Revista JBCOMS - Volume 5, Number 1, 2019

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Volume 5, Number 1, 2019 - ISSN 2358-2782

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VEJO V

24ª Conferência Interna

21 a 24 de Maio, 20

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

Adrian Bencini

Clarice Maia Soares Alcântara

Darklilson Pereira Santos

Leonardo Perez Faverani

Rafaela Scariot de Moraes

Ricardo Augusto Conci

Waldemar Daudt Polido

Trauma

Aira Bonfim Santos

Florian Thieringer

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 University Hospital Basel - Suíça 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

Chi Yang

Eduardo Hochuli Vieira

Eduardo Seixas Cardoso

João Carlos Birnfeld Wagner

Luis Raimundo Serra Rabelo

Sanjiv Nair

Universidade de Pernambuco - FOP/UPE - Camaragibe/PE - Brazil Instituto Prevent Senior – São Paulo/SP - Brazil Shanghai Jiao Tong University - China 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 Bangalore Institute of Dental Sciences - Índia

Universidad Nacional de La Plata - Argentina 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 Rui Fernandes University of Florida - EUA 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

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Crisis in Brazilian scientific research Gabriela Granja Porto

6

Letter from the President: Chairman’s letter José Rodrigues Laureano Filho

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Largest World Congress on Oral and Maxillofacial Surgery will be held on May 2019 in Rio de Janeiro Interview Sanjiv Nair Articles

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Evaluation of different measurement methods for facial analysis in orthographic surgery Leandro Almeida Nascimento Barros, Raildo Silva Coqueiro, Matheus Melo Pithon, Luciano Cincurá Silva Santos

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Etiology and incidence of facial fractures in a hospital located in a municipality in the extreme south of Santa Catarina state (Brazil) Eron José Baroni, Rodrigo Aparecido Tocunduva Celin, Soraia Pereira da Cunha

30

Assessment of craniometric points in Class III patient profile radiographs and their relationship with natural head position Niedja Ramos de Lima, Emerson Filipe de Carvalho Nogueira, Danilo de Moraes Castanha, José Rodrigues Laureano Filho

36

Tooth in fracture line: extract or maintain?

Thiago Marques de Mesquita, Basílio de Almeida Milani, Thais Benedetti Haddad Cappellanes, Rosany Guarnnetti dos Santos, Talita Lopes

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Surgical approach of impacted mandibular fourth molars: case report Felipe Aurélio Guerra, Natasha Magro Érnica, Geraldo Luiz Griza, Eleonor Alvaro Garbin Júnior

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Mandibular reconstruction after Pindborg tumor: case report

Henrique Clasen Scarparo, Roniele Lima dos-Santos, Alexandre Maranhão Menezes Neto, Francisco Samuel Rodrigues Carvalho, Fabricio De Lamare Ramos, Fábio Wildson Gurgel Costa, Eduardo Costa Studart Soares

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Treatment of bilateral fracture in severely displaced atrophic mandible

Lorenzzo De Angeli Cesconetto, André Vítor Alves Araújo, Antonio Dionizio Albuquerque Neto, Daniel Assunção Cerqueira, Antonio Augusto Campanha

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Nasolabial cyst – diagnosis and surgical treatment: Case report

Marcos Antonio Torriani, Ângelo Niemczewski Bobrowski, Rafael Jobim Rodrigues, Raquele Soares Matos, Stefany Rodrigues Santos, Tanielley Viera Machado, Caroline Kommeling Cassal

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Information for authors

Editorial

Crisis in Brazilian scientific research

We finished these 12 months with some concerns about the path scientific research is taking in Brazil, which affects us as professionals, either directly or indirectly. We know that, for a country to have science, the population should realize that it widely brings welfare and progress to the nation. The society and mainly the country leaders should notice that the formation of a critical mass is directly related to improvement in the productive system and, consequently, to the progress of a nation.

However, the serious economic, political and social crisis the country has been facing in recent years has led to an immediate cut of resources that were already insufficient. One of the major impacts was the approval of a constitutional amendment that freezes the public expenditures for a period of 20 years, besides the cuts in direct resources for the Brazilian post graduation. These measures may cause damages that are difficult to overcome. Therefore, Brazilian research, which had grown considerably in the last two decades and still needed to grow more in the quality of scientific research and international insertion, is at serious risk of having its progress compromised.

How to cite: Porto GG. Crisis in Brazilian scientific research. J Braz Coll Oral Maxillofac Surg.

2019 Jan-Apr;5(1):4-5. DOI: https://doi.org/10.14436/2358-2782.5.1.004-005.edt

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Editorial

In such a pessimistic scenario, we still see researchers who creatively try to progress in this crisis and can throw us some light! We cannot give up!

Precisely in this respect, we are trying to advance in our small contribution to diffuse the scientific production of maxillofacial surgeons. We still need to increase the collection of scientific articles to enhance the qualification of our journal. To achieve indexation in other databases, the number of original articles published must be higher. I hereby ask you colleagues for support, so that our journal may be even better every year!

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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Letter from the President

Chairman’s letter Dear colleagues,

How to cite: Laureano Filho JR. Chairman’s letter. J Braz Coll Oral Maxillofac Surg. 2019 Jan-Apr;5(1):6-7.

DOI: https://doi.org/10.14436/2358-2782.5.1.006-007.crt

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Dear members of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology, in this first issue of 2019 we would like to share our actions, thoughts, difficulties and anxieties experienced in our first year in the board and present the perspectives for this beginning year. This initial period was not easy, yet it was not difficult either: it was a moment of much learning, dedication and work, during which some actions were made.

In 2018 we had three important regional events. The ENNEC (North/ Northeast Meeting of Oral and Maxillofacial Surgery and Traumatology), held in Maceió, was tremendously successful, from both scientific, social and financial standpoints. This is a consolidated event, and the designation “Meeting” has lost some of its meaning as compared to the size of the event.

The COPAC (São Paulo Congress of Oral and Maxillofacial Surgery and Traumatology), held in Ribeirão Preto, evidenced the greatness and development of the state of São Paulo, which always provided excellent outcomes.

The Brazilian Southern region was reactivated in Porto Alegre with great impact for this region. A very well-organized event, of low cost and high value of aggregated knowledge.

The ICOMS, world congress of the specialty, which will be held for the first time in Brazil thanks to a partnership between AOMS and the Brazilian College of Oral and Maxillofacial Surgery and Traumatology, is coming closer.

From May 21st to 24th 2019 the city of Rio de Janeiro will receive hundreds of international speakers, more than 1,000 paper presentations, and we are waiting for more than 2,000 participants to make the greatest ICOMS the world has ever seen.

We initiate the organization of our COBRAC, which presents signs of another great upcoming event, with a scientific program in final planning and a great part of sponsors confirmed.

Throughout the year, we kept a fundamental partnership with the Federal Dental Council (CFO), which among other actions also helped us by indicating one of our members for the multiprofessional residency committee. The Ministry of Education (MEC) also opened its doors, and today we have four full members in the multiprofessional residency committee.

The chapter coordinators made their work perfectly in the scientific activities and initiated a greater approximation with the Regional Dental Councils and Brazilian Dental Associations in the states.

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Letter from the President

As a direct benefit for our members, we approved a civil responsibility and temporary disability insurance at no cost for the members. During the first months, all members up to date with their fees will be contacted to sign these products.

Legal support has been offered for the members for suits against health insurance companies. More than 20 cases have been assisted and guided in different situations: attempt of patient deviation, non-authorization of procedures, and even attempt to preclude the accomplishment of surgeries in certain hospitals.

We began to offer lectures on the website and videos targeted to lay individuals to diffuse our specialty in the social networks.

We finalized the affiliation of all members of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology in ALACIBU. This affiliation allows greater contact with specialists from Latin America, more possibilities of events at members discount fees, besides participation in videoconferences promoted by this organization.

We adapted the contract of the Journal with the publishers, enhancing the conditions for the Brazilian College of Oral and Maxillofacial Surgery and Traumatology.

We renewed the registry of residencies, and since 2019 the registered residencies will have exclusive benefits, such as national shifts of residency and international training, whose selection will be open during the first semester.

We also finalized the book Parameters and Recommendations for Oral and Maxillofacial Procedures. This was a project of three boards, with the main goal to achieve the rationale use of ortheses, prostheses and special materials. We released this protocol with the presence of several health insurance companies, representatives of private hospitals, CFO and CRO-SP, among other important organizations, with excellent adherence by the professional community.

We still have much to do for the Oral and Maxillofacial Surgery and Traumatology! We are strong in the goal to develop the specialty by the scientific progress. But we will continue to go beyond, expanding the horizons and providing support and guidance for day-by-day questions.

With warmest regards!!!

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

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

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BBO

CBCTBMF

Largest World Congress on Oral and Maxillofacial Surgery will be held on May 2019 in Rio de Janeiro The Brazilian College of Oral and Maxillofacial Surgery and Traumatology is bringing the event to Brazil

representatives. There will be 157 speakers from almost 80 countries. “We have specialists from India to Brazil, from Chile to Canada. It is a unique opportunity to know what is being done around the world – not only in a region, alike an American or European congress. We are bringing the world of science to Brazil. It’s like when we received the Olympic Games”, enthusiastically says Luiz Marinho.

Hard work was needed for this to happen. Only in 1998, the International Association of Oral and Maxillofacial Surgeons included CBCTBMF as a world representative of the specialty to the international community, and since then the CBCTBMF has made proposals to host the event. “Brazil is the country with the second largest number of papers submitted to IJOMS; with the increase in the number of residencies and many Brazilians doing postgraduate courses abroad, we could demonstrate the scientific value of the specialty in Brazil and strengthen our proposal”, explains Marinho.

After several attempts with the International Association of Oral and Maxillofacial Surgeons, Brazil receives the 24th edition of the International Conference on Oral and Maxillofacial Surgery (ICOMS), a partnership between the Brazilian College of Oral and Maxillofacial Surgery and Traumatology (CBCTBMF) and the international institution. The world’s largest event of the specialty will be held from May 21st to 24th 2019 at the Windsor Barra Hotel & Convention Center, Rio de Janeiro.

The conference occurs biannually and is the main international forum on current ongoing researches, theories and issues related to oral and maxillofacial surgery for surgeons, residents and related health professionals.

According to the oral and maxillofacial surgeon and president of ICOMS, Luiz Marinho, the importance of the event is directly related to the diversity of

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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CBCTBMF

According to the oral and maxillofacial surgeon and coordinator of the scientific committee of ICOMS, Mario Gabriele, the scientific program attempted to include all fields of surgery and news in science, technology and research. “The most current trends in surgery in the world are addressed in the program, with a clinical emphasis, but related to research and evidence-based clinical activity”, says the specialist.

