JBCOMS - Journal of the Brazilian College of Oral and Maxillofacial Surgery by Prod

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Maxillary Advancement with Maxillary Mandibular Advancement with

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Volume 4, Number 2, 2018 - ISSN 2358-2782

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Implant (Anterior Socket Grafting)

Volume 4, Número 2, 2018

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Journal of the Brazilian College of Oral and Maxillofacial Surgery - JBCOMS

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Management

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EDITOR-IN-CHIEF Gabriela Granja Porto

ASSOCIATE EDITOR-IN-CHIEF José Nazareno Gil

SECTION EDITORS

Oral Surgery Andrezza Lauria de Moura Cláudio Ferreira Nóia Danilo Passeado Branco Ribeiro Fernando Bastos Pereira Júnior Luis Carlos Ferreira da Silva Marcelo Marotta Araújo Matheus Furtado de Carvalho

Universidade de Pernambuco - FOP/UPE - Camaragibe/PE - Brazil Universidade Federal de Santa Catarina - UFSC - Florianópolis/SC - Brazil

Universidade Federal do Amazonas - UFAM - Manaus/AM - Brazil Faculdade Ciodonto - Porto Velho/RO - Brazil Universidade Estadual do Rio de Janeiro - UERJ - Rio de Janeiro/RJ - Brazil Universidade Estadual de Feira de Santana - UEFS - Feira de Santana/BA - Brazil Universidade Federal de Sergipe - UFS - Aracaju/SE - Brazil Universidade Estadual Paulista, Instituto de Ciência e Tecnologia - São José dos Campos/SP - Brazil Universidade Federal de Juiz de Fora - UFJF - Juiz de Fora/MG - Brazil

Implants Clarice Maia Soares Alcântara Darklilson Pereira Santos Leonardo Perez Faverani Rafaela Scariot de Moraes Ricardo Augusto Conci Waldemar Daudt Polido Trauma Aira Bonfim Santos Daniel Falbo Martins de Souza Leandro Eduardo Kluppel Liogi Iwaki Filho Márcio Moraes Nicolas Homsi Ricardo José de Holanda Vasconcellos

Universidade Federal de Santa Catarina - UFSC - Florianópolis/SC - Brazil Hospital Alemão Oswaldo Cruz - São Paulo/SP - Brazil Universidade Federal do Paraná - UFPR - Curitiba/PR - Brazil Universidade Estadual de Maringá - UEM - Maringá/PR - Brazil Universidade de Campinas - FOP/Unicamp - Piracicaba/SP - Brazil Universidade Federal Fluminense - UFF - Niterói/RJ - Brazil Universidade de Pernambuco - FOP/UPE - Camaragibe/PE - Brazil

rthognathic Surgery and Deformities O Fábio Gamboa Ritto Fernando Melhem Elias Gabriela Mayrink Joel Motta Júnior José Laureano Filho José Thiers Carneiro Júnior Rafael Seabra Louro

Hospital Universitário Pedro Ernesto - UERJ - Rio de Janeiro/RJ - Brazil Universidade de São Paulo - Hospital Universitário - São Paulo/SP - Brazil Faculdades Integradas Espírito-Santenses - FAESA Centro Universitário - Vitória/ES - Brazil Universidade do Estado do Amazonas - UEA - Manaus/AM - Brazil Universidade de Pernambuco - FOP/UPE - Camaragibe/PE - Brazil Universidade Federal do Pará - UFPE - Belém/PA - Brazil Universidade Federal Fluminense - UFF - Niterói/RJ - Brazil

TMJ Disorders Belmiro Cavalcanti do Egito Vasconcelos Carlos E. Xavier dos Santos R. da Silva Eduardo Hochuli Vieira Eduardo Seixas Cardoso João Carlos Birnfeld Wagner Luis Raimundo Serra Rabelo

Universidade de Pernambuco - FOP/UPE - Camaragibe/PE - Brazil Instituto Prevent Senior – São Paulo/SP - Brazil Universidade Estadual Paulista Júlio de Mesquita Filho - FOAR/Unesp - Araraquara/SP - Brazil Universidade Federal Fluminense - UFF - Niterói/RJ - Brazil Santa Casa de Misericórdia - Porto Alegre/RS - Brazil Universidade Federal do Maranhão - UFMA - São Luís/MA - Brazil

Faculdade Metropolitana da Grande Fortaleza - Fortaleza/CE - Brazil Universidade Estadual do Piauí - UESPI - Parnaíba/PI - Brazil Universidade Estadual Paulista - FOA/UNESP - Araçatuba/SP - Brazil Universidade Positivo - Curitiba/PR - Brazil Universidade Estadual do Oeste do Paraná - UNIOESTE - Cascavel/PR - Brazil Clínica particular - Porto Alegre/RS - Brazil

Pathologies and Reconstructions Darceny Zanetta Barbosa Universidade Federal de Uberlândia - UFU - Uberlândia/MG - Brazil Jose Sandro Pereira da Silva Universidade Federal do Rio Grande do Norte - UFRN - Natal/RN - Brazil Martha Alayde Alcântara Salim Universidade Federal do Espírito Santo - UFES - Vitória/ES - Brazil Renata Pittella Universidade Federal do Espírito Santo - UFES-Vitória/ES - Brazil Ricardo Viana Bessa Nogueira Universidade Federal de Alagoas - UFAL - Maceió/AL - Brazil Sylvio Luiz Costa de Moraes Universidade Federal Fluminense - UFF - Niterói/RJ - Brazil Wagner Henriques de Castro Universidade Federal de Minas Gerais - UFMG - Belo Horizonte/MG - Brazil Ad-hoc Editors André Luiz Marinho Falcão Gondim Diogo Souza Ferreira Rubim de Assis Eider Guimarães Bastos Hernando Valentim da Rocha Junior

Universidade Federal do Rio Grande do Norte - UFRN - Natal/RN Universidade Federal do Maranhão - UFMA - São Luís/MA Universidade Federal do Maranhão - UFMA - São Luís/MA Hospital Federal de Bonsucesso - Rio de Janeiro/RJ

table of contents

Editorial: What is impact factor of a scientific journal? Gabriela Granja Porto

Letter from the President José Rodrigues Laureano Filho

CBCTBMF promotes campaign for the prevention of facial trauma all over Brazil

Protagonism Antenor Araújo

Articles

Negative of coverage in orthognathic surgery by health plans

Three-dimensional airway analysis after orthognathic surgery: pilot study

Comparative study of dipyrone and paracetamol pain control after third molar extraction

Marília de Oliveira Coelho Dutra Leal, Gilberto Paiva de Carvalho, Cláudio Roberto Pacheco Jodas, Rubens Gonçalves Teixeira, Eduardo Daruge Júnior

Rodrigo Marinho Falcão Batista, Joaquim Celestino da Silva Neto, José Romero Souto de Sousa Júnior

Gabriela Mayrink, Bruno Nicolai, Jorge Pedro Aboumrad Júnior

Epidemiology of OMFS surgical procedures of a public hospital

Medical emergencies in dentistry: academic knowledge – a ten-year comparative study

Wellen Gobbi Botacin, Luiz Felipe Nakasome, Raphael Castiglione Coser, Renata Pittella Cancado

Larissa Fochesatto Restelato, Andrea Gallon, Felipe Lange, Tharzon Barbieri

Surgical treatment of zygomatic-orbital fracture sequelae with autogenous graft and alloplastic material Carlos Eduardo Mendonça Batista, Thalita Medeiros Melo, Iluska Castro dos Santos, Jhonatarraty Fonseca de Sena, Éwerton Daniel Rocha Rodrigues, Eider Guimarães Bastos

Alveolar crest expansion for placement of dental implants: case report

Tárcio Hiroshi Ishimine Skiba, Salomão Alves Barbosa, Marcus Zorzimo Moreira, Bruno Costa Martins de Sá, Cláudio Ferreira Nóia

Hemangioma treatment on lip mucosa by sclerotherapy

Jéssica Pimenta dos Santos, Nathalia Soigg Lam, Renata Amadei Nicolau, Iris Maria Frois, Camila Porto Deco, Antonio Carlos Victor Canettieri

Information for authors

Editorial

What is impact factor of a scientific journal?

The Impact Factor (IF), as it was originally named, is the main measure employed to evaluate the scientific journals all over the world, by counting the citations received from published papers. It provides quantitative data that indicates approximately which journals have greater academic prestige. In Brazil, some commissions such as the Qualis Periódicos of CAPES use this tool to compose their evaluations. Herein I will not discuss the distortions of such index, yet it should be noted that there is also a complementary analysis on the quality of the journal, peer review process, productivity, besides other subjective factors about the editorial policy. Also, CAPES recently published a list of predatory journals (https://predaqualis. netlify.com/lista), which present impact factor yet use principles that are discordant in the academic environment – e.g. they do not have an ethical publication policy and charge fees for publication, making a doubtful evaluation of the quality of scientific texts. The Impact Factor of a scientific journal is calculated only among journals that compose the large collection of the Web of Science database and present DOI. Therefore, the citations of issues in non-indexed journals, or considering the Impact Factor for journals outside the WoS, are not counted, even though their citations may be measured in other indexing bases.

How to cite: Porto GG. What is impact factor of a scientific journal? J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):4-5. DOI: https://doi.org/10.14436/2358-2782.4.2.004-005.edt

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):4-5

Editorial

The present calculation, presented in a simple manner for better understanding of the impact factor of a journal per year, is the sum of all citations it received in the two previous years, divided by the total number of papers published in the same journal, as shown in the image below:

2015

IMPACT FACTOR 2017

2016

2017

CITATIONS 2015 + 2016 PUBLICATIONS 2015 + 2016

However, other indexing bases have their calculations and are primarily based on the ratio between published papers and cited papers. The JBCOMS is struggling to be indexed in other databases; therefore, it is fundamental to understand this citation process and consequently enter the hall of differentiated journals.

Profa. Dra. Gabriela Granja Porto Editor-in-Chief of JBCOMS Journal of the Brazilian College of Oral and Maxillofacial Surgery

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):4-5

Letter from the President

How to cite: Laureano Filho JR. Chairman’s Letter. J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):6-7. DOI: https://doi.org/10.14436/2358-2782.4.2.006-007.crt

Dear colleagues, The Brazilian College of Oral and Maxillofacial Surgery and Traumatology has as Mission: “To promote the development of oral and maxillofacial surgery and traumatology in Brazil by the scientific progress achieved by advanced education, enhancement of research and exchange of experiences”; and its Vision is: “To be acknowledged by specialists in oral and maxillofacial surgery and traumatology and by the scientific community as a national and international reference organization”. Based on these concepts, we have conducted our management, which initiated this year, aiming to act equally in the different fields of action of the College. When we discuss about development and progress of oral and maxillofacial surgery and traumatology, we cannot forget to mention our Journal of the Brazilian College of Oral and Maxillofacial Surgery (JBCOMS). Our journal has received special attention by the last boards and has been presenting an important advance in its consolidation as a scientific journal with national and international impact. The strategic planning for the growth of the JBCOMS includes the fulfilment of rules for indexing in the main international platforms, which has been pursued by the previous boards and also by the present. Maintenance of the frequency of publication, with a minimum number of papers per issue, the presence of original papers, besides other parameters, has further strengthened the journal. We released the free access to the English version to meet one more aspect required for indexing. However, only the members have access to the Portuguese version. This action is very important to increase the visualization and access to the journal, which are important aspects for the evolution of the JBCOMS. Other important aspect in the Mission is the organization of events, both local, organized by chapter coordinators and collaborators, or even the well-known ENNEC, COPAC and COBRAC, which are important tools for the growth and solidification of the specialty. The ENNEC – North-Northeast Meeting of Oral and Maxillofacial Surgery and Traumatology, held in early May, was magnificent! An absolute success in attendance, financial and scientific aspects! The COPAC will soon occur with its traditional greatness, excellent scientific program and for the first time in Ribeirão Preto, in next October. In 2019, we will have the ICOMS (International Conference on Oral and Maxillofacial Surgery), in combination with the IAOMS (International Association of Oral and Maxillofacial Surgery), which will be held in Rio de Janeiro. This conference, for the first time in Brazil, will allows us to organize the largest event on Oral and Maxillofacial Surgery and Traumatology of the world, with more than 120 international lecturers already confirmed. Finally, in 2020 we will have the COBRAC in Belém, with some international lecturers already confirmed. Still within the main scope, after this semester, we will offer lectures on the College website, available for the members; and still in 2018, we will have videos properly prepared for lay individuals to know our specialty and what we do. We will use the social networks for that purpose. Other news about the events is the possibility, from this year on, to attend congresses in Latin America, register to the event as members of the ALACIBU with the proper discount. These events are being communicated in our website.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):6-7

Carta do Presidente

However, besides these actions expected by members of the College, we are working on other goals: Training, Direct benefits, Working conditions and Visibility. In Training, after diffusion of the ideal model by the previous board, we are working on the accreditation of residencies and residency-based specialization courses, to standardize the training in the country and offer increasingly well-trained oral and maxillofacial surgeons and traumatologists to the society. We are still focusing on some benefits for the programs: the residents and students of residency-based specialization courses will have the opportunity to participate in the national and international exchange of residents and exclusive activities in the official events of the College. We are preparing a package of direct benefits for the members with several attractions: civil responsibility insurance, juridical assistance, and others, with very attractive conditions. We will soon have news! To improve the working conditions, especially in the action of oral and maxillofacial surgeons and traumatologists with health insurance companies, thus avoiding or minimizing possible damages, we are establishing direct contact with these companies, initially, providing juridical assistance or even judicially when needed. We took a great step toward transparency in the relationships with our patients, industry, hospitals and health insurance companies. Since June, the College is part of the Advisory Board of the Ethics and Health Institute (IES), which provides recommendations to the Managing and Ethics boards of the institution. The IES aims to assure the patient’s safety and sustainability of the health system by an ethical approach between participants of this sector, in an environment with fair and transparent competition. The IES has agreements with the National Sanitary Surveillance Agency (ANVISA), Federal Court of Accounts (TCU), Administrative Council for Economic Defense (CADE) and the National Association of the Public Ministry for Health Defense (AMPASA), aiming to avoid illegal or unethical incentives for public and private agents, practice of illegal or unethical medical procedures, tax evasion, regulatory irregularities, unfair competition, consumer rights violation and falsification. Finally, we increased and distributed the media actions, both locally and nationally, by a partnership with Rede Globo in the Bem Estar show; adhesion to the Yellow May Campaign, with successful participation of most chapters, which allowed several participations in radio and TV programs all over the country; besides specific actions, such as during the Carnival in Salvador and São João party in Aracaju, which also promoted good exhibition in the media. Let’s go ahead! There’s much to do! Together we can!!

José Rodrigues Laureano Filho President of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):6-7

CBCTBMF

CBCTBMF promotes campaign for the prevention of facial trauma all over Brazil To inform motorcyclists and cyclists about the prevention of facial trauma, the Brazilian College of Oral and Maxillofacial Surgery and Traumatology (CBCTBMF) conducted the National Campaign for Prevention of Facial Trauma, during Yellow May. Local coordinators in several cities organized blitzes and actions for motorcyclists and cyclists, providing important information and guidance. The city of Curitiba, in Paraná, prepared actions on May 5th, 14th, 18th and 29th (Figs 1 and 2), with

participation of Harley-Davidson in the Yellow May event (Figs 3 and 4). With support from the Military Police of Paraná, Luciana Signorini conducted the action in some sites in the city, with distribution of folders and guidance for motorcyclists and cyclists about the adequate use of helmet for the prevention of facial trauma. Also, in Paraná, the city of Cascavel promoted the Yellow May campaign on May 17th, under coordination of Greison Rabelo de Oliveira (Fig 5).

Figure 1: Yellow May in Curitiba.

Figure 2: Yellow May in Curitiba.

Figure 3: Yellow May at Harley-Davidson, in Curitiba.

Figure 4: Yellow May at Harley-Davidson, in Curitiba.

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CBCTBMF

Figure 5: Yellow May in Cascavel, ParanĂĄ.

were approached with hints on the prevention and care (Fig 6). Additionally, the team participated in an audience about traffic, in the Legislative Assembly of Pernambuco.

In Recife, under coordination of Gabriela Porto, together with the staff from Detran of Pernambuco, six blitzes were organized during May, in which the motorcyclists

Figure 6: Yellow May in Pernambuco.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):10-3

CBCTBMF

On May 25th, the coordinator of São Luis, Daniel Schimidt, promoted the action. On May 27th, the Yellow May Campaign was held in Vitória, at Praia de Camburi avenue, under coordination of Gabriela Mayrink; and in Rio de Janeiro, under coordination of Ricardo Mattos and the second adjunct Jonathan Ribeiro. In partnership with the dental syndicate of Rio Grande do Norte and the Federal University of Rio Grande do Norte (UFRN), the coordinator Adriano Germano held the campaign in Natal, on May 29th, in front of the Dental School of UFRN, at Senador Salgado Filho avenue. In Uberlândia, on May 30th, at Rondon Pacheco avenue, Maiolino Oliveira organized actions with distribution of leaflets and guidance for cyclists and motorcyclists. The adjunct coordinator of Teresina, Fabrício Serra e Silva, organized the campaign at the parking lot of Estaiada Bridge of the city, with the support of collectors of antique cars and motorcycles, on May 30th.

In the state of São Paulo, three cities promoted actions: Araçatuba, Bauru and Piracicaba. In Araçatuba, at Rui Barbosa square, under coordination of Leonardo Faverani and the presence of the city mayor Dilador Borges and the urban mobility secretary, the team of the College opened the Facial Tent in the Yellow May event – Facial Trauma Prevention. Thirty undergraduate students, MSc students and professor of the discipline of surgery participated. Ludic activities were organized for the population, with dynamics using skulls with facial fractures to promote the awareness on the correct utilization of the helmet, safety belt and safety equipment for cyclists. Actions were also conducted on the traffic lights, with distribution of handouts explaining the importance of prevention of facial traumas (Figs 7 and 8). On May 16th, Eduardo Gonçales organized in the city of Bauru an action at the Entrance Gate of FOB-USP and gymnasium of USP, with distribution of leaflets and guidance on the correct utilization of the helmet. In Piracicaba, on May 19th, Alexandre Tadeu Sverzut prepared the action with support from the Dental School of Unicamp and the presence of undergraduate and postgraduate students and oral and maxillofacial surgery residents. The task involved the distribution of handouts and guidance on the importance to use the helmet, safety belt and prevention of facial trauma. On May 20th, Thompson Gonçalves conducted the Campaign in the city of Fortaleza, with distribution of handouts, and a table with helmets and skull models was mounted for guidance and prevention of facial trauma.

NUMBERS OF ACCIDENTS According to the president of CBCTBMF, José Rodrigues Laureano Filho, the adequate utilization of the helmet reduces in 72% the risk and severity of lesions, reducing the probability of death in up to 39%, besides the treatment costs associated with the accident. The Brazilian traffic is considered one of the worst and most violent in the world, and the increasing number of vehicles also increases the number of accident victims. In Brazil, there are more than 14 million motorcycles on

Figure 7 and 8: Yellow May in Araçatuba.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):10-3

CBCTBMF

the streets, which corresponds to 25% of the national sum of vehicles. The motorcycle became the most popular mean of individual transportation of the country. Data from the Ministry of Health in 2017 demonstrate that traffic accidents caused the death of 34.8 thousand people, among which almost 1/3 (nearly 12 thousand people) were motorcyclists. The same year recorded 95,314 hospitalizations of motorcyclists, which

required an expense of R$ 127 millions, being 50% with hospitalization of ground transportation accident victims of the Brazilian Public Health System (SUS). The accidents with cyclists also reveal a poor scenery: in 2017, 10,764 cyclists were hospitalized due to traffic accidents in Brazil, i.e. 30 hospitalizations per day in the average, or more than one hospitalization pf hour. The costs were greater than R$ 12.5 millions.

MEDIA COVERAGE Radio stations, TV channels, newspapers and websites from all over Brazil published and exhibited notices on the Yellow May – Prevention of Facial Trauma, of the CBCTBMF. The Campaign in the city of Bauru was covered by TV Record and USP, besides local radio stations and newspapers. The SBT and Bandeirantes radio station from Araçatuba also diffused the local action (Fig 9). The Diário do Nordeste and TV news Bom Dia Ceará, from Rede Globo, diffused the event in Fortaleza (Figure 10). In Recife, the Jornal do Commercio, Diário de Pernambuco, TV Globo, SBT and local radio stations highlighted the Campaign (Fig 11).

Figure 9: Leonardo Faverani during interview for SBT.

Figure 10: Thompson Gonçalves during interview for TV Globo.

Figure 11: The president of CBCTBMF, José Rodrigues Laureano Filho, Gabriela Porto and Suzana Carneiro during recording for TV Globo at Pernambuco.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):10-3

Protagonism

Pioneering in Oral and Maxillofacial Surgery Prof. Dr. Antenor Araújo

A VISIONARY OF THE BRAZIL-USA EXCHANGE IN ORTHOGNATHIC SURGERY: AUTOBIOGRAPHY Initially, I would like to thank the Brazilian College of Oral and Maxillofacial Surgery and Traumatology for the opportunity to share moments of my professional life with our colleagues.

For five years, I was training in Clinics Hospital with Dr. Gino Emilio Lasco and Dr. Gerson. For living, I worked as pediatric dentist twice a week and trained in oral and maxillofacial surgery at the Clinics Hospital of São Paulo. Several times, due to the tiredness of working shifts, I stopped at a gas station and slept. By that time, the second track of Via Dutra was under construction. Continuing my university career, I presented my PhD thesis in 1971 and, continuing, I presented my habilitation thesis in August 1979. I underwent a selection for Full Professor in 1983 – by that time, I was the youngest Full Professor at UNESP. I was head of the Department of Diagnosis and Surgery of São José dos Campos Dental School/UNESP several times and Director of this school from 1987 to 1990. At the school, I worked as professor of the Discipline of Oral and Maxillofacial Surgery, under the guidance of Dr. Gerson, together with professors Dr. Franklin Edgard de Moura Campos, Dr. Antonino Kimaid, Dr. Paulo Villela Santos Junior, Dr. Nicolau Diacov, Dr. Job Sarmento da Silva, Dr. Edgard Pereira de Souza, Dr. José Roberto Sá Lima, Dr. Marcelo Marotta Araujo and Dr. Eduvaldo Silvino de Brito Marques. Then, time went by until, in 1976, I decided I had to look for further knowledge abroad. Orthognathic surgery was beginning in several countries.

FAMILY I was born in Sorocaba on August 30th, 1944, son of Yacy Araujo, dentist, and Nydia Passaro Araujo, teacher. I have three children: Marcelo, Adriano (both dentists – the former is maxillofacial surgeon and the second is orthodontist) and Roberta (who is fashion products consultant). My wife Vilma always participates with me in all congresses, both national and international. My father died when I was 14 years and we were raised by my mother, who taught in the morning, afternoon and evening to allow me and my sister to study in good schools. PROFESSIONAL LIFE I completed the high school at Liceu Coração de Jesus and was approved in the entrance examination of São José dos Campos School of Dentistry in 1962, where I graduated in 1967. At the beginning of my professional career I received training from Dr. Miaki Issao as pediatric dentist. I had a clinic in Guaratinguetá, yet I was always focusing on surgery, a field in which I was specializing.

