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

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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

4

Editorial: The QUALIS of a scientific journal Gabriela Granja Porto

6

Letter from the President: José Rodrigues Laureano Filho

12

CBCTBMF publishes, for the first time in Brazil, clinical practice guidelines for the specialty

14

Interview Adrian Carlos Bencini

Articles

22

Bichectomy: a critical view

28

Use of helmet and alcohol between motorcyclists with facial trauma in Agreste and Sertão of the state of Pernambuco - Brazil

Beatriz Sobrinho Sangalette, Larissa Vargas Vieira, Juliana de Almeida Nascimento, Vanessa Interlichia Capelari, André Luís Shinohara, Clóvis Marzola, João Lopes Toledo Filho, Gustavo Lopes Toledo, Marcos Mauricio Capelari

Ilky Pollansky Silva e Farias, Rafael de Sousa Carvalho Saboia, Antônio Azoubel Antunes, Evelyne Pessoa Soriano, José Rodrigues Laureano Filho, Gabriela Granja Porto

37

Cleft lip and palate surgeries: Report of 7-year experience in Centrinho Imperatriz/MA (Brazil)

42

Epidemiological survey of face trauma in a public hospital in Vitória/ES (Brazil)

48

Facial asymmetry corrected with orthognathic surgery

53

Brain abscess due to infection after tooth extraction

60

Orbital blowout fracture: case report

65

Pleomorphic adenoma in upper lip: Case report

69

Flexibilization of the Dental Code of Ethics and social media

72

Information for authors

Lêonilson Gaião, Thainá Barroso Pinheiro de Souza, Raurício Vital Mendes, Patrícia Figueiredo de Macêdo

Gabriela Mayrink, Natália Gonçalves Amaral Avila, Jessika Barcelos Belonia

João Carlos Birnfeld Wagner, Mauricio Roth Volkweis, Rodrigo Andrighetti Zamboni, Tatiana Wannmacher Lepper, Luciana Zaffari, João Ricardo Koch Brandalise

Isabela Potratz Auler, Luccas Lavareze, Ana Luiza Leal, Ramon Gavassoni, Vinicius Antunes, Martha Alayde Alcantara Salim

Silvia Provasi, Douglas Baitelo Marinho, Stephanie Anasenko Correa Borges, Walter Paulesini Junior, Gabriel Baitelo Marinho

Allancardi dos Santos Siqueira, Jiordanne Araújo Diniz, Luiz Henrique Soares Torres, Ana Cláudia Amorim Gomes, Emanuel Dias de Oliveira e Silva

Gustavo Barbalho Guedes Emiliano

Editorial

The QUALIS of a scientific journal There are many doubts, especially for those who are starting an academic career, about what QUALIS means, its purpose or how it is done.

QUALIS is a Brazilian system for evaluation of journals maintained by CAPES (Coordination for the Improvement of Higher Education Personnel). It is used in the evaluation of MSc and PhD programs of the country and is conducted yearly by a committee defined by this institution linked to the Brazilian Ministry of Education.

This evaluation considers several factors, including the circulating number of journal copies, the number of databases in which it is indexed, its impact factor, etc. The strata are classified into 8 levels: A1 (the highest), A2, B1, B2, B3, B4, B5 and C (zero weight). It is worth mentioning that this evaluation is indirect; for this reason, one journal may have a higher QUALIS in one field and lower in another. To benefit the Brazilian journals, even with low impact factor, this committee applies an equivalence factor to some of these journals. For example, a Brazilian journal that has impact factor to be classified as B1 can benefit from this equivalence factor and become A2.

How to cite: Porto GG. The QUALIS of a scientific journal. J Braz Coll Oral Maxillofac Surg.

2018 Sept-Dec;4(3):4-5. DOI: https://doi.org/10.14436/2358-2782.4.3.004-005.edt

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Editorial

This evaluation process has been criticized, especially because one of the criteria is the impact factor published only by JCR (Journal Citation Reports). Despite the disagreement about how this evaluation is performed, it should be remembered that it is the only in force. Therefore, we have to adapt to it, maintaining and stimulating this cycle. For this, it is necessary to promote the citation of papers written by Brazilian authors (an issue discussed in the previous editorial), as well as to intensify the efforts of editors, reviewers and authors to increase the quality of papers produced. At the same time, it is necessary to put pressure on governmental funding agencies, both at the federal level (CAPES and CNPq) and at the state level, so that the financing of the entire process, from scientific research to publication of results in papers, is assured.

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

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

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J Braz Coll Oral Maxillofac Surg. 2018 Sept-Dec;4(3):4-5

Letter from the President

How to cite: Laureano Filho JR. Chairman’s Letter. J Braz Coll Oral Maxillofac Surg. 2018 Sept-Dec;4(3):6-7.

DOI: https://doi.org/10.14436/2358-2782.4.3.006-007.crt

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

Dear Colleagues, The Brazilian society has been going through a debugging process, in which the ethics and transparency have been placed in first priority in all segments. It is not possible to move on without these principles. Therefore, in a work that lasted three boards and is now concluded, the Brazilian College of Oral and Maxillofacial Surgery and Traumatology (CBCTBMF) publishes the first Parameters and Recommendations for Oral and Maxillofacial Procedures. The document shall serve as reference for professionals, clinics, industry, health insurance companies, hospitals and the entire health sector.

In this issue of the Journal, the colleagues may know a little more about this work, which is also published on the website of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology, on the link: www.bucomaxilo.org.br/upfiles/downloads/diretrizes-e-recomendacoes-para-procedimentos-bmf.pdf Together with the publication, the CBCTBMF initiated a work with our legal advisors to assess the feasibility of creating an Ethics Committee inside the institution and, based on this, preparing a Code of Conduct. We are open to receive comments and suggestions from our members, so that we can evolve on this issue. The ideas may be sent to the e-mail revisao.parametros@ bucomaxilo.org.br.

Following the publication of the Parameters and Recommendations for Oral and Maxillofacial Procedures, we will organize meetings with health insurance companies to discuss the main problems faced by the surgeon in this bilateral relationship. The document can guide decisions and serve as reference for one of the aspects that generate most conflicts, namely the use of Ortheses, Prostheses and Special Materials (OPME). However, we still need to advance. We are also creating a committee to conduct a study about the recommendations related to the codes to be used in agreements.

The relationship with health insurance companies is still one of the main problems faced by the specialty. We established a free legal advisory board, especially to assist the members. Since August, our members have another pioneering service in CBCTBMF, through which, accessing a link named Ouvidoria (Ombudsman Office), it will be possible to report abuses or conflicts of the insurance companies or problems related to the professional practice in any field of activity of the maxillofacial surgeon. Access is only allowed to regular members. After evaluation of the complaint, if evidence is available, the member will receive a legal report that may be used as a legal basis for their need. Unfortunately, our current budget does not allow individual resolution of all requests, yet we shall identify collective issues that should have proper legal attention of the College.

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Letter from the President

However, to assure the professional quality we wish, one fundamental aspect for the future of the specialty is the strengthening of academic training in oral and maxillofacial surgery. The CBCTBMF understands that only the residency modality may assure a more solid training compatible with the current scope of the specialty. We insist on the maintenance of discussions with the Federal Dental Council and the Ministry of Education, to assure normalization of the specialty, yet with supervision.

We have also updated the recording of residencies and specialization courses in residency modality, to know the national reality, aiming to select programs whose characteristics are compatible with the achievements of the working group on the programs in the previous board. The accredited residencies, which will be announced soon, will have the opportunity to send their residents to national and international experiences, and the College website will allow diffusion of their events, selections, among other needs. We also intend to value the preceptors of these residencies by inviting them to give lectures in official CBCTBMF events and to participate in commissions designated by the organization.

Within the aspect of scientific update, we started the continuing education on our homepage, in which the member may already attend classes that are available monthly. Come and check it out! Leave your comments and suggestions!

Participate in CBCTBMF events, value the specialty and the association; its growth will have direct impact on your work. Similarly, the journal of the CBCTBMF is always open to the publication of scientific papers, especially researches, that can place it at an even higher level.

Searching for excellence in the training of oral and maxillofacial surgeons, protecting the professional practice and valuing the regular members are some goals of this board, which may only be implemented because previous boards have left their contributions, which now allow us to make well-founded decisions and conduct a more predictable strategic planning.

We are aware of our responsibility and are committed to search for all alternatives for resolutions, always thinking about the benefit of the specialty.

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

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J Braz Coll Oral Maxillofac Surg. 2018 Sept-Dec;4(3):6-7

CBCTBMF

The Brazilian College of Oral and Maxillofacial Surgery and Traumatology publishes, for the first time in Brazil, clinical practice guidelines for the specialty and their rational use. The group of specialists that prepared it used a simple language in introductory pages, so that any citizen can consult it, following the recommendations of the World Health Organization.

The publication has 50 pages and, besides the concept of OPMEs, it presents the methodology of how it was prepared, by Clinical Questions and Evidence-Based Medicine. The indications are directed to the main procedures of the specialty, such as dentoalveolar surgeries, orthognathic deformities, facial bones fractures face, temporomandibular joint dysfunctions, tumors or cysts and bone reconstructions.

The Parameters and Recommendations for Oral and Maxillofacial Procedures will also support the decision making in consulting, auditing, second and third opinions and expert reports. All these segments needed a document that impartially and exclusively aimed at the most resolutive treatment technique, the patient benefit, and the use of prostheses and ortheses rationally and ethically indicated and scientifically accepted.

The document also proposes how the several guidelines should be cited in public and expert texts, in the scientific environment and comments on the specialty, establishing a code for each guideline. It starts by

The Brazilian College of Oral and Maxillofacial Surgery and Traumatology has just completed the first document Parameters and Recommendations for Oral and Maxillofacial Procedures. The publication had collaboration of more than ten of the most respected specialists of the country and, based on the latest national and international scientific evidence, defines the basic parameters for the application of Orthoses, Prostheses and Special Materials (OPME).

In this work, the Brazilian College of Oral and Maxillofacial Surgery and Traumatology publishes a document that will be a reference for professionals, clinics, industry, health insurance companies, hospitals and all players of the sector.

The document has high scientific rigor and will guide the health professional in the clinical decision-making process. The Parameters and Recommendations for Oral and Maxillofacial Procedures will also contribute to improve the health of patients and enhance the knowledge of professionals in the field, besides being a reference for referrals involving the dental specialty of Oral and Maxillofacial Surgery and Traumatology in the rational use of OPMEs. Besides defining the parameters for a better understanding, the document presents concepts of what are ortheses, prostheses and special materials (OPME),

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CBCTBMF

the ALPHA Recommendation – code α. 01.01, which proposes the basic ethical sense, conceptual beginning, reminding that, even though there are parameters and technical suggestions for the professional practice, the fundamental beginning of everything, the structural basis of relationships, is based on the respect to the patient, with a specialist full of character and integrity of principles, in the construction of the best technical results, based on the current scientific knowledge and available in the Brazilian reality.

Regular revisions and updates to the document are planned. The suggestions, contributions and criticisms of specialists should be sent to the Brazilian College of Oral and Maxillofacial Surgery and Traumatology, which will provide the referrals, discussions and considerations that may be included or not in future revisions. The email for referrals is revisao.parametros@ bucomaxilo.org.br.

The full text of Parameters and Recommendations for Oral and Maxillofacial Procedures is available on the website of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology, at www.bucomaxilo.org.br/upfiles/downloads/diretrizes-e-recomendacoes-para-procedimentos-bmf.pdf.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Interview

Interview with Adrian Carlos Bencini

» PhD in Dentistry - Gold Medal UNLP. » Specialist in Oral and Maxillofacial Surgery and Traumatology. » University Specialist in Oral Implantology - USC. » University Specialist in Orthognathic Surgery - UEMC. » President of the Latin American Association of Oral and Maxillofacial Surgery and Traumatology (ALACIBU). » Head of Oral and Maxillofacial Surgery Department of Interzonal Hospital San Juan de Dios in La Plata. » Professor of Surgery B (Oral and Maxillofacial), Dental School of UNLP. » Professor of Oral and Maxillofacial Surgery II, Dental School of UCALP. » Full Professor of Orthognathic Surgery, Dental School of UNLP. » Director of G.IN.I (Group of Research in Implantology ). » Former president of the Argentinian Society of Oral and Maxillofacial Surgery and Traumatology (SACyTBMF - AOA). » Member of IAOMS, ALACIBU, SLACATM, ICOI, IOCIM, SIAOyCBMF , SECOM, SECIB, SACyTBMF, SOLP, AOA.

How to cite: Bencini AC, Porto GG. Interview with Adrian Carlos Bencini. J Braz Coll Oral Maxillofac Surg.

2018 Sept-Dec;4(3):14-21.

DOI: https://doi.org/10.14436/2358-2782.4.3.014-021.oar Submitted: September 03, 2018 - Revised and accepted: October 10, 2018

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Bencini AC, Porto GG

How do you see the integration of Latin American countries for the growth of Oral and Maxillofacial specialty ?

Although Oral and Maxillofacial Surgery and Traumatology has different names across Latin America, including Cirurgia Bucomaxilofacial, Cirurgia Oral e Maxilofacial, Cirurgia Bucal e Maxilofacial, Cirurgia Bucomaxilofacial, Cirurgia e Traumatologia Bucomaxilofacial or Cirurgia e Traumatologia Oral Maxilofacial, we have achieved that all societies or associations of member countries of the Latin American Association of Oral and Maxillofacial Surgery and Traumatology (ALACIBU) define it as the dental specialty that deals with the diagnosis, treatment (medical and surgical) and prevention of disease, trauma and malformations (congenital or acquired), in both functional and esthetic aspects, of soft and hard tissues of the oral and maxillofacial region, as well as organs that integrate its function.

This was the first big step.

Conversely, we started to work on several local and regional projects, in a combined and coordinated manner, with all ALACIBU member countries.

Even in the particular case of Brazil, which for years was represented only by SOBRACIBU, as of this year, and thanks to the management of Dr. José Rodrigues Laureano Filho and his board of directors, the Brazilian College of Oral and Maxillofacial Surgery and Traumatology has joined this important working group. This fact marks a “before and after” in the history of ALACIBU, since, with the inclusion of the College, for the first time we managed to gather all specialized societies of Latin America in the Association.

That is why I dare to say that ALACIBU is achieving a real integration of all specialists of the region, as well as institutions that represent them in each country. This joint, organized and coordinated task of ALACIBU, strengthens the actions carried out in each country, aiming at a better training of specialists and therefore the growth of the specialty in terms of quantity and quality of trained human resources. This formation of young professionals is fostered not only by the knowledge they receive in their homes or universities, but also the knowledge incorporated in each of the many scientific events (congresses, conferences and symposia) held by ALACIBU and each society of ALACIBU members.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Next year, for example, two of the most important events of the specialty will be held in Latin America. From May 21 to 24, in Rio de Janeiro (Brazil), there will be the 24th ICOMS 2019, the world congress of the specialty, gathering leading professionals from around the world. The XXI CIALACIBU 2019, the Latin American congress of the specialty, will be held in Cancún (Mexico) in December 1 to 3, which also has a scientific and social program of excellence.

You have prominent work in alveolar ridge reconstructions. How do you manage the treatment of atrophic alveolar ridges? What is the key to treatment success?

The key to the successful treatment of atrophic alveolar ridges is based on the fact that everything must be considered in terms of implant-assisted prosthetic rehabilitation and following pre-established guidelines and protocols.

The alveolar ridge reconstruction for implant placement is influenced by several factors. One of the main aspects is the type of rehabilitation (prosthesis) that we will offer to the patient, which in turn depends on the esthetic and functional demands.

Depending on the prosthesis we plan to place, we determine the characteristics and position of implants to be placed. Once this is determined, we should assess other important factors, such as type and volume of the defect that will be reconstructed and the its location in the arch.

Always considering the fixed implant-supported prosthesis as gold standard, we will divide the therapeutic options for the mandible and maxilla depending on the defect to be regenerated, either in the anterior or posterior region, or if there is lack of width, height or tissue in both dimensions.

Since your question is directed to the reconstruction of alveolar ridges, we will exclude from this analysis the options of maxillae removed due to different pathologies and requiring graft reconstruction not only of the ridge, but also of the bone base.

It is important to note that there is no conceivable process for the reconstruction of alveolar ridges without the use of membranes. Collagen membranes, which may be resorbable or non-resorbable, are fundamental. Similarly, in all our patients, I currently use the protocol published by Joseph Choukroun with the use of platelet-rich fibrin membranes (APRF + IPRF) associated with bone grafts (Fig. 1).

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Interview

Figure 1: Utilization of platelet-rich fibrin membranes associated with bone grafts.

yet without enough height for placement of implants with 11.5 or 13 mm length, we can use an alveolar distraction technique, sandwich technique (with interposition of bone tissue) or block autologous graft (onlay graft), the latter option with worse prognosis than the previous alternatives.

When the area to be reconstructed requires simultaneous increase in width and height, we use block autologous grafts. These may be achieved from intraoral donor areas (chin), for small volume defects; or, for defects with larger volume, extraoral donor sites (usually iliac crest graft). Both cases are associated with heterologous or synthetic particle grafts with granulometry varying from 250 to 1000 microns and, as mentioned, the use of fibrin membranes rich in growth factors.

In the posterior maxillary region, besides all these options, it is possible to perform a technique for maxillary sinus lift, if the cause of the lack of bone height is excessive pneumatization of the maxillary sinus (Fig 4).

In the maxilla (anterior or posterior region) with a transverse defect (insufficient bucco-palatal width) yet high enough to accommodate an implant of 11.5 or 13 mm in length, there may be two treatment options: with an initial bone of 4 to 5 mm, we may perform a bone expansion technique (split crest). We initiate the demarcation of crest osteotomy using inserts (saws) of the electric scalpel, with Zekryas drills or chisels. Then, we can expand the bone using threaded or thrust digital expanders, osteotomes or chisels, so that, after expansion is achieved, the implants can be placed, and bone regeneration performed by the use of a particulate graft and covering membranes (Fig 2).

However, if the bone width is smaller than 4 mm, a block bone graft – of veneer type, for buccal onlay – should be performed, usually removed from the chin and supplemented with particulate graft and membrane. Then, in a second surgical stage, the implants are placed in the ideal positions, according to the prosthetic planning (Fig 3).

On the other hand, if there is enough bone width,

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Bencini AC, Porto GG

Figure 2: Bone expansion using the split crest technique.

Figure 3: Onlay buccal bone graft, veneer type.

Figure 4: Maxillary sinus lift.

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Interview

Similarly, for the anterior and posterior mandibular region, in the presence of transverse defects (insufficient width), it is possible to perform the split crest technique (with a residual alveolar ridge with 4 to 5 mm width) or buccal onlay graft (for ridges smaller than 4 mm wide ). In defects in height (yet with sufficient width), we can choose a technique of alveolar distraction, a sandwich technique or autogenous block graft.

It is important to note that, in some cases, in the posterior mandibular region, when there is a defect in bone height , there is the option of lateralization (or transposition) of the inferior alveolar nerve to provide apical anchorage implants placed simultaneously to the vertical alveolar ridge reconstruction.

It should be emphasized that this sinus lift technique is a procedure that increases the availability in bone height, yet if the patient simultaneously presents resorption of the alveolar crest in width or height, this defect must be reconstructed together with maxillary sinus lift. We usually perform this volumetric reconstruction simultaneously with maxillary sinus lift, with a block graft of the chin or external oblique line (Fig. 5). Otherwise, if reconstruction is not performed and only the maxillary sinus lift is done, to achieve optimal implant anchorage, the implant should be placed apically to the ideal position and the patient will eventually use excessively long crowns (to compensate for the vertical defect), away from the desired rehabilitation.

Figure 5: Maxillary sinus lift and block graft removed from the external oblique line.

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Bencini AC, Porto GG

Finally, more specifically, how do you manage the alveolar ridge after serial extractions?

After multiple or serial extractions, when there is no significant vertical bone loss, it is usual to try to place simultaneous (immediate) implants at the site of extraction and perform the reconstruction of defects in implant surrounding tissues using heterologous or synthetic grafts associated with APRF + IPRF and the use of collagen membranes (Fig. 6). In some cases, in the same procedure, we even place a connective tissue graft from the palate.