In addition to the several symposia, the event will offer specific lectures with world leaders in many areas of Oral and Maxillofacial Surgery. The organization of ICOMS in Brazil is based on four important foundations: strong scientific program; great concern with residents and how to prepare the future of the specialty for the new generations; unique networking opportunities between Brazilian and international companies, provided by the event; and perfect ceremonial, reinforcing the Brazilian culture and hospitality.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

It should be mentioned that the cost for registration for ICOMS is cheaper than American and European congresses, with thrice the number of speakers and variety in the scientific program, besides the possibility of interaction with the main leaders of oral and maxillofacial services in the world.

The organizers are prepared to receive up to four thousand people, including Brazilians and international speakers. “The organization and security teams are the most qualified and experienced in the market, so that the event is successful”, adds ICOMS president Luiz Marinho.

“We are all committed to make this event a success, and working for the College, by the College and in favor of Oral and Maxillofacial Surgery “, concludes Luiz Marinho. https://icoms.iaoms.org/

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Interview

Interview with Sanjiv Nair

» Professor and Head of the Department of Oral and Maxillofacial Surgery and Traumatology at the Bangalore Institute of Dental Science and Research. » Consultant Surgeon at Columbia Asia Hospitals, B. M Jain Hospital and Mallya Hospital in Bangalore (India). » Specialist in Oral and Maxillofacial Surgery – Trivandrum Medical College. » Scholarship Program Coordinator in Facial Esthetic Surgery, Rajiv Gandhi University of Health Sciences.

How to cite: Nair S, Porto GG. Interview with Sanjiv Nair. J Braz Coll Oral Maxillofac Surg. 2019 Jan-Apr;5(1):12-3. DOI: https://doi.org/10.14436/2358-2782.5.1.012-013.int Submitted: January 09, 2019 - Revised and accepted: February 08, 2019

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Nair S, Porto GG

What training does an oral and maxillofacial surgeon need to work in India?

The Maxillofacial Surgery training in India begins with an undergraduate program in Dentistry that lasts 4 to 4.5 years, depending on the university. After that, there is one year of mandatory rotating training. The specialization in Maxillofacial Surgery is performed in centers accredited by the Dental Council of India and lasts 3 years – during which basic surgical skills are taught. This prepares the specialists for complementary training in advanced head and neck surgeries.

Advanced surgical training is available by scholarships, which are facilitated by AOMSI (Association of Oral and Maxillofacial Surgeons of India). These scholarships are offered in Trauma, Deformities and Oncology. The period is one and a half years for Oral Oncology, two years for Head and Neck, and one year for Trauma and Orthognathic Surgery. After this training, most surgeons join academic institutions, hospitals or clinics.

training to provide quality care in head and neck surgeries. The only common platform between countries is the International Association of Oral and Maxillofacial Surgeons (IAOMS). The establishment of an International Certification Board would allow equity in both knowledge and clinical practice. However, some challenges should be overcome, due to linguistic and cultural barriers.

What are your country's expectations regarding ICOMS 2019?

Most of us are excited and anxious about ICOMS 2019 in Brazil, a country that has many cultural and economic similarities with India. The Indian Association and I myself have promoted the ICOMS. I expect to see a large contingent in Rio. Concerning our expectations, we would like to see a mixture of academic and ethnic flavors. The ICOMS has always been a potpourri of cultures; I am sure the same will happen in Brazil.

In our country, the great majority of facial traumas result from traffic accidents. What is the reality in India?

Traumas in India are very similar to those in Brazil: traffic accidents. It is a combination of irresponsible driving and poor infrastructure. Interestingly, during my period as president of AOMSI, I made a movie called "Face It", which attempted to combine all traffic violations, and had more than 2.5 million views. I would like to share with you the link to this video: https://m.youtube.com/watch?v=bXK7BmYECPk

How do you see the future of the specialty in India and third world countries?

India is a rapidly growing nation and the profession is encouraging. The advantage of being a maxillofacial surgeon is the training in the stomatognathic system , which includes the head and neck.

The limitation is the need to customize this globalized training. It is known that Third World countries and developing nations have a uniform pattern of

Profa. Dra. Gabriela Granja Porto - Editor-in-Chief of the 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

Evaluation of different measurement methods for facial analysis

in orthographic surgery LEANDRO ALMEIDA NASCIMENTO BARROS1 | RAILDO SILVA COQUEIRO1 | MATHEUS MELO PITHON1 | LUCIANO CINCURÁ SILVA SANTOS1

ABSTRACT Objective: To evaluate if there are significant differences between the techniques of digital (using the Digital Smile Design, DSD) and manual measurements (using goniometer and cephalometry). Methods: A comparative cross-sectional study was performed with a sample of 18 individuals (male and female, mean age = 23 years) with different dentofacial deformities. Manual, digital (DSD) and cephalometric measurements of each of these individuals were evaluated and compared to each other. The anatomical points measured in soft tissue were A’ and Pog’. Pearson correlation coefficient and Students t-test were used for variables with normal distribution, Spearmans coefficient and Mann-Whitney test for samples with abnormal distribution, with significance level of 5%. Results: There were no statistically significant differences between the measurement methods: manual/digital, manual/ cephalometric and digital/cephalometric, (p> 0.05). Linear correlation tests of the Pog point presented a very strong correlation: manual/DSD (r = 0.93), manual/cephalometric (r = 0.93) and digital/cephalometric (r = 0.99). At point A, correlations in the comparison were: manual/DSD (r = 0.69), moderate; manual/cephalometric (r = 0.67), moderate; digital/cephalometric (r = 0.96), very strong. Conclusions: There were no significant differences between the techniques. The DSD measurement values are more correlated with cephalometry than the manual technique.

Keywords: Orthognathic surgery. Photography. Planning. Smiling.

Universidade Estadual do Sudoeste da Bahia, Departamento Saúde I (Jequié/BA, Brazil).

1

How to cite: Barros LAN, Coqueiro RS, Pithon MM, Santos LCS. Evaluation of different measurement methods for facial analysis in orthographic surgery. J Braz Coll Oral Maxillofac Surg. 2019 Jan-Apr;5(1):14-21. DOI: https://doi.org/10.14436/2358-2782.5.1.014-021.oar

» Patients displayed in this article previously approved the use of their facial and intraoral photographs.

Submitted: August 08, 2017 - Revised and accepted: October 24, 2018 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article.

Contact address: Luciano Cincurá Silva Santos Av. Otávio Santos, n. 227. Centro Médico Otávio Santos Salas - 209/211 Recreio, Vitória da Conquista/BA, Brazil E-mail: cincuraluc@uol.com.br - matheuspithon@gmail.com

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Barros LAN, Coqueiro RS, Pithon MM, Santos LCS

INTRODUCTION Orthognathic surgery is a treatment modality applied for correction of severe craniofacial deformities, aiming to re-establish the health of facial structures, correct occlusal pathologies, and improve the patient’s self-esteem concerning the dental and facial esthetics.1,2 The surgical treatment involves facial skeletal changes and is complex, especially related to occlusion. In some cases, the correction of occlusion does not necessarily improve the facial harmony.3,4 The surgical decision is directly related with the individuality of the patient and clinical findings.5,6 The facial analysis surveys a list of surgical options guided by cephalometric data and analysis of occlusion, and guides the best surgical alternative, reducing the risks and increasing the chances of success.7 To initiate the analysis using the virtual planning of smile (Digital Smile Design, DSD), a detailed analysis of the facial structures is initially necessary; the second stage comprises the examination of dental structures. Multiple extra and intraoral photographs may be used to aid the planning. The DSD concept presents different levels of esthetic analysis, including facial harmony and oral and maxillofacial esthetics. It may also address the oral esthetics; dentogingival and dental.8-10 In orthognathic surgery, the DSD concept may aid the measurement; by observation of the facial thirds on frontal and lateral photographs, the relationship between the cranial base, maxilla and mandible may be analyzed. The relationship between the anatomical landmarks Sn and Pog’ on the photograph may evidence the patient needs, without the analysis of radiographs.11 Additionally, the use of technology by softwares as PowerPoint (Microsoft, Redmond, Washington, USA), in which the DSD protocol may be done, also allows the insertion of digital cephalogram on the computer, allowing cephalometric tracings.12 The Digital Smile Planning (DSD)13-16 is a tool that enables accurate planning, based on the patient’s wishes about treatment. Thus, the goal of esthetic treatments is to create designs that associate the patient needs and biological and functional aspects.

The DSD concept uses digital tools to aid the diagnosis, analysis and documentation, incorporated in the treatment plan.17 Thus, to establish a more accurate tool for facial analysis in orthognathic surgery, it is necessary to

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

correlate and compare the facial analysis model with the DSD concept and cephalometry, which is considered the gold standard.

METHODS Sample Selection This non-probabilistic sample consisted of 18 individuals, including males and females. The inclusion criteria were: (1) individuals presenting dentofacial deformities; (2) presenting all maxillary anterior teeth; (3) no previous esthetic facial surgery; (4) no neurological disorders; (5) no syndromes.

The study was approved by the Institutional Review Board of Universidade Estadual do Sudoeste da Bahia (Resolution CNS 466/12, protocol #17333113.1.0000.0055). Individuals who accepted to participate signed an informed consent form and an image utilization consent.

This study used a digital camera Canon® EOS Rebel T5I (Tokyo, Japan), with macro lens 100 Canon® 1.2.8 (setting 1:1, automatic focus, shutter speed 1:125, diaphragm opening F8), tripod, black nonwoven fabric and goniometer (Fig 1, 2).

Data were collected as follows. The individual was asked to stay at 1 m from the wall and 2.1 m from the camera.9,10 Black nonwoven fabric was used as background. To avoid distortions in perspective, the camera distances and setting were standardized, framing only the face of the individual.11 The photographs were obtained by the same calibrated operator in the following order: frontal at rest, left profile and right profile, and the last photograph of each participant was obtained with a millimeter goniometer ruler (Fig 3), which served as basis to calibrate the digital ruler.

Each participant was asked to sit on a stool with height adjustment, with the arms relaxed, long hair tied on the head and lips at rest. During the photographic procedure, the participant could not use any accessory: glasses, cap, earrings, jewelry or any other object that might interfere with the measurement.

All participants were instructed as to the ideal head positioning: Frankfurt plane parallel to the ground.12 The photographs were analyzed on the computer using a slide presentation software (PowerPoint®, Microsoft, Redmond, Washington, USA). The anatomical points traced on the photographs were: Porion (Po) – uppermost point on the tragus; Orbitale (Or) – lowermost point on the lower orbital edge; Soft

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Evaluation of different measurement methods for facial analysis in orthographic surgery

Pogonion (Pog’) - most anterior point corresponding to the bony Pog; A’ point – most concave point on the upper lip, corresponding to the bony A point.

The profile photo with the millimeter ruler was inserted in PowerPoint software; following, the Frankfurt plane was identified, and the anatomical landmarks were connected (Po-Or). A vertical line was traced perpendicular to this plane, passing through point Sn (Fig 3). Positioning of the vertical line is justified to analyze the relation of maxilla and mandible with the facial plane. After insertion of the digital ruler in PowerPoint, it was calibrated by millimetric pairing with the ruler on the photograph (Fig 3). The calibrated digital ruler was inserted at the region of anatomical landmarks analyzed (Fig 4).