BRAZIL-USA EXCHANGE I applied to the residency in Dallas-Texas/USA, at Parkland Memorial Hospital, under supervision of Dr. Robert V. Walker, and in Northwestern (Chicago/USA), with Dr. Roger H. Kallal. I was really unsure about which to choose; however, Prof. Walker came to Curitiba in a congress of the

UNIVERSITY CAREER I remained in the dental school for training in Surgery, and I was hired in 1970 by Dr. Gerson Munhoz dos Santos, my “guru” and guide of my entire professional life.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):14-7

Brazilian College of Oral and Maxillofacial Surgery and, after that, I shall not deny that the cold weather of Chicago guided me closer to Dallas. Some time later, I received the response of my approval and I definitely decided to go to Dallas. I had no idea I was going to the cradle of orthognathic surgery, which in fact was beginning all over the world. My professors were Dr. Robert W. Walker (Fig. 1), an incomparable professional who strengthened the oral and maxillofacial surgery all over Latin America, Europe and other countries; besides Dr. Douglas P. Sinn, Dr. Bruce N. Epker, Dr. Larry M. Wolford and the creator of Orthognathic Surgery, Dr. Willian H. Bell (Fig. 2). However, I did not know I was being proofed as the first resident who was not an English native speaker, which meant that, if everything was ok, we would be opening the doors for new residents from Latin America. This worked and, soon after me, came Dr. Cesar Guerrero from Venezuela, and Dr. Paulo José de Medeiros, from Rio de Janeiro. The doors were open and many other residents from Latin America and other countries could enjoy the knowledge of great masters. I was professor at UNESP and submitted a proposal to FAPESP for a scholarship for investigation in orthognathic surgery to be conducted at Parkland Memorial Hospital, in Dallas – Texas/USA; for my surprise, this request was denied under the explanation that this surgery was performed in Brazil for several years. This was a great deception, because it did not correspond to reality. FAPESP submitted the proposals for analysis by a reviewer; my investigation would be about “Total maxillary advancement with and without bone grafting”. The

president of FAPESP himself told me "pack your luggage"; however, the professor who analyzed my report maintained his report and FAPESP did not allow to appeal. And now? With three young children, I decided to face it and thus I arrived in Dallas in 1976, affording the expense for myself and my family only with the dental school income. It was not easy but, as you may imagine, it was worth it! In the last three months of residency I got a scholarship from CAPES that allowed me to complete my course. As previously mentioned, I had already presented my PhD thesis, which allowed me to be in Dallas as a fellow, more related with research. However, this was not my goal; therefore, I asked Dr. Walker to remain as resident, so as I could work some shifts and make more surgeries. That was hard, but that was the right way.

Figure 1: With Drs. Robert V. Walker and Ed Ellis, as lectured in a congress in Austria.

Figure 2: Dr. Antenor Araujo, Dr. Willian H. Bell and Dr. Cesar Guerrero, in a course in Venezuela.

ORTHOGNATHIC SURGERY IN BRAZIL I came back to Brazil in 1978 to begin a new life. As I arrived, I participated in a congress of the College in Belo Horizonte, and so was the beginning of orthognathic surgery in Brazil. There were courses, conferences, and orthognathic surgery was expanding; other surgeons went to Dallas: Mario Gabrielli, Luiz Augusto Passeri, Waldemar Polido, João Milkle, Celso Palmieri, Jean Peter Ilg, Paulo José de Medeiros, and others – all with the goal to learn and diffuse the new surgery in Brazil. However, there was a problem: here we did not have adequate instruments for the accomplishment of orthognathic surgeries. Then, we joined with Quinelato and developed the instruments for the surgeries, which facilitated the surgical procedures.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):14-7

Oral Surgery about "Total maxillary advancement with and without bone grafting", together with Drs. Epker, Larry and Shendel, which by that time became a classic reference of orthognathic surgery, with international impact. Also, besides these professors, I could only feel extremely happy. It is curious to mention, that this paper was the outcome of that investigation that was refused by FAPESP.

I was invited to visit Centrinho, at Bauru/SP, by the orthodontist Dr. Leopoldino Capellozza, who presented a series of cases with cleft lip and palate for whom they were searching for a solution. I explained that my training in this field had not been much developed. We decided to invite Dr. Larry M. Wolford, our friend and professor, to perform these surgeries in combination, and train a surgeon from Centrinho that might continue our work later on. Dr. Leopoldino and I met Dr. Larry, in Dallas, with a bag full of cases to be planned. Following, Dr. Larry came to Brazil, and it all happened! Dr. Reinaldo Mazzotini took the responsibility to create the Orthognathic Surgery section; there he operated the patients and also trained new surgeons. Dr. Larry came to Brazil several times, especially in Centrinho. There was a large number of patients, thus we invited Dr. Roger H. Kallal, who also came yearly to Centrinho to perform surgeries. We often made 6 up to 8 surgeries per day. When we received visits from Larry and Kallal, the demand was very large, and we increasingly became good friends.

ACKNOWLEDGMENT In 2004, I received a prize from the American College during a Congress in Hollywood/Florida (Fig. 3), which brought me great satisfaction and pride by the words therein engraved (Fig. 4): "In acknowledgment for your inspiring leadership in the development of maxillofacial surgery. In appreciation for your willingness to share your knowledge".

ACTION TO STRENGTHEN THE SPECIALTY A group of surgeons willing to promote the continuity gathered with the goal to further develop the specialty, and then we established the College in 1970, in Brasília, in an assembly where I was present. I was honored to be elected president in two boards; we bought a headquarter and later we moved to a larger one. We enhanced the courses, residencies were created, and the teaching level was much enhanced. We currently have 1,100 members; the College is known internationally and is still increasing. In São José dos Campos, we created the Study Center with the Hospital Policlin, where we were president for several years. With the Study Center, we created the residency of our clinic, together with Hospital Policlin, where surgeries are performed in both inpatient and outpatient basis, and has completed 11 years, being acknowledged by the Brazilian College of Surgery and Federal Dental Council, training surgeons who in turn go back to their states and train new surgeons. I published three books: 'Cirurgia Ortognática', 'Manual de orientação aos pacientes com vistas à Cirurgia Ortognática' and 'Aspectos atuais da cirurgia e traumatologia bucomaxilofacial', besides several papers and other chapters in books from colleagues. However, one in particular is my favorite, which was published in Journal

Figure 3: Prize received.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):14-7

Protagonism

The selection was done secretly among surgeons from 20 countries and Caribbean islands, which were influenced by the United States and Europe by residency programs, congresses and publications, and by the work conducted for the benefit of the specialty. Currently, I continue my normal activities, with a private office in the city of São Paulo and doing surgeries at Hospital Sírio Libanês, in the clinic at São José dos Campos, doing surgeries at Hospital Policlin and several other public and private hospitals, and I keep intense activity as coordinator of our residency, with thorough activity with the residents, which renews me, always aiming to diffuse new knowledge for the growth of our specialty, posting in blogs and creating new study centers to allow better training of new colleagues and residents.

Figure 4: Lecturing the opening conference of the Congress of the American College.

Prof. Dr. Antenor Araújo - Full Professor at São Paulo State University, Dental School (São José dos Campos/SP, Brazil). - Coordinator of the Residency Course in Oral and Maxillofacial Surgery and Traumatology of Hospital Policlin (São José dos Campos/SP, Brazil). - Fellowship in Surgery by Parkland Memorial Hospital (Dallas/TX, USA). How to cite: Araújo A. Pioneering in Oral and Maxillofacial Surgery. J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):14-7. DOI: https://doi.org/10.14436/2358-2782.4.2.014-017.pio

E-mail: bucomaxilo@drantenor.com.br

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):14-7

OriginalArticle

Negative of coverage in orthognathic

surgery by health plans MARÍLIA DE OLIVEIRA COELHO DUTRA LEAL1,2,3 | GILBERTO PAIVA DE CARVALHO3,4,5 | CLÁUDIO ROBERTO PACHECO JODAS6,7 | RUBENS GONÇALVES TEIXEIRA8,9 | EDUARDO DARUGE JÚNIOR10,11

ABSTRACT Survey of the jurisprudence of the Court of Justice of São Paulo, 2014, in lawsuits of negative coverage of orthognathic surgery by Private Health Care Plans. Documentary analysis through access to the page www.tjsp.jus.br; search in the field “Jurisprudência (Pesquisa livre)”. Use of the keywords: buco maxilo facial AND plano de saúde AND negativa de cobertura; survey of processes; data collection of specific processes of orthognathic surgery: sex of the applicant, month of the trial, Private Health Care Plans involved, region of origin, outcome of the action for the patient, motivation of the negative and legislation used. There were 106 judgments (58 were orthognathic surgery). The Unimed System accounted for 36% of these processes. Only two decisions were unfavorable to patients. The “Need for an accredited professional to evaluate the choice of procedure and/or material (Medical Board)” was the justification most used by the PPAS to deny surgeries, followed by “No contractual coverage/list of procedures of the National Agency of Supplementary Health (ANS)”. The legislations most cited in the proceedings were from ANS. There was a high incidence of orthognathic surgery in the Court of Justice of São Paulo, 2014. Of the decisions, 96% were favorable to the patients. Keywords: Orthognathic surgery. Prepaid health plans. Health services coverage. Oral surgical procedures.

Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba, Programa de Pós-graduação em Biologia Buco-Dental – Histologia (Piracicaba/SP, Brazil). Specialist in Oral and Maxillofacial Surgery, Faculdade São Leopoldo Mandic (Campinas/SP, Brazil). 3 Instituto Médico Legal (Boa Vista/RR, Brazil). 4 Doctorate degree in Oral and Dental Biology – Anatomy, Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba (Piracicaba/SP, Brazil). 5 Universidade Federal de Roraima, Centro de Ciências da Saúde, Curso de Enfermagem, Disciplinas de Anatomia, Morfologia e Fisiologia (Boa Vista/RR, Brazil). 6 Doctorate degree in Orthodontics, Faculdade São Leopoldo Mandic (Campinas/SP, Brazil). 7 Faculdade São Leopoldo Mandic, Programa de Pós-graduação em Odontologia e Departamento de Cirurgia e Traumatologia Bucomaxilofaciais (Campinas/SP, Brazil). 8 Complexo Hospitalar Edivaldo Orsi, Serviço de Cirurgia e Traumatologia Bucomaxilofaciais (Campinas/SP, Brazil). 9 Doctorate degree in Dentistry, Universidade Federal do Rio de Janeiro (Rio de Janeiro/RJ, Brazil). 10 Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba, Programa de Pós-graduação em Biologia Buco-Dental, Disciplina de Odontologia Legal (Piracicaba/SP, Brazil). 11 Doctorate degree in Dental Radiology, Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba (Piracicaba/SP, Brazil). 1

How to cite: Leal MOCD, Carvalho GP, Jodas CRP, Teixeira RG, Daruge Júnior E. Negative of coverage in orthognathic surgery by health plans. J Braz Coll Oral Maxillofac Surg. 2018 MayAug;4(2):18-24. DOI: https://doi.org/10.14436/2358-2782.4.2.018-024.oar

Submitted: May 25, 2015 - Revised and accepted: January 25, 2018

» The authors report no commercial, proprietary or financial interest in the products or companies described in this article.

Contact address: Marilia de Oliveira Coelho Dutra Leal Faculdade de Odontologia de Piracicaba - Unicamp/ Departamento de Morfologia, Av. Limeira, 901, Areião, Piracicaba/SP – CEP: 13.414-903 E-mail: marilialeal@hotmail.com

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):18-24

Leal MOCD, Carvalho GP, Jodas CRP, Teixeira RG, Daruge Júnior E

INTRODUCTION The main focus in healthcare has changed in the last decades. The importance of psychosocial aspects and patient’s perception was acknowledged as aspects not only guiding the treatment plan, but also the investments and socioeconomic concerns. The same is observed in the field of orthognathic surgery, in which the functional (non-esthetic) component, which was focused on the surgical management, was changed to a more holistic approach of the patient.1 The occlusal outcome should ideally be achieved in orthognathic surgery, yet it should be combined with an ideal morphological outcome. For that purpose, the surgeon should include in the therapy some data to complement the cephalometric analysis, searching for additional surgical techniques to be included in treatment planning.2 The Brazilian Federal Constitution (CFB) assures, among the Fundamental Rights and Guarantees, to Brazilians and foreigners living in the country, the inviolable right to life, as well as the right to health in its Social Rights.3 In practice, the Brazilian State is unable to offer what is foreseen in its Constitution, i.e. the access to health for all individuals by the Brazilian Public Health System (SUS), which is free. Due to this imbalance, since the 1990s, there has been an increase in private health insurance operators (OPPAS), to compensate for the demands unassisted by the Federal Government system. The Law 8078/90 of the Consumers Protection and Defense Code (CPDC) considers the OPPAS as supplier, which is any person, physical or legal, public or private, national or foreign, and his or her work as a service, which is any activity offered in the consumer market for a payment.4 The National Consumer Relations Policy recognizes the consumer’s vulnerability in the consumer market; therefore, it ensures that the contract clauses are interpreted more favorably for the consumer. Finally, to achieve a balanced relation between consumers and suppliers, the economic order is always based on good faith. The Law 9656/98, which addresses the private health insurance plans, states that the Private Health Care Plan is the continued provision of services or coverage of care costs at a pre- or post-defined price, for an indefinite period, aiming to guarantee, without financial limit, the healthcare by the facility of access and care by professionals or health services, freely

chosen, members or not of accredited, contracted or referenced network, to offer medical, hospital and dental care, to be paid in full or in part by the contracted operator, by reimbursement or direct payment to the provider, on behalf of the consumer.5 The National Supplementary Health Agency (ANS) is an autarchy related to the Ministry of Health that regulates, establishes norms, controls and supervises activities to guarantee the supplementary health care.6 Two important regulations were made by the ANS in 2007, by means of a summary: adoption of the understanding that the requests of oral and maxillofacial procedures should be covered by the operators, even when performed by the dentist; and the prohibition of denial of hospitalization and laboratory/ complementary examinations solely because the professional does not belong to the operator’s accredited or referenced network.7 The list of procedures of the ANS in the head and neck group was last updated in 2015, by Normative Resolution #387. This act establishes the procedures that must necessarily be offered by plans with hospital coverage.8 The question is: the patients aims to assure their health in full, without shortcomings; conversely, the OPPAS aim to achieve profit, since they are companies. Due to this divergence, there are imbalances in this consumer relation, e.g. the exclusion of some procedures in Oral and Maxillofacial Surgery and Traumatology (OMFST), more specifically in orthognathic surgery. In turn, the State, which has the original obligation to provide healthcare to all individuals, aware of this unequal relationship, intervenes by its related organs to create specific laws to regulate this relation. The changing focus in the health area, the development of new surgical techniques and consequent increase of demand for surgical procedures led to changes in Brazilian regulation to address these changes, yet unfortunately this did not occur as fast as such changes. Due to this imbalance, there is a large number of lawsuits involving orthognathic surgery in second instance in the Justice Court of São Paulo (TJSP). It is necessary to analyze the result of these decisions for the patients, as well as the reason for the denial of surgery by the OPPAS, since these processes aim to assure the citizen rights to health services, and of dental professionals to offer their services. Therefore, this study investigated the jurisprudence of the TJSP, in the year 2014, about questions

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Negative of coverage in orthognathic surgery by health plans

SULTAS”; among the consultation options available, “Jurisprudência” was selected. This opened another page entitled “Consulta Completa”. Under the title “Consulta Completa”, the fields were filled as follows. Under “Pesquisa livre”, the following key words were entered: oral maxillofacial AND health insurance AND coverage denial; in “Como utilizar os filtros?”, the option “Pesquisar por sinônimos” was selected. Under the title “Pesquisa por campos específicos”, the fields were filled as follows: in “Data do julgamento”, from “January 1st to December 31st 2014”; in “Data do registro”, from “January 1st to December 31st 2014”; in “Origem”, the option “2º grau” was selected; in “Tipo de Decisão”, “Acórdãos” was selected; the results were then ordered by date and the search was performed, which retrieved 130 judgments. Data from the 130 judgments were collected and analyzed by the main investigator to select the judgments of interest for this study. The inclusion and exclusion criteria were applied. Information on the judgments were transferred to a previously designed questionnaire for data collection. The questionnaires were organized in chronological order. Data from the questionnaire were tabulated and entered in the software Excel 2016®. A databank was thus obtained to analyze the results in the State of São Paulo in the year 2014.

involving the OMFST, related to denials of orthognathic surgeries. The secondary objectives were to allow both surgeon and patient the prevention of future lawsuits by the assessment of data such as city of origin, reason for denial, legal rationale and results of lawsuits for the patient. MATERIAL AND METHODS Setting The investigation comprised documental analysis (by internet access) of second-instance lawsuits on the webpage of the TJSP, to investigate the jurisprudence related to denials of coverage of orthognathic surgeries in the year 2014. Identification of sources to achieve the study data Data were collected on the TJSP webpage by consultation of the jurisprudence of second-instance lawsuits, of Judgment type, in the period January 1st to December 31st 2014. General characteristics of the study population The judgments related to OMFST were searched on the TJSP webpage, and, among these, specific cases of orthognathic surgery. They presented information of interest, including patient’s gender; city of origin of the lawsuit; result of second-instance lawsuit, either favorable or unfavorable for the patient; reason for denial by the OPPAS; the OPPAS involved; and legal rationale.

RESULTS A total of 130 judgments were found after search in the TJSP website. Among these, 106 cases were actually related with the OMFST specialty, which were subdivided into 58 judgments on orthognathic surgery and 48 on other OMFST procedures. A more accurate analysis of the 58 cases involving orthognathic surgery was then conducted. The cases involved 34 female patients and 24 males. The district of origin of first-instance lawsuits included 38 cases from the city of São Paulo, 11 from Campinas, two from Guarujá, two from São José dos Campos and one from each of the following cities: Araçatuba, Araras, Jundiaí, Santo André and São Bernardo do Campo (Fig 1). The distribution of decisions of judgments, according to the months, was as follows: January = 4, February = 5, March = 6, April = 3, May = 6, June = 1, July = 1, August = 0, September = 9, October = 8, November = 10 and December = 5 (Fig 2).

Inclusion and exclusion criteria The study included TJSP judgments related to cases of denial of orthognathic surgery by OPPAS in the year 2014. The study excluded judgments that: a) did not present expressions to clearly indicate orthognathic surgery; b) did not present sufficient data about the type of surgery; and c) addressed other medical specialties. If the same lawsuit had two judgments in 2014, the last decision was considered and the first was excluded from the study. Study design The study analyzed records on the webpage www.tjsp.jus.br. The icon “PROCESSOS” was selected, which opened a window with the option “CON-

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Leal MOCD, Carvalho GP, Jodas CRP, Teixeira RG, Daruge Júnior E

= 13); need for an accredited professional to evaluate the requested procedure and/or material – medical board (n = 12); lack of contractual coverage, i.e. not listed under the ANS procedures (n = 11); request of the surgery by a dentist, rather than a medical professional (n = 6); the fact that the dental professional was not contracted (n = 4); the operator postponed the approval of surgery (n = 4); preexisting diseases or injuries (n = 4); and the reason for denial was not mentioned in the lawsuit (n = 1) (Fig 4). The following laws were mentioned in the judgments: Law 8078/90, Consumers Protection and Defense Code (n = 29); ANS legislation (n = 27); Law 9656/98, which regulates the private health insurance operators (n = 17); TJSP summaries (n = 11); summary of the Superior Justice Court/STJ (n = 4); resolutions of the Supplementary Health Council/CONSU (n = 2); Resolution of the Federal Medical Council/ CFM (n = 2); resolution of the Federal Dental Council/ CFO (n = 1) (Fig. 5).

The following operators denied the requests of orthognathic surgery: Sistema Unimed (n = 22), Sul América Companhia de Seguro Saúde (n = 19), Amil Assistência Médica Internacional S. A. (n = 6), Greenline Sistema de Saúde Ltda. (n = 3), Somel Sociedade para Medicina Leste Ltda. (n = 1), Notredame Seguradora S/A (n = 1), Centro Transmontano São Paulo (n = 1), Associação dos Beneficiários de Assistência à Saúde dos Juízes do Trabalho da 15ª Região (n = 1), Santa Helena Assistência Médica S/A (n = 1), Life Empresarial Saúde Ltda. (n = 1), Bradesco Saúde S/A (n = 1) e Allianz Saúde S/A (n = 1) (Fig 3). In the decisions, the judgment was favorable for the patient in 56 cases and unfavorable in only two cases. There were several causes leading to the denial of surgeries by the OPPAS, and more than one cause often appeared in the same judgment. The most recurrent were: lack of coverage of supplies or consumption material necessary for the surgical procedure (n

2% 2% 2% 2% 3%

2% São Paulo Guarujá Campinas Santo André

19%

Araras São José dos Campos 3%

65%

Araçatuba

Figure 1: Percentage of spatial distribution of judgments (city of origin).

mb e

pte

Au g

ne Ju

ril

Ma y

rch

ry ua

Ja n

bru ary

Jundiaí

Oc r tob No er vem be r De ce mb er

São Bernardo do Campo

Figure 2: Variation of chronological distribution of judgments in the TJSP in 2014.

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Negative of coverage in orthognathic surgery by health plans

Allianz Saúde S/A

Bradesco Saúde S/A

Life Empresarial Saúde Ltda

Santa Helena Assistência Médica S/A

Assoc. Benef. de Assist. à Saúde dos Juízes...

Centro Transmontano São Paulo

Notredame Seguradora S/A

Samel Sociedade para Medicina Leste Ltda

2% 5%

Greenline Sistema de Saúde Ltda

10%

Amil Assistência Médica Internacional S.A Sul América Companhia de Seguro Saúde

33% 38%

Sistema Unimed

0% 5% 10% 15% 20% 25% 30% 35% 40%

Lack of coverage of necessary material

Need of accredited professional to evaluate the procedure/material (medical board)

Lack of contract coverage / ANS list Surgery requested by dental professional instead of medical professional

Dental surgeon is not accredited

Operator postponed the approval of surgery

10% 19%

Preexisting diseases or lesions Lack of coverage for dental treatment (esthetic)

21% 22%

Not informed in the process 0%

2% 2%

Figure 3: Percentage of distribution of judgments according to the OPPAS.

10%

15%

20%

25%

Figure 4: Percentage of types of rationale for denial.

Law no 8078/90 ANS

31%

12%

Law no 9656/98 TJSP STJ 18%

CFM CONSU CFO 29%

Figure 5: Percentage of distribution of laws in the judgments.