However, when the extracted teeth exhibit marked bone loss, usually due to a preexisting severe periodontal disease, we can choose two therapeutic options. One of these is to regenerate (grafting) the

alveolar ridges (post-extraction sockets); after vertical healing, we can reconstruct the defect by alveolar distraction, sandwich technique or onlay block graft over the ridge. The other alternative is to perform a sandwich technique in the same procedure, simultaneously with the extractions (Figs 7 to 9).

To perform this last therapeutic option, removal should be performed without flaps, preserving the integrity of the interdental papilla, then cleaning the sockets and performing 5-mm buccal incision below the union between free and attached gingiva.

The mucoperiosteal flap is raised towards the bone base, preserving the integrity and insertion of buccal and lingual (or palatal) mucoperiosteal tissue of the edentulous sockets, as well as the papillae. This

Figure 6: Placement of immediate implants after multiple extraction, with reconstruction of surrounding tissues with heterologous particulate graft with APRF + IPRF and membranes.

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Interview

Figure 7: Preoperative aspect for planning of serial extractions.

Figure 8: Sandwich technique after extractions.

Figure 9: Transoperative aspect of placement of bone graft + membranes.

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Bencini AC, Porto GG

Once the osteotomies have been completed, the bone block (disc) is moved to the ridge and secured with a plate and titanium screws. The gap is filled with particulate bone graft, always placing a membrane to isolate the palatal or lingual periosteum of the graft and another on the buccal side, to make the buccal periosteum proper.

allows the distraction disk (bone block with at least 4 mm in height), marked by osteotomies, to maintain the insertion of tissues around its contour.

Osteotomy is performed at the buccal cortex region, ideally with an electric scalpel, with saw or chisel and hammer. Then, osteotomy of the medullary bone and lingual or palatal bone plate is performed with chisel and hammer, to avoid morbidity of the bone tissue.

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

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

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OriginalArticle

Bichectomy:

a critical view BEATRIZ SOBRINHO SANGALETTE1 | LARISSA VARGAS VIEIRA1 | JULIANA DE ALMEIDA NASCIMENTO2,3 | VANESSA INTERLICHIA CAPELARI4,5 | ANDRÉ LUÍS SHINOHARA6,7 | CLÓVIS MARZOLA8,9 | JOÃO LOPES TOLEDO FILHO6,10 | GUSTAVO LOPES TOLEDO1,2,11 | MARCOS MAURICIO CAPELARI12,13

ABSTRACT Introduction: Recently, a surgical procedure has been causing controversy as to its applicability, its prognosis and which professional is able to perform it. This is the bichectomy, a technique that aims to remove the adipose body from the cheek, which seems to be feasible for aesthetic and functional purposes, provided that its main indication is to meet the patients first need, either purely cosmetic, with some caveats, or related to chewing, pain and psychosomatic discomfort. Another question is related to the future aesthetic-functional satisfaction of the individual, given the unknown long-term consequences. Questions arise about which professional could perform the procedure: plastic surgeon or buco-maxillofacial surgeon, since even with exhaustive discussions in the legal area, there are still gaps and biases in interpretation regarding the competence of each one to do so. Method: In order to elucidate these questions, a review of literature based on legislation and relevant bibliographies was carried out. Conclusions: The technique is applicable and with legal protection both by the physician and by the dental surgeon. However, regarding its legal aspect, certain issues should be considered in terms of their feasibility and long-term prognosis.

Keywords: Facial asymmetry. Legislation, dental. Lipectomy.

Universidade de Marília, Faculdade de Odontologia (Marília/SP, Brazil).

Universidade de São Paulo, Faculdade de Odontologia de Bauru (Bauru/SP, Brazil).

Specialist in Tax and Civil Law, Universidade de São Paulo, Faculdade de Odontologia de Bauru (Bauru/SP, Brazil).

4 Private practice (Santa Cruz do Rio Pardo/SP, Brazil).

5 Specialist in Orthodontics, Sociedade de Promoção Social do Fissurado Lábio Palatal, Hospital de Reabilitação de Anomalias Craniofaciais (Bauru/SP, Brazil).

6 Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Anatomia (Bauru/SP, Brazil).

7 PhD in Sciences, concentration in Anatomy, Universidade de São Paulo, Faculdade de Odontologia de Bauru (Bauru/SP, Brazil).

8 Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Cirurgia (Bauru/SP, Brazil).

9 PhD in Dentistry, Universidade Estadual Paulista Júlio de Mesquita Filho (Araraquara/SP, Brasil) - In memoriam.

10 PhD in Morphofunctional Sciences, Universidade de São Paulo, Faculdade de Odontologia de Bauru (Bauru/SP, Brazil).

11 Postdoctoral in Sciences, Universidade de São Paulo, Faculdade de Odontologia de Bauru (Bauru/SP, Brazil).

12 Faculdade de Odontologia da Associação Paulista dos Cirurgiões-Dentistas, (Bauru/SP, Brazil).

13 PhD and MSc in Public Health, Universidade de São Paulo, Faculdade de Odontologia de Bauru (Bauru/SP, Brazil).

1 2 3

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

How to cite: Sobrinho Sangalette B, Vieira LV, Nascimento JA, Capelari VI, Shinohara AL, Marzola C, et al. Bichectomy: a critical view. J Braz Coll Oral Maxillofac Surg. 2018 Sept-Dec;4(3):22-7.

DOI: http://dx.doi.org/10.14436/2358-2782.4.3.022-027.oar

Submitted: January 09, 2018 - Revised and accepted: April 18, 2018

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

Contact address: Beatriz Sobrinho Sangalette Av. Waldemar Kireff, 185, apt. 22, Jardim Araxá – Marília/SP CEP: 17.5250-20 – E-mail: beatrizsangalett@gmail.com

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Sobrinho Sangalette B, Vieira LV, Nascimento JA, Capelari VI, Shinohara AL, Marzola C, Toledo Filho JL, Toledo GL, Capelari MM

INTRODUCTION Buccal fat pad removal is a procedure that has recently increased among esthetic-functional surgical techniques for the face and masticatory system, although it concomitantly raises questions among academics and dental and medical professionals. The technique aims at removing the buccal fat pad from the cheek, which assigns its volume, in order to thin the face, when performed for purely esthetic purpose.1 The technique goes beyond, presenting a functional purpose especially in the reduction of chronic masticatory trauma in the oral mucosa, which may result from such anatomical structures with large volume, is harmful to the oral tissues and can induce several pathological lesions, including neoplasms. Thus, its indication does not apply exclusively for esthetic reasons, being considered an esthetic-functional procedure of the masticatory system.2,3,4 Several applications are converted into functional benefits to the patients, such as use of this fat as autogenous graft in defect areas requiring filling, e.g. for the reconstruction of ankylosed temporomandibular joint (TMJ), with interposition of the buccal fat pad;3 closure of oro-sinusal communications, filling of orbital cavities in blowout fractures, among others.5,6,7 The surgical procedure is relatively easy, although it presents risks of transoperative accidents and postoperative complications with serious consequences and difficult resolution by professionals without proper preparation, or even by those who have recognized experience and technical training in the subject.1,4.5 Such circumstances occur due to the several anatomical structures topographically found in the region, such as the buccal branches of the facial nerve and the parotid duct.8 Concerning the prognosis, there seems to be a huge gap between the indication and feasibility of the technique for certain circumstances, evidencing a lack of scientific production that must be solved, to definitively support the applicability of this surgical modality.

Regarding the qualification for this procedure, concerning which professional would be apt, it is certain that the fundamental basis of the “Professional Exercise” is based on the Constitution, which refers to the ordinary laws that regulate the professions, their regulations, and the guidelines of professional coun-

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

cils, their normalization, following the hierarchy and subordination of the Norms of Right, as proposed by Hans Kelsen, represented by a pyramid with the Federal Constitution in its vertex; ordinary laws in the middle; and the regulations of public and private autarchies at a lower level of the pyramid base.9,10 This paper presents a critical reflection on the applicability and feasibility of buccal fat pad removal, looking at the prognosis in the long term, discussing legal aspects of its application and which professional is able to perform it, questions that justify its importance.

METHODS An integrative review of the national and international literature was conducted on the databases Bireme, PubMed, SciELO and LILACS, using the following inclusion and exclusion criteria: » Inclusion criteria: papers citing surgery of the buccal fat pad. » Exclusion criteria: papers outside this subject.

The national laws and related articles were also surveyed, to allow discussion and conclusion.

RESULTS The literature review retrieved one complete article and one monograph that directly addressed the buccal fat pad removal. In addition, concerning the anatomy of the buccal fat pad and underlying region, the review found one article and a brief description in one book. For innervation, two papers addressed the anatomy of the region and potential risks of injury to the facial nerve during esthetic treatments. Regarding the functional applications of the buccal fat pad, four articles were used. To complement this, we searched for literature describing the level of knowledge of professionals in the area about the limits of their specialty, and three papers were found in the research.

Concerning the guidelines, 2 articles and 1 book were included – the latter citing the Pyramid of Kelsen. Additionally, 4 Resolutions of the Federal and Regional Dental Councils, besides 3 Laws, being one reporting the attributions of dental professionals and the other of medical professionals. The Federal Constitution of Brazil and the International Classification of Diseases were also used.

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Bichectomy: a critical view

DISCUSSION This surgical procedure is applied for removal of the buccal fat pad or Bichat’s ball, discovered in 1802 by the anatomist and physiologist Marie François Xavier Bichat1. However, the Brazilian Portuguese name for this surgery, bichectomia, sounds like “Bichat’s Ball Removal”, and the utilization of eponyms was terminated in 1955 at the Paris Congress.

Therefore, based on the current esthetic-functional approach, it seems more appropriate to use the term “Facial Lipectomy”, since the procedure comprises removal of fat tissue from the buccal region, influencing the facial harmony.

This procedure rapidly entered the field of esthetic surgery, since the removal of this fat improves the facial harmony,1 and it may only be removed by surgical intervention, since it is not consumed even under extreme diet.11 However, this approach differs from important functional concepts, such as the mechanical function played by such anatomical structure, serving as a cushion between the masseter and buccinator muscles, minimizing the friction between them.8 It should be considered that the gradual loss of facial fat, due to aging, can lead to the future indication of facial filling to recover the youthful appearance, being a questionable esthetic technique, considering the possible functional problems and also the need for other future procedures to maintain the facial esthetics harmony over the years.4 Simultaneously, there are reasons for its maintenance; but, when necessary, the buccal fat pad can be used, for example, for TMJ reconstruction,3 rehabilitation of patients with clefts, closure of oro-sinusal communications, and others.4,6,7 The fundamental need of this fat may be inferred, because when it is absent, some surgical procedures become unviable or difficult to solve.3,6 It is questioned: should this procedure be conducted for exclusively esthetic purposes?

Considering the esthetic-functional aspects, the concept of “Health” should not be overlooked. The World Health Organization defines health not as an absence of disease, but as “the complete physical and psychosocial well-being of the individual”. The analysis of this concept highlights the thin limit between function and esthetics, and to the reflection: to which extent do significant esthetic changes influence a person’s psychosocial behavior? What are the

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

psychosomatic consequences? Is it possible to stratify the physical and the mental? Mental and behavioral disorders, group “F” of ICD-10 (International Classification of Diseases), are not diseases12? And if they are, does their treatment lack a functional basis? The answer to this last question can be no other than a definite “yes”.

Procedures performed in this region without adequate morphophysiological and technical-surgical knowledge can have several consequences, because the buccal fat pad, composed of buccal, pterygoid, deep temporal and pterygomaxillary processes, is located in a region with two branches of the trigeminal nerve: the mandibular and maxillary branches, besides deep branches of the maxillary, mandibular, superficial temporal arteries and branches of the facial artery; any harm to this region can cause irreversible damage.4 Possible damages to the facial nerve are cited, since branches of its motor portion pass through the region of the masseter and buccinator muscles, giving motricity to masticatory muscles, as well as facial expression.8 Consequently, traumatic lesions in this region can cause total or partial paralysis of the face, with not only functional but also esthetic and psychological involvement, due to obvious esthetic damages, such as loss of muscle tone, altered speech (particularly in lip consonants), absence of lip seal, saliva escape, loss of buccinator muscle function in mastication, among other sequelae.8 The technique performed for esthetic-functional purpose includes partial fat removal, usually removing the desired amount, sometimes only on one side of the face, not affecting the facial harmony and esthetics, with predictable prognosis, which is often favorable, notwithstanding it may be used as an adjunct and complementary procedure to the correction of greater esthetic and functional disorders.3,4 Concerning the “prognosis” in the long term, when the objective is purely esthetic, there is no literature and no specific standard that can be followed and expected, currently being a non-elucidated question. In an era when concepts and fundamentals are endorsed by the “evidence-based science”, it is essential to encourage scientific production to prove the effectiveness of the technique, indicating a favorable prognosis in the short, medium and long term.

Considering the legal understanding that permeates the “Professional Exercise”, it is a guaranteed

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Sobrinho Sangalette B, Vieira LV, Nascimento JA, Capelari VI, Shinohara AL, Marzola C, Toledo Filho JL, Toledo GL, Capelari MM

The Dental Code of Ethics, regulated by Resolution CFO 118/2012, in Art. 5, Chapter II, assigns the right to “diagnose, plan and perform treatments, with freedom of belief, within the limits of their attributions, observing the current state of science and professional dignity”.18 Once again, this guideline is vague, since it allows the accomplishment of dental procedures, provided they do not go beyond the limits of attribution, which tacitly refers to the same issue pointed out in Law: the need for concepts and knowledge acquired in professional academic training.

To meet the determination of the limits of action, the CFO has issued Resolution 63/2005, which defines one of its specialties, among others: “Art. 41- The Oral and Maxillofacial Surgery and Traumatology is the specialty that aims at the diagnosis and surgical and coadjutant treatment of diseases, traumas, congenital and acquired lesions and anomalies of the masticatory system and related structures, and associated craniofacial structures.”; indicating an anatomical limit and restricting a surgical modality: “Art. 43 – Dentists are not allowed to use the infrahyoid cervical access, since it goes beyond their area of ​​action, as well as the practice of esthetic surgery, except for esthetic-functional surgeries of the masticatory system.” Despite this restriction, ironically, it considers such guideline in Art. 73, that the dentist works on “face harmonization in the maxillomandibular complex”,19 although this norm is corroborated

by Resolution CFO 100/2010: “Art. 2 – It is exclusive competence of medical professionals to perform the treatment of malignancies, neoplasms of major salivary glands (parotid, submandibular and sublingual), infrahyoid cervical access, as well as the practice of esthetic surgery, except for functional-esthetic surgeries of the masticatory system, which are competence of dental professionals”.2 Both regulations establish a well-defined anatomical limit of restriction of action of dentists, which obviously does not include the location of the buccal fat pad, nor does it preclude the accomplishment of buccal fat pad removal by the trained dentist. However, it restricts the accomplishment of esthetic surgeries, except for the esthetic-functional surgeries of the masticatory system. This aspect requires an interpretation of what would be the “esthetic-functional”. What is functional is not discussed; it is up to the dentist. However, the “esthetic” might not be related to the physical alteration of facial dishar-

constitutional right, whose acts are competences determined by a regulatory law, foreseen in the Federal Constitution: “Art. 5, subsection XIII – All are equal before law, without distinction of any kind, assuring to Brazilians and foreigners living in Brazil the inviolability of the right to life, liberty, equality, security and property, in the following terms: (...) the exercise of any work or profession is free, provided it meets the professional qualifications established by law(...)”.13 The Constitution determines professional regulation by ordinary laws, in this case, the medical and dental professions.

The Law 12842/2013 regulates the Medical Act, addressing: “(...) Art. 4 The following are private activities of the medical doctor: II – indication and accomplishment of surgical intervention and prescription of pre- and postoperative medical care; III – indication and accomplishment of invasive procedures, either diagnostic, therapeutic or esthetic, including deep vascular accesses, biopsies and endoscopies;(...)”.14 Besides, the Resolution 1950/2010 of the Federal Medical Council (CFM) states: “Art. 2 – It is the exclusive competence of medical doctors to treat malignancies, neoplasms of major salivary glands (parotid, submandibular and sublingual), infrahyoid cervical access, as well as the practice of esthetic surgery, except for the functional esthetic surgeries of the masticatory system.”15 In Medicine, there is a clear legal and normative possibility for therapeutic or esthetic surgical procedures, except for specifically dental procedures.

Conversely, Dentistry, regulated by Law 5081/1966, comprehensively determines: “Art. 6 – It is the duty of the dental professional: I – to practice all procedures pertinent to Dentistry, from knowledge acquired in regular postgraduate courses”.16 Thus, for Dentistry, the legal regulation demands the professionals to practice their actions resulting from knowledge acquired in undergraduate and postgraduate courses, inferring postgraduate courses as regular courses of MSc, PhD and also specialization, improvement and others, according to the Educational Law and Guidelines.17 The subject in question should have been included in the syllabus content and curriculum of the regular course of Dentistry or postgraduate course.

In this rationale, Dentistry issued Resolutions that regulate its professional practice.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Bichectomy: a critical view

Consequently, if such goal is not achieved, the obligation was not fulfilled. The professional should either achieve the result or bear the consequences. If there is an obligation of result, it is sufficient for the injured party to prove, besides the existence of the contract, regardless of the reasons, and it is up to the professional to prove the fortuitous event or force majeure, in which case he or she will not have responsibility.20 Most of the medical and dental therapies involve an obligation of means, when the functional aspect correlates with the concept of “health�.12 Obviously, the obligation of result seems to be associated with the purely esthetic question.

Hermeneutics, or legal interpretation, is the key to this issue.

mony or anomaly? Additionally, even implicating in psychosomatic or psychosocial pathology, as characterized by Mental and Behavioral Disorders, group F of ICD-1012? Such condition, correlated with non-acceptance of the imbalanced physical condition, whose functional psychiatric treatment might require a coadjutant treatment, also functional, to search for facial harmony by buccal fat pad removal, transforming it into a functional surgery of the masticatory system, could not be indicated? The answer to these questions seems to be no other than a definite yes.

Thus, for Dentistry, the legal and normative possibility of this procedure is evident.

Concerning the civil liability of the dental or medical professional, it is necessary to know whether the treatment performed comprises an obligation of means or result. There is an obligation of means when the benefit itself demands nothing more from the executor than simply applying a given procedure without looking at the result. This is the case of medical and dental professionals, who do their best and use all the means necessary to obtain the cure of the patient, yet without ever securing the result: the cure itself.

The professional must act with diligence, offering all his knowledge to the patient. If you do not succeed, it does not mean that you have failed to fulfill your contractual obligation. Conversely, in the obligation of result, the professional is obliged to reach a certain goal, desired by the patient. What matters is the end result, regardless of the diligence shown during treatment.

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CONCLUSION It is concluded that the technique is applicable, with legal support, by medical and dental professionals. With respect to the legal aspects and obligations of result and means, it is advisable to perform this procedure with a preferential and essentially functional, or esthetic-functional purpose, since when applied for an exclusively esthetic purpose, its consequences, feasibility, risks of transoperative accidents and postoperative complications, with uncertain and still indefinite prognosis in the long term, and considering the possible legal involvement, unless there is a better judgment. Further studies should be designed and conducted for better elucidation.

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Sobrinho Sangalette B, Vieira LV, Nascimento JA, Capelari VI, Shinohara AL, Marzola C, Toledo Filho JL, Toledo GL, Capelari MM

References:

1. Stevao ELL. Bichectomy or bichatectomy. A small and simple intraoral surgical procedure with great facial results. Adv Dent Oral Health. 2015;1(1):1-4.

2. Brasil. Resolução CFO 100/2010, de 18 de março de 2010. Baixa normas para a prática de Cirurgia e Traumatologia Bucomaxilofaciais, por cirurgiões-dentistas.

Entidades de Fiscalização do Exercício das Profissões Liberais. Diário Oficial da União [da] República Federativa do Brasil. 2010 30 Mar. 3. Capelari MM, Marzola C, Simoneti LF, Toledo GL, Toledo-Filho JL, Gonçalves PZ, et al. The electromyography in the arthroplasties of TMJ ankylosis. Rev Odontol (ATO). 2016;16(1):35-44.

4. Oliveira JCCA. Cirurgia de Bichectomia com finalidade estético-funcional: revisão de literatura e relato de dois casos [monografia]. Aracajú (SE): Universidade Tiradentes; 2017.