The manual , digital (DSD) and cephalometric measurements were obtained at three different moments (T1, T2 e T3) by a single calibrated examiner. One month after completion of manual measurement, the photographic protocol and digital measurement were randomly performed. After 15 days, the lateral cephalograms of each patient were obtained and measurements were performed.

In the manual measurement , the patient was instructed to remain seated on a chair with height adjustment and follow the same instructions as the photographic protocol. The conventional analysis as performed using a goniometer. The investigator obtained the manual measurements of A’ and Pog’ and

registered the respective values. After manual and digital measurements, the digital cephalogram (gold standard) of each patient was used for cephalometric tracing. The cephalograms were obtained by a third examiner, specialist in Dental Radiology. The cephalograms were obtained on a single radiography machine (Gnatus®, model Pax-400, 80 kV, 10 mA, Ribeirão Preto/SP, Brazil). The exposure time of each radiograph was 15 seconds.

The patient followed the same instructions of the photographic protocol concerning head positioning.

Using a goniometer, the patient’s head was positioned as desired. The digital ruler was calibrated on the millimeter ruler of the cephalogram. The regions measured A” and Pog” represented the soft tissue points A’ and Pog’ on the lateral cephalogram (Fig 5).

All cephalometric tracings were performed on the digital cephalogram by the same examiner, in random sequence. To increase the study reliability, each radiograph was traced twice, with a one-week interval.

PILOT STUDY The intra-examiner error was evaluated by eight volunteers to calibrate the manual measurement technique with the goniometer and the digital technique (DSD), including the identification of points and revision of the entire methodology, including analysis of photographs, quality of images and calibration of the digital ruler.

Figure 1: Goniometer employed.

Figure 2: Tracing of Frankfort plane and vertical line.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Barros LAN, Coqueiro RS, Pithon MM, Santos LCS

Figure 3: Calibration of DSD ruler on the goniometer.

Figure 4: Measurement using the DSD concept.

STATISTICAL ANALYSIS To analyze the normality of values, the Shapiro-Wilk test was applied for samples up to 20 participants and significance level of 5%. A statistical software was used to calculate the standard deviation, standard error, Pearson correlation coefficient for variables with normal distribution and Spearman coefficient for variables with abnormal distribution.

Comparison between samples with normal distribution was performed by the Student’s t test.

Variables with normal distribution were compared by the Mann-Whitney test. All statistical tests were applied at a significance level of 5%.

RESULTS The results obtained in the present study are presented in Tables 1 to 5.

DISCUSSION Planning in orthognathic surgery has been increasingly optimized. The 3D technology is promising with the advent of planning based on tomographs and softwaresr.18 However, the facial analysis is mandatory and cannot be neglected, since it is clinically made.19,20 The digital smile design presents useful features

Figure 5: Cephalometric measurement.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Evaluation of different measurement methods for facial analysis in orthographic surgery

Table 1: Analysis of standard deviation, median and minimum and maximum absolute values.

Variables

Mean

Standard deviation

Minimum to maximum values

A’-m A’-d A’-c Pog’-m Pog’-d Pog’-c

1,70 1,35 1,27 6,60 5,52 5,52

1,72 1,70 1,85 7,33 8,81 8,35

– 4,0 e 1,0 – 4,0 e 1,0 – 4,0 e 5,0 – 18,0 e 4,0 – 18,0 e 4,0 – 18,0 e 4,0

A’-m = manual A’; A’-d = digital A’; A’-c = cephalometric A’; Pog’-m = manual Pog’; Pog’-d = digital Pog’; Pog’-c = cephalometric Pog’.

Table 2: Correlation of Pog’ between manual, DSD and cephalometric groups.

Variables

r

p

Result

Pog’ m-d Pog’ m-c Pog’ d-c

0,9301 0,9364 0,9957

0,0001* 0,0001* 0,0001*

muito forte muito forte muito forte

*Pearson test at a significance level of 5%. Pog’ m-d (manual x digital); Pog’ m-c (manual x cephalometric) and Pog’ d-c (DSD x cephalometric).

Table 3: Correlation of A’ between manual, DSD and cephalometric groups.

Variables

r

p

Resultado

A’ m-d A’ m-c A’ d-c

0,6921** 0,6724** 0,9684*

0,0001 0,0021 0,0001

moderado moderado muito forte

*Pearson correlation test for samples with normal distribution; **Spearman correlation test for samples with abnormal distribution. A’ m-d (manual x DSD); A’ m-c (manual x cephalometric) and A’ d-c (DSD x cephalometric).

Table 4: Values related to comparison of Pog’ between manual, DSD and cephalometric groups.

Table 5: Values related to comparison of A’ between manual, DSD and cephalometric groups.

Variables

p

Variables

Pog’ m-d

0,4691

A’ m-d

0,8371**

Pog’ m-c

0,6111

A’ m-c

0,9621**

Pog’ d-c

0,8107

A’ d-c

0,7061*

Student t test at a significance level of 5%.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

p

**Mann-Whitney test; *Student t test. Significance level of 5%.

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Series 1 Linear (Series 1)

Digital Pog’

A

Series 1 Linear (Series 1)

digital A’

Série 1 Linear (Series 1)

A’ cephalometric

Pog’ cephalometric AB

Digital Pog’

B

C

Series 1 Linear (Series 1)

A’ manual

Pog’ manual

A

A’ manual

Pog’ manual

Barros LAN, Coqueiro RS, Pithon MM, Santos LCS

digital A’

Series 1 Linear (Series 1)

A’ cephalometric

Pog’ cephalometric

C

Figure 6: Values related to comparison of Pog’ between manual, digital (DSD) and cephalometric groups.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Series 1 Linear (Series 1)

Figure 7: Values related to comparison between groups manual, digital (DSD) and cephalometric A’.

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Evaluation of different measurement methods for facial analysis in orthographic surgery

tically significant difference. For the values of A’ DSD/ cephalometric, there was very Strong correlation. The point A’ DSD is more easily observed due to the possibility to use zoom and resources of PowerPoint, which allow better observation of the subnasale region.

Studies indicate strong correlation between the techniques of photographic and cephalometric measurement for vertical and horizontal variables.23,24,25 However, some points may present low correlation. In the scientific literature, there are evidences that, depending on the anatomical point analyzed, there may be variations from “strong” to “very strong” between the measurement techniques DSD and cephalometric; similarly, points that are difficult to identify may present low correlation.24,25 Conversely, the manual measurement technique cannot be undervalued, since the comparison between groups also revealed excellent correlations, even though this technique requires greater professional experience for its accomplishment.

The intergroup analysis did not reveal statistically significant differences between the manual, DSD and cephalometric methods (p >0.05) (Table 4 and 5).

Comparison between the DSD method and cephalometry achieved satisfactory statistical results, since the inclusion and exclusion criteria favored the location of Subnasale, Porion and Orbitale points. Individuals presenting syndromes, for example, might have alterations between these points, which would preclude the digital technique. The DSD measurement technique presents good reproducibility, being easy to use even by unexperienced surgeons.

Other studies should be conducted to validate the technique, as well as including measurements of other soft tissue points.

CONCLUSION Comparison between measurement techniques revealed no statistically significant differences between the group means. All variables of DSD measurement were reliable and presented high correlation indices, when compared to cephalometry.

Therefore, measurement with the DSD concept seems to be more accurate, besides having excellent tools, which may aid the diagnosis as a complement to facial analysis. Further studies should be conducted, especially to check other soft tissue points.

for maxillofacial surgery practice, since this tool aids the facial examination. Utilization of the DSD concept associated with facial analysis maximizes the esthetic-functional gains and minimizes the divergences between planning and the postoperative result.11,13,18 The standardized photographs have great advantages in Orthodontics and Orthognathic Surgery.

These include the absence of radiation; fast image achievement and editing; low cost; magnified view of facial contours; detection of asymmetries and deviations. The software resources, such as zoom, contrast and brightness, allow accurate analysis of the relationship between maxillary and mandibular structures with the cranial base. Other advantage of photography in planning is related to the possibility of analysis by the professional together with the patient concerning the craniofacial problems involved, treatment predictability and legal records.21 In the descriptive statistics (mean, standard deviation and absolute values), the variables calculated in manual, DSD and cephalometric measurements revealed that the measurements presented approximate values, reflecting non-significant p values for all variables. These findings involving both manual and digital measurement techniques corroborate studies that compare the cephalometric and photometric measurements.22,23 The intergroup analysis evidenced strong correlation between variables: Pog’ manual/DSD (r=0.93), manual/cephalometric (r=0.93) and DSD/cephalometric (r=0.99). The manual, DSD and cephalometric techniques did not present significant differences between correlation coefficients. These results indicate good reliability of the digital technique, since it presents very strong correlation, especially with cephalometric measurement. They also justify the excellent correlation results, due to the easy demarcation and identification of point Pog’ by the three techniques.

These results corroborate the findings of other authors.22,23 The correlation was moderate between variables A’ manual/DSD (r=0.69); moderate between manual A’ /cephalometric (r=0.67); and very strong between A’ DSD/cephalometric (r=0.96). the variation between correlation groups may be explained by the greater difficulty to identify the subnasal point by the manual technique in some patients, despite the lack of statis-

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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References:

1. Emadian Razvadi ES, Soheilifar S, Esmaeelinejad M, Naghdi N. Evaluation of the changes in the quality of life in patients undergoing orthognathic surgery: a multicenter study. J Craniofac Surg. 2017 Nov;28(8):e739-43.

2. Martins MM, Araujo SP, Miguel JA, Goldner TA, Mendes MA. Tratamento orto-cirúrgico da classe II com avanço mandibular. RGO - Rev Gaúcha Odontol.

2011;59(3):509-14.

3. Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning--Part II. Am J Orthod Dentofacial Orthop. 1993 May;103(5):395-411.

4. Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning. Part I. Am J Orthod Dentofacial Orthop. 1993 Apr;103(4):299-312.

5. Suassuna TM, Abreu TC, Santos LAM, Noleto JW, Ribeiro ED. Estabilidade das vias aéreas após ortognática: revisão sistemática. J Braz Coll Oral Maxillofac Surg. 2017;3(3):30-6.

6. Pinto Júnior AAC, Fonseca VJ, Cunha JF, Lehman LFC, Campos FEB, Castro WH. Cirurgia ortognática bimaxilar iniciando pela mandíbula. J Braz Coll Oral Maxillofac Surg. 2017;3(1):30-5.

7. Fish LC, Epker BN. Dentofacial deformities related to midface deficiencies. Integrated orthodontic-surgical correction. J Clin Orthod. 1987;21(9):654-64.

8. Omar D, Duarte C. The application of parameters for comprehensive smile esthetics by digital smile design programs: a review of literature. Saudi Dental J. 2018;30(1):7-12.