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Leal MOCD, Carvalho GP, Jodas CRP, Teixeira RG, Daruge Júnior E

DISCUSSION The rationale #1, “ lack of coverage of supplies or consumption material necessary for the surgical procedure”, under the explanation that there is no contractual coverage for them, disagrees from the social function of the pre-established health contract. Surgical materials must be funded by OPPAS, since they are fundamental for the procedure. In addition, excluding them from coverage would be illegal, because when the plan includes hospitalization, the article 12, item I, “e” of Law 9656/98 establishes minimum obligations and demands coverage “of any and all fees, including materials used”.5 Article 10, item VII of the same law also prohibits the exclusion of coverage of material related to or fundamental for the surgical procedure.5 Therefore, the need for the surgical procedure, as well as the surgical material required, are uncontroversial. By its denial, the OPPAS mitigates their commitment and responsibility assumed contractually and legally, leaving the patient at disadvantage, which is incompatible with the principle of good faith and contractual balance, since it would mean the restriction of fundamental rights (right to life and health), which is forbidden by law.4 The rationale #2, “need for an accredited professional to evaluate the requested procedure and/ or material – medical board” has no legal support, since the medical audit of OPPAS cannot preclude the treatment nor disagree with the prescription of the surgeon assisting the patient . The summary #96 of the TJSP states that “if there is medical indication of examinations associated with the illness covered by the contract, the denial to cover the procedure shall not prevail”.9 The medical board has no competence to establish the most appropriate method to treat the disease, nor the materials to be used. The rationale #3, “lack of contractual coverage / not listed under the ANS procedures list”, is not sustained and jeopardizes the contract object, i.e. the maintenance of user’s health.4 Resolution 387 of 2015 describes the coverage of hospital structure that is necessary for the accomplishment of dental procedures requiring hospitalization10. Additionally, there is jurisprudential understanding to recognize that orthognathic surgery is not a purely dental procedure, since it requires medical intervention. Also, according to the same resolution, the oral and maxillofacial surgical procedures are present in the list of ANS procedures with mandatory coverage;10 therefore, the

coverage of orthognathic surgery is also foreseen. The Summary 100 of the TJSP states that “The health insurance contract is subject to the provisions of the Consumers Defense Code and Law 9656/98, even though the agreement was entered into force before the validity of these legal instruments”.11 Therefore, the allegation of lack of contractual coverage is invalid even for contracts signed before 1990. The rationale #4, “request of the surgery by a dentist, rather than a medical professional” is abusive, considering the joint resolution of the CFO (#100) and CFM (#1950), both of 2010, which defines that the responsibility of the surgical procedure belongs to the professional (either medical or dental) who prescribed the intervention.12,13 The rationale #5, “ the dental professional was not contracted” is absolutely abusive, because such rationale denies the right to choose the surgeon. The ANS Summary 11, item 2, clearly prohibits the denial to authorize the procedure solely because the requesting professional does not belong to the operator’s accredited or referenced network.7 The rationale # 6, “ the operator postponed the approval of surgery”, is improper because the delay in allowing the surgery is unwarranted. The artifices used for such delay are often correlated with the alleged need for an accredited professional to evaluate the choice of the procedure, which has already been demonstrated as improper. The rationale #7, “ preexisting diseases or injuries”, is based on a clause present in some contracts, which generally provides partial and temporary coverage for up to 24 months, during which the consumer shall not be covered for declared preexisting diseases or injuries. However, the previous existence of disease is not enough; this also requires knowledge of the consumer about the existence of the disease. Resolution 162 of the ANS explains that the preexisting diseases are those known by the user at the moment of contract.14 In addition, there is understanding that health insurance operators should request previous examinations for precaution, or even that the operators should demonstrate the user’s bad faith by deliberately hiding the disease upon contract. Summary 105 of the TJSP clearly states the understanding of this Court: “The denial to cover preexisting diseases and lesions shall not prevail if the operator did not request previous medical examination upon admission under the contract”.15

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Negative of coverage in orthognathic surgery by health plans

CONCLUSION According to the present study, the decisions of the Justice Court of the State of São Paulo in the year 2014 were favorable for the patients in 96% of cases. It was also concluded that the Consumers Protection and Defense Code is the Federal Law that most

ensures the patients’ rights. The specific legal support to the professional work of the oral and maxillofacial surgeon is assured by the ANS, by regulating the hospital environment. Interestingly, there are specific summaries of the TJSP to provide legal foundations for the lawsuits.

References:

1. Silva I, Cardemil C, Kashani H, Bazargani F, Tarnow P, Rasmusson L, et al. Quality of life in patients undergoing orthognathic surgery: a two-centered Swedish study. J Craniomaxillofac Surg. 2016 Aug;44(8):973-8. 2. Goga D, Battini J, Belhaouari L, Courtois R, Hardy C, Martin T, et al. [Improving the esthetic results and patient satisfaction in orthognatic surgery]. Rev Stomatol Chir Maxillofac Chir Orale. 2014 Sept;115(4):229-38. 3. Brasil. Constituição (1998). Constituição da República Federativa do Brasil. Brasília, DF; 1988. Art. 5º e 6º. [Acesso em: 15 fev 2017]. Disponível em: http://www.planalto.gov. br/ccivil_03/constituicao/constituicao.htm. 4. Brasil. Lei nº 8.078/90, de 11 de setembro de 1990. Dispõe sobre a proteção do consumidor e dá outras providências. Diário Oficial da União, 11 set 1990. Art. 51, I, IV e § 1º, I e II [Acesso em: 15 fev 2017]. Disponível em: http://www.planalto.gov.br/ccivil_03/leis/L8078.htm. 5. Brasil. Lei nº 9656/98, de 03 de junho de 1998. Dispõe sobre os planos e seguros privados de assistência à saúde. Diário Oficial da União, 3 jun 1998. Art.10º, inc. VII; 12º, inc. I “e”. [Acesso em: 15 fev 2017]. Disponível em: http://www.planalto.gov.br/ccivil_03/leis/l9656.htm. 6. Brasil. Decreto-lei nº 3.327/2000, de 03 de janeiro de 2000. Aprova o Regulamento da Agência Nacional de Saúde Suplementar - ANS, e dá outras providências. Diário Oficial da União, 3 jan 2000. Art. 1º. [Acesso em: 15 fev 2017]. Disponível em: http://www.planalto.gov.br/ ccivil_03/decreto/D3327.htm.

7. Brasil. Súmula Normativa nº11, de 11 de agosto de 2007. Agência Nacional de Saúde Suplementar. Diário Oficial da União, Brasília, DF, 11 ago 2007. Itens 1 e 2. [Acesso em: 15 fev 2017]. Disponível em: http://www.ans.gov.br/ component/legislacao/?view=legislacao&task=TextoLei&format=raw&id=MTIxMw==. 8. Brasil. Resolução Normativa nº 387, de 28 de outubro de 2015. Agência Nacional de Saúde Suplementar. Diário Oficial da União, 28 out 2015. Anexo 1. Itens 1 e 2. [Acesso em: 15 fev 2017]. Disponível em: http://www.ans. gov.br/component/legislacao/?view=legislacao&task=TextoLei&format=raw&id=MzExMA. 9. São Paulo. Tribunal de Justiça de São Paulo. Súmula nº 96, de 13 de fevereiro de 2012. Diário da Justiça Eletrônico, 13 fev 2012, p. 1. [Acesso em: 16 fev 2017]. Disponível em: http://www.tjsp.jus.br/Download/SecaoDireitoPrivado/Sumulas.pdf. 10. Brasil. Resolução Normativa nº 383, Art. 22, VIII e IX, de 28 de outubro de 2015. Agência Nacional de Saúde Suplementar. Diário Oficial da União, 28 out 2015. [Acesso em: 16 fev 2017]. Disponível em http://www.ans.gov.br/ component/legislacao/?view=legislacao&task=TextoLei&format=raw&id=MzExMA==. 11. São Paulo. Tribunal de Justiça de São Paulo. Súmula nº 100, de 28 de fevereiro de 2013. Diário da Justiça Eletrônico, 28 fev 2013, p. 1. [Acesso em: 16 fev 2017]. Disponível em: http://www.tjsp.jus.br/Download/SecaoDireitoPrivado/Sumulas.pdf.

12. Conselho Federal de Odontologia. Resolução nº 100, de 18 de março de 2010. Baixa normas para a prática da Cirurgia e Traumatologia Buco-Maxilo-Faciais, por cirurgiões-dentistas. Rio de Janeiro, 18 mar 2010. [Acesso em: 16 fev 2017]. Disponível em <http://cfo.org. br/servicos-e-consultas/ato-normativo/?id=1420. 13. Conselho Federal de Medicina. Resolução nº 1950, de 07 de julho de 2010. Diário Oficial da União, 7 jul 2010, seção I, p.132. [Acesso em: 16 fev 2017]. Disponível em: https://sistemas.cfm.org.br/normas/visualizar/resolucoes/BR/2010/1950. 14. Brasil. Resolução Normativa nº 162, Art. 2, I, de 17 de outubro de 2007. Agência Nacional de Saúde Suplementar. Diário Oficial da União, 17 out 2007. [Acesso em: 16 fev 2017]. Disponível em: http://www.ans.gov.br/component/ legislacao/?view=legislacao&task=TextoLei&format=raw&id=MTIyMw==. 15. São Paulo. Tribunal de Justiça de São Paulo. Súmula nº 105, de 28 de fevereiro de 2013. Diário da Justiça Eletrônico, São Paulo, SP, 28 fev 2013, p. 1. [Acesso em: 16 fev 2017]. Disponível em: http://www.tjsp.jus.br/Download/ SecaoDireitoPrivado/Sumulas.pdf.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):18-24

OriginalArticle

Three-dimensional airway

analysis after orthognathic surgery: pilot study RODRIGO MARINHO FALCÃO BATISTA1,2 | JOAQUIM CELESTINO DA SILVA NETO2,3 | JOSÉ ROMERO SOUTO DE SOUSA JÚNIOR4,5

ABSTRACT Objective: To evaluate three-dimensional changes in the airway after orthognathic surgery. Methods: Retrospective descriptive study in patients with dentofacial deformities, who underwent orthognathic surgery from May 2014 to November 2014. This study obtained data from nine (n=9) patients with Class III facial pattern, and described the volumetric changes through CT scans analyzed by the Dolphin Imaging® software. These CT scans were obtained at two different times. The used surgical procedures followed the surgical protocol for treatment of dentofacial deformities at Hospital Getúlio Vargas (Recife/PE, Brazil). Results: There was a decrease in volumetric measurements in the post-operative (T1) period for the regions of nasopharynx, hypopharynx and in total airway. Also it was noted a small increase in volume in for oropharynx, however for the used margin of error (5.0%), it was not observed any significant difference between the ratings for any of the variables. Conclusion: The airways volumes are directly influenced by the movements made by orthognathic surgery. These movements may lead to an increase or decrease in these volumes. It was observed an increase in volumetric average in the middle portion of the airway. For superior, lower and total airway volumes, there was a decrease in mean values. Keywords: Orthognathic surgery. Sleep apnea, obstructive. Dentofacial deformities.

Graduado em Odontologia, Universidade Federal de Pernambuco (Recife/PE, Brazil). Hospital Getúlio Vargas, Programa de Residência em Cirurgia e Traumatologia Bucomaxilofacial (Recife/PE, Brazil). 3 Doctorate and Master’s degree in Oral and Maxillofacial Surgery, Universidade de Pernambuco (Recife/PE, Brazil). 4 Doctorate degree in Dentistry, Faculdade de Odontologia de Pernambuco (Recife/PE, Brazil). 5 Universidade de Pernambuco, Faculdade de Odontologia, Curso de Especialização em Ortodontia e Ortopedia Facial (Camaragibe/PE, Brazil). 1

How to cite: Batista RMF, Silva Neto JC, Sousa Júnior JRS. Three-dimensional airway analysis after orthognathic surgery: pilot study. J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):25-31. DOI: https://doi.org/10.14436/2358-2782.4.2.025-031.oar

» The authors report no commercial, proprietary or financial interest in the products or companies described in this article. » Patients displayed in this article previously approved the use of their facial and intraoral photographs.

Submitted: October 14, 2016 - Revised and accepted: March 24, 2018

Contact address: Rodrigo Marinho Falcão Rua João Ramos, nº 286, apto. 1701, Graças, Recife/PE CEP: 52.011-080 E-mail: dr.rodrigomarinho@hotmail.com

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):25-31

Three-dimensional airway analysis after orthognathic surgery: pilot study

INTRODUCTION According to the International Classification of Sleep Disorders, the Obstructive Sleep Apnea Syndrome (OSAS) is grouped within the dyssomnias and is defined as an intrinsic sleep disorder, characterized by the appearance of repeated episodes of upper airway obstruction (apneas) occurring during sleep, usually associated with a reduction in blood oxygen level.1 The prevalence of OSAS is 1 to 4% of the world male adult population. The literature has associated this condition to a significant increase in morbidity and mortality, especially when related with cardiovascular diseases as infarction and stroke. Individuals with OSAS present increased risk to other diseases that contribute to cardiovascular morbidity, e.g. diabetes mellitus, thyroid disorders, blood hypertension, obesity, hyperlipidemia, and male gender.2 According to the American Academy of Sleep Medicine, the severity of OSAS should be assessed by polysomnography. This examination is the standard diagnostic method of sleep apnea. The repeated throat obstructions occur during sleep, causing recurrent apneas (breathing pauses of at least ten seconds) or hypopneas. The sum of apneas and hypopneas per hour of sleep provides the apnea-hypopnea index (AHI). The severity of apnea is determined by the AHI and may be mild (5 < AHI < 15/hour); moderate (15 < AHI < 30/hour) or marked (AHI > 30/hour).2,3 The OSAS has been independently associated with insulin resistance, suggesting that it may be an important factor for the development of type 2 diabetes and metabolic syndrome (MS), i.e. the combination of factors as obesity, insulin resistance, hypertension and dyslipidemia. There is increasing experimental clinical evidence of the role played by obstructive sleep apnea in the development and severity of metabolic disorders3. The obstructive sleep apnea syndrome (OSAS) is a common problem and has also been acknowledged as a risk factor for car accidents. This condition causes fragmentation of nighttime sleep, hypoxia and daytime sleepiness, impairing the performance in car driving. Consequently, individuals with OSAS are involved in a higher rate of accidents compared to normal individuals.4 Previous studies reported the induction of sleep-related respiratory disorders after procedures with posterior mandibular repositioning. Investiga-

tions demonstrated narrowing of the retrolingual and hypopharyngeal airways, and posterior and inferior positioning of the hyoid bone and tongue. This problem has been increasingly investigated in the last two decades, due to the potential to cause severe consequences such as obstructive sleep apnea syndrome (OSAS).5 Conversely, the obstructive sleep apnea may be treated by bimaxillary advancement. The airway may be increased by advancement of the suprahyoid and velopharyngeal muscles. This increase is more marked when a counterclockwise rotation of the maxillomandibular complex is performed in individuals with great occlusal plane inclination, and the genial tubercles are moved forward beyond the teeth, thus maximizing the advancement of the hyoid bone, tongue base and related soft tissues.5,6 Several methods are available for airway evaluation: cephalometric radiographs, nuclear magnetic resonance imaging, computed tomographies and cone-beam computed tomographies, all of which have great value for such evaluation. However, the literature reports that more data may be achieved by multislice computed tomographies, which therefore is the most reliable examination to evaluate upper airway alterations after orthognathic surgery procedures.7 This study analyzed the volumetric alterations occurring in the airway, in three subdivisions and in total, after accomplishment of orthognathic surgery for correction of functional dentofacial deformity. MATERIAL AND METHODS This descriptive retrospective study was conducted on a database of tomographies obtained to evaluate the airway volumetric changes in individuals submitted to orthognathic surgery at Hospital Getúlio Vargas (Recife/PE, Brazil) in the period May 2014 to November 2014. Patients included in the sample were referred to the hospital by the Brazilian Public Health System (SUS) and were assisted in the Oral and Maxillofacial Surgery and Traumatology service. All patients presented diagnosis of dentofacial deformity and preoperative orthodontic treatment. The patients were informed on the study and consented to participate, signing an informed consent form. The study compared computed tomographies at two different moments – preoperative (T0) and postoperative (T1) – corroborating the protocol of this hos-

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):25-31

Batista RMF, Silva Neto JC, Sousa Júnior JRS

way diagnostic tool. For this analysis, the airway was divided as described in the study of Gokce et al.2, and the software was used to calculate the following airway volumes (Fig 1): » Upper airway volume (in red, Fig. 1). » Middle airway volume (in blue, Fig. 1). » Lower airway volume (in green, Fig. 1). » Total upper airway volume. At the interface of Dolphin Imaging®, a region was generated by delineation of points and lines in green color, and the volume of interest in violet color (Fig. 2). The volume calculated by the software was shown as a three-dimensional structure and its numerical result was exhibited on the upper part of the screen (Fig. 3). Data were descriptively analyzed by percentages for categorical variables and the following measurements: mean, standard deviation and median for the variable age. The Wilcoxon test for paired data was applied to check for significant data between the two evaluations. The statistical significance was set at 5% or p ≤ 0.05, and the statistics software SPSS (Statistical Package for the Social Sciences v. 21) was used for data entry and statistical calculations.

pital service, which includes the achievement of: one preoperative tomograph for surgical planning using the software Dolphin Imaging® 11.7 (Dolphin Imaging and Management Solutions, Chatsworth, Calif., USA); and other tomograph after 90 days, to evaluate the postoperative stability. All imaging examinations were performed at the Radiology Service of Hospital Getúlio Vargas, using the 6-channel equipment Philips Briliance CT 64-Slice, with a protocol of facial tomograph with 8-mm sections, 0.4-mm spacing between sections, at 120Kv and 100mAs/slice. During examination the patients were asked to adapt a centric relation bite record in the oral cavity, which was obtained in wax on the same day of the tomographic examination. After achievement of the preoperative tomograph, the cases were planned on the software Dolphin Imaging® 11.7. The cases were surgically treated according to traditional techniques for the accomplishment of orthognathic surgeries, following the protocol of Epker et al8. After the procedures, the patients were followed periodically and the postoperative tomograph was obtained 90 days postoperatively. This second examination followed the same protocol as the preoperative examination. After achievement of tomographic data, the software was used for quantitative analysis using an air-

UWRP

UPW NPW MPW

RW U

PPW BoT LPW

UWRP - Retropalatal anterior pharyngeal wall UPW - Upper pharyngeal wall NPW - narrowest pharyngeal wall RW - Retro-velar wall MPW - Middle pharyngeal wall U - Uvula PPW - Posterior pharyngeal wall BoT - Base of the tongue LPW - Lower pharyngeal wall V - Valeculla

Figure 1: Volumetric regions analyzed.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):25-31

Three-dimensional airway analysis after orthognathic surgery: pilot study

Figure 2: Delineation of volumetric region to be analyzed.

orthognathic surgery in the period May 2014 to November 2014, who met all inclusion criteria. All individuals in the study were classified as Class III malocclusion. The age of individuals ranged from 18 to 46 years, with mean 25.70 years, standard deviation 8.76 years and median 24.00 years. Table 1 presents the results of age range and gender of participants. In this table, it should be highlighted that six individuals were aged 18 to 24 years, and the remaining three individuals 25 to 46 years; there were five females and four males. Table 2 presents the results of statistics of study variables according to the evaluation and the mean of absolute difference. In this table, the following should be highlighted: except for the middle airway, which presented higher mean at T1 than T0, the other three means analyzed were correspondingly higher preoperatively than postoperatively, and the greater difference between means occurred in the total airway (with mean difference of 1586.66), followed by the upper airway difference (514.35) and lower airway (314.31); however, for the error margin established (5.0%), no significant difference was observed between evaluations for any variable analyzed.

Figure 3: Composition and digital measurement of the volume analyzed.

RESULTS The sample included nine (n = 9) individuals diagnosed with dentofacial deformity and submitted to

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):25-31

Batista RMF, Silva Neto JC, Sousa Júnior JRS

Table 1: Distribution of participants according to age range and gender. Variable

TOTAL

9 AGE RANGE (YEARS) 6 3 GENDER 4 5

100.0

18 a 24 25 a 46 Masculino Feminino

66.7 33.3 44.4 55.6

Table 2: Statistics of volumes analyzed, according to the evaluation. Evaluation Variable

Upper airway Middle airway Lower airway Total airway

Before (T0)

After (T1)

Absolute difference

Mean ± SD (Median)

Mean

6440.74 ± 1879.56 (5811.70) 6345.04 ± 3452.41 (5283.73) 6248.81 ± 5047.80 (3926.77) 18591.86 ± 10693.28 (14676.63)

5926.39 ± 2217.09 (5763.97) 6370.86 ± 3997.34 (4888.03) 5934.50 ± 5174.44 (3835.10) 17005.20 ± 9933.22 (12539.43)

514.35 -25.82 314.31 1586.66

Valor de p

p* = 0.250 p* = 1.00 p* = 0.250 p* = 0.129

* Wilcoxon test for paired data.

DISCUSSION This study evidences shows the impact of orthognathic surgery on the airway, in relation to each of the four volumes analyzed: the volume at the nasopharynx (upper airway); volume at the oropharynx (middle airway); volume at the hypopharynx (lower airway); and the total airway volume. The volumes were evaluated and measured on the software Dolphin Imaging® 11.7, which has devices for manipulation of tomographic examinations that allow accurate definition of volumes, besides accompanying the tissue contours and being compatible with the newest operating systems.9 Cevidanes et al.10 reported the importance and high degree of accuracy allowed by computer-assisted orthognathic surgery. This precision is fundamental when transferring the virtual planning to the operating room, allowing detailed planning of the surgical procedure, repositioning of osteotomies , bone reconstructions, training of residents and anticipation of surgical difficulties that may occur. All present cases were planned using the software Dolphin Im-

aging® 11.7, in which, among the nine cases, five (55.55%) were planned and used prototyped guides (splints) for surgery, without any problems during surgery.10 Gocke et al.2 conducted a clinical study on 25 patients and reported a statistically significant reduction in hypopharynx volumes of 27.47%. This finding was compatible with the present study, in which the hypopharynx volume was reduced, yet without statistically significant difference.2 In the present study, there was a slight increase in the mean volumes postoperatively, regarding the oropharynx volumes. This disagrees with the study of Gocke et al.2, which observed a decrease of 19.01% in postoperative volumes for the same region. The data found for the variables nasopharynx volume and total volume were different from those found by Gocke et al.2, who reported a significant increase in nasopharynx airway volume and total volume in patients submitted to bimaxillary orthognathic surgery, with gains of 46.36% and 7.24% in the respective volumes.2

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):25-31

Three-dimensional airway analysis after orthognathic surgery: pilot study

displacement of the soft palate. In combination, these factors promote elongation and narrowing of the soft palate. Therefore, maxillary advancement may not result in significant gain in upper airway, and this reduction may be even more pronounced when combined with mandibular setback.11,13-18 Degerliyurt et al.12 found similar results in their study, thus compatible with the present research. In their sample of 47 patients submitted to two types of orthognathic surgery to correct the Class III facial pattern, the authors observed reduction in the airway for both techniques, yet with lower reduction for cases submitted to combined maxillary/mandibular surgery. Another aspect to be considered is the time required for the soft tissues to adapt to new positions of the facial skeleton. Some studies did not present a significant difference in airway volume changes after periods ranging from one week to three months (early postoperative period), alike studies in late postoperative periods from one to two years. This study evaluated changes in the early postoperative period of 3 months and may still require longer time for soft tissue adaptation.2

Similarly, Hernandez-Alfaro et al.5, in a comparative study of volumetric airway alterations, evaluated the volumetric changes in patients submitted to orthognathic surgery and found a significant increase in total airway volume in all groups analyzed. This study also mentioned that the greatest gains occurred in the group submitted only to mandibular advancement (78.3%), and these results disagree with the present study.5 These changes in airway volumes occur due to anterior maxillary displacement and posterior mandibular movement after bimaxillary orthognathic surgery. The increase in total airway volume occurs due to advancement of the velar and velopharyngeal musculature caused by Le Fort I osteotomies, reducing the constrictor effect of the posterior mandibular repositioning. Studies have concluded that bimaxillary surgery for correction of Class III skeletal deformities present lower tendency to decrease the airway than single-jaw surgeries.2 Kawamata et al.3 evaluated the airway after single-jaw orthognathic surgery with posterior mandibular repositioning for prognathism correction and observed a significant decrease in values postoperatively. The tomographic evaluation conducted three months after surgery revealed a mean setback of 7.8 ± 2.1 mm, leading to a decrease of 23.6% in the airway of patients.3 In a review article, Lye et al.11 reported that, opposite to logical deduction, maxillary advancement not always leads to increased volume of the upper airway. Two studies analyzed, in which orthognathic surgeries were performed to correct Class III dentofacial deformities – consisting of maxillary advancement and mandibular setback – presented significant reduction of the upper airway volume. Another study also reported decrease in nasopharynx volume, yet without significant difference. In this study, the authors presented lower rates of volume reduction in the group submitted to bimaxillary surgery compared to the group submitted only to mandibular setback.11 It has been proposed that this decrease in the upper airway occurs due to two reasons. The first is that maxillary advancement causes adaptive changes in the soft palate to maintain the velopharyngeal seal and palatal function. The second reason concerns the posterior and superior tongue movement after mandibular setback, which causes backward and upward

CONCLUSIONS According to the present methodology, the following could be concluded: » There was reduction in volumes at the nasopharynx, hypopharynx and total airway after orthognathic surgery comprising maxillary advancement and mandibular setback. However, the results did not present statistically significant difference between preoperative and postoperative periods. » There was increase in oropharynx volume after orthognathic surgery comprising maxillary advancement and mandibular setback. However, the results did not present statistically significant difference between preoperative and postoperative periods. » Further studies should be conducted including larger number of patients; longer postoperative follow-up periods; utilization of computed tomography associated with polysomnography, for a more accurate evaluation of the improvement in breathing quality during sleep; evaluation of these aspects on the improvement in quality of life of patients; and planning of strategies for the treatment of obstructive sleep apnea syndrome.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):25-31

Batista RMF, Silva Neto JC, Sousa Júnior JRS

References:

1. Tasali E, Mary SM. Obstructive Sleep Apnea and Metabolic Syndrome Alterations in Glucose Metabolism and Inflammation. Proc Am Thorac Soc. 2008 Feb 15;5(2):207-17. 2. Gokce SM, Gorgulu S, Gokce HS, Bengi AO, Karacayli U, Ors F. Evaluation of pharyngeal airway space changes after bimaxillary orthognathic surgery with a 3-dimensional simulation and modeling program. Am J Orthod Dentofacial Orthop. 2014 Oct;146(4):477-92. 3. Kawamata A, Fujishita M, Ariji Y, Ariji E. Three-dimensional computed tomographic evaluation of morphologic airway changes after mandibular setback osteotomy for prognathism. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000 Mar;89(3):278-87. 4. Kiely JL, McNicholas WT. Cardiovascular risk factors in patients with obstructive sleep apnoea syndrome. Eur Respir J. 2000 July;16(1):128-33. 5. Hernández-Alfaro F, Guijarro-Martínez R, MarequeBueno J. Effect of mono- and bimaxillary advancement on pharyngeal airway volume: Cone-Beam Computed Tomography Evaluation. J Oral Maxillofac Surg. 2011 Nov;69(11):e395-400. 6. Ronchi P, Novelli G, Colombo L, Valsecchi S, Oldani A, Zucconi M, et al. Effectiveness of maxillomandibular advancement in obstructive sleep apnea patients with and without skeletal anomalies. Int J Oral Maxillofac Surg. 2010 June;39(6):541-7.