5. Zanetti LSS, Uceli CM, Marano RR, Coser RC, Rangel JA, Beccalli I. Análise do grau de conhecimento de médicos e dentistas sobre a especialidade de CTBMF na Grande Vitória/ ES. Rev Bras CTBMF. 2011;10(1):13-22.

6. Farias JG, Cancio AV, Barros LF. Fechamento de fístula bucossinusal utilizando o corpo adiposo bucalTécnica convencional x técnica do túnel: relato de casos clínicos. Rev Cir Traumatol Buco-Maxilo-Fac. 2015;15(3):25-30.

7. Laurentino-Filho J, Jardim JF, Queiroz SBF, Carvalho-Neto ACGS. Tratamento de fistula bucossinusal com o corpo adiposo da bucal: relato de caso. Rev Expressão Católica. 2012;1(2):193-204.

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8. Madeira MC, Rizzolo RJC. Anatomia da Face. 8ª ed.

São Paulo: Sarvier; 2012.

9. Fiamoncini ES, Capelari MM, Marzola C, Pastori CM, Toledo-Filho JL, Toledo GL, et al. Acessos cirúrgicos para fraturas da parede anterior do seio frontal: revista da literatura e relato de cinco casos. Rev Odontol (ATO). 2015;15(10):496-545.

10. Kelsen H. Teoria pura do direito. 9ª ed. São Paulo: Ed. Revista dos Tribunais; 2013.

11. Bernardino-Júnior R, Sousa GC, Lizardo FB, Bontempo DB, Guimarães PP, Macedo JH. Corpo adiposo da bochecha: um caso de variação anatômica. Biosci J. 2008;24(4):108-13.

12. Organização Mundial da Saúde. Classificação estatística Internacional de doenças e problemas relacionados à saúde. CID-10. Décima Revisão. 5a ed. São Paulo: Edusp; 1997. 3v.

13. Brasil. Constituição da República Federativa do Brasil.

Brasília; 1988.

14. Brasil. Lei 12.842, de 10 de julho de 2013. Dispõe sobre o exercício da Medicina. Diário Oficial da União [da] República Federativa do Brasil. 2013 Jul 11; Sec. 1:1-2.

15. Brasil. Resolução CFM 1.950/2010, de 07 de julho de 2010. O Conselho Federal de Medicina e o Conselho Federal de Odontologia estabelecem, conjuntamente, critérios para a realização de cirurgias das áreas de bucomaxilofacial e crânio-maxilo-facial. Entidades de Fiscalização do Exercício das Profissões Liberais.

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16. Brasil. Lei 5.081, de 24 de agosto de 1966. Regula o exercício da Odontologia. Atos do Poder Legislativo.

Diário Oficial [dos] Estados Unidos do Brasil. 1966 Ago 24; Sec. 1:1.

17. Brasil. Lei 9.394, de 20 de dezembro de 1996. Lei de Diretrizes e Bases da Educação Nacional. Estabelece as diretrizes e bases da educação nacional. Diário Oficial da União [da] República Federativa do Brasil.

1996 Dez 23; Sec. 1.

18. Brasil. Resolução CFO 118/2012, de 11 de maio de 2012. Revoga o Código de Ética Odontológica aprovado pela Resolução CFO-42/2003 e aprova outro em substituição. Entidades de Fiscalização do Exercício das Profissões Liberais. Diário Oficial da União [da] República Federativa do Brasil. 2012 Jun 14; Sec. 1:118-21.

19. Brasil. Resolução CFO 63/2005, de 08 de abril de 2005. Aprova a Consolidação das Normas para Procedimentos nos Conselhos de Odontologia. Rio de Janeiro; 2005 Abr 19.

20. Kato MT, Goya S, Sales-Peres SHC, Sales-Peres A, Bastos JRM. Responsabilidade Civil do cirurgião-dentista. Rev Odontol Univ Cidade São Paulo.

2008;20(1):66-75.

J Braz Coll Oral Maxillofac Surg. 2018 Sept-Dec;4(3):22-7

OriginalArticle

Use of helmet and alcohol between motorcyclists with facial trauma in Agreste and Sertão of the state

of Pernambuco - Brazil

ILKY POLLANSKY SILVA E FARIAS1 | RAFAEL DE SOUSA CARVALHO SABOIA2 | ANTÔNIO AZOUBEL ANTUNES2 | EVELYNE PESSOA SORIANO2 | JOSÉ RODRIGUES LAUREANO FILHO2 | GABRIELA GRANJA PORTO2

ABSTRACT Introduction: Identification of risk factors for facial trauma can help in the design of accident prevention programs. The present study aimed to evaluate the use of helmet and alcohol among motorcyclists with facial trauma in Agreste and Sertão of the state of Pernambuco. Methods: A cross-sectional study was performed with patients admitted from April 2015 to April 2016. The sample (n = 112) was characterized as to gender, age, use and type of helmet, driver’s license, alcohol use, power and purpose of the motorcycle, occurrence of previous accident, hospitalization time, place and level of complexity of the facial fracture. The alcohol use disorder was evaluated by the Alcohol Use Disturbance Identification Test (AUDIT). Results: Facial trauma was more prevalent in men (90.2%) from 20 to 29 years (50.9%). The type of helmet “open without visor” was the most used (40.2%), and the jaw was the most affected (52.9%). The AUDIT revealed that the “low risk” profile was the most prevalent (90.2%). There were no statistically significant associations (p> 0.05). Conclusions: The profile of motorcyclists with facial trauma is composed of male subjects, 20 to 29 years old, with open helmet without visor and mandibular fracture.

Keywords: Facial injuries. Accidents, traffic. Alcohol-induced disorders.

Universidade de Pernambuco, Hospital Regional do Agreste (Caruaru/PE, Brazil).

1

How to cite: Silva e Farias IP, Saboia RSC, Antunes AA, Soriano EP, Laureano Filho JR, Porto GG. Use of helmet and alcohol between motorcyclists with facial trauma in Agreste and Sertão of the state of Pernambuco - Brazil. J Braz Coll Oral Maxillofac Surg. 2018 Sept-Dec;4(3):28-36.

DOI: http://dx.doi.org/10.14436/2358-2782.4.3.028-036.oar

Universidade de Pernambuco, Faculdade de Odontologia de Pernambuco, Programa de Pós-Graduação em Perícias Forenses (Camaragibe/PE, Brazil).

2

Submitted: February 09, 2018 - Revised and accepted: April 18, 2018 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article.

Contact address: Gabriela Granja Porto Universidade de Pernambuco/Faculdade de Odontologia de Pernambuco Av. General Newton Cavalcanti, 1650 – CEP: 54.753-220 – Camaragibe/PE E-mail: gabriela.porto@upe.br

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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J Braz Coll Oral Maxillofac Surg. 2018 Sept-Dec;4(3):28-36

Silva e Farias IP, Saboia RSC, Antunes AA, Soriano EP, Laureano Filho JR, Porto GG

INTRODUCTION The trauma to the facial region may be considered an important aggression in trauma centers, due to the emotional commitment and esthetic and functional sequelae it brings to the victim. The prevalence of facial trauma is high compared to injuries in other anatomical regions, since this area usually is not externally protected, becoming more susceptible to the environment.1,2 In Brazil, traffic accidents deserve special attention, because they are a critical and worrisome aspect in the statistics of important causes of death, disability and sequelae, especially among younger and male individuals.3 In Brazil, the motorcycle represents a socially important transportation means, especially for the working class, who uses it for transportation and/or for office, taxi and delivery services. Due to the affordable cost of the vehicle and service charges, this equipment facilitates the purchase for professionalization and contributes to social mobility.4 Notwithstanding, trauma is often related to alcohol use, and its abuse has reached massive proportions,5 being the country developed or not, and is considered a public health problem. In addition, alcohol has a strong association with facial injuries, due to interpersonal violence and road accidents.6,7 It has been shown that alcohol interferes with cognitive and motor responses and impairs the ability to solve problems in a conflict situation. Because of these effects, there is a direct correlation between alcohol consumption and the risk of a person involved in a dangerous situation to be a victim of facial trauma, such as car accidents and interpersonal violence.6 In this sense, the World Health Organization created a scale called AUDIT (Alcohol Use Identification Test Disturbance), to study the profile of alcohol consumption in users who seek help in large centers. This scale is sensitive and identifies the risks and harms of alcohol use, the degree of chemical dependence,8 and presents important advantages over other screening instruments, because it identifies excessive alcohol users who do not meet the criteria for addiction or still have no real problems related to it.9 The consequences of motorcycle accidents are diverse and can lead not only to death but also to traumatic brain injury (TBI), trauma to the upper

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

limbs, lower limbs, trunk, and facial trauma, possibly causing fracture of facial bones, which, if not properly treated by a competent professional (in this case, the maxillofacial surgeon), can cause deformities that alter the masticatory function, ocular movement and nasal breathing.10 Since the identification of risk factors for facial trauma may help to design accident prevention programs, this study evaluated the use of helmet and alcohol among motorcyclists with facial trauma in the agreste and sertĂŁo of the state of Pernambuco.

METHODS This cross-sectional study with inductive approach and statistical-descriptive procedure was conducted on motorcyclists with facial trauma assisted at a hospital in Pernambuco from April 2015 to April 2016. This hospital is a reference in the agreste and sertĂŁo of the state of Pernambuco, covering 33 cities included in the IV Regional Health Management (GERES).

This study was registered in Plataforma Brasil, reviewed and approved by the Institutional Review Board of University of Pernambuco (Brazil), under protocol CAAE n. 57061115.9.0000.5207, and followed the national and international guidelines for research on humans (Resolution 466/12 of the Brazilian National Health Council and Declaration of Helsinki). The study included patients who signed an informed consent form, after being informed about the study proposal, and who had clinical conditions to understand the methodological instruments used.

The sample (n = 112) was characterized by gender, age group (10 - 19 years old; 20 - 29 years old; 30 - 39 years old; 40 - 49 years; 50 - 59 years; and 60 years or older), use and type of helmet (Fig 1), use of driving license, use of alcohol, power of motorcycle (50 or more cc), purpose of the motorcycle (work, leisure, sports, others), previous occurrence of accident, hospital stay (discharge on the same day; 1 -2 days; 3 - 4 days; 5 - 7 days; 8 - 10 days; more than 10 days), site and level of complexity of the treatment of facial fracture (Tab. 1). The alcohol use disorder was evaluated by the AUDIT (Alcohol Use Disturbance Identification Test). Tables 2 and 3 present the questions and the content of questions for each domain evaluated in the AUDIT, respectively.

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J Braz Coll Oral Maxillofac Surg. 2018 Sept-Dec;4(3):28-36

Use of helmet and alcohol between motorcyclists with facial trauma in Agreste and Sertão of the state of Pernambuco - Brazil

The AUDIT is a test widely used in several countries, because it is easy to apply and has low cost, consisting of ten questions. The total score varies from 0 to 40 points and, according to it, it is possible to identify four patterns of alcohol use or risk zones: I) low risk use (0 - 7 points); II) risky use (8 - 15 points); III) harmful use (16 - 19 points); IV) probable dependence (20 or more points).13

To obtain the diagnosis, in addition to clinical examination, conventional radiographic examinations of the face were requested for better detailing.

Computed tomography and 3D reconstructions were requested when conventional radiographic images were not clear enough for correct visualization of the fracture.

In this study, the following classifications and concepts were used: 1) panfacial fractures - in which at least two of the three facial thirds present fracture11; and 2) multiple mandibular fractures - those in which there is association of two or more fractures that compromise the mandibular bone in different anatomical regions12.

Data were tabulated on the Microsoft Excel® software (version 2013), and the statistical-descriptive analysis was performed by the chi-square test (p < 0.05), using the software Statistical Package for Social Sciences (SPSS for Windows, version 23.0, SPSS Inc , Chicago, IL, USA).

Helmet full without visor with shovel

Helmet open with visor

RESULTS The sample age ranged from 10 to 68 years, with a mean of 29.12 years, standard deviation of 10.56 years and a median of 26 years.

Table 4 shows the results of sample characterization, highlighting that the most prevalent age group was 20 to 29 years (50.9%), followed by the age range 30 to 39 years (24.1%); the majority (90.2%) were males; the use of helmets was reported by 75.9% of drivers, being the type “open without visor” the most used (40.2%); motorcycles with power greater than 50cc were more prevalent (93.7%); exactly half had driving license; approximately 1/3 (33.0%) used alcohol before the accident; when questioned about the

Helmet mixed with removable chin Helmet full with visor and shovel protector, without visor with shovel

Helmet open without visor with or without shovel

Helmet open with visor with or without shovel

Figure 1: Types of helmets.

Table 1: Classification of facial fractures according to the treatment complexity.

Classification

Description of fractures

N1

Dentoalveolar and nose bones Zygomatic complex, maxilla Le Fort I, mandible (simple, symphysis, parasymphysis and body) Maxilla Le Fort II and III, mandible (multiple, angle and condyle) Panfacial and nasoorbitoethmoidal

N2 N3 N4

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Silva e Farias IP, Saboia RSC, Antunes AA, Soriano EP, Laureano Filho JR, Porto GG

Table 2: AUDIT questions.

1. How often do you have a drink containing alcohol?

(0) Never (1) Monthly or less (2) 2 to 4 times a month (3) 2 to 3 times a week (4) 4 or more times a week

6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

2. How many drinks containing alcohol do you have on a typical day when you are drinking?

(0) 1 or 2 (1) 3 or 4 (2) 5 or 6 (3) 7, 8, or 9 (4) 10 or more

7. How often during the last year have you had a feeling of guilt or remorse after drinking?

(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

3. How often do you have six or more drinks on one occasion?

(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?

(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

4. How often during the last year have you found that you were not able to stop drinking once you had started?

(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

9. Have you or someone else been injured as a result of your drinking?

(0) No (1) Yes, but not in the last year (2) Yes, during the last year

5. How often during the last year have you failed to do what was normally expected from you because of drinking?

(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

10. Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down?

(0) No (1) Yes, but not in the last year (2) Yes, during the last year

Table 3: Contents of questions related to each domain of the AUDIT.

1. ALCOHOL INGESTINO PATTERN

2. SIGNS AND SYMPTOMS OF DEPENDENCE

3. PROBLEMS RELATED TO ALCOHOL INGESTION

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

Q1. Frequency of use Q2. Quantity on a typical day Q3. Frequency of excess drinking Q4. Difficulty to control the use Q5. Increased importance of drinking Q6. Drinking at morning Q7. Feeling of guilt after alcohol ingestion Q8. Forgetfulness after ingestion Q9. Lesions caused by alcohol ingestion Q10. Concern from other people

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Use of helmet and alcohol between motorcyclists with facial trauma in Agreste and SertĂŁo of the state of Pernambuco - Brazil

Table 4: Sample profile (n = 112) concerning the age range, gender, use and type of helmet, motorcycle power, driving license, alcohol ingestion and purpose of utilization of motorcycle.

Variable

Table 5: Sample profile (n = 112) concerning the previous occurrence of accident, period of hospitalization, site and complexity in the treatment of facial fractures and AUDIT classification.

n (%)

Age range (years) 10 to 19

11 (9.8)

20 to 29

57 (50.9)

30 to 39

27 (24.1)

40 to 49

10 (8.9)

50 to 59

5 (4.5)

60 or older

2 (1.8)

Variable

n (%)

Previous accident

20 (17.9)

Hospitalization

112 (100)

Length of hospital stay (days)

Gender

1 to 2

19 (17)

3 to 4

38 (33.9)

Male

101 (90.2)

5 to 7

28 (25)

Female

11 (9.8)

8 to 10

11 (9.8)

Use of helmet

85 (75.9)

>10

16 (14.3)

Type of helmet

Fracture site

Open with visor

10 (8.9)

Open without visor

45 (40.2)

Integral with visor

10 (8.9)

Full with visor and shovel

1 (0.9)

Full without visor with shovel

8 (7.1)

Mixed with removable chin protector. without visor with shovel

11 (9.8)

Did not use helmet

27 (24.1)

Motorcycle power

Mandible

59 (52.7)

Maxilla

15 (13.4)

Dentoalveolar

4 (3.6)

Nasal

6 (5.4)

N.O.E.

3 (2.7)

Panfacial

7 (6.2)

Zygomatic

18 (16)

Complexity of fractures

Higher than 50 cc

105 (93.7)

50 cc

7 (6.3)

N1 (Dentoalveolar / O.P.N.)

10 (8.9)

Yes

56 (50)

42 (37.5)

No

56 (50)

N2 (Zygomatic complex. maxilla Le Fort I. mandible (simple. symphysis. parasymphysis and body))

Alcohol ingestion

37 (33)

N3 (Maxilla Le Fort II and III. mandible (multiple. angle and condyle))

50 (44.7)

N4 (Panfacial / N.O.E.)

10 (8.9)

Driving license

Purpose of motorcycle use Leisure

26 (23.2)

Work

50 (44.6)

Leisure/sport

1 (0.9)

Low risk use (0 to 7 points)

101 (90.2)

Work/leisure

32 (28.6)

Risky use (8 to 15 points)

10 (8.9)

Work/leisure/sport

3 (2.7)

Harmful use (16 to 19 points)

1 (0.9)

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

AUDIT classification

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J Braz Coll Oral Maxillofac Surg. 2018 Sept-Dec;4(3):28-36

Silva e Farias IP, Saboia RSC, Antunes AA, Soriano EP, Laureano Filho JR, Porto GG

Table 6: Evaluation of fracture complexity according to the use and type of helmet, motorcycle power, driving license, alcohol ingestion and AUDIT classification.

Fracture complexity level Variable

Use of helmet Yes No Total group Type of helmet Open with visor Open without visor Integral with visor Full with visor and shovel Full without visor with shovel Mixed with removable chin protector. without visor with shovel Total group Motorcycle power Above 50 cc 50 cc Driving license Yes No Alcohol ingestion Yes No AUDIT Low risk use Risky/harmful use Total group

N1

N2

N3

TOTAL

p

%

n

%

n

%

n

%

n

%

9 1 10

10.6 3.7 8.9

33 9 42

38.8 33.3 37.5

35 15 50

41.2 55.6 44.6

8 2 10

9.4 7.4 8.9

85 27 112

100 100 100

6 1

13.3 12.5

4 15 4 1 6

40 33.3 40 100 75

5 17 6 1

50 37.8 60 12.5

1 7 -

10 15.8 -

10 45 10 1 8

100 100 100 100 100

2

18.2

3

27.3

6

54.5

-

-

11

100

9

10.6

33

38.8

35

41.2

8

9.4

85

100

10 -

9.5 -

40 2

38.1 28.6

46 4

43.8 57.1

9 1

8.6 14.3

105 7

100 100

p(1) = 0.742

6 4

10.7 7.1

22 20

39.3 35.7

24 26

42.9 46.4

4 6

7.1 10.7

56 56

100 100

p(2) = 0.807

1 9

2.7 12

19 23

51.4 30.7

14 36

37.8 48

3 7

8.1 9.3

37 75

100 100

p(1) = 0.129

10 10

9.9 8.9

36 6 42

35.6 54.5 37.5

47 3 50

46.5 27.3 44.6

8 2 10

7.9 18.2 8.9

101 11 112

100 100 100

p(1) = 0.255

p(1) = 0.599

p(1) = 0.427

levels concerning the most frequent treatment were N3 (44.7%) and N2 (37.5); the majority (90.2%) were classified as having low risk for alcohol use disorder.

Table 6 presents the results of the study of the association between the level of complexity of fractures in relation to the treatment with each of the following variables: helmet use, helmet type, motorcycle power, driving license, alcohol use and the AUDIT classification. However, for the fixed margin of error (5%), no statistically significant associations were found for any variable analyzed (p > 0.05).

purpose of utilization of the motorcycle, the most frequent were work (44.6%), work/leisure (28.6%) and leisure (23.2%).

The AUDIT score ranged from 1 to 19, with a mean of 3.66, standard deviation of 3.22 and median of 3 .