9. Garcia PP, Costa RG, Calgaro M, Ritter AV, Correr GM, Cunha LF, et al. Digital smile design and mockup technique for esthetic treatment planning with porcelain laminate veneers. J Conserv Dent. 2018 July-Aug;21(4):455-8.

10. Kravitz ND. Smile analysis and design in the digital era.

J Clin Orthod. 2017;51(9):602-5.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

11. MacLaren EA, Culp L. Smile Analysis. The Photoshop Smile Design Technique: Part I. J Cosmetic Dent.

2013;29(1)94-108.

12. Meza RS. Sagittal Cephalometric Diagnosis Using Power Point (Microsoft® Office). Rev Mexicana Ortod.

2016;4(1):9-17.

13. McLaren EA, Garber DA, Figueira J. The Photoshop Smile Design technique (part 1): digital dental photography. Compend Contin Educ Dent. 2013 NovDec;34(10):772, 774, 776 passim.

14. Meereis CT, Souza GB, Albino LG, Ogliari FA, Piva E, Lima GS. Digital Smile Design for Computer-assisted Esthetic Rehabilitation: two-year follow-up. Oper Dent.

2016 Jan-Feb;41(1):E13-22.

15. Rojas-Vizcaya F. Prosthetically guided bone sculpturing for a maxillary complete-arch implant-supported monolithic zirconia fixed prosthesis based on a digital smile design: a clinical report. J Prosthet Dent.

2017;118(5):575-80.

16. Santos FR, Kamarowski SF, Lopez CAV, Storrer CLM, Teixeira Neto A, Deliberador TM. The use of the digital smile design concept as an auxiliary tool in periodontal plastic surgery. Dent Res J (Isfahan). 2017 Mar-Apr;14(2):158-61.

17. Cooper GE, Tredwin CJ, Cooper NT, Petrie A, Gill DS. The influence of maxillary central incisor height-towidth ratio on perceived smile aesthetics. Br Dent J. 2012;212(12):589-99.

18. Vale F, Scherzberg J, Cavaleiro J, Sanz D, Caramelo F, Malo L, et al. 3D virtual planning in orthognathic surgery and CAD/CAM surgical splints generation in one patient with craniofacial microsomia: a case report.

Dental Press J Orthod. 2016;21(1):89-100.

19. Levine JP, Patel A, Saadeh PB, Hirsch DL. Computeraided design and manufacturing in craniomaxillofacial surgery: the new state of the art. J Craniofac Surg.

2012 Jan;23(1):288-93.

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20. Nadjmi N, Mollemans W, Daelemans A, Van Hemelen G, Schutyser F, Berge S. Virtual occlusion in planning orthognathic surgical procedures. Int J Oral Maxilofac Surg. 2010;39(5):457-62.

21. Peck S, Peck L. Selected aspects of the art and science of facial esthetics. Semin Orthod.

1995;1(2):105-26.

22. Paixão BM, Sobral CM, Vogel JC, Araújo TM. Comparative study between manual and digital cephalometric tracing using Dolphin Imaging software with lateral radiographs. Dental Press J Orthod.

2010;15(6):123-30.

23. Vasconcelos MHF, Janson G, Freitas MR, Henriques JFC. Avaliação de um programa de traçado cefalométrico. Rev Dental Press Ortod Ortop Facial.

2006;11(2):44-54.

24. Reche R, Colombo VR, Verona J, Moresca CA, Moro A. Análise do perfil facial em fotografias padronizadas. Rev Dental Press Ortod Ortop Facial.

2002;7(1):37-45.

25. Colombo VL, Moro A, Rech R, Verona J, Costa GCA. Análise facial frontal em repouso e durante o sorriso em fotografias padronizadas.Parte II: Avaliação durante o sorriso. Rev Dental Press Ortod Ortop Facial. 2004 Jul-Ago;9(4):86-97.

J Braz Coll Oral Maxillofac Surg. 2019 Jan-Apr;5(1):14-21

OriginalArticle

Etiology and incidence of facial fractures in a hospital located in a municipality in the extreme south of

Santa Catarina state (Brazil) ERON JOSÉ BARONI1,2 | RODRIGO APARECIDO TOCUNDUVA CELIN1 | SORAIA PEREIRA DA CUNHA1

ABSTRACT Trauma are among the leading causes of death and morbidity in the world. Among the various types, face trauma stands out as one of the most important, since it has emotional and functional repercussions, and the possibility of permanent deformities. Therefore, the present study aims to identify the etiology and prevalence of facial fractures in the Service of Buccomaxillofacial Surgery and Traumatology of a Reference Hospital in the Municipality of Criciúma, Santa Catarina state (Brazil), from January 2003 to December 2015. A total of 1,822 cases of facial traumas was treated at the Surgery and Traumatology Service, between January 2003 and December 2015. The most prevalent age group was from 21 to 30 years, representing 32.5%.

Men were responsible for 66.6%, while women, 33.4%. Trauma related to auto accidents were prevalent (22.2%). The most fractured bone was the nasal (37.8%). The incidence of facial fractures can be reduced by educational measures, such as routine use of seat belts and helmets; by the lower consumption of alcohol, respecting speed limits and by strategies to deal with hostile situations, in order to avoid the growing interpersonal violence.

Keywords: Multiple trauma. Epidemiology. Facial bones.

Universidade do Extremo Sul Catarinense, Departamento de Odontologia (Criciúma/SC, Brazil).

1

How to cite: Baroni EJ, Celin RAT, Cunha SP. Etiology and incidence of facial fractures in a hospital located in a municipality in the extreme south of Santa Catarina state (Brazil). J Braz Coll Oral Maxillofac Surg. 2019 Jan-Apr;5(1):22-9. DOI: https://doi.org/10.14436/2358-2782.5.1.022-029.oar

Hospital São José, Departamento de Cirurgia e Traumatologia Bucomaxilofacial (Criciúma/ SC, Brazil).

2

Submitted: September 14, 2017 - Revised and accepted: June 21, 2018

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

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Contact address: Rodrigo Aparecido Tocunduva Celin Rua Miguel Narciso, 230 – Gravatá CEP: 88.372-534 – Navegantes/SC E-mail: rctocunduva@outlook.com

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Baroni EJ, Celin RAT, Cunha SP

INTRODUCTION Traumas are among the leading causes of death and morbidity in the world. Among the different types, facial trauma stands out among the most important, because of its emotional and functional effects and the possibility of permanent deformities. Facial traumas account for 7.4 to 8.7% of emergency attendances. The large number of facial lesions are related to the great exposure and poor protection of the region, often leading to serious trauma.1 The oral and maxillofacial surgeon is the only specialist with the necessary training to provide complete craniomaxillofacial care, presenting the medical-dental knowledge and the required skills to manage the reconstruction of all facial structures.2 Trauma to the facial region is observed daily in emergency hospitals and affects mainly the youngest population, having as main causes traffic accidents, motorcycle accidents, bike accidents, aggressions and runovers. Other causes of injury also include falls, sports accidents and work injuries. Therefore, thorough study on the epidemiology of facial trauma is paramount for accomplishment of the most appropriate treatment. 3 Brazil presents scarce data regarding facial fractures when compared to other countries. It is important to continuously diffuse data related to the epidemiology of facial trauma, to achieve the necessary information for the evaluation and development of preventive measures, which will assist in the reduction of facial injuries. This highlights the importance of the present study, since the present data will aid competent organs of the health area for preventive campaigns and organization of referral and counter-referral in the care for patients with facial trauma.

Therefore, this study identified the etiology and prevalence of facial fractures in the Surgery and Traumatology Service of Hospital São José, in the city of Criciúma/Santa Catarina, from January 2003 to December 2015.

METHODS This descriptive cross-sectional study had the main objective to identify the etiology and incidence

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

of facial fractures in patients assisted at the Oral and Maxillofacial Surgery and Traumatology Service of Hospital São José, in the city of Criciúma/SC, in the period January 2003 to December 2015.

The study approved by the Institutional Review Board of Universidade do Extremo Sul Catarinense under protocol n. 62231716.7.0000.0119, on April 6 th, 2017; and also by the Institutional Review Board of the hospital under protocol n.

62231716.7.3001.5364, on May 12 th, 2017. Both are available in CEP/CONEP - Plataforma Brasil.

Data were collected by direct analysis of the records, registered by the Oral and Maxillofacial Surgery and Traumatology team in electronic form, within the period January 2003 to December 2015.

The sample was selected from patients attending the oral and maxillofacial surgery and traumatology service of a large hospital, located in the city of Criciúma/SC, with facial fractures, in the aforementioned period.

Data collection was performed by two undergraduate dental students on May 2017, at four pre-established dates, together with the hospital’s directors board.

The questionnaire consisted of four parts: month and year of occurrence, indirect patient data (gender, age), etiology of trauma and type of fracture (anatomical location).

In the first visit, the medical records within the study period were screened by the students for sample selection, applying the inclusion and exclusion criteria of the study. Only patients with facial fractures were included, which is the area of work action of the oral and maxillofacial surgeon.

Data were transferred to Microsoft Excel worksheets (Microsoft Corp., USA). Collection of data respected total confidentiality about the identity of patients attending the service.

After data collection, they were organized and grouped by etiology, types of fractures (identifying the most prevalent fractures and their causes), most affected gender and mean ages related to the most recurrent fracture.

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Etiology and incidence of facial fractures in a hospital located in a municipality in the extreme south of Santa Catarina state (Brazil)

RESULTS After data collection, among the 1,822 patients analyzed in this study, 1,214 were males (66.6%) and 608 females (33.4%). The most affected age group was 21 to 30 years, representing 32.5% of the total sample, followed by 11 to 20 years (23.2%) and 31 to 40 years (15.7%). Table 1 and Figure 1 show these data in more detail.

Data were collected according to their respective years of occurrence. The highest number of occurrences was recorded in 2003 (12%), followed by 2005 (10.9%), 2006 (10.2%) and 2004 (9.5%). The years 2010, 2011 and 2012 registered the same number of occurrences (8.4%), followed by years 2009 (7.6%), 2007 (7.4%), 2008 (7.1%), 2015 (6.2%), 2014 (2.4%), and finally 2013 (1.5%). Table 2 details the number of occurrences per year.

Analysis of the occurrences from January 2003 to December 2015, it can be concluded that in 2003, the highest incidence was registered in May, with 38 cases of fractures (17.4%); in 2004, there were 21 cases in August (12.1%); in 2005, March and September registered 25 cases (12.6%); in July 2006 there were 20 cases (10.8%); April 2007 had 21 cases (15.6%) and May 2008 presented 23 cases (17.8%), In 2009, the highest incidence was also recorded on May, with 23 cases (16.5%). In the years 2010, 2011 and 2012, the same incidences were recorded in the same month: December, with 31 cases (20.3%). In 2013, the highest number occurred in June, with 6 cases (22.2%); in 2014, August registered 7 cases (15.9%); and in 2015, the highest incidence occurred in May, with 23 cases (20.4%). Table 3 presents details related to the months and their respective years.