7. Uesugi T, Kobayashi T, Hasebe D, Tanaka R, Ike M, Saito C. The effect of mandibular setback or two-jaws surgery on pharyngeal airway among different genders. Int J Oral Maxillofac Surg. 2014 Sept;43(9):1082-90. 8. Epker BN, Stella JP, Fish LF. Dentofacial deformities: Integrated Orthodontic and Surgical correction. 2nd. ed. St Louis: Mosby; 1995. 2 v. 9. Sant´Ana E, Furquim LZ, Rodrigues MTV, Kuriki EU, Pavan AJ, Camarini ET, et al. Planejamento digital em cirurgia ortognática: precisão, previsibilidade e praticidade. Rev Clín Ortod Dental Press. 2006 AbrMaio;5(2):92-102. 10. Cevidanes L, Tucker S, Styner M, Kim H, Chapuis J, Reyes M, et al. 3D Surgical Simulation. Am J Orthod Dentofacial Orthop. 2010 Sept;138(3):361-71. 11. Lye KW. Effect of orthognathic surgery on the posterior airway space (PAS). Ann Acad Med Singapore. 2008 Aug;37(8):677-82. 12. Degerliyurt K, Ueki K, Hashiba Y, Marukawa K, Nakagawa K, Yamamoto E. A Comparative CT evaluation of pharyngeal airway changes in class III patients receiving bimaxillary surgery or mandibular setback surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008 Apr;105(4):495-502. 13. Sassani A, Findley LJ, Kryger M, Goldlust E, George C, Davidson TM. Reducing motor-vehicle collisions, costs, and fatalities by treating obstructive sleep apnea syndrome. Sleep. 2004 May 1;27(3):453-8.

14. Gami AS, Howard DE, Olson EJ, Somers VK. Day– Night pattern of sudden death in obstructive sleep apnea. N Engl J Med. 2005 Mar 24;352(12):1206-14. 15. Laureano JRF, Silva EDO, Vasconcellos RJH, Silva LCF, Rocha NF. Alterações em discrepâncias antero-posteriores na cirurgia ortognática. Rev Cir Traumatol Buco-Maxilo-Fac. 2005;5(1):45-52. 16. Hsu SS, Gateno J, Bell RB, Hirsch DL, Markiewicz MR, Teichgraeber JF, et al. Accuracy of a Computer-Aided Surgical Simulation Protocol for Orthognathic Surgery: A Prospective Multicenter Study. J Oral Maxillofac Surg. 2013 Jan;71(1):128-42. 17. Medeiros PJ, Medeiros PP. Ortognática para o ortodontista. São Paulo: Ed. Santos; 2001. 18. Araújo A. Cirurgia Ortognática. São Paulo: Ed. Santos; 1999.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):25-31

OriginalArticle

Comparative study of dipyrone and paracetamol pain control

after third molar extraction GABRIELA MAYRINK1,2 | BRUNO NICOLAI1 | JORGE PEDRO ABOUMRAD JÚNIOR1

ABSTRACT Pain is an unpleasant sensory experience, a stimulus known throughout the world; however, is subjective in nature and quite unique in the majority of patients undergoing surgery in the oral cavity. Analgesics can be used in oral surgery postoperative, being dipyrone, an acetaminophen the most common. In the present study, 20 patients were selected from the Department of Oral and Maxillofacial Surgery and Traumatology of the Faculdades Integradas Espírito Santenses (FAESA), which, according to the inclusion criteria, would undergo extraction of third molars. All patients were pre-operatively treated with 4mg dexamethasone 2 hours before the procedure. Each extraction was performed on different days and dipyrone 500mg or acetaminophen 750mg was selected for the postoperative. A visual analog scale was used by the patient to indicate the amount of postoperative pain. Analysis of evaluated quantitative criteria was conducted, such as effectiveness of the drug, the opinion of patients and duration of the pain, and in both groups an analgesic advantage of dipyrone was observed. Dipyrone 500mg demonstrated superior analgesic efficacy than acetaminophen 750mg, in controlling postoperative pain in third molar surgery. Keywords: Pain. Surgery, oral. Analgesia.

Faculdades Integradas Espírito-Santenses, Centro Universitário, Faculdade de Odontologia (Vitória/ES, Brazil). Doctorate degree in Oral and Maxillofacial Surgery, Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba (Piracicaba/SP, Brazil).

How to cite: Mayrink G, Nicolai B, Aboumrad Júnior JP. Comparative study of dipyrone and paracetamol pain control after third molar extraction. J Braz Coll Oral Maxillofac Surg. 2018 MayAug;4(2):32-7. DOI: https://doi.org/10.14436/2358-2782.4.2.032-037.oar

Submitted: June 01, 2016 - Revised and accepted: March 24, 2018 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. Contact address: Gabriela Mayrink Av. Dr. Olivio Lira, 353/ 1402, Torre Principal, Praia da Costa, Vila Velha/ES – CEP: 29.101-950 E-mail: gabimayrink@gmail.com

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):32-7

Mayrink G, Nicolai B, Aboumrad Júnior JP

INTRODUCTION Pain is a biological protective phenomenon and is inherent to dental procedures, especially surgical, and its intensity is nearly always related to the extent of surgery and surgical technique.1 The occurrence and intensity of pain depend on individual characteristics, type of procedure, quality of treatment proposed, cultural and social influences.2 Any surgical intervention causes tissue destruction, triggering acute inflammatory responses. These damages are recognized by chemical mediators that induce the migration of inflammatory cells to the injured site, causing heat, redness, pain, edema and function loss. In a first moment, inflammation is considered protective and the utilization of anti-inflammatory drugs, regardless of the dose or pharmacological components, aims to reduce the exacerbation of inflammation; however, they do not present inhibitory action over it.2,3 After tooth extraction, pain affects nearly all patients, reaching peak intensity between 6 and 8 hours and gradually reducing after the first 24 hours, thus requiring analgesics in the postoperative period.4,5 The corticosteroids are the most effective anti-inflammatory drugs available, because they inhibit the enzyme phospholipase A2. Its inactivation reduces the availability of arachidonic acid in the cells and reduces the cyclooxygenase and lipoxygenase metabolites, thus reducing the symptomatic clinical manifestations of inflammation.2 The corticosteroids act in an indirect manner. Simply put, they induce the synthesis of lipocortins, which are a group of proteins responsible for phospholipase A2 inhibition. Thereby, they reduce the availability of arachidonic acid and consequently the synthesis of pro-inflammatory substances. All this process demands time, since the corticoid should cross the cytoplasmic membrane of target cells and bind to specific receptors in the cytosol. Following, the corticoid-receptor complex migrates into the nucleus of the target cell, where it creates messenger RNA. For this reason, the full therapeutic action of corticosteroids is relatively inert. Even though this binding occurs within minutes, the anti-inflammatory effect of corticoids may be evidenced after 1 or 2 hours. Due to the need of biological time to complete their action, the most adequate analgesic setting for prescription of corticoids would be preventive, initiating before the noxious stimulus, i.e. before tissue trauma.6

Dipyrone and acetaminophen are the analgesics routinely used in the dental clinic. Their mechanisms of action are usually based on inhibition of the synthesis of prostaglandins, which are responsible for mild and moderate pain, local vasodilation and increase vascular permeability.7 The acetaminophen is a non-opioid analgesic with antipyretic action, effective for the relief of mild to moderate pain.4 Though largely employed, its mechanisms of action are not fully understood. A study using models of nociceptive pain suggested that analgesics by acetaminophen involves indirect activation of CB1 receptors, by the acetaminophen metabolite and endocannabinoid uptake inhibitor AM 404. However, the contribution of the cannabinoid system for the anti-hyperalgesia against inflammatory pain, the main indication of acetaminophen and precise location of relevant CB1 receptors have not yet been described.4,8 The dipyrone (metamizol, in some countries) is an effective analgesics for the control of mild to moderate pain. It inhibits the synthesis of prostaglandins to a lower extent than other drugs in the same group. Its analgesic power is recognized as superior to other antipyretic analgesics. This probably occurs because dipyrone plays several pharmacological functions within the central nervous system and presents capacity to inhibit the migration of neutrophils, which may be related with its mild anti-inflammatory action. Its analgesic activity, though not fully elucidated, is assigned to the direct depression of nociceptive activity, thus reducing the hyperalgesia state.9 In the 1970s, the dipyrone was prohibited in the United States and several European countries after fatal reports of agranulocytosis in patients using this analgesic. After its prohibition, little information was available to quantify the risk of its use.10 Therefore, this study evaluated the control of postoperative pain, for one week, in patients submitted to surgery for third molar extraction, to provide rationale for adequate drug selection, either sodium dipyrone 500 mg or acetaminophen 750 mg, aided by dexamethasone 4 mg preoperatively, all by oral ingestion. MATERIAL AND METHODS This blind randomized clinical prospective study was conducted on patients attending the dental clinics of FAESA Centro Universitário (Vitória/ES), in the

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):32-7

Comparative study of dipyrone and paracetamol pain control after third molar extraction

postoperative instructions regarding diet, hygiene and general care. A period of seven days was allowed between procedures. After surgery, the patient received a Visual Analogue Scale (VAS) to measure the pain intensity. In this scale, 0 indicated absence of pain and 10 maximum pain. This scale was verbally explained to the patient in a simple manner, allowing him or her to be familiar with the document. Meanwhile, other data were filled by the investigator, including type of extraction, duration of the procedure, classification of the tooth according to Pell and Gregory and Winter, and other observations deemed of interest. The results were tabulated to compare the efficacy of drugs employed within each group. Data were statistically analyzed by the McNemar and paired t tests.

Discipline of Oral and Maxillofacial Surgery and Traumatology. The patients were selected considering a good general health, besides indication for extraction of third molars on both sides and dental arches. Patients with systemic diseases precluding the use of drugs, hypersensitivity to the drugs employed, pregnant or nursing women, and local contraindications for surgery. All patients were informed on the study, which was approved by the Institutional Review Board under protocol n. 021358/2015 and signed an informed consent form agreeing to participate. The patients who met the criteria were included in the study. Preoperatively, all patients used dexamethasone 4 mg (generic drug manufactured by EMS), by oral ingestion, two hours before the procedure. The extractions of third molars were performed by the same operator, in different days, allowing one week between surgeries. Only one tooth was extracted per session. As a rule, the same patient should have contralateral third molars in the same dental arch, in similar anatomical position as described by Pell and Gregory (1933) and Winter (1926), established by a previous radiographic evaluation. The patients were divided into two groups: » Group 1: patients requiring extraction of maxillary third molars on both sides with similar classifications. The drug employed after extraction at one side was different than extraction on the contralateral side. For example, if after extraction of tooth #18 the patient was prescribed acetaminophen 750mg (generic drug, Medley), then after extraction of tooth #2 the patient would be prescribed dipyrone 500mg (generic drug, Medley). » Group 2: patients requiring extraction of mandibular third molars on the right and left sides with similar classification. The drug protocol was the same as described for Group 1. Both drugs were prescribed for oral ingestion, at every 6 hours during the first 24 hours, and could be continued on the following day if pain persisted. The first dose of the drug of choice was administered to the patient soon after the procedure, still under the effect of anesthesia. The surgical procedure met all principles of surgical technique and was performed under local anesthesia (2% lidocaine with epinephrine 1:100,000), with mean of two tubes per surgery. All patients received

RESULTS Overall 20 patients were assisted, being 10 with maxillary third molars bilaterally (Group 1) and 10 patients with mandibular third molars bilaterally (Group 2). In Group 1, according to Pell and Gregory and Winter, 16 teeth were classified as A and 4 were classified as B; all teeth were vertical, and it was mandatory to have the same classification for the right and left sides in the same patient. The surgical procedures had mean duration of 53 minutes. In Group 2 (mandibular surgeries), the patients presented the following classifications according to Pell and Gregory and Winter: IA = 8, IB = 3, IIA = 4 and IIB = 5, and all teeth were in vertical position. Surgeries had a mean duration of 74.5 minutes. Since each patient was his or her own control, a paired sample was thus achieved; therefore, all tests were applied for paired samples. The non-parametric McNemar test was applied to evaluate the following questions presented to the patients: 1) How did you feel after cessation of anesthesia? 2) Did you use drugs to cease the pain? 3) How long did you remain without pain under the drug action? 4) How long did the pain last? 5) What is your opinion about the drug? The study hypothesis was that there was no difference between treatments. When the p value is low-

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):32-7

Mayrink G, Nicolai B, Aboumrad Júnior JP

Table 1: Descriptive statistics of procedure duration and pain intensity according to the procedure and results of comparison test – maxillary teeth (GROUP 1). Variables

Duration of procedure Pain intensity

Procedure

Median

Mean

Standard deviation

Dipyrone Acetaminophen Dipyrone Acetaminophen

50,00 50,00 2,00 3,00

52,73 56,82 2,09 3,64

16,79 13,47 2,21 2,87

p value

0,406 0,003

Table 2: Descriptive statistics of procedure duration and pain intensity according to the procedure and results of comparison test – mandibular teeth (GROUP 2). Variables

Duration of procedure Pain intensity

Procedure

Median

Mean

Standard deviation

Dipyrone Acetaminophen Dipyrone Acetaminophen

75,00 70,00 3,50 5,50

75,50 74,00 3,30 5,70

15,36 14,87 2,41 2,36

0,796 0,025

DISCUSSION The utilization of corticosteroid preoperatively is justified by its characteristics for reduction of edema, trismus, and, to a lesser extent, pain in the postoperative period after third molar extraction. Its use is well known and reported in studies evaluating its capacity to reduce the edema after extraction of third molars, and reported effective reduction of swelling, compared to other drugs for that purpose. 11,12,13 Since the non-steroidal anti-inflammatory drugs (NSAIDS) present great analgesic effect, which might mask the study results, it was decided to use the corticosteroid preoperatively, to assure the anti-inflammatory effects yet without great influence on pain control. The drug prescribed for each side was randomly selected, since even though the teeth presented similar anatomical position, the operator often had greater easiness to perform extraction at one side compared to the other. Therefore, the extraction considered as simpler might have a less painful postoperative recovery.

er than 0.050 this hypothesis is rejected, i.e. there is difference in the percentages tested. Group 1 presented statistically significant difference between drugs for the question “What is your opinion about the drug”. There was higher percentage of responses “Good” for acetaminophen (72.7%), and higher percentage of “Very good” for dipyrone (72.7%), with p=0.031. The other variables did not present statistically significant difference between the procedures. Group 2 did not exhibit statistically significant difference in the responses to the questions. The metric variables (duration of procedure and pain intensity, VAS) were analyzed by the paired t test. When the result indicates p value lower than 0.050 (statistically significant), there is difference between the procedures. Statistically significant difference was observed for pain intensity (maxillary and mandibular teeth). In this case, it may be stated that the group treated with acetaminophen presented higher values compared to the group treated with dipyrone.

p value

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):32-7

Comparative study of dipyrone and paracetamol pain control after third molar extraction

using acetaminophen reported pain for 7 days; conversely, the longer case of pain reported for dipyrone was 5 days after tooth extraction. This demonstrates that, concerning the evolution of pain, dipyrone is also better than acetaminophen, especially in the first 24 hours after the surgical procedure. The present results agree with the study of Queiroz et al.4, in which dipyrone presented greater analgesic efficacy compared to acetaminophen, especially in the final 24h and total 48h of follow-up. In the first 6h there was no statistically significant difference between drugs. The double-blind study of Saska et al.9 compared the analgesic efficacy between the association of tramadol + acetaminophen, isolated use of acetaminophen and isolated use of dipyrone, in patients submitted to extraction of impacted third molars. Similar to the present study, this investigation presented superiority of dipyrone in relation to acetaminophen. When acetaminophen was associated with tramadol, an analgesic with central action, the efficacy was similar to dipyrone. The present data, as well as previous findings in the literature, suggest that the difference between these drugs for pain control may be related with the difference mechanisms of action of dipyrone and acetaminophen. Thus, this study suggests that the association of dexamethasone 4mg two hours before the procedure by oral ingestion, and the utilization of dipyrone (500mg) for up to 48 hours postoperatively is an excellent protocol to provide comfort to the patient during recovery after third molar extraction, either maxillary or mandibular.

In the last decade, there has been a significant increase in the use of drugs for postoperative pain control, and several studies have been conducted to demonstrate the best efficacy, duration, safety, and obviously the lower number of side effects. Some studies, as that conducted by Laureano Filho et al.14, evaluated the efficacy of new analgesics marketed by the pharmaceutic industry as more effective, such as ketorolac, compared to acetaminophen, after third molar extraction. This study demonstrated lack of statistically significant difference between drugs for postoperative pain control in surgeries of impacted teeth. In the present study, the results were favorable for dipyrone compared to acetaminophen, in the parameters of pain intensity by VAS and the patient’s opinion about the drug. Though subjective, they revealed greater analgesic efficacy for pain control after extraction of third molars, both mandibular and maxillary. Considering the pain intensity according to VAS, most individuals in Group 1 reported bearable discomfort. Among those who reported not having felt pain, the most significant number was observed among individuals taking dipyrone as analgesic. Group 2 exhibited a greater number of patients using acetaminophen who reported having felt unbearable pain. In the same group, when dipyrone was the analgesic of choice, there was no report of unbearable pain. This distribution of pain levels observed in study subjects during the study period suggests superiority of analgesic action for dipyrone compared to acetaminophen. Concerning analysis of the evolution of pain after third molar extraction, the maximum pain level occurred in the first 24 hours and sometimes extended up to 48 hours. In Group 1, for patients using acetaminophen, the pain intervals were divided between 24 and 48 hours after the procedure. When dipyrone was used, in nearly all cases the pain lasted 24 hours postoperatively. In one case in Group 2, the patient

CONCLUSION This study suggests the greater efficacy of dipyrone (500mg) compared to acetaminophen (750mg) for postoperative pain control in patients submitted to third molar extraction.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):32-7

Mayrink G, Nicolai B, Aboumrad Júnior JP

References:

1. Fattah CMRS, Aranega AM, Leal CR, Martinho J, Costa AR. Controle da dor pós-operatória em cirurgia bucal: revisão de literatura. Rev Odontol Araçatuba. 2005;6(2):56-62. 2. Bassanezi BSBI, Oliveira-Filho AG. Analgesia pós-operatória Rev Col Bras Cir Rio de Janeiro. 2006;33(2):56-62. 3. Kim K, Brar P, Jakubowski J, Kaltman S, Lopez E. The use of corticosteroids and nonsteroidal anti-inflammatory medication for the management of pain and inflammation after third molar surgery: A review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009 May;107(5):630-40. 4. Queiroz TP, Santos PL, Esteves JC, Stellin GM, Shimuzi AS, Betoni Junior W, et al. Dipirona versus paracetamol no controle da dor pós-operatória. Rev Odontol UNESP. 2013;42(2):78-82. 5. Berge TI. Pattern of self-administered paracetamol and codeine analgesic consumption after third-molar surgery. Acta Odontol Scand. 1997;55(5):270-6.

6. Andrade ED. Prevenção e controle da dor. In: Terapêutica medicamentosa em Odontologia. 3a ed. são Paulo: Artes Medicas; 2014. p. 49-51. 7. Goodman AG. As bases farmacológicas da terapêutica. 8a ed. Rio de Janeiro: Guanabara Koogan; 1991. 8. Klinger-Gratz PP, Ralvenius WT, Neumann E, Kato A, Nyilas R, Lele Z, et.al. Acetaminophen Relieves Inflammatory Pain through CB1 Cannabinoid Receptors in the Rostral Ventromedial Medulla. J Neurosci. 2018 Jan 10;38(2):322-34. 9. Saska S, Scartezini G, Souza RF, Hochuli-Vieira E, Pereira Filho VA, Gabrielli MAC. Cloridrato de tramadol/ paracetamol no controle da dor pós operatória em cirurgia de terceiros molares inclusos. Rev Cir Traumatol Buco-Maxilo-Fac. 2009;9(4):99106. 10. Andrade SE, Martinez C, Walker AM. Comparative safety evaluation of non-narcotic analgesics. J Clin Epidemiol. 1998;51(12):1357-65.