Table 5 shows that the previous occurrence of accident was 17.9%; the most frequent hospitalization period was 3 to 4 days (33.9%); the most frequently fractured bone was the mandible (52.7%), followed by the zygomatic bone (16%); the fracture complexity

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

N4

n

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Use of helmet and alcohol between motorcyclists with facial trauma in Agreste and Sertão of the state of Pernambuco - Brazil

DISCUSSION The prevalence of oral and maxillofacial trauma may vary according to geography, socioeconomic distribution and trends in the universe that contains the sample, as well as traffic laws and seasonal variations. 15 Violent deaths, particularly traffic accidents, have ceased to be exclusive of developed countries and have become a major cause of lesions, disability and death in developing countries, particularly affecting young people in productive age. 16 Traffic accidents involving motorcycles have two very distinct characteristics: one refers to leisure situations, linked to transgression; the other is linked with work activities, related with poor work conditions, promoting stress and incapacitating the driver to act with balance and tranquility.17 Concerning the distribution of patients according to gender, there was predominance of males (90.2%), corroborating other studies in the literature.18,19 This fact may be explained by the greater involvement of men in outdoor activities and their greater exposure to violent interactions, and it should also be highlighted that male drivers outnumber the females.20 However, there is a worldwide tendency of increased prevalence in women, since they are increasingly exposed to the risk factors that cause maxillofacial traumas,21 as justified by the greater involvement in the practice of physical activities, greater number of female drivers, increased violence in cities associated with the greater participation of women in activities outside home, bringing them closer to the risk group of males.22 In relation to the age group, it was more prevalent from 20 to 29 years (50.9%), similar to other studies.16,23,24 The high prevalence of these traumas in this age group can be assigned to the fact that this age group practices exercises and dangerous sports, and also uses transportation means at high speed.25 A study that analyzed 125 medical records of victims of facial fractures treated in public and private services in the city of Taubaté, between January 2000 and March 2003, concluded that traffic accidents in general (car, motorcycle, bike and runover) were responsible for 65.6% of cases of fractures, with motorcycle accidents being the most frequent (26.4% of cases). 26 One explanation for this fact is that the motorcycle, as a fast, easily accessible and low cost transportation means, justifies the large number of

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

these vehicles and drivers in several Brazilian cities and regions. Associated with this, in some regions, the use of motorcycles as a leisure and/or work tool, often without legal regulations, further increases the search for this vehicle and predisposes to an increase in accident rates. 27 In the present study, 17.9% of respondents reported involvement in previous motorcycle accidents. A study found in the literature concluded that 51% of the sample had already suffered more than one accident, while 8% already had more than 10 accidents.28 Another study concluded that motorcyclists interviewed showed the marks of accidents with satisfaction and vanity, demonstrating that taking risks and overcoming challenges for them are considered heroic acts. 17 The majority of drivers in this study stated that they were driving a motorcycle with power greater than 50 cc (93.7%), which is in accordance with another finding in the literature, in which 98.1% of the patients, at the moment of trauma, were on motorcycles with 100 to 300 cc.27 This may be justified by the ease to purchase more powerful motorcycles rather than less powerful, either by consortium or financing.

Regarding the helmet, 75.9% of patients were using it at the moment of the trauma, corroborating another study in which a frequency of 62.3% was found.27 This value should be close to or equal to 100%, considering its mandatory use since the implementation of the Brazilian Traffic Code in 1998.

The highest frequency of helmets used was the ‘open and without visor’ type, which does not offer adequate protection, since it promotes greater exposure of the middle and lower facial thirds, corroborating the result found in this study, in which the levels of complexity of fractures in relation to the treatment (N2 and N3) represented 82.2 % of cases, reflecting greater exposure of the face in this type of helmet.

Another important fact concerns the ingestion of alcoholic drinks, which revealed that 33% of drivers made use of this drug. This value can be considered high, since the ‘Dry Law’ of traffic, implemented in 2008 and hardened in 2012 by a resolution, began to consider a crime driving under the influence of any amount of alcohol. Therefore, it was to be expected that people had not ingested alcohol.

It is important to note that the driver, under the influence of alcohol, often presents in a sleepy state,

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Silva e Farias IP, Saboia RSC, Antunes AA, Soriano EP, Laureano Filho JR, Porto GG

the low sample size, which can be improved by the use of a wider study method, including more hospital settings, both public and private. Nevertheless, it was possible to trace an epidemiological profile of motorcyclists with facial trauma assisted at the Regional Hospital of Agreste, Caruaru/PE, serving as a basis for the implementation of supervision and stricter prevention measures.

with its reduced reflex capacity and difficulty to keep balance on the motorcycle, besides presenting destructive behaviors such as euphoria, fury, self-confidence, depression or inattention, which corroborates as an aggravating factor (both in number and severity) for accidents.29 Traffic accidents also pose great costs for the countryâ&#x20AC;&#x2122;s economy. A study conducted on epidemiological data of traffic accidents in Brazil between the years 2003 and 2013 revealed that, in a single year, about 14 million reais were spent only to finance the treatment for victims of this type of accident.30 Statistical tests related to the complexity level of facial fractures and other variables, such as helmet use, helmet type, motorcycle power, driving license, alcohol use and AUDIT classification, did not present statistically significant association (p > 0.05). This may point to some weaknesses in this study, such as

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

CONCLUSION The profile of motorcyclists with facial trauma is male, aged 20-29 years, with an open helmet without a visor, and mandibular fracture. Although the use of the correct type of helmet and the greater control of alcohol consumption may contribute to reduce the prevalence of facial trauma among motorcyclists, the results of this study did not show statistically significant associations.

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Use of helmet and alcohol between motorcyclists with facial trauma in Agreste and Sertão of the state of Pernambuco - Brazil

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© Journal of the Brazilian College of Oral and Maxillofacial Surgery

11. Jack JM, Stewart DH, Rinker BD, Vasconez HC, Pu LL. Modern surgical treatment of complex facial fractures: a 6-year review. J Craniofac Surg. 2005 July;16(4):726-31.

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29. Shekar BRC, Reddy CVK. A five-year retrospective statistical analysis of maxillofacial injuries in patients admitted and treated at two hospitals of Mysore city.

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J Braz Coll Oral Maxillofac Surg. 2018 Sept-Dec;4(3):28-36

OriginalArticle

Cleft lip and palate surgeries: Report of 7-year experience in Centrinho

Imperatriz/MA (Brazil) LÊONILSON GAIÃO1,2 | THAINÁ BARROSO PINHEIRO DE SOUZA3 | RAURÍCIO VITAL MENDES3 | PATRÍCIA FIGUEIREDO DE MACÊDO3

ABSTRACT Objective: To quantify the frequency of different types of surgeries in patients with cleft lip and palate, from September 2008 to July 2015 in the Centrinho Imperatriz.

Methods: A retrospective study was conducted, based on 226 surgical descriptions of medical records of patients undergoing surgical procedures for the rehabilitation of cleft lip and palate. Results: Regarding the surgeries performed: a) 119 patients were male; b) 66 had unilateral left transforamen clefts; c) the average age was 11.14 years; d ) among the abnormalities, the most frequent were those associated with the eyes and ears; e) 2014 was the year with the highest number of surgeries (n=47); f) among the performed surgeries, primary palatoplasty was the most frequent (n=86), followed by unilateral cheiloplasties (n=61), buconasal fistula closures (n=34) and other surgical procedures (n=45), such as alveolar bone graft, secondary palatoplasty, bilateral cheiloplasty and rinoplasty. Conclusion: According to the results, it can be concluded that: 1) there was a slight predominance of male patients; 2) patients with left unilateral transforamen cleft diagnosis were more frequent; 3) the most prevalent surgeries were palatoplasty; and 4) cheiloplasty and palatoplasty were performed more than secondary surgeries.

Keywords: Cleft palate. Cleft lip. Surgery, oral.

PhD in Oral and Maxillofacial Surgery and Traumatology, Pontifícia Universidade Católica do Rio Grande do Sul (Porto Alegre/RS, Brazil).

1

How to cite: Gaião L, Souza TBP, Mendes RV, Macêdo PF. Cleft lip and palate surgeries: Report of 7-year experience in Centrinho Imperatriz/MA (Brazil). J Braz Coll Oral Maxillofac Surg. 2018 Sept-Dec;4(3):37-41.

DOI: http://dx.doi.org/10.14436/2358-2782.4.3.037-041.oar

DeVry Faculdade de Imperatriz, Graduation in Dentistry, Disciplines of Surgery and Implantology (Imperatriz/MA, Brazil).

2

Submitted: May 30, 2016 - Revised and accepted: January 25, 2018

DeVry Faculdade de Imperatriz, Graduation in Dentistry (Imperatriz/MA, Brazil).

3

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

Contact address: Leonilson de Melo Gaião Av. Prudente de Morais, s/n, Parque Sanharol – Imperatriz/MA – CEP: 65.900-000 - Brazil E-mail: gaiao@drgaiao.com

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Cleft lip and palate surgeries: Report of 7-year experience in Centrinho Imperatriz/MA (Brazil)

INTRODUCTION Cleft lip and palate (CLP) is the most prevalent craniofacial deformity, affecting the lips, nose, alveolar region and palate. Its prevalence varies according to race and population site. In Brazil, it is estimated that one in every 1,000 newborns has cleft lip and palate. The patient with this deformity requires rehabilitative treatment, including several clinical and surgical treatments.1 Clinically, the clefts may present varying degrees of severity according to their extent; they may be unilateral or bilateral, complete or incomplete.2 Besides constituting a serious esthetic problem, the affected individuals present functional disorders, including malocclusion and speech alterations. Therefore, the treatment is long and consists of several stages, with risk of discontinuity, highlighting the need of bond and patient adherence.

The primary surgeries include initial repair of the lip and palate, with or without rhinoplasty. Secondary surgeries include lip revision, fistula closure, alveolar bone graft, palate repair or velopharyngeal surgery, and rhinoplasty. When the same or better results may be achieved by primary surgeries, the secondary surgeries may be unnecessary for patients and their families.3 Some cases with limited maxillary growth may require orthognathic surgery.4 Several protocols with different techniques and timing are used in treatment centers for patients with cleft lip and palate worldwide. Multicentric longitudinal comparative studies have sought protocols with the best results regarding facial esthetics, occlusal relationships and speech quality.5-8 Thus, this study aimed to quantify the frequency of different types of surgeries performed in patients with cleft lip and palate, from September 2008 to July 2015, at Centrinho Imperatriz, Maranhão , Brazil.

Imperatriz between September 2008 and July 2015.

The study was approved by the Institutional Review Board of DeVry FACIMP, at Imperatriz/MA (protocol n. 080/2016).

Data were collected from 226 surgeries descriptions performed on 218 patients with CLP, being 119 males and 99 females, living in the Tocantina Region, which includes cities in southwestern Maranhão, southeastern Pará and northern Tocantins.

All patients treated at Centrinho Imperatriz have their data and surgical records, including pre- and postoperative photographs, registered in the Smile Train Express Database, for further analysis by Smile Train, an American organization that supports CLP treatment centers in developing countries. From these records, information was collected related to the cleft diagnosis, structures involved, mean age of patients, presence of associated anomalies, and number and types of surgeries performed.

RESULTS The study analyzed 226 surgeries on 218 patients with CLP, being 119 males and 99 females, from September 2008 to July 2015 at Centrinho Imperatriz.

The most frequent diagnosis in the patients analyzed was unilateral left cleft lip and palate (Table 1).

The mean age of patients assisted at Centrinho Imperatriz was 11.14 years (Table 2).

Concerning the presence of other associated anomalies, the most frequent were those associated with the eyes and ears (Table 3).

Table 4 presents the number of surgical procedures performed between September 2008 and July 2015, evidencing a progressive increase observed over the years.

Regarding the types of surgical procedures performed at Centrinho Imperatriz, primary palatoplasty was the most frequent among primary surgeries.

Concerning the secondary surgeries, fistula closure was the most common (Table 5).

MATERIAL AND METHODS This retrospective study was based on the surgical descriptions from patients assisted at Centrinho

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Gaião L, Souza TBP, Mendes RV, Macêdo PF

Table 1: Sample distribution according to the type of cleft.

Patient diagnosis

Male

Female

Total: n (%)

Complete left cleft lip and palate Cleft palate Complete bilateral cleft lip and palate Complete right cleft lip and palate Right cleft lip Left cleft lip Bilateral cleft lip Total

37 22 20 21 11 10 2 123

29 24 15 13 10 11 1 103

66 (29.2%) 46 (20.4%) 35 (15.5%) 34 (15%) 21 (9.3%) 21 (9.3%) 3 (1.3%) 226 (100%)

Table 2: Sample distribution according to the mean age of patients, per year.

YEARS

AGE (years)

2008 2009 2010 2011 2012 2013 2014 2015 Mean

13.17 13.33 11.92 10.67 13.83 7.67 8 10.58 11.14

Table 3: Sample distribution according to the associated anomalies.

Associated anomalies

Male

Female

Total

Without anomalies Eyes Ears Members Fingers and toes Delayed growth Intellectual disability Skull Skin Tongue Heart Urinary system Mandible Total

92 5 3 4 3 3 4 3 1 1 0 0 0 119

88 4 2 0 1 1 0 0 1 1 1 0 0 99

180 9 5 4 4 4 4 3 2 2 1 0 0 218

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Cleft lip and palate surgeries: Report of 7-year experience in Centrinho Imperatriz/MA (Brazil)

Table 4: Sample distribution according to the quantity of surgeries performed per year.

YEARS

QUANTITY OF SURGERIES

2008 2009 2010 2011 2012 2013 2014 2015

16 25 25 13 17 46 47 37

Table 5: Sample distribution according to type of surgery performed.

Surgeries performed

Primary surgeries Primary palate repair Unilateral lip repair Bilateral lip repair Secondary surgeries Fistula closure Nose revision Alveolar bone graft Secondary palate repair Total

Quantity: n (%)

86 (38%) 61 (27%) 12 (5.3%) 34 (15%) 14 (6.3%) 14 (6.3%) 5 (2.1%)

159 (70,4%)

67 (29.6%)

226 (100%)

DISCUSSION The rehabilitation of patients with cleft lip and palate is still complex, with a permanent search for more effective protocols. However, the literature5-9 indicates the need for reference centers with multidisciplinary teams. Centrinho Imperatriz was established in 2007 and has made efforts and partnerships to achieve better results; however, it is difficult to conduct clinical research, due to the diversity of patients, almost always delayed in the different treatment stages.

The sample was similar to the literature concerning the male predilection (n = 119; 54.6%), unilateral left cleft lip and palate in males (n = 37; 16.4%) and cleft palate in females (n = 24; 45.4%).9-12 Many factors contribute to a safe surgical procedure: trained professionals, environment, equipment and adequate materials for the procedure. However,

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

Total

the timing of procedures, as well as the techniques employed, are priority in the protocols.

For the primary surgeries, according to the protocol of Centrinho Imperatriz, lip repair for individuals with unilateral left cleft lip and palate is performed at 6 months of age, followed by palatoplasty in two stages: posterior palate at 12 months and anterior palate at 18 months of age. For patients with complete bilateral cleft lip and palate, lip repair is performed in two stages, beginning by the wider side at 6 months and the other at 9 months of age. The alveolar bone graft should be performed before canine eruption.13,14 The present study revealed a mean age of 11.14 years â&#x20AC;&#x201C; relatively late, compared to the surgical protocols proposed at Centrinho Imperatriz. This reinforces this hypothesis of late treatments with a 7:3 ratio between primary and secondary surgeries in the present sample (Table 5).

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Gaião L, Souza TBP, Mendes RV, Macêdo PF

Approximately one-sixth of the sample presented some associated anomaly, which reinforces the need for reference centers with a multidisciplinary team9. A complete diagnosis regarding he detection of malformations associated to CLP is important not only for the treatment, but also for genetic counseling of the patient’s family.

When establishing a service protocol, the expectations regarding the results achieved increase at every passing year15. There was a significant increase in the number of surgeries performed per year, adding up to 47 corrective surgeries in 2014. This magnitude of productivity occurred due to several factors, mainly including the limited availability of professionals and

operating theaters. All procedures were performed at the Municipal Hospital of Imperatriz, linked to the Brazilian Public Health System. Among these procedures, 206 were performed by maxillofacial surgeons and 20 by plastic surgeons.

CONCLUSION According to the results obtained, it can be concluded that: 1) there was a slight predominance of male patients; 2) patients with diagnosis of left unilateral cleft lip and palate were the most frequent; 3) the most prevalent surgeries were palatoplasties; and 4) lip and palate repairs were more accomplished than secondary surgeries.

References:

1. Raposo-do-Amaral CE, Kuczynski E, Alonso N. Qualidade de vida de crianças com fissura labiopalatina: análise crítica dos instrumentos de mensuração. Rev Bras Cir Plást. 2011;26(4):639-44.

2. Neves ACC, Monteiro AM, Ng HG. Prevalência das fissuras labiopalatinas na associação de fissurados labiopalatinos de São José dos Campos/SP. Rev Biociência. 2002 Jul-Dez;8(2):69-74.

3. Sitzman TJ, Mara CA, Long RE Jr, Daskalogiannakis J, Russell KA, Semb G, et al. The Americleft Project: Burden of Care from Secondary Surgery. PRS Global Open. 2015 July;3(7):442-50.

4. Carlini JL, Strujak G, Biron C, Medeiros PJ, Ritto FG. Estabilidade da cirurgia ortognática em pacientes portadores de fissura labiopalatina. J Braz Coll Oral Maxillofac Surg. 2015 Maio-Ago;1(2):24-9.

5. Fudalej P, Hortis-Dzierzbicka M, Dudkiewicz Z, Semb G. Dental arch relationship in children with complete unilateral cleft lip and palate following warsaw (one-stage repair) and Oslo protocols. Cleft Palate-Craniofac J. 2009 Nov;46(6):648-53.

6. Ozawa TO, Shaw WC, Katsaros C, Kuijpers-Jagtman AM, Hagberg C, Semb G, et al. A New yardstick for rating dental arch relationship in patients with complete bilateral cleft lip and palate. Cleft Palate-Craniofac J. 2011 Mar;48(2):167-72.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

7. Dogan S, Olmez S, Semb G. Comparative assessment of dental arch relationships using goslon yardstick in patients with unilateral complete cleft lip and palate using dental casts, two-dimensional photos, and two-dimensional images. Cleft Palate Craniofac J. 2012 May;49(3):347-51.

8. Kozelj V, Vegnuti M, Drevenšek M, Hortis-Dzierzbicka M, Gonzalez-Landa G, Hanstein S, et al. Palate Dimensions in six-year-old children with unilateral cleft lip and palate: a six-center study on dental casts. Cleft Palate-Craniofac J. 2012 Nov;49(6):672-82.

9. Sandrini FAL, Robinson WM, Paskulin G, Lima MC. Estudo familiar de pacientes com anomalias associadas às fissuras labiopalatinas no serviço de defeitos de face da Pontifícia Universidade Católica do Rio Grande do Sul. Rev Cir Traumatol Buco-Maxilo-Facial. 2006 Abr-Jun;6(2):57-68.

10. Cymrot M, Sales FCD, Teixeira FAA, Teixeira Junior FAA, Teixeira GSB, Cunha Filho JF, et al. Prevalência dos tipos de fissura em pacientes com fissuras labiopalatinas atendidos em um Hospital Pediátrico do Nordeste brasileiro. Rev Bras Cir Plást. 2010;25(4):648-51.

11. Vasconcelos BCE, Silva EDO, Porto GG, Pimentel FC, Melo PHNB. Incidências de malformações congênitas labiopalatais. Rev Cir Traumatol Buco-Maxilo-Facial.

2002 Jul-Dez;2(2):41-6.

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12. Martelli JH, Porto LV, Martelli DRB, Bonan PRF, Freitas AB, Coletta RD. Prevalência de fissuras orais nãosindrômicas em um hospital de referência no estado de Minas Gerais, Brasil, entre 2000 e 2005.

Braz Oral Res. 2007;21(4):314-7.

13. Ibrahim D, Faco EFS, Santos Filho JHG, Souza RA. Enxerto ósseo alveolar secundário em pacientes portadores de fissuras lábio-palatais: um protocolo de tratamento. Rev Fac Odontol Lins. 2004;16(2):13-8.

14. Freitas JAS, Garib DG, Trindade-Suedam IK, Carvalho RM, Oliveira TM, Lauris RCMC, et al. Rehabilitative treatment of cleft lip and palate: experience of the Hospital for Rehabilitation of Craniofacial Anomalies – USP (HRAC-USP) – Part 3: Oral and Maxillofacial Surgery. J Appl Oral Sci. 2012;20(6):673-9.