Table 1: Sample distribution by age range and gender.

Females

Males

Age range (years)

n (total)

(n)

%

(n)

%

1-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 Overall total

85 424 593 287 206 99 56 72 1.822

31 133 211 81 80 24 24 24 608

5,1 21,8 34,7 13,3 13,1 4 4 4 100

54 291 382 206 126 75 32 48 1.214

4,44 24 31,4 17 10,3 6,19 2,68 3,99 100

SOURCE: Files of Hospital São José (2003 to 2015).

Females 33,4%

Males 66,6% Figure 1: Sample distribution by gender.

SOURCE: Files of Hospital São José (2003 to 2015).

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Table 2: Distribution of occurrences per year.

Year

n

%

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 TOTAL

219 173 198 183 135 129 139 153 153 153 27 44 113 1.822

12,0 9,5 10,9 10,2 7,4 7,1 7,6 8,4 8,4 8,4 1,5 2,4 6,2 100,0

SOURCE: Files of Hospital São José (2003 to 2015).

Table 3: Distribution of occurrences per months and their respective years.

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Total

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

Total geral

8 23 16 18 38 24 22 22 12 7 20 9 219

10 8 16 8 12 19 16 21 17 12 14 20 173

9 10 25 14 9 21 16 17 25 16 18 18 198

5 19 14 14 16 17 20 16 15 19 14 17 186

7 11 10 21 11 15 8 7 19 11 9 6 135

8 10 11 12 23 11 8 9 8 9 9 11 129

8 10 11 12 23 11 8 9 8 9 9 21 139

12 10 11 12 23 11 8 9 8 9 9 31 153

12 10 11 12 23 11 8 9 8 9 9 31 153

12 10 11 12 23 11 8 9 8 9 9 31 153

1 2 3

2 6 1 2 3 4 3 7 3 3 5 5 44

3 10 11 5 23 2 8 9 8 9 9 16 113

97 139 151 142 228 163 136 147 142 125 135 217 1822

1 6 3 3 3 3 1 1 27

SOURCE: Files of Hospital São José, 2003 to 2015.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Etiology and incidence of facial fractures in a hospital located in a municipality in the extreme south of Santa Catarina state (Brazil)

Table 4 and Figure 2 present the details concerning the etiological factor.

The fractures were classified according to the affected bones. The nasal bone was the most affected (37.8%), followed by the orbit and zygomatic bone (18.9%), mandible (17%), maxilla (11.9%), zygomatic arch (6.5%), multiple fractures (5.4%) and alveolar fractures (2.5%). The distribution of the frequency of fracture is presented in Table 5 and Figure 3.

The etiological agents were classified as car accidents, motorcycle accidents, physical aggression, falls, sports accidents, firearm accidents, work accidents and others. The most frequent etiological factor was car accidents (22.2%), followed by physical aggression (19.0%), others (18.3%), motorcycle accidents (12.2%), falls (10.2%), sports accidents (8.2%), work accidents (6.3%) and firearm accidents (3.6%).

Table 4: Sample distribution by etiological factor.

Etiological factor

n

%

Car accidents Motorcycle accidents Physical aggression Fall Sports accidents Firearm accidents Work accidents Others Total

405 223 346 185 150 65 115 333 1.822

22,2 12,2 19,0 10,2 8,2 3,6 6,3 18,3 100%

SOURCE: Files of Hospital São José. 2003 to 2015.

18,3%

22,2%

6,3% 3,6%

12,2%

8,2% 10,2%

19%

CAR

MOTORCYCLE

AGGRESSION

FALL

SPORTS

FIREARM ACCIDENTS

WORK ACCIDENTS

OTHER CAUSES

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Figure 2: Sample distribution by etiological factor. SOURCE: Files of Hospital São José (2003 to 2015).

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Baroni EJ, Celin RAT, Cunha SP

Table 5: Sample distribution according to fractured region.

Fractured region

n

%

Alveolar Multiple fractures Mandible Maxilla Nasal bone Orbit and zygomatic bone Zygomatic arch Total

46 99 309 217 689 344 118 1.822

2,5 5,4 17,0 11,9 37,8 18,9 6,5 100

6,5%

2,5% 5,4%

SOURCE: Files of Hospital São José (2003 to 2015).

17%

18,9%

11,9% 37,8%

Alveolar

Multiple

Mandible

Nasal

Orbit and malar

Zygomatic arch

Maxilla

DISCUSSION This study agrees with the literature regarding the observation that facial trauma is observed daily in emergency hospitals and mostly affects younger individuals, having as main causes traffic accidents and physical aggression. Comprehensive study on the epidemiology of facial trauma is fundamental for accomplishment of the most appropriate treatment. Consequently, evaluation of the incidence and etiology of facial fractures allows a more accurate and appropriate treatment.3

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Figure 3: Sample distribution according to fractured region. SOURCE: Files of Hospital São José (2003 to 2015).

This study comprised a sample of 1,822 patients assisted at an outpatient clinic of a large hospital, located in a city in the extreme south of Santa Catarina, covering 13 years of evaluation of the Oral and Maxillofacial Surgery and Traumatology service.

The distribution of facial lesions in the statistics of this study reveals that the nasal bone accounted for the largest number of cases with 37.8%, a similar result as a study conducted in the city of Pelotas/RS, which presented 35.84% of nasal bone trauma analyzing the same aforementioned ser-

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Etiology and incidence of facial fractures in a hospital located in a municipality in the extreme south of Santa Catarina state (Brazil)

explained by the greater activity of this age group, with greater exposure to risk factors and a less prudent, often inconsequential, profile because of their age.¹ Fractures are less frequent in children and adults over 60 years. The low incidence of facial trauma in these age groups is related to the family attention, permanence inside home, care during childhood and inherent characteristics of the elderly: they attend few social and sports activities, seldom leave the house, and are usually accompanied when they leave. 8 Traffic accidents, usually car and motorcycle accidents, are reported in the literature as the main cause of fractures, affecting up to 90% of cases. Other frequently cited etiologies include interpersonal aggression, falls, and daily activities. This study corroborates the literature; however, it disagrees with studies performed in the countryside of São Paulo, which reaches up to 90% of cases.8,9 This study presented an incidence of 34.4%, with car accidents accounting for 22.2%. A very worrying fact was that the second most common cause in the present study was physical aggression, with 346 cases (19%), which agrees with a study conducted in Brasília/DF, demonstrating that domestic violence and interpersonal aggression are common in this region. 11 Conversely, several studies indicate aggression as currently presenting the most common etiology, surpassing traffic accidents, despite the increase in the number of vehicles circulating in urban centers. This reflects the increase in violence and unemployment in the cities; on the other hand, currently there are stricter traffic laws, with higher fines. 1 Accidents were the most frequent etiology in this study, accounting for 34.4% of patients, corroborating the results found by most authors.12 Even though the stricter application of the new traffic code reduced the number of patients with facial fractures related to this etiology, there are still expressive data on this subject. 9,13 This is in line with this research, in which the number of traumas has been decreasing over the years due to the mandatory use of seat belts, helmets and the “dry law”.

vice4. It also agrees with a study conducted in the city of Bauru/SP, which observed a rate of 48.49% of nasal bone traumas. 5 However, analyses conducted in the cities of Florianópolis/SC and Blumenau/SC revealed the mandible as the most affected bone in facial trauma.6,7 Regarding the location of fractures, data may differ from the literature. In a study conducted in the city of Botucatu/SP, the incidence occurred in the following order: mandible, zygomatic, nasal, maxillary and frontal8. One explanation for this apparent inversion would be the underreporting of nasal traumas due to correction of these fractures in medical emergency rooms. Most often, the medical doctor is concerned about pain, nasal bleeding and swelling, rarely observing deviations of the septum and septal pyramid.

This study corroborates the literature, since among the 1,822 visits, 66.6% were males and 33.4% females, which is perfectly comparable with most studies, which also evidenced this disproportion. This much higher rate may be explained by the greater exposure of males to daily activities as heavy work, greater numbers of drivers and greater strength in violent sports, besides the greater predisposition to interpersonal violence.9 However, especially in the last three decades, there has been an increase in traumas in females, usually in the age group up to 40 years. This is related to behavioral changes in women in society, with a greater number of female drivers, association of alcohol and driving, their insertion in work outside home and the practice of sports as leisure and health activity, including sports involving physical contact, such as soccer, basketball and martial arts.8 The age with the highest prevalence was 21 to 30 years, consistent with several studies. An investigation conducted in a hospital at Juiz de Fora/MG observed that the greater frequency of oral and maxillofacial lesions and wounds in young adult males may be explained by the fact that men work outside the home and take on risky activities, making them more vulnerable to accidents. 10 Another study conducted in Brasília/DF confirms that this fact can be

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Baroni EJ, Celin RAT, Cunha SP

CONCLUSION It could be concluded that males are more frequent victims of facial trauma than females, in a ratio of 2: 1, with car accidents being the main etiological factor, predominantly in the age group 21 to 30 years.

Traffic accidents and interpersonal violence were the main etiological factors of facial trauma, accounting for 53.4% ​​of cases surgically treated by the Surgery and Traumatology team of Hospital São José.

The nasal bone was the most affected in facial traumas, followed by the orbit, zygomatic bone and mandible. This is due to their central position and projection in the face, being easily fractured due to their thin structure.

Legal and educational measures are fundamental for the prevention of facial trauma and should be strictly applied, highlighting the use of seat belts, helmets, observation of speed limits and awareness on the alcohol/driving binomial. The “dry law” acts as a preventive and punitive measure for violators.

References:

1. Rezende Filho Neto AV, Macedo JLS, Silva RV, Dantas CCB, Santos CP, Vieira PB, et al. Epidemiology of patients with facial fractures treated by the plastic surgery team in emergency room in the Federal District of Brazil.

Rev Bras Cir Plast. 2014;29(2):227-31.

2. Bagheri SC. Revisão clínica de cirurgia bucomaxilofacial.

2ª ed. Rio de Janeiro: Elsevier; 2015.

3. Marques AC, Guedes LJ, Sizenando RP. Incidência e etiologia das fraturas de face na região de Venda Nova - Belo Horizonte, MG - Brasil. Rev Médica Minas Gerais.

2010;20(4):500-2.

4. Portolan M, Torriani MA. Estudos de Prevalência das Fraturas Bucomaxilofaciais na Região de Pelotas. Rev Odonto Ciência. 2005 Jan-Mar;20(47):63-8.

5. Marzola C, et al. Etiologia e incidência das fraturas faciais no Serviço de Cirurgia e Traumatologia Bucomaxilofacial do Hospital de Base de Bauru, São Paulo, Brasil. Rev Odontol. 2014;14(2):73-86.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

6. Maliska MCS, Lima JSM, Gil JN. Analysis of 185 maxillofacial fractures in the state of Santa Catarina, Brazil.

Braz Oral Res. 2009 July-Sept;23(3):268-74.