11. Skjelbred P, Løkken P. Post-Operative pain and Inflammatory Reaction Reduced by Injection of a Corticosteroid. Eur J Clin Pharmacol. 1982;21(5):391-6. 12. UStün Y, Erdogan O, Esen E, Karsli ED. Comparison of the effects of 2 doses of methylpredni¬solone on pain, swelling, and trismus after third molar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003 Nov;96(5):535-9. 13. Bahn SL. Glucocorticosteroids in dentistry. J Am Dent Assoc. 1982 Sept;105(3):476-81. 14. Laureano-Filho JR, O’brien PM, Allais M, Oliveira Neto PJ. Comparaçao entre o cetorolaco e paracetamol na dor pós operatória. J Braz Coll Oral Maxillofac Surg. 2015 Jan-Abr;1(1):28-35.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):32-7

OriginalArticle

Epidemiology of OMFS surgical procedures

of a public hospital

WELLEN GOBBI BOTACIN1 | LUIZ FELIPE NAKASOME1 | RAPHAEL CASTIGLIONE COSER2,3 | RENATA PITTELLA CANCADO3,4

ABSTRACT Introduction: Face traumas represent the majority of patients in Bucomaxillofacial Surgery services. Methods: This is a retrospective quantitative study based on the medical records of patients treated at the Oral and Maxillofacial Surgery service of a public hospital between December 2013 and December 2014. Results: 201 surgical procedures were performed; the majority in males; aged between 19 and 35 years; from the Grande Vitória region (Espírito Santo, Brazil); they remained hospitalized for one day; fracture was the main etiology and the months of July, August and September were the most prevalent ones. In the medical records of the victims of fracture, accidents with motor vehicles was the main etiology; the most prevalent months were April, May and June; mostly men; aged 36 to 59 years; the jaw was the most affected bone. Conclusion: the main etiology of the surgeries was fracture; in male patients; aged 19 to 35 years; from the Metropolitan Region of Grande Vitória, in the months of July, August and September; with one day of hospitalization. In patients who were victims of fracture, the main etiology was motor vehicle accidents; the most affected bone was the mandible; mainly men; aged 36 to 59 years; the most prevalent months were April, May and June. Keywords: Mandibular fractures. Epidemiology, descriptive. Sex distribution.

Universidade Federal do Espírito Santo, Curso de Odontologia (Vitória/ES, Brazil). Master’s degree in Oral and Maxillofacial Surgery, Universidade Estadual do Rio de Janeiro (Rio de Janeiro/RJ, Brazil). 3 Universidade Federal do Espírito Santo, Curso de Odontologia, Departamento de Clínica Odontológica, Disciplina de Cirurgia Bucomaxilofacial (Vitória/ES, Brazil). 4 Doctorate degree in Oral and Maxillofacial Surgery, Pontifícia Universidade do Rio Grande do Sul (Porto Alegre/RS, Brazil). 1

How to cite: Botacin WG, Nakasome LF, Coser RC, Cancado RP. Epidemiology of OMFS surgical procedures of a public hospital. J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):38-44. DOI: https://doi.org/10.14436/2358-2782.4.2.038-044.oar

Submitted: March 23, 2017 - Revised and accepted: September 28, 2017 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. Contact address: Renata Pittella Cancado E-mail: pittella@uol.com.br

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):38-44

Botacin WG, Nakasome LF, Coser RC, Cancado RP

INTRODUCTION Surgery is the therapeutic option of choice for several pathophysiologic disorders, involving the repair of an organ or removal of the entire organ or part of it.1 The procedures performed in oral and maxillofacial surgery aim to treat congenital or acquired facial deformities, for both functional and esthetic rehabilitation. Reparative surgeries aim to reestablish the breathing, mastication and speech functions associated with facial hard and soft tissue structures. Trauma is one of the main public health problems in all countries, regardless of the socioeconomic development, and corresponds to the third greatest cause of mortality in the world, being only behind neoplasms and cardiovascular diseases.9 Trauma played a fundamental role in strengthening the maxillofacial surgery as an independent specialty.11 The facial fractures are characterized as one of the main causes of attendance in oral and maxillofacial surgery services. Facial injuries occur in large number in metropolitan areas and are caused by accidents, which have become daily occurrences in the urban world. However, in emergency rooms in the countryside, the diagnosis of facial fractures is seldom addressed by the doctors on duty, except for cases with obvious facial disfigurement.12 The fractures cause esthetic and functional impairment and considerably burden the individual and society.13 The facial traumas can be considered one of the most significant aggressions observed in trauma centers, due to the emotional consequences, possibility of deformity and also their economic impact on the health system.² Mandibular fractures can lead to deformities, either by displacement or unrestored bone loss, with changes in dental occlusion or in the temporomandibular joint (TMJ).14 These traumas may have several origins, such as physical aggression or accidents, among which the car crashes are the most common cause. According to the World Health Organization (OMS),7 the traffic kills more than one million people per year, and wounds 20 to 50 million people. Car accidents have negative impact not only related with the costs, but also related with pain, suffering and reduced quality of life not only to the victim, but also to their families and the entire society.10 The face, alike the oral cavity, are very susceptible to fractures, and the injuries cause physical, functional, esthetic and often psychological sequelae.8

Since the mandible is the only movable bone in the face and is involved in functions with complex physiology, due to its unprotected and prominent position in relation to the facial skeleton, it is the facial bone more susceptible to fractures.³ The literature presents several epidemiological studies about cases assisted in hospitals that perform oral and maxillofacial surgical procedures. 2-6,8-10 However, epidemiological investigations conducted at different regions reveal that similar studies in different metropolitan regions present different final databanks, justifying the relevance of the present study to reveal the epidemiological profile of a population sample. The results reveal the profile of the population living in that region, and this profile is influenced by the cultural aspects of the community, local human development index, urban organization, municipal policy, and the entire socioeconomic complex of each region. Therefore, this study aimed to achieve information on the hospitalizations and identify the characteristics of attendances in the Oral and Maxillofacial Surgery Service of a public hospital in great Vitória (ES). METHODS This epidemiological study with descriptive quantitative it retrospective approach was conducted on medical records of patients assisted at the oral and maxillofacial surgery service of Hospital Santa Casa de Misericórdia at Vitória (ES). The study period was December 2013 to December 2014. Before study onset, the project was approved by the Institutional Review Board of the Sciences and Health Center of UFES under number 1.208.805. The study analyzed 201 records from the information system of the hospital. No record was excluded from the sample. The survey was conducted by two calibrated investigators. Data were analyzed and kept in secrecy, in accordance with the confidentiality term. The results were divided according to the variables: gender, age range, patient’s origin, etiology of the procedure, etiology of fracture, bone region affected, prevailing months and period of hospitalization (in days). Thereafter, the records of patients who were victim of fractures were counted separately, analyzing the gender, etiology of fracture, age range, prevailing months and bone most affected by fractures.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):38-44

Epidemiology of OMFS surgical procedures of a public hospital

and cysts 15%. Infections including abscesses, osteomyelitis and other infections added up to 9%; TMJ disorders and other disturbances, 4%; impacted teeth, 3%. Records not presenting data about the etiology represented 3%. Odontomas accounted for 2%, and benign neoplasms 1%. Cleft palate, patient infected by HIV, dementia, enophthalmos, gingival hyperplasia and idiopathic thrombocytopenic purpura, in combination, added up to 3% (Fig 3). Among a total of 91 fractures, 48% involved mandibular fractures; 40% were fractures of the maxilla and malar bones; 9.5%, fracture of nasal bones; and 2.5%, fracture of the skull and other facial bones (Fig 4). The main cause of fracture was traffic accidents (car and motorcycle accidents and runovers), which represented 23.8% of the total, followed by falls (10.5%); shotgun accidents (SGA) (8.8%); aggression (6.4%), bicycle fall (2.2%) and sports accident (1%). The records not informing the cause of fracture added up to 47.3% (Fig. 5). Considering the fractures, the most prevalent months were analyzed. These, in turn, were grouped in periods. In December 2013 there was no case of fracture. January, February and March 2014 represented 16% of surgeries for fracture repair. The second trimester, corresponding to the months of April, May and June 2014, was the period with the greatest number of cases (38%). July, August and September 2014 accounted for 27%. The last trimester, comprising the months of October, November and December 2014, corresponded to 19%. The highest number of fractures occurred in male individuals, adding up to 82% of patients, while females accounted for 18% of the sample. The age ranges were also divided by periods. The greatest number of fractures occurred among adults, in the age range 36 to 59 years, with 57% of the total. Young adults, aged 19 and 35 years, represented 35%. Adolescents in the age range 12 to 18 years represented 5.5%. Elderly above 60 years accounted for 2.5%. The present sample did not include children up to 11 years of age.

Data were tabulated in Microsoft Office Excel® spreadsheets and evaluated by statistical analysis, according to central tendency measurements (mean and percentage). RESULTS The study analyzed records off 201 patients who underwent some surgical procedure in the oral and maxillofacial surgery and traumatology (OMFST) service of a public hospital in great Vitória in the period December 2013 to December 2014. Among the records, 65% were from males and 35% from females. The prevailing age range was young adults, aged 19 to 35 years, accounting for 32% of the patients. Children aged 0 to 11 years represented 1%; adolescents (12 to 18 years) corresponded to 7%; adults (36 to 59 years) comprised 23.5%, and elderly (60 years or older) 8.5% of the sample. Records not presenting the patient’s age represented 28% of the sample (Fig 1). Regarding the origin of patients, 73.5% were from the metropolitan region of Vitória, including the cities of Vitória, Cariacica, Fundão, Guarapari, Serra, Viana and Vila Velha; 17% were from the countryside of the state, and this information was not available for 9.5% of the patients. The months were grouped in periods. December 2013 corresponded to 4.5% of the total; January, February and March 2014, 19.5%; April, May and June 2014, 27.5%; July, August and September 2014, 29%; October, November and December 2014, 19.5%. The period of hospitalization was also analyzed. This information was not available on the records in 59% of cases. One day of hospitalization corresponded to 13%; two days, 2.5%; three days, 8%; four days, 2%; five days, 2.5%, six days, 1.5%. Eight days, ten days and thirteen days represented 0.5% each (Fig 2). Concerning the etiology of surgeries, 45% corresponded to facial fractures. Anomalies in interarch and dentofacial relationships accounted for 16%,

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):38-44

Botacin WG, Nakasome LF, Coser RC, Cancado RP

Hospitalization Period

Age 14% No date

12%

28,0%

Elderly

10%

8,5%

Adults

23,5%

6% 32,0%

4% 0%

1,0% 0%

10%

7,0%

Children

Young Adults Teenagers

13% 12,50%

15%

20%

25%

35%

2,50% 1,50% 0,50% 0,50% 0,50%

1 day 2 days 3 days 4 days 5 days 6 days 8 days 10 days 13 days

30%

Figure 1: Mean age of patients who underwent surgery.

Figure 2: Hospitalization period of patients submitted to surgical procedures.

Etiologia das cirurgias Other conditions

Beningn neoplasm

Odontoma

No data

Impacted teeth

3% 4%

TMJ dysfunction

Infections Cysts

15%

Dentoskeletal deformities

16% 45%

Facial fractures

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Figure 3: Etiology of surgical procedures.

Etiology of fractures

Location of the fracture 9,5%

25%

23,80%

Mandible

48% 40%

47,30%

Zygomatic bone and maxilla

8,80%

Nasal bones

10,50% 1,00%

Cranium and other facial bones

Traffic Accident Falls Bicycle accident No data

6,40%

Firearm accident Aggression Sports accident

Figure 5: Etiology of fractures.

Figure 4: Location of facial fractures.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

2,20%

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):38-44

Epidemiology of OMFS surgical procedures of a public hospital

DISCUSSION Currently, due to the technological advances, growing number of people practicing extreme sports and the increase in crimes, it is paramount to offer scientific update for professionals delivering care to the oral and maxillofacial region.6 Dental surgeries, including orthognathic surgeries, complex trauma surgeries, for extensive pathologies, and others, are classified as greater risk (middle to high) due to the potential hemorrhagic risk.1 However, there is some difficulty to deal with these data, since their quantification is often not possible, due to incomplete records or lack of information. Analysis of the records of all patients who underwent surgery during the study period (December 2013 to December 2014) revealed predominance of hospitalization for one day, in 13% of the sample. In the studies of Cavalcanti et al.2 and Massuia et al.9, most patients were hospitalized for 24 to 72 hours, agreeing with the present study, in which there was predominance of one day of hospitalization (24 hours). Therefore, it is assumed that most patients did not suffer injuries of greater severity, considering that they were hospitalized for less than four days.2 The prevalence of facial fractures is high among patients of any emergency service; in large centers, the diagnosis of facial fractures seems to be widespread, while in small emergency rooms in the countryside this type of fracture is not always properly addressed, especially in lower intensity traumas and when midface is affected.9 In this study, 17% of patients came from the countryside, similar to the studies of Rafael and Demuner4 and Bortoli et al.11 This reveals the incidence of patients coming from other regions to seek for care, due to the difficult access to this type of service in smaller cities, combined to the good infrastructure of the city of Vitória in the field of oral and Maxillofacial Surgery and Traumatology. Isolated analysis of the fracture victims revealed that the majority were males (82%), corroborating the findings of most studies. The males represent the majority because they are more exposed to risk factors, have more active participation, are more involved in fights and accidents, to the practice of extreme sports, and work in more dangerous professions. This also occurs because they are more exposed to violence, due to excessive ingestion of alcoholic beverages and imprudence in the traffic.8 However, the number of traumas in females has been increasing. In this study, women

accounted for 18% of the sample. Over time, women are no longer restricted to home activities; they work outside home, increasingly practice physical activities and extreme sports, and the number of female drivers is increasing. In this study there was predominance of fracture victims in the age range 36 to 59 years (57%), with a mild variation in age range in most studies, in which the prevalence of age is usually between the second and third decades of life. This may be explained by the greater dissemination of information to young people regarding the prevention of fractures, e.g. in the case of traffic accidents, which is an important cause of fracture, with many awareness campaigns, thus reducing the number of young people involved. Regarding the etiology of fractures, most cases in this study occurred due to traffic accidents (47.30%), agreeing with most studies, yet in disagreement with the studies of Cavalcanti et al.2, Stolz et al.6 and Massuia et al.9, in which interpersonal violence (physical aggression) was the most prevalent etiology – which yet accounted for only 6.4% in the present study. Another study5 reported falls as the major cause of trauma, which represented only 10.50% in the present study. According to data from DETRAN (State Traffic Department), in 2015 there were 8,791 traffic accidents only in Vitória, which is a very high number, explaining why traffic accidents were the main cause of fractures in the present study. A study conducted only on pediatric patients (aged less than 18 years) indicated that traffic accidents were the main cause of fractures in children, highlighting their influence on the etiology of fractures.5 The industrial development in the 20th century promoted a considerable increase in the number of vehicles running around the world. Road systems and urban planning in general failed to follow the increase in traffic volume3. The number of vehicles in use, the imprudence of some drivers and the pedestrians’ susceptibility in this situation led to this great influence of traffic accidents among fracture victims. The low number of elderly victims of trauma is related to their lower exposure to risk factors; in this study the elderly represented only 2.5% of the sample, since they spend more time in their homes, usually going out accompanied, and falls are their main cause of fractures. The prevalence of fracture among children is also small, which may be assigned to the care received by children and their stay at home.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):38-44

Botacin WG, Nakasome LF, Coser RC, Cancado RP

The analysis of epidemiological data demonstrates the need for some measures to reduce the number of fractures, including the application of stricter traffic laws, adequate supervision, policies to increase the awareness on alcohol ingestion and lower tolerance to avoid aggressions.

In this study, the mandible was the bone with the highest number of fractures, with 48%, alike most studies. Because of its position, the mandible receives great part of the traumas to the lower facial third2. Additionally, it is the only movable bone on the face and is more vulnerable to strong impacts and fractures, since in cases of fall it is the main site bumping into the object. However, according to other authors, the nasal bones are the most affected, appearing in this study as the third most prevalent site (9.50%), due to their prominent location and because they were constituted by thin bony structures, besides being a region subject to friction and bumps. This divergence about the most affected region occurred because the present study analyzed the records of hospitalized patients, and in that case the mandible was the facial region with the highest number of fractures. The nasal bone is the prevailing site when analyzing the records of patients seen in the emergency room, since their involvement is visible and usually does not require hospitalization for rehabilitation. Regarding the time period, the literature states that most cases of fracture occur in holiday months, when individuals are more exposed to risk factors. The present study grouped periods by trimester, revealing predominance of cases in the period corresponding to the months of April, May and June 2014, with 38% of cases of fracture. Martini et al.10 reported March as the highest number of fractures, followed by November and October; while in another study4 the most prevalent months were January, February and March. This divergence concerning the months may be explained by the fact that the present study included records of patients submitted to elective procedures, in which the surgical intervention occurred sometime after the injury.

CONCLUSION After analysis of the records of all patients assisted by the Oral and Maxillofacial Surgery service of Hospital Santa Casa de Misericórdia de Vitória (ES), the following was concluded: » Fracture was the main etiology of surgical procedures. » There was predominance of the male gender. » The most prevalent age in this study was 19 to 35 years. » The region of great Vitória was the predominant origin of patients in the sample. » July, August and September were the months with the highest number of surgical procedures performed. » The prevailing period of hospitalization was one day (24 hours). Concerning the analysis of records of fracture victims: » Traffic accidents were the main etiologic factor of trauma in the present study. » The prevailing months were April, May and June. » The mandible was the most affected bone. » The age range most affected by fractures was 36 to 59 years. » There was predominance of the male gender.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):38-44

Epidemiology of OMFS surgical procedures of a public hospital

References:

1. Carvalho RWF, Pereira CU, Laureano Filho JR; Vasconcelos BCE. O paciente cirúrgico. Parte I. Rev Cir Traumatol Buco-Maxilo-Fac. 2010 Out-Dez;10(4):85-92. 2. Cavalcanti AL, Lima IJD, Leire RB. Perfil dos pacientes com fraturas maxilo-faciais atendidos em um hospital de emergência e trauma, João Pessoa, PB, Brasil. Pesqui Bras Odontoped Clin Integr. 2009 Set-Dez;9(3):339-45. 3. Leporace AAF, Paulesini Júnior WP, Rapoport A. Estudo epidemiológico das fraturas mandibulares em hospital público da cidade de São Paulo. Rev Col Bras Cir. 2009;Nov-Dez;36(6):472-7. 4. Rafael CR, Demuner C. Prevalência das fraturas faciais no hospital São Lucas, na região da Grande Vitória, no período de janeiro de 2000 a julho de 2005 [trabalho de conclusão de curso]. Vitória: Faculdade de Saúde e Meio Ambiente; 2006. 5. Souza DFM, Santili C, Freitas RR, Akkari M, Figueiredo MJPSS. Epidemiology of children’s facial fractures in the emergency room of a tropical metropolis. Acta Ortop Bras. 2010;18(6):335-8. 6. Stolz ASB, Meller FB, Quesada GA, Bergolli C, Escobar CAB, Martins EM. Análise epidemiológica de fraturas bucomaxilofaciais em pacientes atendidos no Hospital Universitário de Santa Maria-HUSM: um estudo retrospectivo. Rev Odontol Bras Central. 2011;20(53): 129-35.

7. Brasil. Organização Mundial da Saúde. Plano de Trabalho Bianual 2008-2009. Produto da Produção Técnica.2009. [Acesso em: 21 ago 2016]. Disponível em: http://www.paho.org/bra/. 8. Freitas DA, Caldeira LV, Pereira ZM, Silva AM, Freitas VA, Antunes SLNO. Estudo epidemiológico das fraturas faciais ocorridas na cidade de Montes Claros/MG. Rev Bras Cir Cabeça Pescoço. 2009 Abr-Jun;38(2):113-5. 9. Massuia PDS, Silveira FGL, Assunção LF, Garcia ERBR, Sanches VM. Epidemiologia dos traumas de face no serviço se cirurgia plástica e queimados da Santa Casa de Misericórdia de São José do Rio Preto. Rev Bras Cir Plást. 2014;29(2):221-6. 10. Martini MZ, Takahashi A, Oliveira Neto HG, Carvalho Júnior JP, Curcio R, Shinohara EH. Epidemiology of mandibular fractures treated in a Brazilian level I trauma public hospital in the city of São Paulo, Brazil. Braz Dent J. 2006 Sept;17(3):243-8. 11. Bortoli MM, Eidt JMS, Engelmann JL, Rocha FD, Conto FD. Trauma maxilofacial: Avaliação de 1385 casos de fraturas de face na cidade de Passo Fundo-RS. Rev Cir Traumatol Bucomaxilofac. 2014 Abr. jun;14(2):87-94. 12. Motta MM. Análise epidemiológica das fraturas faciais em hospital secundário. Rev Bras Cir Plást. 2009 Abr-Jun;24(2):162-9.

13. Horibe EK, Pereira MD, Ferreira LM, Andrade Filho EF, Nogueira A. Perfil epidemiológico de fraturas mandibulares tratadas na Universidade Federal de São Paulo: Escola Paulista de Medicina. Rev Assoc Méd Bras. 2004 Out-Dez;50(4):417-21. 14. Andrade Filho EF, Fadul JRR, Azevedo RAAA, Rocha MAD, Santos RA, Toledo SR, et al. Fraturas de mandíbula: análise de 166 casos. Rev Assoc Méd Bras. 2000;46(3):272-6. 15. Brasil. DETRAN-ES. Relatório de Acidentes do Anuário Estatístico de Trânsito do Detran-ES.2015 [Acesso em: 16 ago 2016]. Disponível em http://www.detran. es.gov.br/default.asp.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):38-44

OriginalArticle

Medical emergencies in dentistry: academic

knowledge – a ten-year comparative study

LARISSA FOCHESATTO RESTELATO1,2 | ANDREA GALLON1,3 | FELIPE LANGE1,4 | THARZON BARBIERI1,5

ABSTRACT Introduction: Patients suffering from some kind of systemic grievance are common, contributing to the increase of medical emergencies in dental services. It is important that the dental surgeon be technically and psychologically prepared for immediate prescription of assistance in situations with imminent risk of death. Objective: The objective of this study was to verify the knowledge of dentistry undergraduate students of final phases, related to the management of anaphylactic shock, obstruction of the airway passages, and cardiopulmonary arrest. Methods: This quantitative and transversal research was composed of 53 undergraduate students who answered a multiple choice questionnaire. The t-Student test was used, with significance level of p <0.05. Results: The findings show that although the academic students can identify causes and symptoms of anaphylactic shock, 75% did not know how to treat it. About choking, 66% did not know how to treat it. For cardiorespiratory arrest, 87% did not recognize the signs and symptoms, and 96% did not know how to reanimate. Conclusion: This study ratifies the findings of the literature, in which most of the professionals are not capable of taking account of these situations. The undergraduate courses need to rethink the teaching to give better preparation for the professionals entering the labor market. Keywords: Anaphylaxis. Heart arrest. Airway obstruction.