15. AlonsoN, Tanikawa DYS, Lima Junior JE, Ferreira MC. Avaliação comparativa e evolutiva dos protocolos de atendimento dos pacientes fissurados. Rev Bras Cir Plást. 2010;25(3):434-8.

J Braz Coll Oral Maxillofac Surg. 2018 Sept-Dec;4(3):37-41

OriginalArticle

Epidemiological survey of face trauma in a public hospital

in Vitória/ES (Brazil) GABRIELA MAYRINK1,3 | NATÁLIA GONÇALVES AMARAL AVILA2,4 | JESSIKA BARCELOS BELONIA2,4

ABSTRACT Introduction: Facial trauma can be considered one of the worst injuries found in public hospitals, due to its emotional and functional repercussions, the possibility of deformity and dissatisfaction with aesthetics, work withdrawal and the economic impact they cause in the public health system. Methods: The present retrospective epidemiological study was performed by the analysis of medical records of patients attended due to trauma, at the surgical center of the Maxillofacial Surgery and Traumatology department of a public hospital in Vitoria/ES, Brazil, in the period of September 2014 to September 2016. Results: In the trauma analysis, of the 355 medical records analyzed, 82% were male and 18% female. Most were young, between 20 and 29 years of age. Of all facial fractures, mandible was more frequent (37.7%), and the major cause of facial trauma was traffic accidents (37.7%), followed by interpersonal violence (33.5%), fall (14.9%), sports accident (7%), work accident (2.3%), unknown (3.7%) and iatrogenic (0.8%). Conclusion: Data from this study show the need for information for the population and educational campaigns leading to prevention of facial trauma.

Keywords: Trauma centers. Facial injuries. Health services research.

Hospital Estadual São Lucas, Departamento de Traumatologia (Vitória/ES, Brazil).

1

How to cite: Mayrink G, Avila NGA, Belonia JB. Epidemiological survey of face trauma in a public hospital in Vitória/ES (Brazil). J Braz Coll Oral Maxillofac Surg. 2018 Sept-Dec;4(3):42-7.

DOI: http://dx.doi.org/10.14436/2358-2782.4.3.042-047.oar

Faculdades Integradas Espírito-Santenses, Graduation in Dentistry (Vitória/ES, Brazil).

2

PhD in Oral and Maxillofacial Surgery and Traumatology, Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba (Piracicaba/SP, Brazil).

3

Submitted: March 21, 2018 - Revised and accepted: June 13, 2018 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article.

DDS, Faculdades Integradas Espírito-Santenses (Vitória/ES, Brazil).

4

Contact address: Gabriela Mayrink Av. Dr. Olivio Lira, 353/ 1402- Praia da Costa – Vila Velha/ES CEP: 29.101-950 E-mail: gabimayrink@gmail.com

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Mayrink G, Avila NGA, Belonia JB

INTRODUCTION According to data from the World Health Organization, traumas are among the leading causes of death and morbidity in the world. A total of 16,000 people die from trauma every day, and facial trauma is one of the most prevalent.1,2 Facial trauma can be considered one of the worst aggressions observed in trauma centers, due to its emotional and functional effects, possibility of deformity and dissatisfaction with esthetics, work absenteeism, besides the economic impact of such traumas on the health system. 3,4,5 The patterns of facial fracture are related to several aspects, such as geographical area to be investigated, the socioeconomic backgrounds, period of investigation and climatic conditions. Traumas are more common on weekends and summer months.

They also depend on regulations concerning the local traffic laws and cultural aspects. 6,7 Considering the high incidence and prevalence of facial trauma, studies are needed to understand the patterns of these lesions, to provide appropriate and effective treatments and approaches. Additionally, such epidemiological information may also be used for the establishment of protocols aiming at prevention programs. 1 The prevention programs can be very helpful, since they involve health measures or campaigns to reduce this type of trauma.

Thus, the present study conducted an epidemiological survey of facial traumas at a public hospital in Vitória (ES), which is a reference trauma center in the region of Great Vitória.

The study analyzed records of 355 patients, victims of face trauma. The study included all patients assisted at the Oral and Maxillofacial Surgery and Traumatology service of this hospital within the defined time period. Records with missing information were excluded.

Data were collected concerning the etiology of trauma, geographic region, age group, type of fracture, and gender of patients. Data were tabulated in Microsoft Excel software and submitted to statistical analysis.

RESULTS After the exclusion of medical records with missing information, data were descriptively analyzed to characterize the sample. Categorical variables were expressed in absolute and relative frequencies. The relationship between categorical variables with more than one response and gender was analyzed by the proportions test. The study hypothesis was that two proportions were similar between genders; when the p value was significant (<0.050), this hypothesis was rejected, i.e. there was difference between proportions.

The study sample included 355 records of patients who suffered from facial trauma. As shown in Table 1A, 82% were males and 18% females. Concerning the mean age of patients, most were young people between 20 and 29 years (33.2%).

The site with highest occurrence was Great Vitória, with 50.7% of patients, more specifically in Cariacica (Table 1B). The state countryside was present in 20.6% of cases, and 1.1% were from out of the state.

Table 2A shows the most common types of trauma, with mandibular fracture being the most prevalent (37.7%), followed by zygoma (36.6%), nose (29%), orbit (6.2%), maxilla (5.9%), isolated soft tissue lesion (i.e. without bone fracture) (3.1%), dentoalveolar fracture (2.3%), frontal bone fracture (2.3%) and panfacial fracture (1.4%).

Since the mandible presented the highest occurrence, Table 2B presents which mandibular anatomical regions were most commonly found: body (32.1%), angle (29.1%), condyle (21.6%), symphysis (16.4%), parasymphysis (12.7%), ramus (5.2%) and coronoid process (0.7%).

METHODS The present epidemiological, retrospective, observational, descriptive and cross-sectional study was conducted by analysis of records of patients assisted at the surgical center of the Oral and Maxillofacial Surgery and Traumatology Service of São Lucas State Hospital, in Vitória/ES, in the period September 2014 to September 2016.

This study was approved by the Institutional Review Board of FAESA University Center. The informed consent form was not necessary because this was a retrospective two-year study that used only information from medical records, respecting the secrecy in the identification of patients.

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Epidemiological survey of face trauma in a public hospital in Vitória/ES (Brazil)

Table 1A: Sample characterization: absolute and percentage numbers.

Variables

Gender Male Female Age range 17 to 19 years 20 to 29 years 30 to 39 years 40 to 49 years 50 to 59 years 60 years or more Place Great Vitória State countryside Outside the state Not informed Total

n

%

291 64

82.0 18.0

27 118 98 58 42 12

7.6 33.2 27.6 16.3 11.8 3.4

180 73 4 98 355

50.7 20.6 1.1 27.6 100.0

Table 1B: Sample characterization: absolute and percentage numbers of places in Great Vitória.

Table 2A: Absolute and percentage numbers of types of facial fractures.

Type of fracture

n

%

Mandible Zygoma Nose Orbit Maxilla Dentoalveolar Frontal Panfacial Soft tissue lesion Total

134 130 103 22 21 8 8 5 11 355

37.7 36.6 29.0 6.2 5.9 2.3 2.3 1.4 3.1 100.0

n

%

Cariacica

59

32.8

Vila Velha

56

31.1

Vitória

34

18.9

Guarapari

14

7.8

Serra

10

5.6

Viana

7

3.9

Total

180

100.0

Table 2B: Absolute and percentage numbers of types of mandibular fracture.

Mandible

n

%

Body

43

32.1

Angle

39

29.1

Condyle

29

21.6

Symphysis

22

16.4

Parasymphysis

17

12.7

Ramus

7

5.2

Coronoid

1

0.7

Not informed

12

9.0

Total

134

100.0

centage in the analysis, Table 3B subdivides the types of accidents, as follows: motorcycle (78%), bicycle (22.9%), car (11.9%) and runovers (10.1%). Concerning the interpersonal violence, physical aggression accounted for most cases (70.6%), followed by gunshot wounds and cold steel weapons.

Concerning the etiology of trauma (Table 3A), the major cause of facial trauma were traffic accidents (37.7%), followed by interpersonal violence (33.5%), fall (14.9%), sports accident (7%), work accident (2.3%), unknown (3.7%) and iatrogenesis (0.8%).

Regarding traffic accidents, with the highest per-

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Cities in Great Vitória

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Mayrink G, Avila NGA, Belonia JB

Table 3A: Absolute and percentage numbers of etiology.

Table 3B: Absolute and percentage numbers of traffic accidents.

Etiology

n

%

Traffic accidents Interpersonal violence Fall Sports accident Work accident Unknown Iatrogenesis Total

134 119 53 25 8 13 3 355

37.7 33.5 14.9 7.0 2.3 3.7 0.8 100.0

n

%

Motorcycle

85

78.0

Bike

25

22.9

Car

13

11.9

Runover

11

10.1

Total

109

100.0

from epidemiological studies conducted in São Paulo (2003), Recife (1988, 1998) and Brasília (2004) revealed that the majority of patients had the following characteristics: male gender and age between 20 and 40 years.3,4.8,9 Males accounted for 82% of all traumas. This number can be attributed to the fact that males represent the majority of the economically active population, are more abusive in drug and alcohol consumption, are the majority in traffic (and thus more exposed to the risk of trauma), and are also more involved in interpersonal violence.1,9,10,11 As in the present study, the highest prevalence regarding the age distribution of patients occurred in young adults (18 to 40 years). This age range can be considered a risk group because it presents greater physical capacity and is more present in high risk situations.1,10 Data from the literature show that, in young adulthood, trauma is also the major cause of death.7 The area of greatest ​​ incidence of trauma was the region of Great Vitória, more specifically in Cariacica, which is a city with high rate of violence in that region.

Regarding the etiology of the trauma, there was predominance of traffic accidents, with 134 patients (37.7%) of the sample, followed by interpersonal violence, with 119 patients (33.5%). The literature shows the relationship between socioeconomic background

Data were crossed between gender and age, type of fracture and gender, and etiology and gender. After application of the proportions test, which analyzed these relationships, and considering as significant results with p<0.050, statistically significant difference was only found between zygoma fracture and the male gender, and this percentage was higher and increased proportionally.

DISCUSSION The present study evaluated the profile of 355 patients, victims of facial trauma, assisted at the department of Oral and Maxillofacial Surgery at a public hospital in Brazil. Located in Vitória, capital of the state of Espírito Santo, the São Lucas Hospital is a reference trauma center for the metropolitan region of Great Vitória (comprising the cities of Vitória, Vila Velha, Serra, Guarapari, Cariacica, Fundão and Viana). These cities correspond to more than half of the urban population of the entire state, with approximately 1,910,101 inhabitants, according to IBGE data from 2016.

Descriptive analysis of data revealed the importance to disseminate such results, to raise the awareness and establish preventive measures to reduce the incidence of facial trauma.

As observed, trauma mostly affected males, especially at the age range 20 to 29 years. Similar data

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Epidemiological survey of face trauma in a public hospital in Vitória/ES (Brazil)

there was greater awareness about the prevention of accidents and stricter traffic laws. This change in drivers’ awareness reduced the traffic violence as etiologic factor of facial trauma, from 23.3% to 14% in the study sample.14 Among the traffic laws, we emphasize the Lei Seca (“Dry Law”) in 2008, and later in 2011 a resolution of this law, which considers a crime driving under any amount of alcohol (zero tolerance). The study of Porto et al.15 comprised an epidemiological survey of data from hospital admissions due to car accidents in Brazil, obtained from a database of the Ministry of Health. The result revealed a reduction of hospitalization rates involving car accidents since the increased in strictness of the Operação Lei Seca (“Dry Law Operation”).15 However, in some countries such as Switzerland and Nigeria, despite the introduction of traffic rules such as seatbelt, helmet use and the installation of safety devices in cars (airbags), the results were not as effective to reduce the number of traumas. The greatest benefit was not a reduction in the number of accidents, but a reduction in their severity.6,11,16 The mandible was the most affected anatomic region. This agrees with the literature, which mentions that this fact is due to its position in the face and its mobility, increasing the predisposition to fractures.4,17 Interpersonal violence is usually associated with zygoma and mandibular fractures; most of them are less complex traumas and easier to treat when compared to traffic accidents. This occurs because, in crashes, the bone absorbs an impact with much greater force and at higher speed.16 According to the Map of Violence published by Waiselfisz,18 until 2008, the state of Espírito Santo ranked second among states with highest number of homicides per inhabitant. This justifies the high number of patients with facial fractures due to interpersonal violence in the present sample, almost equaling the number of traffic accidents.18 The association with consumption of alcohol, tobacco and drugs can increase the risk of traumas, either by traffic accidents or aggressions. Alcohol, being the main one, has the effect of disinhibiting the patient, which increases the chance of being more violent.2,16 The results obtained in more recent studies show a change in the etiology of trauma. In older publica-

and the etiology of trauma. Thus, developing countries present higher rates of facial trauma related to traffic accidents, such as Brazil, India and China. In developed countries, he major cause was physical aggression, such as the United States and European countries.5 The present case series is a small sample that portrays this reality from Brazil.

Brazil is on the fifth place concerning the traffic accidents, behind India, China, United States and Russia. In the state of Espírito Santo, more than half of traffic accidents is concentrated in the cities of Vitória, Vila Velha, Serra and Cariacica.12 This study revealed that motorcycle accidents had the highest prevalence, followed by bicycle, cars and runover. According to data in the literature, motorcyclists present 30 times higher risk of death in traffic accidents compared to car accidents.13 It should be emphasized that patients who died before intervention by the maxillofacial surgeon were not included in this study. The numbers of facial fractures would probably be even higher if these traumas with greater impact had been included in the sample.

According to data from DENATRAN (National Traffic Department), the number of motorcyclists increased between 2011 and 2016 by 21.2% per year.5 This is a cause of concern, since the increase in the number of vehicles, combined to lack of or even negligence in the use of adequate safety equipment, creates a great risk situation for facial trauma.

The present sample had no data regarding the use of safety equipment (helmets, bicycle chin protectors). The world literature presents the common fact that, in most motorcycle or bicycle accidents, the helmet was missing or incorrectly used, even though this is a mandatory safety equipment. Besides avoiding death, the correct use of the helmet reduces the severity of injuries in facial traumas, especially in soft tissue injuries and zygomatic fractures.13 These data evidence the importance of stricter traffic laws, as well as awareness of motorcycle and bicycle users.

Some studies suggest a tendency of reduction in the severity of traumas due to traffic accidents, thanks to investments to improve the road conditions, better vehicle safety systems, punitive laws for drivers who use alcohol, mandatory use of the seat belt, among others.1,3 The study by Meira et al.14 compared facial trauma data in a public hospital, also in Brazil, in a 14-year interval. In that interval between collections,

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Mayrink G, Avila NGA, Belonia JB

tions, the studies showed traumas by car accidents as the main reason; in more recent studies, this pattern has changed and placed interpersonal violence had the highest prevalence in the etiology of facial traumas.4 The present sample still presents traffic accidents as the main cause, yet the number almost equals that of physical aggressions.

This context shows a health system still focused on curative rather than preventive measures, which is costlier for the public system. A study carried out in Brazil in 2004 at Restauração Hospital in Recife/PE, analyzed the cost for victims of facial trauma, and the results obtained in a period of one year (2001-2002) showed an expense of R$ 71,574.01 for 129 patients; in the following year (2002-2003), of R$ 123,036.50 for 180 patients. This accounted for 8.5% of these hospital costs.19

This analysis clearly evidences the need for attention in preventive and educational measures related to the epidemiology of facial trauma, with programs focused mainly on traffic accidents and interpersonal violence, addressing traffic education and safety, use of alcohol and drugs, and manifestations of violence.

CONCLUSION In this sample, facial traumas were more prevalent in young men. The most frequent etiology was traffic accidents, followed by interpersonal violence. Data demonstrate the need for educational campaigns and prevention of facial trauma.

References:

1. Carvalho TBO, Cancian LRL, Marques CG, Piatto VB, Maniglia JV, Molina FD. Six years of facial trauma care: an epidemiological analysis of 355 cases. Braz J Otorhinolaryngol. 2010;76(5):565-74.

2. Campos MLR, Costa JF, Almeida SM, Delwing F, Furtado FMS, Lima LNC. Análise de lesões orofaciais registradas no Instituto Médico-Legal de São Luís (MA) no período de 2011-2013. Rev Brasl Odontol Legal.

2016;3(2):21-31.

3. Wulkan M, Parreira JG, Botter DA. Epidemiologia do trauma facial. Rev Assoc Med Bras. 2005;51(5):290-5.

4. Macedo JLS, Camargo LM, Almeida PF, Rosa SC. Perfil epidemiológico do trauma de face dos pacientes atendidos no pronto socorro de um hospital público.

Rev Col Bras Cir. 2008;35(1):9-13.

5. Ribeiro ALR, Gillet LCS, Vasconcelos HG, Rodrigues LC, Pinheiro JJV, Alves-Júnior SM. Facial fractures: large epidemiolofigc survey in Northern Brazil reveals some unique characteristics. Am Assoc Oral Maxillofac Surg. 2016;74(12):2480.e1-12.

6. Brasileiro BF, Passeri LA. Epidemiological analysis of maxillofacial fractures in Brazil: a 5-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006 July;102(1):28-34.

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7. Mello Filho FV, Ricz H. Epidemiological modifications of facial trauma and its implications. Braz J Otorhinolaryngol. 2014 May-June;80(3):187-8.

8. Falcão MFL, Segundo AVL, Silveira MMF. Estudo epidemiológico de 1758 fraturas faciais tratadas no Hospital da Restauração, Recife/PE. Rev Cir Traumatol Buco-Maxilo-Fac. 2005;5(3):65-72.

9. Siqueira SP, Lauxen JR, Conto F, Ávila VJB. Gastos financeiros do Sistema Único de Saúde com pacientes vítimas traumatismo facial. Rev Ciênc Méd Biol.

2016;15(1):27-33.

10. Paes JV, Paes FLS, Valiati R, Oliveira MG, Pagnoncelli RM. Retrospective study of prevalence of face fractures in southern Brazil. Indian J Dent Res. 2012 JanFeb;23(1):80-6.

11. Menezes MM, Yui KCK, Valera MC. Prevalência de traumatismos maxilo-faciais e dentais em pacientes atendidos no pronto-socorro municipal de São José dos Campos/SP. Rev Odonto Ciênc.

2007;22(57):210-6.

12. Castiglioni AH, Faé MI. Inter-relação entre a frota de veículos, a ocorrência de acidentes de trânsito e o adensamento populacional no Espírito Santo. Ateliê Geográfico. 2014;8(1):103-27.

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13. Adams NS, Newbury PA, Eichhorn MG, Davis AT, Mann RJ, Polley JW, et al. The effects of motorcycle helmet legislation on craniomaxillofacial injuries. Plast Reconstr Surg. 2017;139(6):1453-7.

14. Meira HC, Oliveira FLC, Noronha VRAS, Naves MD. Acidentes de trânsito e epidemiologia do trauma facial. J Braz Coll Oral Maxillofac Surg. 2016;2(1):31-7.

15. Porto GG, Silva CCG, Pereira VBS, Oliveira JJ, Antunes AA, Leal JF. Acidentes automobilísticos no Brasil: estudo observacional da Operação Lei Seca. J Braz Coll Oral Maxillofac Surg. 2015;1(3):27-32.

16. Lee KH, Qiu M. Characteristics of alcohol-related facial fractures. J Oral Maxillofac Surg.

2017;75(4):786.e1-7.

17. Leporace AAF, Paulesini W Júnior, Rapoport A, Denardin OVP. Epidemiologic study of mandible fractures in a public hospital of São Paulo. Rev Col Bras Cir. 2009;36(6):472-7.

18. Waiselfisz JJ. O mapa da violência 2011: os jovens do Brasil. Brasília: Instituto Sangari; 2011.

19. Silva JJ, Cauas M. Avaliação da violência urbana e seu custo cirúrgico na vítima do trauma de face no hospital Restauração - Recife PE. Odontol Clín Cient.

2004;3(1):49-56.