7. Martins JJC, Keim FS, Helena ETS. Aspectos epidemiológicos dos pacientes com traumas maxilofaciais operados no Hospital Geral de Blumenau, SC de 2004 a 2009. Arq Int Otorrinolaringol. 2010;14(2):192-8.

8. Montovani JC, Campos LMP, Gomes MA, Moraes VRS, Ferreira FD, Nogueira EA. Etiologia e incidência das fraturas faciais em adultos e crianças: experiência em 513 casos. Rev Bras Otorrinolaringol. 2006;72(2):235-41.

9. Marzola C, Toledo FJL, Toro ILS. Prevalência de fraturas do complexo zigomático e maxilares na Região de Bauru - São Paulo, no período de 1996-1998, no Serviço de Cirurgia Buco Maxilo Facial do Hospital de Base da Associação Hospitalar de Bauru. Rev Odontol ATO. 2005;5(5):578-606.

29

10. Carvalho TBO, Cancian LRL, Marques CG, Piatto VB, Maniglia JV, Molina FD. Seis anos de atendimento em trauma facial: análise epidemiológica de 355 casos.

Braz J Otorhinolaryngol. 2010;76(5):565-74.

11. 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.

12. Lins MA, Albuquerque GC, Oliveira AL, Martins VB, Fayad FT, Oliveira MV, Motta Júnior J. Epidemiology of facial trauma in a hospital in the municipality of Manaus-Amazonas. J Braz Coll Oral Maxillofac Surg.

2018 Jan-Abr;4(1):28-32.

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

J Braz Coll Oral Maxillofac Surg. 2019 Jan-Apr;5(1):22-9

OriginalArticle

Assessment of craniometric points in Class III patient profile radiographs and their relationship

with natural head position NIEDJA RAMOS DE LIMA1 | EMERSON FILIPE DE CARVALHO NOGUEIRA1 | DANILO DE MORAES CASTANHA2 | JOSÉ RODRIGUES LAUREANO FILHO1

ABSTRACT Introduction: Cephalometry plays an important role in the planning of orthognathic surgeries. However, it is susceptible to variations in the Natural Head Position (NHP), condition that may impair planning and results. Objective: To evaluate the NHP of Class III patients during cephalometric measurements, with the aim of verifying possible changes in position and angulation of their craniometric points.

Methods: Nine patients in the NHP were subjected to photographic records. Then, cephalometric tracings were superimposed on the photographs in a 1:1 ratio. After the superposition, six points were delimited (glabella, pronasale, subnasale, upper lip, lower lip and soft tissue pogonion), and the distances between points in the two images were measured and evaluated through statistical analysis. Results: All craniometric cephalometric points were divergent from the photographs, with linear changes in cephalometric points ranging from 1 to 16 mm and angular changes from -1° to -9°. Women showed greater disparity as well as taller patients demonstrated greater position variation. Conclusion: All patients presented head position variation during cephalometric measurements and the inclination was higher in women and in the taller patients, and the size of the mandibular protrusion did not influence the degree of inclination.

Keywords: Orthognathic surgery. Cephalometry. Angle Class III malocclusion.

Universidade de Pernambuco, Departamento de Cirurgia e Traumatologia Bucomaxilofacial (Recife/PE, Brazil).

1

How to cite: Lima NR, Nogueira EFC, Castanha DM, Laureano Filho JR. Assessment of craniometric points in Class III patient profile radiographs and their relationship with natural head position. J Braz Coll Oral Maxillofac Surg. 2019 Jan-Apr;5(1):30-5.

DOI: https://doi.org/10.14436/2358-2782.5.1.030-035.oar

Faculdade ASCES, Departamento de Cirurgia e Traumatologia Bucomaxilofacial (Caruaru/ PE, Brazil).

2

Submitted: June 11, 2018 - Revised and accepted: September 02, 2018

Contact address: José Rodrigues Laureano-Filho E-mail: laureanofilho@gmail.com - emerson_filipe@hotmail.com

» 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.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Lima NR, Nogueira EFC, Castanha DM, Laureano Filho JR

INTRODUCTION Large bone discrepancies between the maxilla and mandible cause malocclusion and esthetic changes. For this reason, detailed analysis of the facial skeleton is fundamental before any corrective interventions. Orthognathic surgery can improve the quality of life of patients with dentofacial deformities, achieving excellent stability and function in the long term. The craniofacial skeleton may be evaluated by two manners namely by facial analysis and cephalometric analysis. However, none of these methods excludes the other, and their combination provide complete data for the diagnosis and treatment of these cases. 1 Cephalometric evaluation is an important part of the stages that compose the planning of orthognathic surgery, as well as to evaluate the long-term stability postoperatively.2 The main failure of cephalometry is related to its dependence on intracranial reference points, which may vary biologically, without any predictable relation with facial deformity. Thus, surgical or orthodontic planning based on cephalometry may often disagree with the clinical evaluation.3 The natural head position (NHP) is a standardized and reproducible position in upright posture, with the eyes focused on a distant point at the eyes level, which implies a horizontal visual axis. 4,5 Studies suggest the use of NHP and the true vertical line (TVL) for cephalometric analysis. 6,7 Thus, it is important to achieve the cephalometric records and facial analysis in NHP to correct the patient’s profile more naturally. 9 Planning the treatment of dentofacial deformities is fundamental for a successful outcome. Many lateral cephalograms do not agree with the natural head position when the true vertical line is used as reference. Planning based on wrong positioning may impair the final outcomes. Therefore, this study compared the head position on cephalometric radiographs with the clinical NHP of patients with Class III profile, by superimposition of craniometric points.

METHODS Nine patients were selected by a case series study, among which 6 were males and 3 females. Dental occlusion and facial pattern were assessed on the initial consultation, as well as vertical

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

and transverse maxillary evaluation, presence of asymmetry, height, weight and gender. The project was approved by the Institutional Review Board of Universidade de Pernambuco (PROGEPE) under protocol n. 65907416.7.0000.5207.

For the photographic record, the patients were instructed to stand in upright orthostatic position, with the eyes directed to a mirror in front of them. Natural head position and the relaxed lip position were obtained so as the data could be adequately collected. Photographs were taken with a Nikon © D80 digital camera. For recording of the natural head position, the individuals were instructed to stand relaxed with their feet spaced about 10 cm; then, they were instructed to tilt their heads back and forth, reducing the amplitude until they felt that their natural balance had been reached. The patient had a mirror placed 1 meter ahead and should look at his own reflected eyes, keeping the pupils in the center of the eye. To achieve the photographs, the camera was mounted vertically on a tripod at a standard distance of 1.52 m lateral to the patient’s face, exactly perpendicular to the facial profile and centralizing the framing on the soft facial tissues. Patient and camera were equidistant 1 m from the wall, and a true vertical line was recorded using a 400-g bob positioned near the individual’s soft tissue profile, so that the image appeared on the photographic record, as evidenced in Figure 1. 5.10 All radiographs analyzed were obtained less than three months apart from the photograph or soon thereafter, in the same radiology laboratory, using the Orthopantomograph® Instrumentarium OC200D or Instrumentarium Op 300 machines.

The radiographs were obtained conventionally, with patient positioning guided by the radiology technician considering the Frankfurt plan. For cephalometric tracing, an acetate sheet was superimposed to the cephalometric radiograph and fixed to the film viewer. Then, a detailed drawing of the facial profile contour was performed with 0.5 mm graphite pencil.

Six points were identified for evaluation on both radiography and photograph: Glabella (Gb), Pronasale (Pn), Subnasale (Sn), Upper lip (Ls), Lower lip (Li), Soft tissue pogonion (Pg’), as shown in Figures 2A and 2B. The tracing and lateral photography were superimposed at a ratio of 1:1, according to Figure 2C,

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Assessment of craniometric points in Class III patient profile radiographs and their relationship with natural head position

Figure 1: Patient positioning during photographic recording.

A

B

C

Figure 2: A) Identification of points on the cephalometric tracing. B) Identification of points on the lateral photograph. C) Image superimposition.

Data obtained were presented to mean dispersion and standard deviation measurements and were submitted to the Shapiro- Wilk normality tests and the Levene test for homogeneity of variance, to verify the initial assumptions of the statistical tests. For normally distributed data, the t test for paired samples was applied, considering the natural head position as the reference value, considered as 0. For non-normally distributed data, an alternative to the t test was applied, the non-parametric Mann-Whitney test. The Student’s t test for paired values was not used for comparison between the observed means; the Mann-Whitney test was used for comparison of medians. A significance level of α = 5% was considered throughout the study.

keeping the TVL and the radiograph vertical line parallel to each other, maintaining the fulcrum at point Sn. From there, the distances between the same points marked on the cephalometric tracing and NHP photography were measured, as well as the variation in angulation between the Gb-Sn line on the photograph and on the lateral radiograph. The angulation was measured from an angle formed between a line drawn from the glabella to the subnasale and the true vertical line; the variation in angulation was considered negative when the photograph exhibited a counterclockwise rotation in relation to the cephalometric Gb-Sn line, being considered positive in cases with clockwise rotation of the same line on the cephalometry.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Lima NR, Nogueira EFC, Castanha DM, Laureano Filho JR

RESULTS The distances found between points marked on the cephalometry and on the lateral photograph, as well as the difference in angulation between cephalometry and NHP photography are shown in Table 1. The distance between points ranged from 1 to 16 mm. The angulation ranged from -1° to -9°, with a mean of -4.7°.

All points were altered. The glabella presented a mean variation of 5.06 mm and the nasal point of 2.66 mm. The upper lip presented the lowest variation, with 1.67 mm. The lower lip showed variation of 3.78 mm, and the soft tissue pogonion had the greater disparity (6.44 mm).

Evaluation of the angulation variations in relation to gender is presented in Table 2. Regarding angulation, data were normally distributed (p=0.9824) and homogeneous (p=0.5547). The mean angulation was -5.0° for females and -4.67° for males. When performing the t test for angulation, statistical difference was observed between the means of the two groups, males and females, with p=0.0001038 (confidence interval = 3.596299 – 7.292590). It should

be remembered that the confidence interval is a type of interval estimate of an unknown populational parameter – in this case, angulation.

The height variation of the studied sample was 1.62 m to 1.82 m, with mean of 1.72 m. The patients were divided in two groups: one group <1.72 m and the other > 1.73 m. The correlation of height with mean angulation is presented in Table 3. It can be observed that patients > 1.73 m had greater mean variation than patients <1.72 m.

The variation of angulation related to the soft tissue pogonion/true vertical line distance is shown in Table 4. The patients were divided in two groups: one with distance Pg’/TVL < 4 mm, and another in which this distance was > 4mm. In this case, data were not normally distributed (p=0.0004194) and were heterogeneous with respect to the variance (p<0.001). Patients in the second group had a mean angulation greater than those of the first group. When performing the Mann-Whitney test, no statistically significant difference was observed between patients with greater or smaller mandibular protrusion concerning the angulations found (p-value 0.6213).