How to cite: Restelato LF, Gallon A, Lange F, Barbieri T. Medical emergencies in dentistry: academic knowledge – a ten-year comparative study. J Braz Coll Oral Maxillofac Surg. 2018 MayAug;4(2):45-51. DOI: https://doi.org/10.14436/2358-2782.4.2.045-051.oar Universidade do Oeste de Santa Catarina (Joaçaba/SC, Brazil). Doctor in Dental Surgery, Universidade do Oeste de Santa Catarina (Joaçaba/SC, Brazil). Master’s degree in Collective Health, Universidade do Oeste de Santa Catarina (Joaçaba/ SC, Brazil). 4 Master’s degree in Human movement Sciences, Universidade do Estado de Santa Catarina (Florianópolis/ SC, Brazil). 5 Master’s degree and Specialist in Implantology, Faculdade de Medicina e Odontologia São Leopoldo Mandic (Campinas/SP, Brazil). 1

Submitted: November 28, 2017 - Revised and accepted: March 24, 2018

2 3

» The authors report no commercial, proprietary or financial interest in the products or companies described in this article. Contact address: Larissa Fochesatto Restelato E-mail: larissa_restelato@hotmail.com

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):45-51

Medical emergencies in dentistry: academic knowledge – a ten-year comparative study

INTRODUCTION Medical emergencies are situations that define a health disorder occurrence with imminent death risk or that causes great suffering for the patient. Thus, the first aid should be immediate, not allowing to postpone the attendance to patients in such risk situations. It is increasingly common to provide care for patients with some systemic disease (diabetes, hypertension, cardiopathies, asthma and renal and hepatic diseases), and there has also been an increase in the number of medical urgencies and emergencies in the dental clinic, not necessarily related to the dental treatment.1 The anaphylaxis, or anaphylactic shock, is an acute and potentially fatal hypersensitivity reaction that affects several organs and systems simultaneously.2 A mild manifestation of this reaction may be observed, limited to the upper airway, skin and gastrointestinal tract. When the occurrence is generalized, there may be anaphylactic shock with sudden and potentially fatal reaction.1,3,4 Choking is also a possible emergency situation. Patients undergoing dental treatment are susceptible to choke, with risk of aspiration/swallowing of some objects to the oropharyngeal cavity.5 The aspiration of foreign bodies is less frequent when compared to swallowing, usually without surgical intervention.4 Thus, the dentist (DDS) has great responsibility, since besides the inherent problems of the stomatognathic system, he or she may also manage other situations that make the patients vulnerable and may often be irreversible.6 The medical emergency known as cardiopulmonary arrest (CPA) may be understood as a sudden interruption of systemic circulation and/or respiration. In ten to fifteen seconds, the individual becomes unconscious due to the arrest of blood circulation in the brain; if this circulation is not caught up, the brain lesion starts to take place within three minutes, and the chances of resuscitation after ten minutes are almost null, leading to total and irreversible arrest. There are also other coadjutant signs, such as paleness, cyanosis of the extremities, mydriasis, and interruption of bleeding during a surgery.7,8,9 It is recommended that the DDS should have basic emergency equipment in the dental office, including syringes, Ambu bag, portable oxygen system, stethoscope, sphygmomanometer (for children and adults) and an AED (automatic external defibrillator), Guedel cannula, besides the following drugs: adrenaline, promethazine hydrochloride, bronchodilator, glycose, glucagon, captopril, nitroglycerin, aromatic ammonia and aspirin5,10.

Also, Hanna et al.11 highlighted that the DDS should have a good psychological preparation, and also be technically trained when providing emergency care to the victim. Therefore, this study analyzed the knowledge of undergraduate students from the eighth to tenth periods of Dentistry of Unoesc Joaçaba (SC) concerning the management of anaphylactic shock, airway obstruction and cardiopulmonary arrest (CPA), and compared with a similar study conducted in 2006 by Seleri in the same institution.20 METHODS This quantitative, cross-sectional study was conducted on 67 undergraduate students from the eighth to tenth periods of Dentistry of Unoesc Joaçaba (SC), in the second semester of 2016, under IRB approval n. 2101040. The study employed a closed structured questionnaire with multiple-choice questions applied personally, individually and without consultation, in the classroom, during the regular academic activity, in the presence of the investigator, and with a predetermined time period for conclusion. After collection, the questionnaires were stored in sealed envelopes, identified by grade, to assure the confidentiality of participants. The results were analyzed by descriptive and inferential statistics, with comparisons by the Student t test, at a statistical significance level of p<0.05. Among the 67 students that could participate, only 53 students (79%) responded the questionnaire. RESULTS The results were compilated and are presented in Tables 1 and 2. Concerning the causes of anaphylactic shock (AS), 24 students (45%) were able to identify them, while 29 (55%) were not aware. In a similar study conducted in 2006 by Seleri20, it was observed that 42 (59%) students could not identify the causes, while 28 (41%) could do it. The relationship between the two studies was statistically significant (p < 0.05) according to the Student t test. Regarding the signs and symptoms, 23 (43%) students were able to identify them, as compared to 30 (57%) who were not. In 2006, Seleri20 achieved the following result: 33 (47%) positively identified the signs and symptoms, and 37 (53%) could not recognize them. There was statistically significant relationship, with p<0.05, between the results of both studies.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):45-51

Restelato LF, Gallon A, Lange F, Barbieri T

Table 1: Distribution of the frequency of variables investigated by Seleri20 in 2006 and in the present study. Present study

Causes of anaphylactic shock* Signs and symptoms of anaphylactic shock* Treatment of an anaphylactic shock victim Signs and symptoms of choking Treatment of a choking victim Prevention of choking in the clinic Signs and symptoms of cardiopulmonary arrest* First aid procedures to be performed in case of cardiopulmonary arrest Resuscitation of a cardiopulmonary arrest victim* Do you consider yourself ready to treat a medical emergency in the dental office? After graduation, do you intend to study and learn more about it?*

Seleri20, 2006

Yes 24 23 13 50 18 43 7 40 2

No 29 30 41 3 35 10 46 13 51

Yes 28 33 33 64 34 64 47 61 40

No 42 37 37 6 36 6 23 9 30

*p < 0.05, Student t test.

Table 2: Distribution of frequency of variables investigated by Seleri20 in 2006 and in the present study, according to the periods. Seleri20, 2006

Present study

8 period

9 period

10 period

8 period

9th period

10th period

8 12 12 25 11 29 16 23 14 25

9 5 12 16 7 17 11 16 12 16

11 16 9 23 16 27 20 22 14 18

6 6 3 12 4 13 4 7 1 3

13 10 5 23 10 17 1 18 0 4

4 7 15 15 4 13 2 15 1 4

*p < 0.05, Student t test.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):45-51

Medical emergencies in dentistry: academic knowledge – a ten-year comparative study

In this study, when comparing the three grades, the results demonstrated that 4 (25.57%) students in the eighth period, 10 (43.47%) in the ninth period and 4 (25%) in the tenth period were aware of how to treat a choking victim (Tab. 2). Seleri20 reported that 11 (42.3%) students in the eighth period, 7 (41.2%) in the ninth and 16 (59.3%) in the tenth period knew how to treat, with statistically significant relationship between the two studies (p < 0.05). Analysis of the responses between the study grades revealed that 4 (28.57%) students in the eighth period, 1 (4.34%) in the ninth period and 2 (12.5%) students sin the tenth period knew how to mention the signs and symptoms. In the study of Seleri,20 16 (61.5%) students in the eighth period, 11 (64.7%) in the ninth period and 20 (74.1%) in the tenth period correctly identified these signs, with statistically significant correlation (p < 0.05) between studies. Concerning the resuscitation in case of cardiopulmonary arrest, the relationship between these two studies, in the three periods, was also statistically significant (p < 0.05), since only 1 (7.14%) student in the eighth period, none (0%) in the ninth period and 1 (6.25%) in the tenth period knew how to perform resuscitation in a CPA. In 2006, Seleri20 reported that 14 (53.8%) students in the eighth period, 12 (70.6%) in the ninth and 14 (51.9%) in the tenth knew the procedure to resuscitate a CPA victim. In this study, 3 (21.42%) students in the eighth period, 9 (17.39%) in the ninth period and 4 (25%) in the tenth period stated they were ready to treat a medical emergency in the dental office. The same was reported by Seleri20, in 2006, who observed that 25 (69.2%), 16 (94.1%) and 18 (92.6%) students in the eighth, ninth and tenth periods, respectively, considered themselves trained. The relationship between the two studies was statistically significant (p < 0.05). When stratifying the result, between periods, it was observed that 10 students (71.42%) in the eighth period, 22 students (95.65%) in the ninth period and 14 students (87.5%) in the tenth period demonstrated interest in deepening their knowledge. Similarly, in 2006, Seleri20 reported that 26 (100%) students in the eighth period, 17 (100%) in the ninth and 25 (92.6%) in the tenth period wished to study more about the medical emergencies in Dentistry. The relationship between the two studies was statistically significant (p < 0.05).

When questioned about the signs and symptoms of CPA, 7 (13%) students were aware about it, compared to 46 (87%) who were not. In 2006, Seleri20 reported that 47 students (67%) could recognize it, while 23 (33%) did not know the signs and symptoms of this disorder. When comparing both studies, there was statistically significant relationship (p < 0,05). Concerning the CPA, in the present study, two (4%) knew about resuscitation, and 51 (96%) did not. Seleri20 identified that 40 (57%) students knew while 30 (43%) did not know how to perform resuscitation. The relationship between the two studies was significant (p < 0.05). When questioned about continuing education, 47 (89%) students stated they had interest in searching for new courses, while only 6 (11%) did not intend to enhance. Seleri20 also observed similar outcomes, since 68 (97%) students reported interest, while only 2 (3%) did not intend to search for courses in this field. Table 2 reveals that, when questioned about the signs and symptoms of AS, 6 (42.85%) students of the eighth period, 10 (43.47%) from the ninth period, and 7 (43.75%) from the tenth period were able to identify them. There was statistically significant relationship (p<0.05) compared to the study of Seleri20 in 2006, in which the signs and symptoms were recognized by 12 students (46.2%) in the eighth period, 5 (29.4%) in the ninth period and 16 students (59.3%) from the tenth period. Thereafter, when addressing the treatment of an anaphylactic shock victim, the question was properly answered by 3 (21.42%) students of the eighth period, 5 (21.73%) of the ninth period and 5 (31.25%) of the tenth period. Similarly, in the study of Seleri,20 12 (46.2%) students of the eighth period, 12 (75%) of the ninth and 9 (34.6%) of the tenth period knew the correct treatment, making the relationship between studies statistically significant (p < 0.05). The results related with choking, between study grades, demonstrated that 12 (85.71%) students int he eighth period, 23 (100%) in the ninth period and 15 (93.75%) in the tenth period were able to identify its signs and symptoms. Table 2 reveals a statistically significant relationship (p < 0.05) between the two studies, while Seleri20 reported that 25 (96.2%) students of the eighth period, 16 (94.1%) of the ninth period and 23 (88.5%) of the tenth period understood the signs and symptoms.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):45-51

Restelato LF, Gallon A, Lange F, Barbieri T

DISCUSSION The results concerning anaphylactic shock, in this study, were assertive regarding the causes and signs and symptoms described in the literature. According to Gaujac et al.3 and Bernd et al.2, the most common causal agents of AS may be antibiotics (penicillin, cephalosporin, tetracycline), anesthetics, analgesics and NSAIDs. Among the antibiotics, penicillin is the most common cause of anaphylaxis. Concerning anesthetics, ester-type anesthetics are more likely to trigger this type of reaction. The group of analgesics does not present more severe reactions concerning the anaphylactic shock.3 It should be mentioned that skin manifestations are the most frequent, including redness, itching, urticaria, angioedema, peripheral vasodilation, paleness, sweating and cyanosis of the extremities. If the respiratory system is affected, reaching the pharynx, the patient reports itching, a closed throat sensation, dysphagia, dysphonia, hoarseness and dry cough. The cardiovascular condition affected by the anaphylactic shock triggers events as hypotension at various levels, dizziness, fainting sensation and blurred vision, and may complicate further evolving to bronchospasm, convulsions, glottis edema and mainly cardiovascular failure. Biphasic reactions may occur few hours after the immediate initial phase; however, with the reappearance of symptoms, the manifestations are more intense and refractory to therapy.2,12 Contrary to the report of Hanna et al.11, in a similar study in which the findings showed assertiveness for the treatment of anaphylactic shock, this study revealed that most participants are unaware of the appropriate treatment, characterized by immediate intervention to achieve access to the airway and airflow to maintain the vital signs.12 For the treatment of skin reactions, the DDS should remove the causal agent, observe the vital signs and apply intramuscular injection of promethazine 50mg and betamethasone 4mg, monitoring the patient for 20 to 30 minutes.2 If the condition is unstable, the patient should be placed in Trendelenburg position, medical aid should be immediately requested, followed by subcutaneous injection of 0.3 ml of adrenaline (1:1000) without hypotension. If there is hypotension, intravenous injection is recommended. The same volume should be administered at every 5 or 10 minutes.2,3,13 If the condition is stable, and to avoid biphasic reactions, antihistamine and corticosteroid should be prescribed, namely diphenhydramine and hydrocortisone are the first choice.2

If the patient warns the DDS during anamnesis about a possible anaphylactic shock, the DDS may prescribe oral dexamethasone preoperatively as a prophylactic measure, thus reducing the likelihood of an allergic reaction.3 Anaphylaxis is potentially fatal, underrecognized and undertreated, and the fast epinephrine administration is essential to prevent hospitalization and death, increasing the responsibility of the DDS in managing this occurrence.11,14 As compared to the study of Seleri20 (2006), similar and satisfactory results were observed for signs and symptoms of airway obstruction. The most common sign of choking is when the conscious victim presents a face of respiratory distress and stands with the universal sign of choking, i.e. with the hands wrapping the throat and the fingers extended.15 Additionally, there is difficulty to breathe, the patient coughs with a strident noise, breathing becomes noisy, and paradoxical breathing may occur, yet without synchronization and in different rhythms, with cyanosis and even unconsciousness.5 Knowing how to treat an airway obstruction was not a positive aspect in this study, as mentioned in the results. Colet et al.7 and Ribeiro5 instructed unblocking by hyperextension of the head with chin elevation, with upward mandibular movement, to widen the airway. If the foreign body can be seen and is accessible by hyperextension, it should be removed with the index finger “in hook”.8 Another maneuver that may be followed is positioning behind the victim and, with the torso slightly inclined, apply five dry knocks with the base of one hand, in the middle of the back between the scapula bones, and then perform the Heimlich maneuver if choking persists. With the victim slightly inclined, the DDS should position behind him or her with her arms around the abdomen, locate the navel, and with the hand closed in wrist, the thumb turned inwards and the other hand superimposed on the first, support the hands one finger above the navel and apply five successive compressions, in inward and upward direction.5,8,16 If the DDS is unable to surround the victim’s abdomen, then the victim should be laid on the floor on a flat surface; then the professional should sit with the knees beside the patient’s hip, placing the hands open one over the other in the upper abdomen and inferiorly to the rib cage, using his or her weight to press and making a strong and fast pressure inward and upward.16 Subsequently, it

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):45-51

Medical emergencies in dentistry: academic knowledge – a ten-year comparative study

is necessary to check if the victim resumed breathing. If necessary, reposition and repeat the five cycles until unblocking. This maneuver should not last longer than five seconds.8 If the patient does not display changes that indicate aspiration, being conscious and calm, the professional should warn about what happened and the dental procedure initiated should be finalized as soon as possible. The patient should then be referred or taken to a medical service for clinical and imaging examinations to locate the foreign body.4 As a general rule, for any medical emergency, the best method to prevent this problem is the use of physical barriers, such as rubber dam, to avoid aspiration/ swallowing of foreign bodies, endodontic files or drills,17 besides the use of dental floss to tie the prosthetic structures and orthodontic accessories.4 Some parameters are fundamental to understand and evaluate the cardiopulmonary arrest (CPA): responsiveness, breathing and pulse. If no response is noticed by tactile touch – i.e. unconscious – the emergency medical service should be called to follow the emergency protocols.7,8 Queiroga et al.6 suggested the offer of hospital curriculum, since in their study the highest rate of correct responses concerning the diagnosis of CPA was observed for the group that had received training in the oral and Maxillofacial Surgery and Traumatology service (OMFST), representing only 22.5% of the sample. In this case, the authors assigned the good results directly to participation in the service. Though not based on hospital training, this study corroborates the results found by Queiroga et al.6, for the identification of signs and symptoms of cardiopulmonary arrest. In a patient with CPA, without cardiopulmonary resuscitation and defibrillation maneuvers, the chances of survival of the victim decrease between 7 and 10%, and studies corroborate that the victim submitted to defibrillation in up to eight minutes has higher chance of survival.8,18 There is clear and consistent evidence of increased CPA survival when the person present at the site performs cardiopulmonary resuscitation (CPR) and quickly uses an AED. Thus, immediate access to a defibrillator is fundamental in the care system.19 The present findings reveal the low rate of correct answers regarding the treatment of CPA. For chest compressions, the rescuer should keep the arms extended and the elbow joints fixed, positioned with the

hands flat one over the other on the central portion of the sternum, nearly 3 cm above the base of the xiphoid process. The pressure applied on the sternum should depress it in 4 to 5 cm, and nearly 4 cm in pregnant women and infants. For an effective resuscitation, the compressions should be alternated with ventilations, following the rule of 30:2 (30 compressions for every 2 ventilations).7,8,18 It is preferable to use the Ambu bag for ventilation. After completing five cycles, the professional should check the return of breathing and blood flow (assessing the carotid pulse); if negative, a new cycle of compression and ventilation should be initiated. If breathing and blood flow return, the rescuer should put the victim in a recovery position, monitoring at every minute.7,8 The study of Alkandari et al.9 revealed that individuals with more than 10 years of clinical experience had better knowledge of cardiopulmonary resuscitation compared to less experienced professionals, emphasizing the importance of training in CPR. Without training and sufficient practice, the significant amount of theoretical information is forgotten after 12 months, and after 18 months there will be no adequate practical skills. Also, considering the speed of review and update of guidelines, the importance of continuing education cannot be ignored.9 CONCLUSION The study evidenced that medical emergencies are addressed in the graduation in Dentistry at Unoesc. However, the study clearly demonstrated that the students in the final periods present a gap in the consolidation of knowledge related to the subject, especially when compared to a similar study conducted in 2006, and corroborated by the literature, which states that most dentists are not able to assist urgent and emergency cases in the dental office. Over the last 10 years after the first study, the literature evidenced a very subtle change in the management of these events, indicating that the graduation provides the necessary learning to act in situations of anaphylactic shock, choking, and cardiopulmonary arrest. This study highlights the urgent need to strengthen the knowledge on this practice early during the period of professional training, i.e. in the university, allowing the professional to enter the job market with better training for a possible emergency situation.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):45-51

Restelato LF, Gallon A, Lange F, Barbieri T

References:

1. Lucio PSC, Barreto RC. Emergências médicas no consultório odontológico e a (in)segurança dos profissionais. Rev Bras Ciênc Saúde. 2012;16(2):267-72. 2. Bernd LAG, Sá AB, Watanabe AS, Castro APM, Solé D, Castro FM, et al. Guia prático para manejo da anafilaxia - 2012. Rev Bras Alerg Imunopatol. 2012;35(2):53-70. 3. Gaujac C, Oliveira AN, Barreto FAM, Salgado LM, Oliveira MS, Girão RS. Reações alérgicas medicamentosas no consultório odontológico. Rev Odontol Univ Cidade de São Paulo. 2009 Set-Dez;21(3):268-76. 4. Silva RF, Prado FB, Portilho CDM, Silva RF, Daruge Júnior E. Orientações clínicas e éticas em caso de deglutição de corpo estranho durante o atendimento odontológico. Rev Sul-Bras Odontol. 2010 Jul-Set;7(3):354-9. 5. Ribeiro MM. Emergências em consultório médico-dentário: proposta de protocolos. Porto: Universidade do Porto; 2014. 6. Queiroga TB, Gomes RC, Novaes MM, Marques JLS, Santos KSA, Grempel RG. Situações de emergência médicas em consultório odontológico. Avaliação das tomadas de decisões. Rev Cir Traumatol Buco-Maxilo-Fac. 2012 Jan-Mar;12(1):115-22.

7. Colet D, Griza GL, Fleig CN, Conci RA, Sinegalia AC. Acadêmicos e profissionais da Odontologia estão preparados para salvar vidas? Rev Facul Odontol Passo Fundo. 2011;6(1):25-9. 8. Rocha MPS. Suporte básico de vida e socorros de emergência. Brasília, DF: AVM Instituto; 2011. 9. Alkandari SA, Alyahya L, Abdulwahab M. Cardiopulmonary resuscitation knowledge and attitude among general dentists in Kuwait. World J Emerg Med. 2017; 8(1): 19–24. 10. Bordignon MV, Vieira RR, Silva SO, Linden MSS, Trentin MS, Carli JP. Emergências médicas na prática odontológica: ocorrência, equipamento dos cirurgiões-dentistas do Rio Grande do Sul. Salusvita. 2013;32(2):175-85. 11. Hanna LMO, Alcântara HSC, Damasceno JM, Santos MTBT. Conhecimento dos cirurgiões dentistas diante urgência/ emergência médica. Rev Cir Traumatol Buco-Maxilo-Fac. 2014 Abr-Jun;14(2):79-86. 12. Bernd LAG, Solé D, Pastorino AC, Prado EA, Castro FFM, Rizzo MCV, et al. Anafilaxia: guia prático para o manejo. Rev Bras Alerg Imunopatol. 2006;29(6):283-91. 13. Singletary EM, Charlton NP, Epstein JL, Ferguson JD, Jensen JL, MacPherson AI, et al. Part 15: first aid: 2015 American Heart Association and American Red Cross Guidelines Update for First Aid. Circulation. 2015 Nov 3;132(18 Suppl 2):S574-89.

14. Fromer L. Anaphylaxis prevention: epinephrine auto-injector. Am J Med. 2016 Dec;129(12):1244-1250. 15. Saúde e força. Asfixia por engasgo - primeiros socorros. 2013 [Acesso em: 22 Set. 2017]. Disponível em: http://www.saudeeforca.com/asfixia-por-engasgo-primeiros-socorros. 16. Protocolo de emergência em caso de engasgamento. 2012. [Acesso em: 12 set. 2017]. Disponível em: https://www.omd.pt/md/engasgamento/protocoloengasgamento.pdf. 17. Caputo IGC. Emergências médicas em consultório odontológico: implicações éticas e legais para o cirurgião-dentista. Piracicaba: [s.n.]; 2009 18. Travers AH, Chair C, Rea TD, Bodrow BJ, Edelson DP, Berg RA, et al. Part 4: CPR overview: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(Suppl 3):S676-84. 19. American Heart Association. Destaques da American Heart Association. Atualização das Diretrizes de RCP e ACE. 2015. [S.L.]Dallas: American Heart Association; 2015. 20. Seleri E. Conhecimento dos acadêmicos de odontologia frente a situações de urgência e emergência médica no consultório odontológico [trabalho acadêmico]. Joaçaba (SC): Universidade do Oeste de Santa Catarina; 2006.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):45-51

CaseReport

Surgical treatment of zygomatic-orbital fracture sequelae with autogenous graft

and alloplastic material

ABSTRACT The zygomatic-orbital fractures are common facial injuries and their treatment has been a challenge for the surgeon. As a result of this type of trauma, significant complications may occur, including diplopia, enophthalmos, dystopia, restriction of ocular motility, loss of zygomatic projection, telecanthus or amaurosis. Early diagnosis and proper treatment are intended to restore order and orbital volume, function and aesthetics of the area. However, misdiagnoses or an inappropriate initial treatment can lead to delayed repair and secondary complications. Diagnostic capabilities have dramatically evolved and now the surgeon can rely on three-dimensional computerized tomography imaging, which can be used to make a biomodel for prior planning. The availability of numerous biomaterials for bone reconstruction contributed to the evolution of the surgical management of orbital fractures. Among the options for secondary reconstruction may be mentioned the use of: autogenous materials, such as skull cap; halogen materials, which are rarely used; and alloplastics, as titanium screen. The autogenous tissues still remain as standard material. The objective of this study was to describe a case report through the use and advantages of autograft combination with alloplastic grafts in orbital reconstruction, with the aid of rapid prototyping biomodel. Keywords: Orbit. Orbital fractures. Transplantation. Autologous.