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Casereport

Facial asymmetry corrected with

orthognathic surgery JOÃO CARLOS BIRNFELD WAGNER1 | MAURICIO ROTH VOLKWEIS1 | RODRIGO ANDRIGHETTI ZAMBONI1 | TATIANA WANNMACHER LEPPER1 | LUCIANA ZAFFARI1 | JOÃO RICARDO KOCH BRANDALISE1

ABSTRACT Orthognathic surgery is the surgical procedure that aims at treating dentoskeletal or dentofacial deformities such as prognathism, retrognathism and other alterations in the position of the maxilla and/or mandible, searching for function and aesthetics.

The facial asymmetry represents an imbalance in the proportions of the homologous bone structures of the face, when compared with each other. This asymmetric growth affects a large part of the population, but only when it is perceptible by the patient, this asymmetry becomes a problem to be solved. The objective of his work is to report a clinical case of facial asymmetry, exposing the type of surgical treatment proposed with corrective purpose. The proposed treatment combined orthognathic surgery of the mandible and maxilla, with graft in the maxilla using autogenous iliac bone. We can conclude that the use of orthognathic surgery in the treatment of facial asymmetry is a technique of correct choice. The correct diagnosis and planning of the case is fundamental for indicating the surgical procedure.

Keywords: Orthognathic surgery. Facial asymmetry. Surgery, oral.

Irmandade Santa Casa de Misericórdia de Porto Alegre, Serviço de Cirurgia e Traumatologia Bucomaxilofacial (Porto Alegre/RS, Brazil).

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How to cite: Wagner JCB, Volkweis MR, Zamboni RA, Lepper TW, Zaffari L, Brandalise JRK. Facial asymmetry corrected with orthognathic surgery. J Braz Coll Oral Maxillofac Surg. 2018 SeptDec;4(3):48-52. DOI: http://dx.doi.org/10.14436/2358-2782.4.3.048-052.oar

Submitted: August 07, 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: Tatiana Wannmacher Lepper E-mail: tati-lepper@hotmail.com

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Wagner JCB, Volkweis MR, Zamboni RA, Lepper TW, Zaffari L, Brandalise JRK

INTRODUCTION Orthognathic surgery consists of a combined procedure between Orthodontics and Oral and Maxillofacial Surgery, aiming to correct facial deformities.1 Since this treatment involves a functional component (aiming at correction of dental occlusion) and an esthetic component (aiming at better harmony and balance of the facial pattern), it requires precise diagnosis and planning aiming to improve the patientâ&#x20AC;&#x2122;s function and esthetics.2 The facial asymmetry represents an imbalance in the proportions of homologous facial bone structures, when compared to each other. This asymmetric growth affects a great part of the population; however, this asymmetry becomes a problem only when noticed by the patient.

Malformations may arise in isolation in the maxilla or may extend to the other craniofacial structures. The asymmetries may be hereditary, congenital or environmental; their cause may be functional, skeletal, dental, or a combination of these. Genetic factors can affect the development of the mandible, maxilla and other facial bones, causing changes in the size and shape of these bones.

The congenital factors may involve embryonic disorders in the proliferation and development of neural crest cells, causing changes in craniofacial development.

The environmental factors alter the craniofacial development and growth, such as fractures, traumas to the temporomandibular region or pathologies as tumors and infections.

Other factors that may correlate with facial changes are nutritional, hormonal, nerve damage, and vascular lesions.

The correct diagnosis of these deformities and their treatment plan depend on the clinical and radiographic evaluation, analysis of dental casts, of surgery and predictive surgical cephalometric tracing.3,4,5 The facial analysis performed by the surgeon provides a list of surgical options aimed at improving the facial esthetics. These options, analyzed with cephalometric and occlusal data, determine the most appropriate procedure to correct the deformity, with maximum esthetic gain for the patient.6 In some cases, the discrepancy presented by the patient does not allow resolution only with single-jaw surgery, thus a combined procedure is indicated. Therefore, it is necessary to consider the esthetic

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modifications inherent to each movement, while in other cases the double-jaw surgery may be indicated, primarily aiming at a better facial esthetics1.

Thus, this paper reports a clinical case of facial asymmetry, presenting the type of surgical treatment proposed for corrective purpose.

CASE REPORT A 40-year-old female patient attended the Oral and Maxillofacial Surgery and Traumatology Service of Santa Casa de MisericĂłrdia at Porto Alegre (RS) due to referral for orthognathic surgery, with the chief complaint of facial asymmetry and masticatory difficulty.

After anamnesis, facial analysis, intra and extraoral examinations, analysis of panoramic, frontal and lateral radiographs, as well as dental casts and cephalometric analysis, it was observed that the patient had facial asymmetry with midline displacement due to vertical maxillary deficiency on the left side, combined with Class III dentoskeletal deformity (Fig 1 and 2). The proposed treatment included combined orthognathic surgery of the mandible and maxilla, with autogenous iliac bone graft on the maxilla. The orthodontic-surgical preparation was performed preoperatively, and after completion surgery was performed on the dental casts and preoperative exams were obtained. The patient was submitted to surgery under general anesthesia. The surgical procedure consisted of the following steps (Fig. 3): A) Le Fort I osteotomy; B) sagittal osteotomy in the mandible; C) maxillomandibular block using an interocclusal guiding plate; D) graft preparation with accomplishment of two slots in the upper and lower portions, for later insertion in the left maxillary gap; E) graft on the left maxilla, by rigid fixation with system 1.6 plates and screws; F) mandibular retraction and rigid fixation with system 2.0 plates and screws; G) suture with Vycril 4.0 and maintenance of maxillomandibular block . Postoperatively, the patient was medicated with antiemetics, analgesics, corticoids and antibiotics. Ice packs were applied intermittently during the first 24 hours postoperatively.

The patient was kept in follow-up and, as shown in Figure 4, she evolved uneventfully, with resolution of the initial asymmetry and dentoskeletal deformity.

She is satisfied with the result of the proposed treatment, reporting significant esthetic and functional improvement.

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Facial asymmetry corrected with orthognathic surgery

A

B

C

C

D

Figure 1: A) Midline. B) Facial thirds. C) Profile.

A

B

Figure 2: A) Intraoral photograph. B) Panoramic radiograph. C) Posteroanterior radiograph. D) Lateral cephalogram.

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Wagner JCB, Volkweis MR, Zamboni RA, Lepper TW, Zaffari L, Brandalise JRK

A

B

C

D

E

F

Figure 3: A) Le Fort I osteotomy. B) Sagittal osteotomy. C) Maxillomandibular block. D) Iliac crest preparation. E) Rigid graft fixation on the left maxilla.

F) Rigid fixation after mandibular setback.

A

B

C

Figure 4: Postoperative aspect: A) 14 days; B) 21 days; C) 60 days.

DISCUSSION The orthodontic-surgical treatment for correction of dentofacial deformities is well established in the literature, and orthognathic surgery is a surgical procedure with satisfactory predictability, aiming at better bone and dental balance within the facial complex.

According to Ribas et al.7, the maxillomandibular relaŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

tionship corrected by orthognathic surgery favors the masticatory function, speech, respiration and facial esthetics.

Therefore, many implications are involved in this surgical treatment, since the facial changes affect the individualâ&#x20AC;&#x2122;s personal and social life, and sometimes the psychological aspect of the patient should be prepared to receive a surgical procedure of this magnitude.

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Facial asymmetry corrected with orthognathic surgery

CONCLUDING REMARKS The treatment proposed in the described clinical case, with surgical approach in the maxilla, utilization of autogenous graft and surgical approach in the mandible to correct the occlusion and facial pattern, was successful. Correct diagnosis and planning of the case is fundamental to indicate the surgical procedure.

Guimarães Filho et al.8 also highlight that this procedure can significantly improve the quality of life of people with dentofacial deformities, enhancing their self-esteem – similar results to those found in the present report.

The Le Fort I osteotomy is the procedure of choice to correct most maxillary and midface deformities and is considered a stable technique. In some cases, the discrepancy presented by the patient does not allow resolution by single-jaw surgery, e.g. in the maxilla, and a combined procedure is indicated. In these cases, when grafting is necessary, the autogenous graft is chosen as the main material for bone reconstruction, since it presents the three fundamental characteristics for bone repair and graft maintenance: osteoconduction , osteoinduction and osteogenesis.

References:

1. Turvey TA et al. Orthognathic surgry: a significant contribution to facial an dental esthetics. J Am Dent Assoc. 1998 Sept;117(4):49E-55E. 2. Fonseca R. Oral and Maxilofacial Surgery. 1st ed. Hardcover: Elsevier; 2000.

3. Neubert J, Bitter K, Somsiri S. Refined intraoperative repositioning of the osteotomized maxilla in relation to the skull and TMJ. J Craniomaxillofac Surg. 1988 Jan;16(1):8-12.

4. Satrom KD, Sinclair PM, Wolford LM. The stability of double jaw surgery: a comparison of rigid versus wire fixation. Am J Orthod Dentofacial Orthop. 1991 June;99(6):550-63.

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5. Vig KD, Ellis E. Diagnosis and treatment planning for the surgical-orthodontic patient. Dent Clin North Am. 1990 Apr;34(2):361-84.

6. Epker BN. Chaisrisookumporn N, Stella JP, .Cephalometric profile evaluations in patients with cleft lip and palate. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995 Aug;80(2):137-44.

7. Ribas MO, Reis LFG, França BH, Lima AAS. Cirurgia ortognática: orientações legais ortodontistas e cirurgiões bucofaciais. Rev Dental Press Ortod Ortop Facial. 2005;10(6):75-83.

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8. Guimarães Filho R, Oliveira Junior EC, Gomes TRM, Souza TDA. Qualidade de vida em pacientes submetidos à cirurgia ortognática: saúde bucal e autoestima.

Psicologia: Ciência Profissão. 2014;34(1):242-51.

9. Nattrass C, Sandy JR. Adult Orthodontics: a review.

Br J Orthod. 1995 Nov;22(4):331-7.

J Braz Coll Oral Maxillofac Surg. 2018 Sept-Dec;4(3):48-52

Casereport

Brain abscess due to infection after

tooth extraction

ISABELA POTRATZ AULER1 | LUCCAS LAVAREZE1 | ANA LUIZA LEAL1 | RAMON GAVASSONI2 | VINICIUS ANTUNES3 | MARTHA ALAYDE ALCANTARA SALIM1

ABSTRACT Brain abscess is a rare and life-threatening infection to the patient. It can be caused by trauma, neurosurgical complications or metastatic infections originated from other tissues or organs, such as odontogenic infections. The present article reports the case of a patient that developed a severe facial cellulitis and subsequent brain abscess due to third molar extraction under antibiotic prophylaxis, whose treatment was successfully performed in a hospital setting, by a multidisciplinary approach through the combination of intravenous antibiotic therapy, corticoid and prophylactic anticonvulsant, since it was a unique collection of approximately 2 cm. Ideally, the treatment should be individualized according to the patient, with a multidisciplinary approach aiming at a successful treatment.

Keywords: Brain abscess. Focal infection. Dental. Serratia marcescens.

Universidade Federal do Espírito Santo, Departamento de Clínica Odontológica (Vitória/ES, Brazil).

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How to cite: Auler IP, Lavareze L, Leal AL, Gavassoni R, Antunes V, Salim MAA. Brain abscess due to infection after tooth extraction. J Braz Coll Oral Maxillofac Surg. 2018 Sept-Dec;4(3):53-9.

DOI: http://dx.doi.org/10.14436/2358-2782.4.3.053-059.oar

Hospital Santa Casa da Misericórdia de Vitória, Setor de Cirurgia e Traumatologia Bucomaxilofacial (Vitória/ES, Brazil).

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Submitted: April 10, 2018 - Revised and accepted: June 21, 2018

Universidade Estadual do Rio de Janeiro, Faculdade de Odontologia, Disciplina de Cirurgia e Traumatologia Bucomaxilofacial (Rio de Janeiro/RJ, Brazil).

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» 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: Martha Alayde Alcantara Salim E-mail: marthasalim@gmail.com

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Brain abscess due to infection after tooth extraction

INTRODUCTION Brain abscess is defined as a focal infection that begins as a localized area of cerebritis and develops as a purulent collection wrapped by a well-vascularized capsule. It is a rare and serious condition, life threatening for the patient, and may be caused by trauma, neurosurgical complications or from septic sites in several locations.1 Occasionally, odontogenic or post-extraction infections have been reported as a source of bacteria that can lead to brain abscess1, whose pathogens would reach the central nervous system by the hematological or lymphatic via, or by direct extension through the fascial planes. 1,2,3 Patients with immunodeficiency, such as transplanted patients and those with AIDS and/or underlying brain pathologies, such as a previous stroke or neoplasms, seem to be more prone to the occurrence of brain abscess. 2,4,5,6 The diagnosis is based on the clinical status, clinical and neurological examination and complementary neuroimaging tests, such as computed tomography (CT) and magnetic resonance imaging (MRI). There are three types of predominant clinical manifestation: 1) infectious syndrome, with malaise, fever, photophobia, nuchal rigidity and circulatory collapse; 2) intracranial hypertension syndrome: headache, nausea, vomiting and papilledema; and 3) focal neurological syndrome, according to the​​ abscess location, with supratentorial, cerebellar or, more rarely, brainstem symptoms. 6 This treatment of this condition is based on three pillars: antibiotic therapy, neurosurgery and treatment of the primary focus of infection 3. Recent advances in imaging techniques and the development of effective antibiotics have helped to reduce the mortality rate. 2 The aim of the present paper is to present a case report of brain abscess due to odontogenic infection after a third molar extraction.

volume increase on the right side and continuous fever. On the third day after extraction, the dentist removed the sutures and performed surgical irrigation of the area. On the sixth day after extraction, due to progression of the condition, the patient was hospitalized for surgical intraoral drainage and empirical intravenous antibiotic therapy, with crystalline penicillin G 5,000,000 L at every 4 hours, and metronidazole 500mg at every 8 hours. Laboratory tests were performed on the seventh day after extraction, revealing leukocytosis (14,000/mm3).

With worsening of the systemic condition, the patient was referred to the specialized service of Oral and Maxillofacial Surgery and Traumatology. Upon admission, on clinical examination, he presented signs of severe systemic toxemia. Extraoral physical examination revealed erythema on the neck and chest region, with erasure of the sternal notch and swelling on the right hemiface (involving preauricular, temporal, buccal, masseteric, submandibular, sublingual, and submental facial spaces) (Fig 1). At intraoral examination, the pterygomandibular and right lateral pharyngeal spaces were affected; a drain was present on the bottom of the mandibular vestibule, with active purulent drainage. Additionally, the patient presented signs and symptoms of dysphagia, dyslalia, dyspnea and severe trismus, with 6 mm of mouth opening, characterizing a severe facial cellulitis.

New laboratory tests revealed leukocytosis (13,600/mm3) and high CRP (173.55 mg/dL). However, glucose, red blood cells and blood clotting tests were within the normal range. Blood culture was negative for anaerobic and aerobic pathogens.

Computed tomography of the face and airway revealed diffuse density in muscle-fat planes with apparent origin on the region of right masticatory space, involving the palatine tonsil and parapharyngeal space, extending superiorly to the infratemporal fossa on the right side, and inferiorly to the pre-vertebral space, with liquid with organized aspect up to the level of C6 vertebra. Thus, significant reduction in the air column amplitude of the cavum, oropharynx and larynx was observed, with glottis infiltration (Fig 2).

There was also extension of densification of the muscle-fat planes of the right anterolateral aspect of the neck, compatible with cellulitis, and hypodensity affecting the middle third of the right sternocleidomastoid muscle. The tomographic images suggested

CASE REPORT Male patient, aged 32 years, was submitted to extraction of the right third molar. Postoperatively, the patient was prescribed amoxicillin 500 mg (posology 1 capsule at every 8 hours for 7 days). On the second postoperative day, the patient presented intense pain complaints at the extraction site, evolving with

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Auler IP, Lavareze L, Leal AL, Gavassoni R, Antunes V, Salim MAA

Figure 1: Frontal view evidencing extensive volume increase (facial cellulitis) involving the preauricular, masseteric, buccal, submandibular (right side) and submental regions.

Figure 2: Computed tomography of the face and airway exhibiting image of diffuse density on the muscle-fat planes, with apparent origin from the right masticatory space, involving the palatine tonsil and parapharyngeal space, extending superiorly to the right infratemporal fossa and inferiorly to the prevertebral space, with liquid with organized aspect up to the level of C6 vertebra.

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Brain abscess due to infection after tooth extraction

After four days postoperatively, the patient was discharged from the hospital and followed-up at every 3 days on the outpatient clinic, with prescription of ciprofloxacin 500 mg orally at every 12 hours for 10 days. The outpatient control at each follow-up included blood test and CRP. A CT scan was performed twenty days after surgical drainage. There was significant improvement in the inflammatory/infectious process, which at that time was restricted to the palatine tonsil region, masticatory space and right infratemporal fossa, without organized collections.

In the outpatient follow-up 22 days postoperatively, despite the improvement in the clinical status and regression of facial infection, the patient started intermittent headache, which worsened at bedtime, and was referred for evaluation by the neurosurgery department of the same hospital. The magnetic resonance imaging of the skull revealed an encapsulated lesion on the anteromedial region of the right temporal lobe, smaller than 2 cm (Fig. 3).

posterior anterovertebral abscess and extensive and diffuse cellulitis of the face and neck. The chest CT scan did not indicate significant changes.

The patient was immediately hospitalized and submitted to intravenous antibiotic therapy with clindamycin 600mg/4ml at every 6 hours and intravenous gentamicin 80mg/2ml at every 8 hours associated with analgesic and anti-inflammatory drugs.

The patient was submitted to surgery under general anesthesia and bronchofibroscopy-assisted orotracheal intubation to perform drainage of the involved spaces and collection of material for culture and antibiogram. During the procedure, the fixed drains that were previously present were removed. Penrose drains were placed on the extraoral submandibular and retromandibular regions, and intraorally at the buccal sulcus and lateropharyngeal space, which were maintained for 72 hours, with drainage of active purulent secretion.

The result of culture and antibiogram revealed the presence of Serratia marcescens bacteria, which is sensitive to piperacillin tazobactam, cefotaxime, ceftazidime, cefepime, aztreonam, ertapenem, imipenem, meropenem, amikacin, gentamycin, ciprofloxacin and tigecycline; and resistant to ampicillin, ampicillin/sulbactam, cephalothin and colistin. As indicated by the infectious disease doctor, gentamicin was replaced by intravenous ceftriaxone 2 g once daily and intravenous clindamycin 600 mg/4 ml was maintained at every 6 hours.

New laboratory tests were collected after 24 hours of surgical drainage, with persistence of slight leukocytosis (11,400/mm3) yet showing improvement. The new blood culture remained negative for anaerobic and aerobic microbial growth. Still in this period, there was spontaneous purulent drainage through the present drains, with progressive improvement of the clinical status of the patient.

On the third day after surgical drainage, all drains were removed and laboratory examinations and computed tomography of neck soft tissues (expanded to the submandibular region) were requested. The leukocyte count was 9,200/mm 3 and the CRP was 71.80 mg/dL, showing a decrease in these values; blood culture for anaerobes and aerobes remained negative. The tomographic examination showed improvement in all parameters when compared to the preoperative images.

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Figure 3: Axial section of magnetic resonance imaging of the skull evidencing oval lesion in hyposignal on the temporal lobe with approximate diameter of 2 cm.

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Auler IP, Lavareze L, Leal AL, Gavassoni R, Antunes V, Salim MAA

resistance and fascial spaces.8 The location of infection and anatomy of the region will determine the affected space, most commonly affecting the submandibular, submental, sublingual, masticatory and parapharyngeal spaces,3 as seen in the present report.

Patients with immunodeficiency, e.g. transplanted patients and those with AIDS and/or underlying brain pathologies, such as a previous stroke or neoplasms, appear to be more prone to the occurrence of brain abscess.2,4,5,6 Even in cases without serious systemic disorders, as in this case report, there may be serious complications such as the brain abscess.