Table 1: Variation in positioning of craniometric points, after superimposition of cephalogram and lateral photograph in NHP. Measurement

Mean

Standard deviation

Minimum

Maximum

p

Glabella (mm) Nasale (mm) Upper lip (mm) Lower lip (mm) Soft tissue pogonion (mm) Angulation (degrees)

5,06 2,66 1,67 3,78 6,44 -4,7

2,855 1 1,323 2,949 4,275 2,38

1 1 1 1 1 -1

10 4 4 10 16 -9

0,001 0,0 0,005 0,005 0,002 0,0

Table 2: Evaluation of variations in angulation in relation to gender.

Gender

n

Mean

Standard deviation

p

Female Male

3 6

-5,0° -4,67°

2,0 2,733

0,0001038

Table 3: Evaluation of variations in angulation in relation to height.

Height (m)

n

Mean

Standard deviation

< 1,72

4

-4,5°

1,915

> 1,73

5

-5,0°

2,915

Table 4: Evaluation of variations in angulation in relation to soft tissue pogonion.

Student t test for paired samples.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Distance Pg’ - LVV (mm)

n

Mean

Standard deviation

p

<4 >4

5 4

-4,20° -5,5°

2,387 2,517

0,6213

Mann-Whitney test.

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Assessment of craniometric points in Class III patient profile radiographs and their relationship with natural head position

DISCUSSION NHP has been proposed as an extracranial reference in Orthodontics since the 1950s. Its reproducibility mentioned in the literature was statistically and clinically expressive, evidencing that this is a reliable position to obtain lateral cephalograms, especially when the natural head orientation is achieved by an experienced clinician or technician – considering that the natural head position is the habitual for the patient. 10,12 Many studies have been conducted on the stability and reproducibility of NHP with positive results, with both short and long intervals. 5,7,9 In a study published by Rosa,13 the authors found no statistically significant difference in craniocervical analysis performed on radiographs obtained by conventional and NHP methods. However, the present results suggest that there are differences related to posture measurements and facial profile, in agreement with the study that evaluated cephalograms obtained in natural head position and in a standard position and also found differences between them.8,13 In the present comparative study between the skeletal and soft tissue profile evaluations used for sagittal orthodontic diagnosis, comparing lateral cephalograms obtained in natural head position, it was observed that there was no agreement between the diagnoses suggested by the different cephalometric analyses, both in comparisons based on the skeletal tissue to each other and in comparisons between skeleton and soft tissue. This was restated by the present study, which showed variation in the position of points evaluated in soft tissue according to the angulation of the natural head position of each patient. 14 In a similar study, the authors evaluated standard lateral cephalograms with NHP photographs, observing great variation in angulation between cephalograms and photographs. 2 In another study, the researchers attempted to determine the impact of the Frankfurt horizontal line inclination in relation to the extracranial horizontal line with the head in natural position and concluded that soft tissue measurements based on these lines showed significant differences. In this sense, in general, the inclination angles tended to be greater among females in relation to males.11

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Analysis regarding gender related to the head angulation in NHP demonstrated that the mean female angulation was slightly higher than observed for males. However, other studies concluded that females have little postural change. The male sample exhibited statistically different values​. This divergence of results between studies may be due to the fact that the number of females is reduced in relation to the number of males in this study. 8 Regarding studies on natural head position in different malocclusions, the authors evidenced that a forward head posture is observed in Class III patients compared to Class I and II, and that Class III patients tend to tilt the head in ventral direction, compared to Class I patients. 15 In a study comparing cephalograms obtained in natural head position versus the conventional technique in patients without facial deformities, the author showed alteration in posture measurements in relation to the mandibular plane. The linear measurements Pg’-TVL also showed significant changes. In the same study, the author suggested NHP analysis in patients with dentofacial deformities. 16 No studies were found correlating height and Pg’-TVL distance with the head inclination in Class III patients in NHP with the standard position in lateral cephalograms. The results regarding mandibular protrusion in this study showed no statistically significant difference between groups with less protrusion (less than 4 mm) or greater protrusion (greater than 4 mm) in relation to the variations of angulations found.

According to the authors, in a study that evaluated the effect of NHP alteration on the cephalometric measurements, the angular and linear measurements evaluated did not show significant changes even if the NHP was altered in 5 degrees, and the differences observed in cephalometric measurements analyzed do not invalidate the diagnoses achieved.

This demonstrates the reliability of NHP for achievement of lateral cephalograms. 17 Currently, the advent of virtual planning softwares in orthognathic surgery has added some features, with advantage over traditional cephalometric evaluations – which were and still are widely used. The possibility to achieve predictive tracings with greater speed and accuracy is the greater advantage of such softwares. 18

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Lima NR, Nogueira EFC, Castanha DM, Laureano Filho JR

CONCLUSION According to this case series, the standard position used for the achievement of lateral cephalograms did not agree with the clinical achievement of natural head position in Class III patients. The patients had a tendency of clockwise head rotation for the achievement of cephalograms, and this inclination was even greater in females and taller patients, with statistically significant difference. The extent of mandibular protrusion did not influence the degree of inclination. Despite the small sample, this study may demonstrate that some cases have significant variations in head positioning,

which could cause treatment failure. In the search for more concrete conclusions, future studies on larger number of patients are necessary.

In this sense, the literature evidences that natural head position is reproducible and can be used accurately for planning in orthognathic surgery, since it is the patient’s habitual position. Therefore, the surgeon should be aware of these variations, so as they may be corrected during achievement of radiography, minimizing the risks of failure in orthognathic surgeries. Continuation of the study is necessary and important to obtain more consistent results.

References:

1. Wozniak K, Piatkowska D, Lipski M. The influence of natural head position on the assessment of facial morphology. Adv Clin Exp Med. 2012 June;21(6):743-9.

2. Oh J, Han JJ, Ryu SY, Oh HK, MS Kook, Jung S, et al.

Clinical and cephalometric analysis of facial soft tissue.

J Craniofac Surg. 2017 July;28(5):431-8.

3. Sant’ana E, Furquim LZ, Rodrigues MTV, Kuriki EU, Pavan AJ, Camarini ET, et al. Planejamento digital em cirurgia ortognática: precisão, previsibilidade e praticidade. Rev Clín Ortod Dental Press. 2006 Abr-Maio;5(2):92-102.

4. Luyk NH, Whitfield RP, Ward-Booth MB, Williams ED. The reproducibility of the natural head position in lateral cephalometric radiographs. Brit J Oral Maxillofac Surg. 1986;24(5):357-66.

5. Dvortsin DP, Ye Q, Pruim GJ, Dijkstra PU, Ren Y. Reliability of the integrated radiograph-photograph method to obtain natural head position in cephalometric diagnosis. Angle Orthod. 2011 Sept;81(5):889-94.

6. Moorrees CFA. Natural head position - a revival. Am J Orthod Dentofacial Orthop. 1994 May;105(5):512-3.

7. Pereira AL, De Marchi LM, Scheibel PC, Ramos AL. Reprodutibilidade da posição natural da cabeça em fotografias de perfil de crianças de 8 a 12 anos, com e sem o auxílio de um cefalostato. Dental Press J Orthod. 2010 Jan-Feb;15(1):65-73.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

8. Haiter-Neto F, Oliveira SS, Casanova MS, Caldas MP. Telerradiografias obtidas em posição natural da cabeça alteram as grandezas cefalométricas? Rev Dental Press Ortod Ortop Facial. 2007 Jul-Ago;12(4):117-23.

9. Weber DW, Fallis DW, Packer MD. Three-dimencional reproducibility of natural head position. Am J Orthod Dentofacial Orthop. 2013 May;143(5):738-44.

10. Verma SK, Maheshwari S, Gautam SN, Prabhat K, Kumar S. Natural head position: key position for radiographic and photographic analysis and research of craniofacial complex. J Oral Biol Craniofac Res. 2012 Jan-Apr;2(1):46-9.

11. Ferrario VF, Sforza C, Germano D, Dalloca, Miani UM. Head posture and cephalometric analyses: an integrated photographic / radiographic technique. Am J Orthod Dentofacial Orthop. 1994 Sept;106(3):257-64.

12. Rino Neto J, Freire-Maia BAV, Paiva JB. Método de registro da posição natural da cabeça para obtenção da radiografia cefalométrica lateral - considerações e importância do método no diagnóstico ortodôntico-cirúrgico. Rev Dental Press Ortod Ortop Facial. 2003 Maio-Jun;8(3):61-71.

13. Rosa LP. Estudo comparativo do método de posicionamento convencional e natural de cabeça para obtenção de radiografias laterais cefalométricas utilizando a análise crânio-cervical [tese]. São José dos Campos (SP): Universidade Estadual Paulista; 2007.

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14. Grossi VCC, Mazzieiro ET, Siqueira VCV. Estudo comparativo entre avaliações esqueléticas e do perfil tegumentar utilizadas no diagnóstico ortodôntico sagital. Rev Dental Press Ortod Ortop Facial. 2007 Jul-Ago;12(4):107-16.

15. Hedayati Z, Paknahad M, Zorriasatine F. Comparison of Natural Head Position in Different Anteroposterior Malocclusions. J Dent (Tehran). 2013 May;10(3):210-20.

16. Santos SO. Estudo comparativo das telerradiografias laterais obtidas em posição natural da cabeça versus técnica convencional [dissertação]. São José dos Campos (SP): Universidade Estadual Paulista; 2007.

17. Negreiros PE, Siqueira VCV. O efeito da alteração da posição natural da cabeça (PNC) sobre as medidas cefalométricas. Rev Dental Press Ortod Ortop Facial.

2004 Maio-Jun;9(3):59-76.

18. Pinto LAPF, Vargas BC, Ramos V, Coutinho MA, Manhães Júnior LRC. Cefalometria computadorizada das vias aéreas. J Braz Coll Oral Maxillofac Surg. 2016 Maio-Ago; 2(2):16-22.

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OriginalArticle

Tooth in fracture line:

extract or maintain?

THIAGO MARQUES DE MESQUITA1,2 | BASÍLIO DE ALMEIDA MILANI1,3 | THAIS BENEDETTI HADDAD CAPPELLANES1,4 | ROSANY GUARNNETTI DOS SANTOS1,5 | TALITA LOPES1,6

ABSTRACT Fractures located in the mandibular angle may contain teeth in the fracture line and, over the years, different opinions have been observed on the need for extraction or maintenance of these teeth in the fracture line. The objective of this study was to report two cases of treatment of mandibular fractures, with tooth presence in the fracture line, discussing the indications of maintenance and extraction of these teeth. In the first case, it was decided to perform the extraction of the tooth associated with mandibular fracture line. In the second patient, it was opted to maintain this tooth in the fracture line. As a result, we have succeeded in the treatment both in the case where the tooth was maintained and in the case where tooth extraction was performed. We have concluded that must be extracted during surgery teeth that do not have any condition that allows its maintenance, or to prevent the reduction of the fracture. Sound teeth or teeth that facilitate the reduction and fixation of mandibular fractures, even present in mandibular fracture line, must be preserved. The preservation of a tooth in the mandibular fracture line does not increase the chance of infection, provided there is no indication of dental extraction.