Universidade Federal do Piauí, Hospital Universitário, Serviço de Cirurgia e Traumatologia Bucomaxilofacial (Teresina/PI, Brazil). Universidade Federal do Maranhão, Serviço de Cirurgia Bucomaxilofacial (São Luís/MA, Brazil). 3 Specialist in Oral and Maxillofacial Surgery, Universidade Federal do Piauí (Teresina/PI, Brazil). 4 Doctor in Dental Surgery, Universidade Federal de Alagoas (Maceió/AL, Brazil). 5 Doctor in Dental Surgery, Universidade Federal do Piauí (Teresina/PI, Brazil). 6 Oral and Maxillofacial Surgeon, Universidade Federal do Piauí (Teresina/PI, Brazil). 7 Doctorate degree in Dental Clinic (Oral and Maxillofacial Surgery), Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba (Piracicaba/SP, Brazil). 1

How to cite: Batista CEM, Melo TM, Santos IC, Sena JF, Rodrigues EDR, Bastos EG. Surgical treatment of zygomatic-orbital fracture sequelae with autogenous graft and alloplastic material. J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):52-8. DOI: https://doi.org/10.14436/2358-2782.4.2.052-058.oar

Submitted: September 29, 2017 - Revised and accepted: February 02, 2018 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. » Patients displayed in this article previously approved the use of their facial and intraoral photographs. Contact address: Éwerton Daniel Rocha Rodrigues E-mail: ewertondaniel27@hotmail.com

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):52-8

Batista CEM, Melo TM, Santos IC, Sena JF, Rodrigues EDR, Bastos EG

INTRODUCTION Fractures of the zygomatic complex account for 45% of all fractures involving the midface.Âš The signs and symptoms of zygomatic-orbital fractures include the appearance of hypophthalmos, enophthalmos, proptosis, trismus, hypoesthesia and flattening of malar prominence. The late treatment or inadequate surgical planning lead to sequelae such as enophthalmos, persistent diplopia, vertical dystopia, telecanthus, and also malar prominence loss.2,3 The primary repair of fractures is performed in up to 21 days; after this period, the utilization of osteotomies for late treatment may be necessary, and after 4 months the use of grafts is mandatory.2 Usually, enophthalmos and diplopia occur in defects located between the orbital floor and medial wall, or defects related to a poor malar prominence. Achieving acceptable results in the late treatment of orbital fractures is still difficult, because there may be bone loss and consequently loss of reference points, besides cicatricial contraction of tissues. The surgical repair of this type of post-traumatic sequel aims at reestablishing the orbital shape and volume, function and esthetics of the region. The materials employed for late reconstruction should be able to fill the defect space and maintain the stability and necessary volume over time.4 The options for secondary reconstruction of residual enophthalmos include the use of autogenous materials, such as the cranial vault, iliac crest, costal arches, maxillary sinus wall, mandible and cartilages (ear cartilage and nasal septum). Allogeneic materials are rarely used and include dura-mater, freeze-dried fascia lata and bone from cadaver. The alloplastic materials may be resorbable and non-resorbable (titanium mesh, high-density porous polyethylene). The material should be chemically inert, biocompatible and non-allergenic or carcinogenic.3,5,6 The autogenous tissues still remain as standard material, with main advantages of efficacy and reliability. As any other material, they also have disadvantages, due to their unpredictable resorption and the need of a second surgical site. Notwithstanding, when cranial vault bone is used, there is a second surgical site adjacent to the area to be grafted, causing minimum postoperative pain and morbidity.5,6Â The alloplastic grafts are also widely used for internal orbit reconstruction, such as the titanium

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

mesh. These materials are thin, easily establish the internal orbital contour, and are stabilized; they reduce the operative time, present multiple sizes and shapes, and present disadvantages such as some degree of foreign body reaction.3 The sequelae of fractures of the zygomatic-orbital complex require complex orbital reconstruction. To optimize the treatment and achieve a more accurate reconstruction of the internal orbit, the preoperative planning included the use of stereolithographic models. Therefore, surgery is previously planned using the rapid prototyping biomodel, achieved by computed tomography. The prototypes allow analysis and measurement of structures, simulation of osteotomies and customization of implants.7 METHODS A female patient, aged 29 years, of African descent, attended an oral and maxillofacial surgery service complaining of facial pain, masticatory difficulty, dystopia and diplopia. She reported a previous motorcycle accident nearly four years before, and accomplishment of surgery for the treatment of facial fracture. She denied any systemic pathology, continuous ingestion of medication for allergies. Clinical examination revealed the presence of enophthalmos and dystopia of the right eye, preservation of eye movements, diplopia, and scar from the primary surgery (Fig 1A). A facial tomograph was requested (CT), which revealed presence of fixation devices on the right zygomatic-orbital-maxillary complex, located on the frontozygomatic suture, infraorbital rim and zygomatic pillar. The examination also revealed increased orbital space, loss of continuity of the orbital floor, with soft tissue herniation in to the maxillary sinus (Fig 1B, C and D). The patient was informed on the need of a second surgery to correct the enophthalmos and dystopia, as well as on the risks inherent to the procedure. She signed an informed consent form, agreeing with the risks and authorizing surgery and record keeping. Biomodels were requested by rapid prototyping with mirroring, to allow better diagnosis and surgical planning (Fig 2A). This allowed a three-dimensional overall view of the post-traumatic defect. The biomodel with mirroring served as a guide for titanium mesh modeling, reducing the transoperative time and optimizing the outcomes.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):52-8

Surgical treatment of zygomatic-orbital fracture sequelae with autogenous graft and alloplastic material

mesh was placed on the floor and posterolateral wall of the orbital cavity (Fig 2C, 2D). Surgery was finalized by suture of surgical accesses by planes, and analgesics, anti-inflammatory and antibiotics were prescribed on the immediate postoperative period. The patient has been under postoperative follow-up for one year and a half, evidencing significant improvement in enophthalmos, dystopia, and not reporting pain upon mastication, besides the resolution of diplopia (Fig 3).Â

Based on clinical and radiographic examinations, it was planned to achieve coronal, subtarsal and intraoral access to the maxilla, aiming to remove the fixation devices from the frontozygomatic region and zygomatic pillar, besides achievement of a cranial vault graft with approximately 4 c m length and 2.5 cm width (FigÂ 2B). After modeling, a titanium mesh was also placed on the posteromedial wall, followed by insertion of the vault graft, also on the posteromedial wall, for overcorrection of the orbital volume. Thereafter, a second titanium

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Figure 1: A) Frontal view exhibiting enophthalmos, dystopia and loss of zygomatic projection. B) Coronal section evidencing increase of the right orbital cavity. C) 3D reconstruction exhibiting the fixation devices on the right zygomatic-orbital-maxillary complex. D) Sagittal section evidencing herniation of the orbital contents into the maxillary sinus.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):52-8

Batista CEM, Melo TM, Santos IC, Sena JF, Rodrigues EDR, Bastos EG

Figure 2: A) Prototypes employed for surgical planning. B) Donor site of bone graft. C) Grinding of bone graft. D) Placement of titanium mesh and bone graft.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):52-8

Surgical treatment of zygomatic-orbital fracture sequelae with autogenous graft and alloplastic material

Figure 3: A) Postoperative aspect after one year and a half, presenting significant improvement in enophthalmos and dystopia. B) Sagittal section presenting correction of herniated tissue, with adaptation of mesh and graft. C) 3D reconstruction demonstrating mesh adaptation on the posteromedial region, floor and posterolateral wall. D) Correction of orbital cavity increase.

DISCUSSION The treatment of zygomatic-orbital complex fractures remains an issue of considerable discussion. The literature presents variable and often conflicting treatment options.2,3 Delays in the treatment of these fractures may have a high impact on the final result. This may lead to serious complications as enophthalmos, dystopia, diplopia, loss of visual acuity and decreased eye motility. Also the diagnosis, timing and treatment planning may be critical to achieve a good result.8 The clinical diagnosis of sequelae of orbital fractures is based on poor positioning of the eyeball, with enophthalmos and diplopia as the main findings, followed by dystopia, loss of visual acuity and decreased ocular motility9. Computed tomography (CT) is necessary to define the defect extent and the condition of soft tissues. In an analysis of 64 orbital fractures

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

submitted to late treatment,10 all patients underwent CT with axial, sagittal and coronal sections and 3D reconstruction, and an ophthalmologic evaluation was performed before reconstructive surgery. The utilization of a biomodel obtained by rapid prototyping is a useful tool and allows overall diagnostic evaluation of the region before surgery.8 The biomodel achieved in the present case aided measurement of the extent of zygomatic bone flattening, and the difference in volume between the two orbits and the surgical planning. Some strong indications of early orbital repair include: 1) diplopia with radiographic evidence of incarcerated orbital tissue, causing ischemic necrosis; 2) fractures with large increase of the orbital continent, with disturbance in ocular motility; and 3) radiographic evidence of tissue compression accompanied by oculocardiac, enophthalmic or hypoglobe reflex, causing facial asymmetry, which affects the

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):52-8

Batista CEM, Melo TM, Santos IC, Sena JF, Rodrigues EDR, Bastos EG

function and aesthetics.5 Late orbital reconstruction is sometimes necessary due to difficulty in the initial diagnosis of enophthalmos and diplopia, inadequate primary treatment or untreated orbital defects5,8,9. In the present case, the patient had undergone primary treatment; however, enophthalmos and dystopia were clinically observed, besides increased orbital volume on the CT. Scarring contraction and bone loss may impair the identification and mobilization of orbital structures difficult in secondary treatment. Therefore, the latter is technically challenging, requiring greater extent of tissue dissection and sometimes osteotomy and repositioning of bone segments, besides graft placement,4,6,9 which may lead to poor results, when underestimated. In the study of Carr and Mathog,2 78 patients submitted to 81 procedures for repair of complex zygomatic-orbital fractures were evaluated to review the authors’ experience about immediate or late repair. Among the 81 procedures, 49 were primary, i.e. performed 1 to 22 days after the lesion, and 32 were late procedures using osteotomies and/or bone grafts. The early surgical intervention dramatically enhanced the esthetic and functional results, while the late repair was less satisfactory. Among the 32 patients treated late, 18 presented dystopia. Among these, 5 still presented the disorder after surgical intervention. The authors concluded that the treatment of zygomatic-orbital fractures might be performed by primary reduction and fixation up to 21 days. After 3 weeks, osteotomies were necessary and could be successfully applied up to 4 months after the trauma. After 4 months, a successful surgical correction required bone grafts. The objective of treatment of complex orbital injuries includes reestablishment of the orbital shape and volume, since there is a direct relationship between this and enophthalmos (for each 1 ml of increase in volume, there is nearly 0.9mm of increase in enophthalmos), besides enhanced facial esthetics and prevention of complications as restriction of eye movements and visual disturbances.4,7 The mechanisms that induce dystopia and diplopia include increased orbital continent, herniation of orbital soft tissues into the maxillary sinus, atrophy of orbital fat, loss of ligament support and cicatricial contraction.8 The bone loss, loss of ligament support and atrophy of orbital fat lead to retraction of orbital soft tissues7.

In these cases, overcorrection of the orbital defect. is necessary because there is usually some degree of relapse in eyeball projection postoperatively. In the present case, it was decided to use na association of materials (titanium mesh and autogenous graft) aiming to reduce the volume and achieve overcorrection, thus improving the projection of the inferosuperior position of the eyeball. The orbital fractures may be reconstructed with several materials. Due to the anatomical complexity of the orbit, no specific material may be used with ease and success in all situations. Autogenous grafts, human tissue derivatives and titanium mesh are widely used; with the development of biocompatible alloplastic implants, new options (polymers, biological ceramics and composites) were added to the surgeon’s armamentarium.3,6 The material should be selected, in general, according to the defect size, its anatomical location and remaining supporting structure3,4,6,10. Characteristics as stability and fixation, modeling capacity, biological performance, permeability, morbidity to the donor site, radiopacity and cost/benefit may also be discussed in the decision-making process.3 The management of small defects may not be necessary; however, large defects, especially those associated with enophthalmos and dystopia, require sufficiently stiff materials to support the tissues and restore the orbit contour. The autogenous materials are still an excellent option and considered gold standard in reconstructions, due to their rigidity, durability, potential of vascularization and incorporation, with limited immune reaction. The cranial vault bone is the first choice for orbital reconstruction, because of their accessibility, quantity of graft that may be collected, rigidity and capacity to support the orbital tissues, low resorption rate, relative resistance to infection, possibility of modeling and fixation, radiopacity, scar site that may be masked by the hair, and low prevalence of postoperative pain. The morbidity to the donor site remains as the main disadvantage of autogenous grafts.2,4,6 In the present case, the cranial vault presented to be a good option, since the coronal access was performed allowing achievement of a considerable quantity of graft using the same access for fracture exposure. On the post-operative follow-up, the patient did not present any sign or symptom of complication, such as damages to the meninges or intracranial hemorrhage.

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Surgical treatment of zygomatic-orbital fracture sequelae with autogenous graft and alloplastic material

ods with the best results for the different types of fracture, concluded that, with the currently available studies, it was not possible to find sufficient data for the establishment of guidelines, recommending the best reconstruction methods for each type of orbital fracture.

The titanium mesh has been widely used in craniofacial surgery, presenting high biocompatibility, easy modeling and stabilization, and may be used to compensate the volume without the potential for resorption, besides being incorporated by the orbital tissues and allowing osseointegration. The mesh may be a useful implant for reconstruction of extensive anatomical defects, providing adequate support to the orbital content; it is visible on radiographs and produces few artifacts in CT6. He et al.10 compared the use of hydroxyapatite (HA), porous polyethylene (Medpor) and titanium mesh for reconstruction of 64 orbits. A good projection was obtained in 74% (26 out of 35) of cases in which the mesh was used, 83% (10 out of 12) with the combination of mesh and HA or Medpor, 67% (10 out of 12) with Medpor only, and 20% (1 out of 5) with HA. The systematic review conducted by Dubois et al.,5 which aimed to identify the indication of surgery in relation to the defect size and location, besides identifying the reconstruction meth-

CONCLUSION The management of sequelae of zygomatic-orbital fractures with enophthalmos and dystopia is a frequent challenge for the surgeon. The achievement of acceptable results is still difficult, due to the loss of reference points and presence of cicatricial tissue; however, the defects have been reconstructed with autogenous and alloplastic materials, presenting satisfactory outcomes. In the present case, besides the postoperative follow-up for one year and a half, there was improvement in dystopia and enophthalmos, besides eye movement. The patient reported preservation of visual acuity and resolution of diplopia.

References:

1. Kovács AF, Ghahremani M. Minimization of zygomatic complex fracture treatment. Int J Oral Maxillofac Surg. 2001 Oct;30(5):380-3. 2. Carr RM, Mathog RH. Early and delayed repair of orbitozygomatic complex fractures. J Oral Maxillofac Surg. 1997 Mar;55(3):253-8; discussion 258-9. 3. Potter JK, Ellis E. Biomaterials for the orbit. J Oral Maxillofac Surg. 2004 Oct;62(10):1280-97. 4. Ellis E. Orbital trauma. Oral Maxillofacial Surg Clin Noth Am. 2012;24:629-48. 5. Dubois L, Steenen SA, Gooris PJ, Mourits MP, Becking AG. Controversies in orbital reconstruction-I. Defectdriven orbital reconstruction: a systematic review. Int J Oral Maxillofac Surg. 2015 Mar;44(3):308-15.

6. Dubois L, Steenen SA, Gooris PJ, Bos RR, Becking AG. Controversies in orbital reconstruction-III. Biomaterials for orbital reconstruction: a review with clinical recommendations. Int J Oral Maxillofac Surg. 2016 Jan;45(1):41-50. 7. Bell RB, Markiewicz MR. Computer-assisted planning, stereolithographic modeling, and intraoperative navigation for complex orbital reconstruction: a descriptive study in a preliminary cohort. J Oral Maxillofac Surg. 2009 Dec;67(12):2559-70. 8. Tang W, Guo L, Long J, Wang H, Lin Y, Liu L, et al. Individual design and rapid prototyping in reconstruction of orbital wall defects. J Oral Maxillofac Surg. 2010 Mar;68(3):562-70.

9. Hazani R, Yaremchuk MJ. Correction of posttraumatic enophthalmos. Division of Plastic and Reconstructive Surgery. Arch Plast Surg. 2012 Jan; 39(1): 11-7. 10. He D, Li Z, Shi W, Sun Y, Zhu H, Lin M, et al. Orbitozygomatic fractures with enophthalmos: analysis of 64 cases treated late. J Oral Maxillofac Surg. 2012 Mar;70(3):562-76.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):52-8

CaseReport

Alveolar crest expansion for placement of

dental implants: case report

TÁRCIO HIROSHI ISHIMINE SKIBA1,2 | SALOMÃO ALVES BARBOSA3,4 | MARCUS ZORZIMO MOREIRA3,4 | BRUNO COSTA MARTINS DE SÁ1,5 | CLÁUDIO FERREIRA NÓIA6,7

ABSTRACT One of the great challenges of modern dentistry is the installation of dental implants in regions with insufficient bone tissue. In this sense, techniques such as the Split Crest were developed, which consists of a longitudinal osteotomy in the alveolar crest, allowing the expansion of the bone plates and allowing the installation of implants with sufficient surrounding bone. The aim of the present study was to report the clinical case of a patient who sought rehabilitation of the anterosuperior region with dental implants, but whose clinical and radiographic evaluations showed atrophy of the alveolar ridge. The patient was guided and submitted to treatment with alveolar ridge expansion using rotational expanders associated with the immediate placement of the implants in the region corresponding to elements #12 and #21, with subsequent placement of a fixed partial denture with four elements over implants. The alveolar ridge expansion technique proved to be simple and reliable, despite the risks of fracture of the buccal bone plate and excessive vestibularization of the implants Keywords: Dental implants. Osteotomy. Bone development.

Ciodonto, Especialização em Implantodontia (Porto Velho/RO, Brazil). Doctor in Dental Surgery, Universidade Estadual Paulista, Faculdade de Odontologia (Araçatuba/SP, Brazil). 3 Doctor in Dental Surgery, Centro Universitário São Lucas (Porto Velho/RO, Brazil). 4 Specialist in Implantology, Ciodonto (Porto Velho/RO, Brazil). 5 Master’s degree in Implantology, Instituto Latino Americano de Pesquisa e Ensino Odontológico (Curitiba/PR, Brazil). 6 Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba, Disciplina de Cirurgia Bucomaxilofacial (Piracicaba/SP, Brazil). 7 Doctorate degree in Oral and Maxillofacial Surgery, Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba (Piracicaba/SP, Brazil).

How to cite: Skiba THI, Barbosa SA, Moreira MZ, Sá BCM, Nóia CF. Alveolar crest expansion for dental implant insertion: case report. J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):59-63. DOI: https://doi.org/10.14436/2358-2782.4.2.059-063.oar

1 2

Submitted: August 15, 2017 - Revised and accepted: February 12, 2018 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. » Patients displayed in this article previously approved the use of their facial and intraoral photographs. Contact address: Claudio Ferreira Nóia E-mail: claudion@unicamp.br

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):59-63

Alveolar crest expansion for placement of dental implants: case report

INTRODUCTION The rehabilitation of edentulous areas in Implantology may be limited by the lack of bone thickness and height. The bone crests should allow bone structure of at least 1mm on the buccal and lingual regions of implants after placement. Several techniques have been proposed to correct these bone defects, including en bloc bone graft, distraction osteogenesis, sandwich osteotomies, guided bone regeneration, and others. 1-3 However, a new treatment option has been proposed for atrophic alveolar ridges: longitudinal division of the alveolar crest, expanding the bone plates (buccal and palatal), and allowing implant placement with sufficient surrounding bone. The split crest technique (greenstick fracture) consists of a longitudinal osteotomy on the alveolar crest, besides two vertical osteotomies limited or not by the presence of teeth.4-6 This technique presents advantages for the patients, such as implant placement simultaneous to bone graft, less morbidity, lower cost and less invasive procedure.6,7 This paper demonstrates, by a case report and literature review, the technique of alveolar crest expansion, its indications, variations and clinical applications.

The proposed treatment was alveolar ridge expansion with digital expanders (rotary), associated with immediate implant placement at the region corresponding to teeth #12 and #21, for posterior rehabilitation with four-element fixed partial denture on the implants. A horizontal incision was performed on the mucosa and bone crest periosteum, and two releasing incisions were performed on the distal aspect of canines, allowing full flap displacement. In this displacement, especially on the buccal side of the alveolar ridge, the fibromucosa on the palatal aspect was displaced for better visualization of the bone anatomy. After raising the flaps, the horizontal osteotomy was initiated using a bur 701, at a depth of 4mm, extending at a safe distance of 1.5 mm from the canines, and two vertical osteotomies were performed parallel to the canine anatomy, besides one on the midline. The alveolar crest expansion was initiated using a 2.2-mm and then a 2.8 mm digital expander (brand Supremo). Finally, a 2.8-mm bur was used for placement of implants with 3.5 x 11 mm morse cone connection (Cone Morse Cilíndrico, brand Singular Implantes) reaching a torque of 20N. After placement of implants and caps, the gaps were filled with particulate bone (Lumina Bone, brand Critéria), both between bone walls and on the buccal surface, being covered with a collagen membrane (Lumina Coat, brand Critéria). The procedure was completed with simple sutures and fitting of the provisional removable denture (Fig. 2). A four-month period was allowed for osseointegration, before reopening and placement of prosthetic components (microabutment on the implant placed at the region of tooth #12 and miniabutment on tooth #21) with selection of transmucosal height, and an implant-supported four-teeth provisional fixed denture was fabricated (Fig 3 and 4).

CASE REPORT Male patient, aged 32 years, attended the clinics of a specialization course in Implantology for placement of dental implants, with the chief complaint of maladaptation and discomfort of the provisional removable partial denture. Clinical examination revealed lack of support to the upper lip, while on radiographic examination, even though the alveolar ridge height was favorable, the thickness was insufficient for implant placement (Fig 1).

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):59-63

Skiba THI, Barbosa SA, Moreira MZ, Sá BCM, Nóia CF

Figure 1: Clinical and radiographic examination revealed absence of maxillary incisors, and insufficient bone thickness for implant placement.

Figure 2: Clinical sequence of surgical procedure – note the excellent result achieved.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):59-63

Alveolar crest expansion for placement of dental implants: case report

Figure 3: Reopening, placement of abutments, provisionalization and control for gingival contour positioning, while orthodontic treatment is finalized in the mandibular arch.

Figure 4: Computed tomography evidencing implant positioning â&#x20AC;&#x201C; note the volume achieved.