Brain abscesses are often polymicrobial. The microorganisms most commonly found in reports are lusan streptococci (S. viridans) and anaerobic bacteria (bacteroid species, A. actinomycetemcomitans), Staphylococcus aureus and gram-negative facultative anaerobic bacteria (enterobacteria).1 The Serratia marcescens, a pathogen found in this report, is a gram-negative bacterium of the Enterobacteriaceae family, commonly opportunistic in immunosuppressed patients, being common in the oral microbiota and typically found in hospital infections. Generally resistant to a wide variety of antibiotics, the contaminations can result from contaminated medical devices, contaminated fluids, cleaning solutions, and contaminated hands from the hospital staff. The main risk factor for S. marcescens infection in the central nervous system is a post-neurosurgical state.9 Brain abscesses originated from infections disseminated by hematogenous via are usually multiple, deep, poorly encapsulated at the time of diagnosis, presenting a poor prognosis and tending to distribute to areas of greater brain blood flow. Differently, infections developed due to contiguous dissemination tend to form single abscesses, as seen in this case, and confirmed by negative blood cultures for aerobes and anaerobes 6.

The diagnosis is based on the clinical status, clinical and neurological examination and complementary neuroimaging tests, such as CT and MRI. The predominant clinical manifestation can be of three types: 1) infectious syndrome, with malaise, fever, photophobia, nuchal rigidity and circulatory collapse; 2) intracranial hypertension syndrome, with headache, nausea, vomiting and papilledema; and 3) focal neurological syndrome, according to the abscess location, with supratentorial, cerebellar or, more rarely, brain-

The patient was hospitalized, and intravenous antibiotic therapy was initiated with cefepime 2 g at every 12 hours, in combination with dexamethasone 2mg/ml at every 8 hours and phenobarbital 100 mg orally once daily at night for three days, prophylactically, due to the deep location of the lesion in the brain, to avoid possible seizures. The patient was evaluated in the Braden Scale as higher than 16, indicating minimal risk; Fugulin scale as 9 to 14, indicating minimal assistance to the case; and Glasgow as 15, indicating only conservative approach with medication, without the need of surgery to manage the brain abscess. On the second day of hospitalization the patientâ&#x20AC;&#x2122;s clinical condition had improved, without motor deficit or cognitive impairment and no complaints of headache.

At the end of the fourth day of hospitalization, the patient received supervised discharge, returning daily to the hospital for administration of intravenous cefepime 2g/day for further 14 days. The patient remained under the care of the neurosurgery team, evolving positively with the treatment. After 14 days of the first MRI, a new one was performed for control and follow-up, which revealed regression of the collection on the right temporal pole, and marked reduction of the local edema, without appearance of new lesions.

DISCUSSION Cranial trauma, craniomaxillofacial surgeries and metastatic infectious foci (such as odontogenic or maxillofacial infections) may be the cause of brain abscesses, rare infections characterized by a suppuration area inside the skull. 1,2,3 In the present case, the brain abscess evolved from a postoperative infection after third molar extraction.

The oral cavity is known to be home to a rich and abundant microbiota; bacteria that have access to the bloodstream can then spread to distant sites.

The dental procedures advocated as causing brain abscesses are very comprehensive and include extraction, periodontal therapy, local anesthetic injection and dental prophylaxis, 2,7 suggesting that the mechanism responsible for bacteremia is not as critical as the host response.

The dissemination of the infectious process of odontogenic origin may occur through the hematogenic or lymphatic via, or even by contiguity, with the infection spreading through areas of lower tissue

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Brain abscess due to infection after tooth extraction

abscess. Only in some cases, antibiotics are the only form of therapy, which includes multiple abscesses, single lesion in an inaccessible location in the brain, single minor abscess smaller than 2 cm (as described in the reported case), in cerebritis stage, or in a critically ill terminal patient.10 The objectives of surgical treatment of brain abscesses are to decompress the lesion, decrease intracranial pressure and drain purulent secretion. The surgical intervention may involve burr-hole aspiration, open aspiration and excision.9 In the burr-hole aspiration, a single trephine hole is performed, and the abscess contents are aspirated through it. In open aspiration, craniotomy is performed followed by aspiration of the abscess after its location, yet without excision of the lesion wall. Excision involves craniotomy and, subsequently, excision of the abscess, including its wall, but not necessarily complete removal in all cases.10

stem symptoms. The CT improved the diagnosis of brain abscess, allowing better accuracy of the location, evolution stage, loculation, number, presence of brain edema and parameters for neuroendoscopic surgeries.

MRI should be used when available, having the same validity as the CT scan.6 The treatment method is still controversial; however, it has been based on three pillars: 1) clinical treatment with antibiotics; 2) neurosurgical treatment of the abscess, by adequate method and appropriate to the case; and 3) treatment of the primary focus of infection6. Despite controversies regarding the method, there is consensus that early treatment allows more favorable outcomes, since late interventions in advanced stages are commonly related to lethality.1 Surgical drainage of the brain abscess, either by craniotomy or by CT-guided aspiration, is often necessary to relieve the increased intracranial pressure.

Drainage also allows sampling of material to achieve a definitive microbiological diagnosis and appropriate subsequent antibiotic therapy based on the culture results. 10 For bacterial abscesses, intravenous antibiotics are generally recommended for 4 to 6 weeks, when the abscess was surgically drained, or for 6 to 12 weeks, when there is no surgical intervention. However, the duration of treatment may vary according to the clinical evolution and follow-up by imaging tests.10 Surgical intervention is usually postponed until the surrounding capsule is more developed, because the mortality of patients undergoing acute abscess treatment is twice higher than those with chronic

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

CONCLUDING REMARKS Odontogenic or maxillofacial infections may be the cause of brain abscesses. Clinical evaluation, early diagnosis of infection and appropriate treatment may inhibit the subsequent dissemination to other sites. The management of a patient with brain abscess should be multidisciplinary and integrated. In this case, clinical treatment with antibiotic therapy was directed to S. marcescens found in the culture, since it was a single purulent collection of approximately 2 â&#x20AC;&#x2026; cm, with no signs of intracranial hypertension, no alterations in the consciousness level, nor associated hydrocephalus.

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Auler IP, Lavareze L, Leal AL, Gavassoni R, Antunes V, Salim MAA

References:

1. Antunes AA, Santos TS, Carvalho RWF, Avelar RL, Pereira CU, Pereira JC. Brain Abscess of Odontogenic Origin. J Craniofac Surg. 2011 Nov;22(6):2363-5.

2. Corson MA, Postlethwaite KP, Seymour RA. Are dental infections a cause of brain abscess? Case report and review of the literature. Oral Dis. 2001 Jan;7(1):61-5.

3. Azenha MR, Lacerda AS, Bim AL, Caliento R, Guzman S. Celulite facial de origem odontogênica.

Apresentação de 5 casos. Rev Cir Traumatol BucoMaxilo-Fac. 2012 Jan 5;12(3):41-8.

4. Mathisen GE, Johnson JP. Brain abscess. Clin Infect Dis. 1997 Out;25(4):763-79.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

5. Shimomura T, Hori S, Kasai N, Tsuruta K, Okada H. Meningioma associated with intratumoral abscess formation - case report. Neurol Med Chir (Tokyo).

1994;34(7):440-3.

6. Vialogo JGG, Sanches MCA. Abscesso cerebelar tratado clinicamente. Arq Neuriosiquiatr.

2001;59(3-B):824-8.

7. Schuman NJ, Turner JE. Brain abscess and dentistry: a review of the literature. Quintessence Int. 1994 June;25(6):411-3.

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8. Rettore C, Ferreira CJ, Signori PH, Moraes JFD, Stobbe JC, Conto F. Infecções odontogênicas: análise de casos em ambiente hospitalar. J Braz Coll Oral Maxillofac Surg. 2016 Maio-Ago;2(2):23-30.

9. Yang C, Hsu NS, Liu JS, Hueng DY. Serratia marcescens spinal epidural abscess formation following acupuncture. Intern Med. 2014 Aug 1;53(15):1665-8.

10. Lazow SK, Izzo SR, Vazquez D. Do dental infections really cause central nervous system infections? Oral Maxillofac Surg Clin North Am. 2011 Nov;23(4):569-78.

J Braz Coll Oral Maxillofac Surg. 2018 Sept-Dec;4(3):53-9

CaseReport

Orbital blowout fracture:

case report

SILVIA PROVASI1 | DOUGLAS BAITELO MARINHO1 | STEPHANIE ANASENKO CORREA BORGES1 | WALTER PAULESINI JUNIOR1 | GABRIEL BAITELO MARINHO2

ABSTRACT The orbit is a short structure of the face really important, not only esthetically but also functionally, which is highly involved in facial trauma. This study presents a report of a patient traumatized by a physical aggression in the orbital region, presenting a blowout type fracture, which was proposed surgical correction of orbital fracture. Then a reduction of the fracture by internal fixation and titanium mesh adaptation was performed. The procedure achieved success in relation to the complaint of diplopia due to clearing the eye muscles that wore stucked before, and resorption of fat retained in the maxillary sinus due to trauma. Thus, in this case the rehabilitation procedure of traumatized structures was essential for recovering the ocular function of the patient.

Keywords: Fracture fixation. Orbit. Diplopia. Aggression.

Complexo Hospitalar Padre Bento de Guarulhos, Serviço de Residência em Cirurgia e Traumatologia Bucomaxilofacial (Guarulhos/SP, Brazil).

1

How to cite: Provasi S, Marinho DB, Borges SAC, Paulesini Junior W, Marinho GB. Orbital blowout fracture: case report. J Braz Coll Oral Maxillofac Surg. 2018 Sept-Dec;4(3):60-4.

DOI: http://dx.doi.org/10.14436/2358-2782.4.3.060-064.oar

Universidade Cidade de São Paulo, Faculdade de Odontologia (São Paulo/ SP, Brazil).

2

Submitted: June 16, 2016 - Revised and accepted: January 25, 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: Silvia Provasi Ambulatório de Cirurgia Bucomaxilofacial - Av. Emílio Ribas, 1819, Jardim Tranquilidade Guarulhos, São Paulo - CEP: 07.051-000 E-mail: silvia.provasi@gmail.com

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Provasi S, Marinho DB, Borges SAC, Paulesini Junior W, Marinho GB

INTRODUCTION The orbit is a bone cavity that holds and protects the eyeball, being a quadrangular pyramid with its apex located on the posteromedial region. Around 5 years of age, 85% of the orbital growth is completed, reaching maturity between 7 years of age and puberty.1 The orbital anatomy is complex, and several vital structures and highly specialized organs are contained in a small space. The cavity is formed by 7 bones: the orbital part of the frontal bone, maxilla, zygomatic and sphenoid bones, lacrimal bone, orbital process of palatine bone and orbital lamina of ethmoid bone.1,2 The orbital floor is formed, anteromedially, by the orbital process of the maxilla; anterolaterally, by a portion of the zygomatic process; and posteriorly, by a small portion of the palatine bone.4 The thickness of orbital walls varies considerably, while the orbital arch is formed by a denser cortical bone to protect the eyeball. The thickness of some areas of the floor is smaller than 0.5 mm.1 The most common injury to the orbital walls is a defect of up to 2 cm in diameter, limited to only one wall. These defects are usually located in the anterior or middle portion of the orbital floor and are named blowout fractures.1 The diagnosis of orbital fracture is clinical, with tomographic evidence. On clinical examination, asymmetry can be noticed in the positioning of eyeballs, with fall of the affected globe, which also exhibits conjunctival ecchymosis.2,3 The duction test reveals limited movement, mainly upwards, possibly causing diplopia.

It is convenient to perform the forced duction test to differentiate whether the limited movement and diplopia result from muscular entrapment or are caused by other factors, e.g. neurological factors or edema.2 Computed tomography is the imaging examination of choice to confirm the diagnosis and perform the treatment plan of orbital fractures. Conventional radiographs allow accurate assessment of most zygomatic-orbital fractures, yet they are inadequate for the evaluation of internal orbital fractures.2 The treatment of orbital fractures has been historically divided between conservative treatment (with observation for regression of signs and symptoms, and late surgical interventions for persistent sequelae) and immediate treatment. The treatment type is selected according to criteria as esthetic-functional alterations and imaging diagnosis.3,4

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

The objective of this paper is to present a case of blowout orbital fracture successfully treated with the use of titanium plate and rigid internal fixation.

CASE REPORT A 26-year-old male patient, victim of physical aggression, attended the Emergency Room of Padre Bento Hospital (Guarulhos/SP). The patient reported he had been punched on the face. The first procedures were performed, and the patient was stable.

Clinical examination performed by the Oral and Maxillofacial Surgery (CTBMF) team of the hospital revealed that the patient had swelling on the face, bilateral periorbital ecchymosis, subconjunctival hemorrhage, absence of enophthalmos, presence of diplopia on the right eye, palpable bony step on the right orbit floor, good mouth opening and no complaint of dysphagia or dyspnea. Complementary examinations were requested, including computed tomography of the skull and face. The imaging examination revealed an aspect suggestive of fracture of the anteromedial wall of the right orbit floor, with infraorbital fat herniation into the right maxillary sinus (Fig 1), confirming the clinical diagnosis.

The patient was discharged on the same day of the first assistance and was advised to return to the outpatient clinic of oral and maxillofacial surgery of the hospital, for follow-up and management of the orbital floor fracture by the CTBMF team.

After seven days, the patient returned presenting regression of edema on the face and persistent diplopia. A positive result was obtained on the forced duction test and the surgical treatment was proposed.

Fifteen days after the trauma, the patient was clinically reassessed (Fig 2 and 3) and the surgical procedure was performed. A subtarsal incision was made on the right orbital floor region, tissue planes were carefully dissected to avoid future esthetic sequelae in the region, and the affected bone tissue was exposed. During the exposure, bone fracture and entrapment of the inferior rectus and inferior oblique muscles were observed, which caused diplopia. A titanium mesh was adapted on the region and fixed with two screws, to avoid further entrapment of the musculature and restore the patientâ&#x20AC;&#x2122;s visual health.

The planes were repositioned, and an intradermal suture was performed. The patient was discharged

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Orbital blowout fracture: case report

served comparing the computed face tomographies of the face obtained on the follow-ups (Fig 4).

The final result of the surgical intervention was considered satisfactory by the team and the patient (Fig 5). The patient is under clinical and radiographic follow-up, without complaints and with improvement of ocular motricity (Fig 6).

on the day after surgery. The first postoperative follow-up was performed after seven days, presenting good tissue healing and maintenance of sutures. The patient did not complain about pain or diplopia, and the suture was removed. Further postoperative follow-ups were performed after 14 and 21 days, and resorption of the fat in the maxillary sinus was ob-

Figure 1: Computed tomography before surgery, indicating herniation of infraorbital fat into the right maxillary sinus.

Figure 2: Clinical evaluation of ocular motricity of the patient 15 days after the trauma, presenting restriction of eye movement due to entrapment of the inferior rectus and inferior oblique muscles.

Figure 3: Clinical evaluation of the patient 15 days after the trauma.

Figure 4: Computed tomography obtained on late postoperative period, evidencing reestablishment of the infraorbital fat restricted to the interior of the orbital cavity.

Figure 5: Clinical evaluation of the patient at 30-day postoperative follow-up.

Figure 6: Clinical evaluation of ocular motricity of the patient 44 days after surgical intervention, without ocular restriction.

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Provasi S, Marinho DB, Borges SAC, Paulesini Junior W, Marinho GB

DISCUSSION Knowledge on the complex orbital anatomy and the diagnostic means is fundamental for the successful treatment of orbital fractures. The treatment plan should be determined according to the clinical and radiographic observations, as well as the type of fracture, degree of fragmentation, direction and degree of displacement of bone fragments.1 The vast majority of these injuries occur as a result of blunt trauma, usually car accidents or physical aggression, as well as sports accidents, industrial accidents and fall from the own height. Isolated fractures of the orbital wall account for about 4% to 10% of all facial fractures. Conversely, fractures extending beyond the orbit, such as those of the zygomatic complex and nasoorbitoethmoid fractures, account for 30 to 55% of all facial fractures.1 According to the literature, males are the most affected.5,6,7 Several complications of orbital fractures have been described, the most common being diplopia, dystopia, entropion, enophthalmos and infraorbital nerve paresthesia.3,4,8 By definition, blowout fractures are limited to one wall, having 2 cm in diameter or less. Most fractures occur in the inferomedial aspect of the orbit and cause volumetric expansion with posteromedial and inferior displacement of the eye globe, and can occur by two mechanisms: the first is through the force applied to the globe, resulting in sudden increase in the intraorbital pressure, which is more often relieved by traumatic expansion of the weaker wall; the second occurs through the force applied directly to the bone, often on the zygomatic, bone, infraorbital rim or both, leading to fracture of the orbital floor, through the direct transmission of energy from the orbital rim to the floor, and resulting in compressive fracture.1,8 The ideal treatment for these injuries is not consensual among surgeons. Controversy between surgical and conservative treatment is still ongoing.2 Some professionals describe works advocating the systematic exploration of all fractured walls and their respective reconstruction, while others recommend performing surgery only when the patient begins to develop the usual signs and symptoms of this fracture, such as diplopia and enophthalmos, without regression after 14 days of follow-up.1 If these symp-

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

toms disappear and satisfactory ocular function is established, other researchers argue that conservative treatment can be adopted.3 The access of choice for the treatment of orbital fractures depends not only on the advantages and disadvantages, but also on the surgeonâ&#x20AC;&#x2122;s experience to perform it in the best possible manner without causing damage to the patient.2 Several types of incisions can be used to access the orbital rims. The incisions should provide access with minimal morbidity and scarring. The most common approaches are those from the outer surface of the lower eyelid and the conjunctival part of the lower eyelid. The skin incision for subtarsal access is performed at the lower margin of the inferior tarsus, on the subtarsal fold.

Although the final scar at this location may be slightly more noticeable than the subciliary incision, clinical follow-ups reveal lower occurrence of sclera and ectropion by this approach. Its main advantages are the esthetic and functional results associated with transoperative benefits.9 The treatment should be performed by surgical reduction of fractures, with fixation and use of grafts, if necessary, for reconstruction of walls or contours lost in the trauma as soon as possible, to restore the function and esthetics of the orbital and periorbital region.3 The goal of primary reconstruction in blowout fractures is to restore the configuration of the orbital walls, return the prolapsed orbital contents to the orbit and eliminate any invasion or entrapment of soft tissues.1 The surgical treatment of fractures of the inferior orbital walls involves the use of several types of materials: alloplastic, allogenic and autogenous, the latter being the best tolerated by tissues around the recipient region.10 The presented clinical case had good resolution with the use of titanium mesh as restorative material.

The titanium mesh had the function of restoring the orbital floor contour, supporting the eyeball contents.

Titanium meshes are efficient for the primary treatment of blowout fractures. These materials show good results concerning their capacity to reconstruct the orbital floor and support the eyeball contents.2.The easy shaping of the titanium mesh to the orbital floor makes its use practical and effective.10

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Orbital blowout fracture: case report

CONCLUDING REMARKS Orbital fractures are almost always related to urban violence and traffic accidents. Careful evaluation and accurate diagnosis are fundamental to detect ocular and bone injuries and maintain the vision. Surgical

intervention should be based either on the functional deficit or esthetic deformity. The surgical sequence and timing of repair should be well planned, always aiming to achieve the greatest benefit to the patient.

References:

1. Miloro M, Ghali GE, Larsen PE, Waite PD. Princípios de cirurgia Bucomaxilofacial de Peterson. 2a ed. São Paulo: Ed. Santos; 2013.

2. Tavares SSS, Tavares GR, Oka SC-R, Cavalcante JR, Paiva MAF. Fraturas orbitárias: revisão de literatura e relato de caso. Rev Bras Cir Buco-Maxilo-Fac. 2011 Mar-Abr;11(2):35-42.

3. Scolari N, Heitz C. Protocolo de tratamento em fraturas orbitárias. Rev Facul Odontol Passo Fundo. 2012 Set-Dez;17(3):365-9.

4. Kuhnen RB, Silva FM, Scortegagna A, Cabral RJB. Fraturas de orbita: sinais e sintomas baseados nas estruturas anatômicas envolvidas. Int J Dent. 2006 Jan-Mar;1(1):20-4.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

5. Mello-Filho FV, Ricz H. Braz J Otorhinolaryngol.

2014;80(3):184-8.

6. Sassi LM, Dissenha JL, Bezeruska C, Guebur MI, Hepp V, Radaelli RL, et al. Fraturas de zigomático: revisão de 50 casos. Rev Bras Cir Cabeça Pescoço.

2009 Out-Dez;38(4):246-7.

7. Lima MA, Pagliuca LMF, Almeida PC, Andrade LM, Caetano JA. Levantamento dos casos de traumatismo ocular num hospital de emergência. Rev Rene. 2010 Jan-Mar;11(1):58-65.

