment. The manuscript has been revised to include detailed technical specifications regarding the anesthetic technique, needle characteristics, and imaging and surgical equipment used during diagnosis and retrieval.
Changes in manuscript
Additional technical details have been included in the Case Report section, specifically:
- Needle characteristics: disposable 25 mm 30-gauge needle (Transcodent, Schleswig-Holstein, Germany)
- Dental syringe: standard aspirating dental syringe (Hu-Friedy, Chicago, IL, USA)
- Local anesthetic: 4% articaine with epinephrine 1:100,000 (Ubistesin Forte®, 3M ESPE, Seefeld, Germany)
- CBCT device: KaVo OP 3D system (KaVo Dental GmbH, Biberach, Germany)
- Image analysis software: OnDemand3D™ (Cybermed Inc., Seoul, South Korea)
- Intraoperative fluoroscopy: Ziehm Solo FD C-arm system (Ziehm Imaging GmbH, Nuremberg, Germany)
- Radiopaque reference markers: BD Venflon™ Pro Safety intravenous trocars (Becton Dickinson, Helsingborg, Sweden)
These additions ensure compliance with standard reporting recommendations.
Comment 3 – Time interval between needle fracture and surgery
It would be important to explicitly state the time interval between needle fracture and surgical retrieval.
Response
We thank the reviewer for highlighting the clinical relevance of this aspect. The manuscript has been revised to explicitly state the time interval between the incident and surgical intervention.
Changes in manuscript
The following information has been added in the History and Presenting Complaint section (Section 2.2):
- The patient presented approximately 12 hours after the incident.
- Surgical retrieval was performed within 18 hours from the time of needle fracture.
This information helps clarify the early referral and timely surgical management in the present case.
Concluding Statement
We sincerely thank the reviewer for the constructive feedback. The suggested revisions have improved the methodological transparency and clinical relevance of the manuscript.