DISCUSSĂ&#x192;O Several surgical procedures have been proposed for reconstruction of regions with bone atrophy, including guided bone regeneration therapy and bone graft. However, these techniques require an approach with multiple surgeries and longer treatment time.5 Economical, less complex and traumatic methods have been designed, allowing immediate implant

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

placement. The alveolar expansion technique uses spacers with increasing diameters that are gently and sequentially introduced in the bone bed, to expand the implant area.2,4,9 The main advantages of this technique include absence of donor site morbidity, due to autogenous bone removal and possibility of immediate implant placement without the need of a second surgical procedure.3,12

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):59-63

Skiba THI, Barbosa SA, Moreira MZ, Sá BCM, Nóia CF

medullary walls should be well-defined; otherwise, the technique shall not allow the expansion of cortical plates. Ideally, a thickness of remaining bone of 3 mm is necessary. These data may be provided by computed tomography, which is a preoperative diagnostic tool that allows three-dimensional visualization, besides informing about bone density.5,10-14 In the present case, this technique allowed alveolar ridge expansion and simultaneous placement of two implants, reducing the quantity of surgeries, compared to the utilization of autogenous bone; and optimized the outcomes.

The lateral condensation of bone enhances the density and improves the primary stability, considered one of the chief reasons for the success of osseointegration. The digital expanders and tactile sensitivity provide more accurate control and generate less heat.4,12-14 For selection of implants to be simultaneously placed, three specific and important characteristics should be considered about the technique of alveolar ridge expansion: the implant shape should be dimensionally similar to the rotary osteotomes (burs) that shape the osteotomy; the abutment-implant interface should minimize the vertical remodeling; and the implant surface should be porous to increase the clot stability. The implant design is critical for this technique, since it avoids fracture of the buccal plate. The alveolar expansion technique is not indicated for all cases. To achieve success, the cortical and

CONCLUDING REMARKS The alveolar ridge expansion technique is a surgical procedure for bone filling (increase) in thickness, is reliable and safe, when well indicated.

References:

1. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long- term efficacy of currently used dental implants: A review and proposed criteria of success. Int J Oral Maxillofac Implants. 1986 Summer;1(1):11-25. 2. Anitua E, Begoña L, Orive G. Controlled ridge expansion. Implant Dent. 2012 June;21(3):163-70. 3. McAllister BS, Haghighat K. Bone augmentation techniques. J Periodontol. 2007 Mar;78(3):377-96. 4. Nishioka RS, Kojima AN. Screw spreading: technical considerations and case report. Int J Periodontics Restorative Dent. 2011 Apr;31(2):141-7. 5. Park JB. Implant installation with simultaneous ridge augmentation. Report of three cases. J Oral Implantol. 2011 Oct;37(5):595-603. 6. Scipioni A, Bruschi GB, Calesini G, Bruschi E, De Martino C. Bone regeneration in the edentulous ridge expansion technique: histologic and ultrastructural study of 20 clinical cases. Int J Periodontics Restorative Dent. 1999 June;19(3):269-77.

7. Scipioni A, Bruschi GB, Calesini, G. The edentulous ridge expansion technique: a five-year study. Int J Periodontics Restorative Dent. 1994 Oct;14(5):451-9. 8. Simion M, Baldoni M, Zaffe D. Jawbone enlargement using immediate implant placement associated with a split-crest technique and guided tissue regeneration. Int J Periodontics Restorative Dent. 1992;12(6):462-73. 9. Tatum OH. The omni implant system. In: Hardin J, editor. Clarke’s Clinical Dentistry. Philadelphia: Mosby; 1984. v. 5. 10. Nóia CF, Sá BCM, Silveira CS, Figueiredo MIO, Garcia SD. Considerações sobre a utilização dos implantes imediatos carregados em região estética relato de caso. Full Dent Sci. 2015;6(23):167-75. 11. Nóia CF, Sá BCM. Preservação do rebordo alveolar com membranas não reabsorvíveis. Full Dent Sci. 2017;8(32):8-14. 12. Nóia CF, Sá BCM. Preservação do rebordo alveolar com implantes imediatos. Full Dent Sci. 2017;8(31):11-6.

13. Lemes HD, Sartori IA, Cardoso LC, Ponzoni D. Behaviour of the buccal crestal bone levels after immediate placement of implants subjected to immediate loading. Int J Oral Maxillofac Surg. 2015;44(3):389-94. 14. Chrcanovic BR, Albrektsson T, Wennerberg A. Dental implants inserted in fresh extraction sockets versus healed sites: a systematic review and meta-analysis. J Dent. 2015 Jan;43(1):16-41.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):59-63

CaseReport

Hemangioma treatment on lip

ABSTRACT Hemangioma is a benign vascular lesion, not uncommon in the clinical practice, and its diagnosis and treatment may be the object of doubt. Non-treatment or inappropriate clinical management can lead to signs of heavy bleeding and postoperative deformities, respectively. The quality of life of the affected individual may be impaired in both cases. Thus, the objective of the present study is to present a clinical case of hemangioma in the lip mucosa treated by chemical sclerotherapy. A 75-year-old male patient, leucoderma, presenting a large lesion on the lower lip mucosa, with nodular, sessile, purplish, painless, slow-growing color. The presence of positive diascopy suggested the diagnosis of hemangioma. Treatment with chemical sclerosis was performed using ethanolamine oleate. Seven days after the first injection (0.05cc of Ethamolim®), ulceration of the lesion was observed without bleeding. After 4 sessions with injections of 0.05cc, total remission of the lesion was obtained. The case was successfully concluded, without bleeding events, acute pain or local deformity. There was no change in the individual quality of life or exposure to unnecessary risks. Keywords: Dentistry. Hemangioma. Sclerotherapy.

Doctor in Dental Surgery, Universidade do Vale do Paraíba (São José dos Campos/SP, Brazil). Universidade do Vale do Paraíba, Departamento de Odontologia, Disciplinas de Cirurgia e Traumatologia Bucomaxilofacial e Estomatologia (São José dos Campos/SP, Brazil). 3 Doctorate degree in Basic Medical Sciences, Universitat Rovira i Virgili (Tarragona, Spain). 4 Doctorate degree and Master’s degree in Biomedical Engineering, Lasertherapy, Universidade do Vale do Paraíba (São José dos Campos/SP, Brazil). 5 Universidade do Vale do Paraíba, Departamento de Odontologia, Disciplina de Endodontia (São José dos Campos/SP, Brazil). 6 Doctorate and Master’s degree in Endodontics, Universidade de São Paulo (São Paulo/ SP, Brazil). 7 Universidade do Vale do Paraíba, Departamento de Odontologia, Disciplina de Estomatologia, Fisiologia e Bioquímica Humana Geral (São José dos Campos/SP, Brazil). 8 Specialist and Doctor in Oral Pathology, Universidade Estadual Paulista Júlio de Mesquita Filho (São José dos Campos/SP, Brazil) 9 Universidade do Vale do Paraíba, Departamento de Odontologia, Disciplina de Estomatologia e Odontologia Legal e Deontologia, Imunologia (São José dos Campos/SP, Brazil). 1

How to cite: Santos JP, Lam NS, Nicolau RA, Frois IM, Deco CP, Canettieri ACV. Hemangioma treatment on lip mucosa by sclerotherapy. J Braz Coll Oral Maxillofac Surg. 2018 MayAug;4(2):64-9. DOI: https://doi.org/10.14436/2358-2782.4.2.064-069.oar

Submitted: August 21, 2017 - Revised and accepted: February 22, 2018 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. » Patients displayed in this article previously approved the use of their facial and intraoral photographs. Contact address: Renata Amadei Nicolau E-mail: renatanicolau@hotmail.com

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):64-9

Santos JP, Lam NS, Nicolau RA, Frois IM, Deco CP, Canettieri ACV

INTRODUCTION The hemangioma is a benign vascular lesion, commonly of red or purple blue color, mainly located on the lip, tongue, buccal mucosa and palate.1,2,3 It is a painless lesion common in childhood and often remains unnoticed by the patient until it causes esthetic discomfort, when patients then seek for treatment.2 The lesion may be lobulated, sessile or pedunculated2 and of variable size,3 and may cause facial asymmetry.3 According to Caliento et al.,2 this lesion has fast evolution and may regress completely after some years. It has been suggested that its development is associated with hormonal changes, infections, traumas and conditions related to pregnancy. Variable techniques are available the diagnosis of hemangioma. Diascopy is a clinical procedure frequently used, consisting in pressing the lesion with a glass to allow compression of congested vessels and consequent disappearance of the vascular lesion for a short time.4,5 Several therapeutic approaches have been described in the literature for cases of hemangioma. One of them is cryotherapy, which acts on the vascular injury by low temperature (-70ºC), using liquid nitrogen until the area freezes, leading to cryonecrosis. This therapy can cause intense discomfort and pain.6 Other high-cost therapies requiring strict technical training are described, such as embolization, radiotherapy, high intensity laser therapy7 (Nd:YAG, 1064nm) or interferon alpha.1 Surgical removal may be indicated, with restriction for lesions not responding to systemic treatment or emergency cases of trauma.8 Among the several therapies available for the treatment of hemangioma, chemical sclerotherapy is the most frequently used, because it presents good clinical result, good esthetics for the patient, minimum risk of bleeding and does not cause surgical trauma.10 One contraindication for drug application is the use in individuals with untreated diabetes, ulcerated lesions and with secondary infection.7 The most commonly indicated sclerosing agent for the treatment of hemangioma is Ethamolin® (monoeth-

anolamine oleate).4,10 The sclerosing agent of choice is injected into the lesion, causing irritation on the vascular wall, making it fibrous and reducing the vessel lumen, consequently decreasing the blood flow.6 Thus, this paper presents a clinical case of hemangioma on the lip mucosa treated by chemical sclerotherapy. CASE REPORT A 75-year-old Caucasoid male patient, retired, presented to the outpatient academic department of Supervised Training in Dentistry complaining of a lower lip injury and informing that the treatment plan presented in his home country (in the European continent) had been excision of the lesion with esthetic involvement. Anamnesis and clinical examination were performed. Intraoral examination revealed a sessile, purple nodular lesion in the lower lip mucosa, close to the lip commissure. Diascopy was performed using a glass slide to compress the lesion, with a positive result, since the lesion almost completely disappeared during compression and after a few moments (Fig 1). The diagnostic hypothesis was vascular lesion, diagnosed as hemangioma. The proposed treatment plan was chemical sclerosis of the lesion using 0.05 g/ml ethanolamine oleate (Ethamolin®). The treatment was conducted as shown in Charts 1 and 2 and illustrated in Figure 2. A 7-day interval was allowed between the first and sixth sessions. A traumatic ulcer appeared, and the lesion regressed in 30%, 7 days after the first injection of sclerosing agent. The pain was relieved by application of steroidal topic anti-inflammatory (triamcinolone acetonide cream). At 14 after the first application, the ulcer was no longer noticed, there was no pain and 50% of the lesion had regressed. On the fifth session, 95% of the lesion had disappeared, without the presence of fibrosis or scars after the sclerosis procedure. Full lesion removal was achieved 28 days after the first injection. The interval between the sixth and seventh sessions was 6 months. After clinical reevaluation and observation of full lesion removal, the patient was discharged.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):64-9

Hemangioma treatment on lip mucosa by sclerotherapy

Figure 1: Clinical aspect of the lesion before (A) and during (B) diascopy.

Session

Procedures performed

Initial evaluation and diascopy of the vascular lesion on the right side.

2nd

1 application – intravascular injection of 0.05cc of Ethamolin® (monoethanolamine oleate 0.05g/ml) into the lesion, using a 1-ml syringe and insulin needle (100 Ul/ml).

2nd application – intravascular injection of 0.05cc of Ethamolin® (monoethanolamine oleate 0.05g/ml) into the lesion, using a 1-ml syringe and insulin needle (100 Ul/ml). Presence of a traumatic ulcer was noticed (approximately 3-mm diameter / lesion reduction of approximately 30%). Prescription of topical triamcinolone (Omcilon® three times a day).

4th

3rd application – intravascular injection of 0.05cc of Ethamolin® (monoethanolamine oleate 0.05g/ml) into the lesion, using a 1-ml syringe and insulin needle (100 Ul/ml). Absence of traumatic ulcer or pain (lesion reduction of approximately 50%).

5th

4th application – intravascular injection of 0.05cc of Ethamolin® (monoethanolamine oleate 0.05g/ml) into the lesion, using a 1-ml syringe and insulin needle (100 Ul/ml). Absence of traumatic ulcer or pain (lesion reduction of approximately 95%).

6th

Evaluation – absence of lesion, with complete regression of the hemangioma. Small residual fibrosis to be re-evaluated on the 7th session.

7th

Re-evaluation – complete absence of signs and symptoms of lip lesion. Patient discharge.

st st

Chart 1: Sequence of hemangioma treatment by sclerotherapy

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):64-9

Santos JP, Lam NS, Nicolau RA, Frois IM, Deco CP, Canettieri ACV

Figure 2: Injection of sclerosing agent (A), presence of traumatic ulcer (B) and final aspect of the lesion (C).

SESSION

REGION

PROCEDURE

1st

Lower lip mucosa

2nd

Intravascular into the lesion

3rd

Intravascular into the lesion

4th

Intravascular into the lesion

5th

Intravascular into the lesion

Initial evaluation (0.05cc) of Ethamolin (monoethanolamine oleate 0.05g/ml) (0.05cc) of Ethamolin (monoethanolamine oleate 0.05g/ml) (0.05cc) of Ethamolin (monoethanolamine oleate 0.05g/ml) (0.05cc) of Ethamolin (monoethanolamine oleate 0.05g/ml)

6th

Lower lip mucosa

7th

Evaluation

Lip mucosa and lower lip Re-evaluation and discharge

QUANTITY OF SCLEROSING AGENT

SITES OF INJECTION

PRESENCE OF ULCER

LESION REDUCTION

01 ml

Yes ≈ 3mm

30%

01 ml

50%

01 ml

95%

No, presence of fibrosis Absent

100% 100%

Chart 2: Comparative table.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):64-9

Hemangioma treatment on lip mucosa by sclerotherapy

DISCUSSION Considering that hemangioma is a common vascular lesion, the diagnosis and adequate therapeutic clinical procedure require detailed description, especially by case studies. Thus, this paper reports a clinical case of hemangioma in the lip mucosa treated by chemical sclerotherapy. The hemangioma is characterized as a lesion with intense red to purple color.1,9 According to Dias et al.8 and Caliento et al.2, the color may vary depending on the lesion depth: the more superficial, the brighter red; and the deeper, the more bluish. The present case exhibited more purple color, i.e. located deep in the mucosa. This information is important, sine it will guide the clinical management, especially at the time of intravascular injection of the sclerosing agent, which was analyzed in this case. The hemangioma may present as a sessile, lobulated or pedunculated mass,2 with variable size.3 Mandú et al.1 reported that, when palpated, this lesion is usually soft and may be circumscribed or diffuse, being asymptomatic in most cases. Since it is a painless lesion, it is often unnoticed by the patient, causing more esthetic than systemic discomfort.2 According to Neville et al.5 and Caliento et al.2, hemangiomas are more common in females, disagreeing with the data presented by Mandú et al.1, who stated that this lesion is more prevalent in males. Its etiology can be either traumatic or genetic, appearing in childhood or in adulthood.3 In the present case report, the lesion was compared with those described in the literature. In addition to the purple aspect of the lesion, it exhibited a sessile nodular appearance, located in the lower lip mucosa,2,3 close to the right inferior lip commissure.

Characteristic of the lesion

Superficial lesions Small superficial lesions Deep and wider lesions

The diagnosis is very important for this type of lesion, because of its vascular origin, with risk of hemorrhage if an inadequate management is selected, even jeopardizing the patient’s life.8 Therefore, biopsy may be contraindicated in some cases with suspect of hemangioma.1 Technical maneuvers are the best approach for a correct diagnosis, including diascopy1, in which the lesion is pressed with a glass, causing compression of vessels and temporary lesion disappearance due to ischemia,1,4 which does not occur in other lesions (e.g. granulomatous). According to Lourenço-Queiroz et al.3, the accomplishment of diascopy in the gingiva and palate poses technical difficulties. Other techniques may aid the diagnosis and description of the lesion, such as Doppler ultrasound, computed tomography and magnetic resonance imaging, which are more commonly used for soft tissue lesions.2,3 According to Caliento et al.2, Neville et al.5 and Mandú et al.1, the treatment of hemangioma should consider the size, location and duration of the lesion, as well as the patient’s age. The treatment may be differentiated into conventional surgery, electrocauterization, high-intensity laser therapy, embolization, cryotherapy and, more commonly, chemical sclerotherapy (Chart 3). However, selection of the technique depends on local factors, professional experience and resources available.1 In the present case, chemical sclerotherapy was indicated using 1 ml of pure ethanolamine oleate (Ethamolin® 0.05g/ml). The injection of ethanolamine oleate required an insulin needle, and the agent was applied at the lesion depth, avoiding necrosis of neighboring tissues, as highlighted by Dias et al.8 and Lourenço-Queiroz et al.3 The quantity of agent used followed the instructions of Dias et al.8, Mandú et al.1 and Lourenço-Queiroz

Risks

Most indicated treatment

No esthetic involvement or in regions that may cause traumas No esthetic involvement or in regions that may cause traumas Surgical management with risk of hemorrhage and postoperative esthetic deformity

Conservative Complete surgical removal of the lesion or by sclerosing agents Chemical sclerosis, cryotherapy, laser therapy, electrocauterization and other approaches (associated or not with the surgical procedure).

Chart 3: Types of indication and risk of treatments for hemangioma. Source: Caliento et al.2, 2014.

J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):64-9

Santos JP, Lam NS, Nicolau RA, Frois IM, Deco CP, Canettieri ACV

agents is contraindicated in patients with untreated diabetes, areas with secondary infection and pregnant women, due to its teratogenic effect. Lemos et al.4 presented other sclerosing agents, such as morrhuate and sodium psyliate, which are no longer used because they triggered allergy, local pain and even anaphylactic shock in individuals sensitive to the drug. As indicated by Lemos et al.4, this paper highlighted the use of sclerotherapy in cases of hemangioma, aiming to eliminate the surgical trauma and reduce the risk of hemorrhage. Complementarily, Palma et al.9 stated that this technique is safe and reliable for the patient, not causing fibrosis or scar on the lesion site.1 CONCLUDING REMARKS It was concluded that treatment with chemical sclerotherapy (ethanolamine oleate) was adequate for the case, considering the diagnosis of vascular lesion by diascopy, lesion location and dimensions. The case was successfully completed, without hemorrhage, acute pain or local deformity. There was no change in quality of life to the individual or exposure to unnecessary risks.

et al.3 Caliento et al.2 suggested the association of the sclerosing agent with an anesthetic with vasoconstrictor, which has the benefit of limiting the agent action only in the desired region, longer duration of peripheral vasoconstriction, and decreased pain after application of the sclerosing agent. The applications in the present case were made at intervals previously mentioned in the literature,1,8 with therapeutic success. In some cases, after application of the sclerosing agent, traumatic ulceration of the lesion may appear.1 The present case exhibited a traumatic ulcer. The pain was relieved by the use of topical steroidal anti-inflammatory. Ethanolamine oleate is the most indicated chemical sclerosing agent, due to total or partial regression of the lesion, if necessary, facilitating the later surgical intervention.1,3,5 The mechanism of action of Ethamolin® is basically an inflammatory response of the vessel, causing fibrosis and obliteration, providing local coagulation of the Hagemman factor. The combined action of Ethamolin® and Hagemman promotes a hemostatic balance, thus avoiding lesion hemorrhage.1,2 According to Caliento et al.2 and Lourenço-Queiroz et al.3, the use of sclerosing

Referencias:

1. Mandú ALC, Lira CRS, Barbosa LM, Silva VCR, Cardoso AJO. Escleroterapia de hemangioma: relato de caso. Rev Cir Traumatol Buco-maxilo-fac. 2013;13(1):71-6. 2. Caliento R, Bim ALC, Marinheiro BH, Moreira Junior JMM, Guedes OA, Barba AM. Tratamento de hemangioma por escleroterapia em aplicação única. Rev Cir Traumatol Buco-maxilo-fac. 2014;14(3):27-32. 3. Lourenço-Queiroz SIM, Assis GM, Silvestre VD, Germano AR, Silva JSP. Tratamento de hemangioma oral com escleroterapia: relato de caso. J Vasc Bras. 2014;13(3):249-53. 4. Lemos PO, Palma HF, Picosse LR, Carubelli CR. Tratamento de hemangioma de lábio inferior com

escleroterapia, revisão de literatura e apresentação de caso. In: 12º Encontro Latino Americano de Iniciação Científica e 8º Encontro Latino Americano de Pós-graduação. São José dos Campos: Universidade do Vale do Paraíba, 2008. p. 1-4. 5. Neville BW, et al. Patologia Oral e Maxilofacial. 3a ed. São Paulo: Saunders Elsevier; 2009. 6. Boraks S. Diagnóstico Bucal. 3a ed. São Paulo: Artes Medicas; 2001. 7. Ribas MO, Laranjeira J, Sousa MH. Hemangioma bucal: escleroterapia com oleato de etanolamina, revisão da literatura e apresentação de caso. Rev Clin Pesq Odontol. 2004;1(2):31-6.

8. Dias GF, França LHG, Fraiz FC, Wambier DS, Kozlowski VA Jr, Céspedes JMA. Hemangioma bucal em crianças. UEPG Ci Saúde. 2013;19(1):21-9. 9. Palma FR, Garcia JAC, Jung R, Garcia RN, Aranha FCS. Escleroterapia de hemangioma oral. Relato de caso. Salusvita. 2016;35(1):85-93. 10. Dall’magro AK, Farenzena KP, Blum D, Vicari T, Pauletti R, Maldaner G. O uso do oleoato de etanolamina na escleroterapia de lesões vasculares da região maxilofacial: revisão de literatura e relatos de casos. Rev Facul Odontol Passo Fundo. 2012;17(1):78-85.

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Book chapter Baker SB. Orthognathic surgery. In: Grabb and Smith’s Plastic Surgery. 6th ed. Baltimore: Lippincott Williams & Wilkins. 2007. Chap. 27, p. 256-67. Book chapter with editor Breedlove GK, Schorfheide AM. Adolescent pregnancy. 2nd ed. Wieczorek RR, editor. White Plains (NY): March of Dimes Education Services; 2001. Dissertation, thesis and monograph Ryckman MS. Three-dimensional assessment of soft tissue changes following maxillomandibular advancement surgery using cone beam computed tomography [Thesis]. Saint Louis: Saint Louis University; 2008. Electronic publication Sant´Ana E. Ortodontia e Cirurgia Ortognática – do planejamento à finalização. Rev Dental Press Ortod Ortop Facial. 2003 maio-jun;8(3):119-29 [Acesso 12 ago 2003]. Disponível em: http://www.dentalpress.com.br/ artigos/pdf/36.pdf.

Paper with up to six authors Espinar-Escalona E, Ruiz-Navarro MB, Barrera-Mora JM, Llamas-Carreras JM, Puigdollers-Pérez A, Ayala-Puente. True vertical validation in facial orthognathic surgery planning. Clin Exp Dent. 2013 Dec 1;5(5):e2318. Paper with more than six authors Pagnoni M, Amodeo G, Fadda MT, Brauner E, Guarino G, Virciglio P, et al. Juvenile idiopathic/rheumatoid arthritis and orthognatic surgery without mandibular osteotomies in the remittent phase. J Craniofac Surg. 2013 Nov;24(6):1940-5.

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