8. Bagheri SC, Bell RB, Khan HA. Terapias atuais em cirurgia bucomaxilofacial. Rio de Janeiro: Elsevier; 2013.

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9. Ellis E III. Acessos cirúrgicos ao esqueleto facial. 2ª ed.

São Paulo: Ed. Santos; 2006.

10. Mororó ABG, Almeida S, Carvalho FSR, Freire Filho FW, Bezerra MF, Tavares RN. Tratamento cirúrgico de fratura orbitária blow-out pura com tela de titânio: relato de caso clínico. Rev Odontol Bras Central.

2013;22(63):120-3.

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Casereport

Pleomorphic adenoma in upper lip:

Case report

ALLANCARDI DOS SANTOS SIQUEIRA1,2 | JIORDANNE ARAÚJO DINIZ1,2 | LUIZ HENRIQUE SOARES TORRES1,2 | ANA CLÁUDIA AMORIM GOMES1,2 | EMANUEL DIAS DE OLIVEIRA E SILVA1,2

ABSTRACT Objective: The objective of this study is to report a case of pleomorphic adenoma in the upper lip, treated by surgical excision of the lesion under local anesthesia. Methods: The patient was treated by surgical excision of the lesion and follows in postoperative follow-up of 1 year without complaint and without signs of recurrence. Results: Pleomorphic adenoma is the most common benign tumor of salivary glands.

The parotid is the most affected, followed by the minor salivary glands located in the lateral posterior region of the palate, and by the upper lip. Has slight predilection for females, and their treatment consists of surgical excision. The prognosis is good since the injury is enucleated. Conclusion: Surgical excision proved to be a satisfactory means of treatment.

Keywords: Adenoma, Pleomorphic. Salivary glands. Lip neoplasms.

Hospital Universitário Oswaldo Cruz, Serviço de Residência em Cirurgia e Traumatologia Bucomaxilofacial (Recife/PE, Brazil).

1

How to cite: Siqueira AS, Diniz JA, Torres LHS, Gomes ACA, Oliveira e Silva ED. Pleomorphic adenoma in upper lip: Case report. J Braz Coll Oral Maxillofac Surg. 2018 Sept-Dec;4(3):65-8.

DOI: http://dx.doi.org/10.14436/2358-2782.4.3.065-068.oar

Universidade de Pernambuco, Faculdade de Odontologia (Recife/PE, Brazil).

2

Submitted: October 01, 2016 - Revised and accepted: January 25, 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: Allancardi dos Santos Siqueira Rua Doutor Silvério Fontes, 436, bairro Cirurgia Aracaju/SE – CEP: 49.055-250 E-mail: allancardi@hotmail.com

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Pleomorphic adenoma in upper lip: Case report

INTRODUCTION The salivary gland tumors account for nearly 3-5% of all head and neck neoplasms, and less than 1% of all tumors.1 Among the former, the allomorphic adenoma (AP) is the most frequent, affecting the parotid gland in about 53-77% of cases, the submandibular in 44-68% and the minor salivary glands in 6.4%. Among these, the palate is considered the most common intraoral site, followed by the upper lip and buccal mucosa.2 It usually presents clinically as a painless, slow-growing, firm increase in volume, without ulceration of the overlying mucosa.3 The differential diagnosis should include neurofibroma, lipoma, dermoid cyst and mucoceles.2 Histologically it presents great heterogeneity, with a variable number of cell proliferation, thus being considered a true mixed tumor, presenting myoepithelial characteristics, duct-like structures and a stroma of chondroid, myxoid, hyaline, adipose and/or bone tissue, presenting fibrous connective capsule of varying thickness and integrity.4 Thus, this paper reports a case of pleomorphic adenoma in the upper lip, treated by surgical removal of the lesion, under local anesthesia.

Service of Oswaldo Cruz University Hospital (HUOC/ UPE) in Recife/PE, presenting a hard and painless volume increase in the region of the upper lip mucosa, on the left side, noticed about one year ago.

Physical examination revealed a nodular lesion with approximately 1.5 cm in diameter, mobile, painless and without color change in the oral mucosa of the upper lip (Fig 1). Based on the clinical history and physical examination, the diagnostic hypotheses of neurofibroma, dermoid cyst , benign tumors of minor salivary glands and mucocele were considered.

Due to the size and location of the lesion, it was decided not to perform incisional biopsy or fine needle aspiration, thus the indicated treatment was excision with a horizontal incision on the region of the upper lip mucosa (Fig 2A, B). The specimen was submitted to histopathological analysis, which revealed fragments of benign neoplasm of glandular origin, cells exhibiting varied fusiform, plasmacytoid and cuboid morphology, forming structures that resemble ducts and/or cell membranes, as well as adipose, myxoid and fibrous extracellular matrix. The fibrous capsule was observed throughout the tumor, as well as a salivary gland lobe (Fig 3A, B). The patient has been followed for one year, without signs of relapse. The patient presented in this study signed an informed consent for publication of photographs and exams.

CASE REPORT A 35-year-old female Caucasoid patient, attended the Oral and Maxillofacial Surgery and Traumatology

Figure 1: Nodular lesion on upper lip mucosa with approximately 1.5 cm in diameter, mobile, painless and without color alterations.

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Siqueira AS, Diniz JA, Torres LHS, Gomes ACA, Oliveira e Silva ED

A

B

Figure 2: A) Incision in oral mucosa for lesion access and tissue dissection. B) Lesion removal after dissection of adjacent tissues.

A

B

Figure 3: A) Sheets of myoepithelial cells with different patterns (HE/400X). B) Duct-like structures, myxoid areas and solid sheets of myoepithelial cells within lymphocytic infiltrate (HE/100X).

DISCUSSION Salivary gland neoplasms account for nearly 1-4% of all neoplasms and 3-5% of neoplasms affecting the head and neck region.5 They usually involve the major salivary glands and about 10-15% of cases involve the minor salivary glands. Among neoplasms of minor salivary glands, pleomorphic adenoma is the most common benign neoplasm.6 A retrospective study conducted to determine the prevalence of diagnosed neoplasms of salivary glands re-

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

vealed that pleomorphic adenoma was the most common benign tumor (83%), while cystic adenoid carcinoma prevailed among malignant tumors (60%). The etiology of this pathology is still uncertain; however, the lesion has been described as having an epithelial origin, with chromosomal abnormalities involving the regions 8q12 and 12q15.7 In a review published by Mortazavi et al.8, 63.7% of cases of pleomorphic adenoma occurred in women and 36.3% in men, ranging from 12 to 65 years of age; 50% of patients were aged 35 to 55 years and only 27.2% were

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Pleomorphic adenoma in upper lip: Case report

stroma, containing mucoid and myxoid areas. It has epithelial elements arranged in structures similar to ducts, sheets, clusters and/or entangled cords, as well as a fibrous pseudocapsule of variable thickness extending through a normal glandular parenchyma.9 The findings of histopathological analysis of the present case agree with the literature.

The treatment of choice for this type of lesion is complete surgical excision with clear margins, followed by histopathological examination to establish the final diagnosis.8,10 Follow-up is necessary to check for relapse and malignant transformation.10 In the present case, it was decided to surgically remove the lesion without breaking the capsule (Fig 2B), as confirmed by histopathological examination. No local relapse was observed after 1-year follow-up.

younger than 20 years. In a retrospective study conducted at the Oral Surgery Service of the University of Barcelona (Spain), the authors described 18 cases of benign neoplasm of minor salivary glands over a 10-year period. Among the cases studied, 66.7% corresponded to women and 33.3% to men. The vast majority (94.4%) were benign tumors; 55.3% had histopathological diagnosis of pleomorphic adenoma.1 In the present case, the patient was female and aged 35 years, corroborating the published studies.

Pleomorphic adenoma usually presents as a painless, slow-growing, firm increase in volume without ulceration of the overlying mucosa.3 When it affects the minor salivary glands, the palate is considered the most common intraoral site, followed by the upper lip and the buccal mucosa.2 Pons Vicente et al.1 described that the preferential location of minor salivary gland tumors was the posterior third of the palate (33.2%), followed by the soft palate (16.7%) and upper lip mucosa (16.7%). In the present case, the affected site was the upper lip, a characteristic that differs from some cases found in the literature.2,5,6 On histological evaluation, the pleomorphic adenoma presents proliferation of polygonal and fusiform myoepithelial cells in a variable

CONCLUSION Benign tumors of the salivary glands are uncommon lesions, presenting low prevalence in the population. Surgical excision proved to be a satisfactory treatment option.

However, due to the tendency of these lesions to develop malignant lesions and the relapse rate, follow up is suggested to confirm the treatment success.

References:

1. Pons Vicente O, Almendros Marqués N, Berini Aytés L, Gay Escoda C. Minor salivary gland tumors: A clinicopathological study of 18 cases. Med Oral Patol Oral Cir Bucal. 2008 Sept 1;13(9):E582-8.

2. Verma P, Sachdeva SK, Verma KG, Sachdeva K. Pleomorphic adenoma of cheek: a rare case report and review of literature. Indian J Dent Res. 2014 Jan-Feb 25(1):122-4.

3. Wang D, Li Y, He H, Liu L, Wu L, He Z. Intraoral minor salivary gland tumors in a Chinese population: a retrospective study on 737 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;104(1):94-100.

4. Freitas R. Tratado de Cirurgia Bucomaxilofacial. 1a ed.

São Paulo: Ed. Santos; 2006.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

5. Vijaya Kumar M, Panga A, Mohammed M, Jabri OBA, Abdullah SK. Pleomorphic adenoma of soft palate - A rare presentation. Int J Biomed Res. 2015;6(06):439-41.

6. Moghe S, Pillai AK, Prabhu S, Nahar S, Kartika UK. Pleomorphic adenoma of the palate: Report of a case.

Int J Sci Study. 2014;2:54-6.

7. Lotufo MA, Júnior CA, Mattos JP, França CM. Pleomorphic adenoma of the upper lip in a child. J Oral Sci. 2008 June;50(2):225-8.

8. Mortazavi H, Alirezaei S, Azari-Marhabi S, Baharvand M, Eshghpour M. Upper lip pleomorphic adenoma: comparison of reported cases between 1990 and 2012. J Dent Mater Tech. 2013;2(4):125-9.

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9. Singh AK, Kumar N, Sharma P, Singh S. Pleomorphic adenoma involving minor salivary glands of upper lip: a rare phenomenon. J Can Res Ther. 2015;11(4):1025.

10. Pardhe ND, Vijay P, Singhal I, Shah G. Pleomorphic adenoma of upper lip: case report. Int J Oral Care Res. 2015;3(8):100-3.

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Opinion article

Flexibilization of the Dental Code of Ethics and social media Gustavo Barbalho Guedes Emiliano

Living on the network involves the exposure to criticism and judgments, confronting the state of the art and the specialized opinion of specialists. In this field, the discussion is even more interesting because there are plenty of different opinions concerning the professional behavior in social media.

In the liquid modernity, a concept introduced by the Polish philosopher Zygmunt Bauman (1925 – 2017), the combination of information and communication technologies with the consumer. society has deeply changed the manner through which we relate to the world.

The short time of utilization (for example, Instagram was only launched worldwide in October 2010) and the insufficient attention of people involved in the training and supervision of the ethical dental practice raise an insecurity in thinking and acting ethically, especially in the professional life in the network.

Dentistry, as any other profession, has always been challenged to position itself in every new means of commercial diffusion, including newspapers (1821), magazines (1876), radio (1930), television (1950), the internet (1992) and, currently, the social networks (2004). A good way to observe the official positions is to search for legal texts produced at the time and follow the reissues. However, it seems that one aspect has never been altered or placed under suspicion: the importance of secrecy.

As any move into the future, it is expected to be done within values and principles shared by the local community in tune with other parts of the world, because ethics as we understand it is not a local manufacturing product. To move in this direction is to carry the burden – sometimes seen as an obstacle to opening

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of the profession – to seek more rights, duties and responsibilities. This evolution gives rise to several legal guarantees that ensure the privacy, confidentiality, consumer's right to health and life, among others.

THE SOCIAL MEDIA X THE PROFESSION I think seriously whenever I hear about the "flexibilization" of guiding principles of the dental code of ethics, despite its more commercial face, because it is a ubiquitous reality, especially in social media.

It is not possible to deny the potential of social media in the valuation of dentistry; in fact, everybody is enchanted by the wonders of Dentistry shown in photos and videos. Perhaps, if this was possible, no one would dismiss its power to spread the state of the art of dental science, new technologies and techniques for the diffusion of professionals, services and products, to emphasize the nobility of the profession by practicing it within Hippocratic and bioethical principles, the care of dentists about the information and respect for the intelligence and the rights of those who consume the publications.

The social networks establish direct communication without intermediaries, without frontiers, highlight the images and tend to lead users to believe that they are defining their own limits, even if contrary to those socially accepted and imposed by the groups they represent. Currently, publishing is part of the dentist's job; and developing skills and competencies in this field is important. Wisely, there is no legal and ethical impediment to publications; quite the opposite, because the society is interested in knowing the professionals available and techniques used – of course, respecting the limits defined in the guidelines.

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Opinion article

there is the fundamental problem that, in Dentistry, the success of treatment is not simply assessed by the image captured shortly after the last clinical session.

Success is the balance of tissues, stomatognathic system, treatment stability, improvement in quality of life and patient well-being over time, not immediately after discharge or completion of treatment. We know that when an image is repeated several times, the unconscious betrays us, naturalizing the scene, the fact or image.

Therefore, I do not think it is positive for Dentistry to see the transformation of human health into a product or thing that should be commercially overexploited or only for that purpose, e.g. with the rationale that this is an alternative to face the economic crisis, competition in the labor market, or an efficient manner to demonstrate the differential in relation to the competition.

In fact, we can state from research that most posts on social networks are published by dentists graduated after 2010 and who do not have a specialist degree, residency or stricto sensu post graduation.

That is, what might be the "solution" becomes a supposed professional match between everyone in the job market, whether or not seen on social networks.

There is obvious interest in knowing more and better about the permissions, not to be so critical concerning the prohibitions, mainly because we do not know their motivations. In these cases, it is worth to think about what Washington Olivetto, a Brazilian publicist, said about communication technologies: "It is very good because today you can express any content. And it is very bad because today you can conceal the lack of content through the form”. I have this always in mind, at least to ask myself: what is the purpose of this publication?

CRISIS ON ETHICAL ASPECTS In this regard, we observe the effects of the insistence on "flexibilization" of the dental ethics with concern, especially with the exploration of Dentistry in all types of material with only commercial purpose, without the support of health publications with educational and informative purpose.

Unfortunately, the posts in social networks intended to the general public not always have an informative content; quite the opposite, because they sometimes appeal to a sensationalist, vulgar, deceptive, repulsive and obscurantist connotation, with doubtful authorship and possibility of any type of image manipulation, just to make them esthetically more convincing.

It should be remembered that non-scientific publications are intended to the lay public, therefore one must take into consideration how they will receive and interpret the dental fact.

The exposure of images of surgeries, identifiable patients with the indicated treatment, images of patients in critical postoperative period, professionals proudly exposing their work instruments – which may certainly be confused or associated with pain, suffering, anxiety and phobia – in my opinion, do not enhance the image of the profession and professionals.

When the reality is inside the office, clinic or hospital, the professional can perfectly modulate the patient's emotions and confidence in the professional and the indicated treatment; thus, it is sometimes necessary.

However, it seems that the most common of all publications, according to common sense and in our research, are the "before and after" images.

Beyond the legal issue of fostering the impression that Dentistry is an exact science with predictable results, which is called obligation of result in Law,

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THERE IS NO EASY SOLUTION Some of the current discussions go through the solution of "flexibilization" of the code, especially Chapter XVI – advertising and publicity.

It is easy to understand that the solution to open the market is to change the way the community sees us by the exposure of treatments performed, assuming they are successful cases.

The semiotic confusion established with the large volume of "before and after" publications is that it raises the assumption that all cases are equal, seemingly easy to treat, and that the greater commitment is related to esthetics and the achievement of results, in detriment of the anatomo-functional balance.

The ethical guidelines in the code serve to protect patients and dentists from excess. The suggested changes will reach all, without distinction of this or that specialty, this or that group; but all, without exception, because the center of the question is Dentistry as a health profession.

If the solution is to disclose the "success" cases to more people, how may we expect that advertising

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Emiliano GBG

elaboration of a dental record to the responsibility for acts practiced during the technique application. Perhaps the "rediscovery" of ethical training may allow a long survival for Dentistry as a health profession.

From these aspects, there is a fundamental question: what Dentistry do we want, or which Dentistry does the Brazilian society need? We should either embrace the value-based dentistry, or we shall lose it to business, pure and simple; and we will increasingly see a war of all for survival, which will inevitably lead to the loss of dignity of the profession and self-respect.

Fractures in the profession will not be reduced if we wait for the others. The society is patient, yet time is not. Changes begin by opening to a new thinking that dental ethics teaches us to be better professionals, allowing a direct communication with the community in an elegant, informative, efficient and, of course, ethical and legal manner. I expect changes not on our dental code of ethics as desired by some, but on the education, guidance and supervision of professional practice. My mirror should be the best, even if it means to struggle against the tide; otherwise, perhaps we may lose the characteristics that make us one of the most beautiful and rewarding professions in the world, a profession that is practiced for the health of human being.

excesses that are tacky, abusive, misleading, pseudoscientific and manipulated like fake news are restricted to groups of "enlightened laymen" and do not negatively affect everyone working in Dentistry.

Before the end of a profession, its image is first ended, that is, with the idea of Dentistry focused on collective and social interest, with the specialization of individualized treatment and not always concealed promises of positive results.

Unlike some who think that opposing changes in the sense of "flexibility” is to assume a retrograde and obsolete position outside the changes of the world, I believe exactly the opposite, and there are objective elements for this. I think it is a current position in fine tune with what the community expects from us and with a vision of the future. After all, it will become increasingly evident that what distinguishes one professional from another, considering that both have the same technical capacity, is the ethics of how it relates to the community, to the class and the patient attention and care. This may only be possible in a clinical environment and with an exchange of looks of complicity between surgeon and patient, and trust between surgeon and family. After all, many aspects of life in society have changed; however, some remain as solid as the respect for health, dignity and life, although their maintenance is a daily battle of institutions and citizens.

Then, what is the solution for these problems?

The solution is facing Dentistry, which offers the solution itself. The solution is ethics. A solution that has always been used in periods of crisis. The solution includes listening to everyone, including the community, dentists of all backgrounds, as well as to deepen the discussions conducted by specialists in ethics, bioethics and Legal Dentistry, to address fundamental issues. To perform a comparative analysis with other codes, observe the best ethical practices in the clinic, encourage the continuing education in dental ethics as other places in the world, to inform the public about concepts, practical applications, reasons for prohibitions, as well as the meaning of privacy, secrecy and justice, and its consequences for Dentistry in the medium and long term, if these universal principles are not adopted. It is to rethink ethics not only as a discipline or content in the human field, with little or no insertion in the clinician's professional life; it is to understand that ethics lies in small acts, from the

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Gustavo Barbalho Guedes Emiliano - Universidade do Estado do Rio Grande do Norte, Departamento de Odontologia, Disciplinas de Ética, Legislação e Odontologia Legal (Caicó/RN, Brazil).

- MSc in Legal Medicine and Forensic Sciences, Universidade de Coimbra, Faculdade de Medicina (Coimbra, Portugal).

- PhD in Health Biotechnology, Universidade do Estado do Rio Grande do Norte (Natal/ RN, Brazil).

E-mail: odonto.legal@yahoo.com.br

How to cite: Emiliano GBG. Flexibilization of the Dental Code of Ethics and social media. J Braz Coll Oral Maxillofac Surg. 2018 Sept-Dec;4(3):69-71.

DOI: http://dx.doi.org/10.14436/2358-2782.4.3.069-071.oar

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OBJECTIVE AND EDITORIAL POLICY The Journal of the Brazilian College of Oral and Maxillofacial Surgery is the official publication of the Brazilian College of oral and Maxillofacial Surgery and Traumatology targeted to the publication of relevant papers for education, information and science of the academic practice of surgery and related areas, aiming at the promotion and exchange of knowledge between the university community and health professionals.

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REFERENCES - All papers cited in the text should be included in the reference list.

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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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