Keywords: Tooth. Mandibular fractures. Tooth extraction.

Hospital Municipal do Campo Limpo (São Paulo/SP, Brazil).

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How to cite: Mesquita TM, Milani BA, Cappellanes TBH, Santos RG, Lopes T. Tooth in fracture line: extract or maintain? J Braz Coll Oral Maxillofac Surg. 2019 Jan-Apr;5(1):36-40.

DOI: https://doi.org/10.14436/2358-2782.5.1.036-040.oar

Especialista em Cirurgia e Traumatologia Bucomaxilofacial, Hospital Municipal do Campo Limpo (São Paulo/SP, Brazil).

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Submitted: 09/04/2015 - Revised and accepted: 25/01/2018

Especialista em Cirurgia e Traumatologia Bucomaxilofacial e Mestre em Clínicas Odontológicas, Universidade de São Paulo, Faculdade de Odontologia (São Paulo/SP, Brazil).

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Mestre em Odontologia, Universidade de Taubaté (Taubaté/SP, Brazil).

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

Especialista em Ortodontia, Sindicato de Odontologia do Estado de São Paulo, Centro de Aperfeiçoamento Profissional e Especialização (São Paulo/SP, Brazil).

» Patients displayed in this article previously approved the use of their facial and intraoral photographs.

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Especialista em Cirurgia e Traumatologia Bucomaxilofacial, Universidade de São Paulo, Faculdade de Odontologia (São Paulo/SP, Brazil).

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© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Contact address: Thiago Marques de Mesquita Rua José Afonso de Melo, 118, Harmony Trade Center, sala 214 Jatiúca, Maceió/AL – CEP: 57.036-510 E-mail: thiagomesquita.bucomaxilo@gmail.com

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Mesquita TM, Milani BA, Cappellanes TBH, Santos RG, Lopes T

INTRODUCTION Mandibular fractures are among the most common types of fracture in facial trauma, ranking second among bones of the maxillofacial skeleton. These fractures can occur in different regions of the mandible, including the body/parasymphysis (33%); condyle (29.3%); angle (23.1%); symphysis (8.4%); and coronoid process (4.8%).1 Among the mandibular fractures, those affecting the angle have the highest rate of complications, associated with several factors, such as tooth in the fracture line and biomechanics of the region.2 Fractures at the mandibular angle may contain a tooth in the fracture line, and divergent opinions have been observed over the years regarding the need for extraction or maintenance of teeth in the fracture line.3 For the adequate treatment of mandibular fractures, it is fundamental to obtain satisfactory reduction of fractured sides and correct reestablishment of dental occlusion. In many situations, the tooth in the fracture line does not preclude fracture reduction and may also be an adjunct transoperatively, providing an optimal occlusal reference.4 The correct management of patients presenting teeth involved in mandibular fractures is fundamental to achieve treatment success, since both extraction and improper maintenance can lead to treatment failure.5 Thus, this paper reports two clinical cases of treatment of mandibular fractures with tooth in the fracture line. In the first case, we decided to extract the tooth associated with the mandibular fracture line. In the second, it was decided to maintain the tooth in the fracture line. Additionally, the indications for maintenance and extraction of these teeth are discussed. As a result, treatment was successful in both cases where the tooth was maintained and where it was extracted.

CASE REPORT 1 A 30-year-old male patient attended the Oral and Maxillofacial Surgery and Traumatology Service at

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Hospital Municipal do Campo Limpo/SP with a history of motorcycle accident about 30 days before, reporting initial care at another hospital, being submitted to tracheostomy and hospitalized for four weeks, partly in the ICU. Physical examination revealed facial asymmetry, with volume increase in the right preauricular region, slight limitation in mouth opening, and a tracheostomy cannula in the cervical region. Intraoral examination revealed significant dental disocclusion. Radiographic and tomographic examinations (Fig 1) evidenced the presence of mandibular fractures in the symphysis and right mandibular angle, also showing the presence of a tooth located in the mandibular angle fracture.

Due to the long period without treatment, the fractured sides had already consolidated. The patient was then submitted to general anesthesia, with intubation through the tracheostomy, for fracture reduction and fixation. Mandibular anterior and right submandibular buccal accesses were performed. The fractures were then mobilized and reduced; maxillomandibular block was performed, and then the fractures were fixated with miniplates of systems 2.0 and 2.4. Transoperatively, the impossibility to main tooth 48 was evidenced, since it presented exposure of the root surface, presence of dental calculus and loss of bone insertion, yet without mobility, thus extraction was performed. Three days postoperatively, the patient was discharged and referred for outpatient control returns (7, 21, 35, 45 and 90 days). At the first return visit, the patient had no pain complaint; he presented mild edema, slight limitation of mouth opening, good dental occlusion, sutures without dehiscence and no signs of infection. After 45 days, the patient was reevaluated and presented normal dental occlusion, normal healing and absence of infection. After 90 days postoperatively the patient presented the same clinical signs of normality and a new radiograph was evaluated, which presented normal bone healing, with the osteosynthesis material in place (Fig 2).

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Tooth in fracture line: extract or maintain?

Figure 1: Mandibular angle fracture and associated tooth 48.

Figure 2: Panoramic radiography three months postoperatively.

CASE REPORT 2 A 16-year-old male patient was admitted to the Oral and Maxillofacial Surgery and Traumatology Service of Hospital Municipal do Campo Limpo/ SP with a history of physical aggression. Physical examination of the face showed edema on the left mandibular angle and limited mouth opening. Intra-

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oral examination revealed ecchymosis in the region of tooth 38, which was included and impacted, as well as dental disocclusion. Radiographic and tomographic examinations evidenced a left mandibular angle fracture, with slight displacement, and presence of tooth 38 in the fracture line (Fig 3).

The patient was then submitted to general an-

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Mesquita TM, Milani BA, Cappellanes TBH, Santos RG, Lopes T

However, in some situations, the indication for extraction of the involved tooth was present even before the fracture. In such situation, and if there is no damage to fracture reduction, there are no reasons that justify the maintenance of this tooth.

According to Shetty and Freymiller,4 the indications for removal of teeth located in the mandibular fracture line are as follows: » Significant periodontitis with marked dental mobility. » Third molars partially erupted and associated with pericoronitis. » Teeth that prevent fracture reduction. » Teeth with exposed root tips or complete exposure of the root surface. » Excessive delay between fracture and definitive treatment.

Ellis,6 in a study on 402 patients among whom 85% had a tooth in the mandibular fracture line, concluded that there is increased risk of postoperative complications when a tooth is present, even though this increase is not statistically significant. The author also showed that there is no increase in postoperative complications or need to remove the fixation material when tooth extraction is indicated.

It should be noted that, after large scale utilization of miniplate fixation systems and administration of antimicrobial agents, there was a reduction in the prevalence of infection in teeth in the fracture line.5 A careful clinical and radiographic evaluation is necessary to reduce the rate of complications after treatment of teeth maintained in place in the mandibular fracture line. When there is indication for extraction, this should not be neglected, which might jeopardize the treatment performed.8 In some cases, transoperative extraction of a third molar present in the mandibular fracture line, for example, might transform a stable fracture with little displacement into an unstable fracture, complicating the reduction and osteosynthesis. In these cases, the best option would be to keep the tooth in place and extract it later, after bone healing at the fracture site.

It should be mentioned that teeth play a fundamental role in the realignment and retention of bone fragments, thanks to their occlusion, avoiding an inadequate fracture consolidation. The faster the immobilization and retention of bone fragments and consequently of the tooth involved in the bone fracture, the

Figure 3: Preoperative radiograph with tooth 38 in the fracture line.

esthesia with nasotracheal intubation, for mandibular reduction and osteosynthesis. By intraoral access, the fracture was reduced and fixated with two plates of system 2.0, being one in the zone of tension and the other in the zone of compression. Tooth 38 did not interfere with fracture reduction and presented normal aspect; thus, it was decided to keep it in place.

Evaluation of the immediate postoperative tomography evidenced correct reduction of the fracture, with osteosynthesis material in correct position and tooth 38 present in the fracture line.

On the second postoperative day, the patient was discharged and referred for outpatient control returns (7, 21, 35 and 45 days). At the end of 45 days, the patient had normal dental occlusion, good mouth opening and no complaints, and was instructed to return after 6 months for reassessment and possible extraction of tooth 38.

DISCUSSION There is an increasing tendency of the surgeons to maintain teeth involved in the mandibular fracture line. This choice is based on a growing number of researches showing no statistically significant difference when teeth present in mandibular fracture line are maintained, compared to fractures in which these teeth are extracted.6-10

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Tooth in fracture line: extract or maintain?

such as significant periodontitis with marked dental mobility; partially erupted third molars and with pericoronitis; teeth that preclude the fracture reduction; teeth with exposed root apices, complete root surface exposure, or in cases of excessive delay between fracture and definitive treatment.

Teeth present in the mandibular fracture line that are healthy or that facilitate reduction and fixation of the mandibular fracture should be maintained.

The preservation of a tooth in the mandibular fracture line does not increase the chance of infection, as long as there is no indication for extraction.

greater will be the chances of maintaining this tooth during fracture consolidation.6 It is advisable to follow the vitality of teeth present in the mandibular fracture line, when these are maintained in place, for at least one year postoperatively, to prevent possible complications in case the loss of vitality of these teeth is a determining factor for infection.9

CONCLUDING REMARKS Teeth should be extracted transoperatively if they present any condition precluding their maintenance,

References:

1. Miloro M, Ghali GE, Larsen PE, Waite PD. Princípios de Cirurgia Bucomaxilofacial de Perterson. 2ª ed. São Paulo: Ed. Santos; 2008. v. 1.

2. Figueiredo MCA, Pastori CM, Marzola C, Toledo Filho JL, Zorzetto DLG, Toledo GL. Fixação interna no tratamento das fraturas de ângulo mandibular - Revista da literatura. Rev Odontol ATO. 2013;13(6):550-95.

3. Spinnato G, Alberto PL. Teeth in the Line of Mandibular Fractures. Oral Maxillofac Surg. 2014 Mar;18(1):7-24.

4. Shetty V, Freymiller E. Teeth in the line of fracture: a review. J Oral Maxillofac Surg. 1989 Dec;47(12):1303-6.

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5. Schaffer M, Rebellato NLB, Passeri LA, Primo BT, Moraes RS. Teeth in the line of mandibular fractures: epidemiology, management and complications. Rev Cir Traumatol Buco-Maxilo-Fac. 2013;13(2):23-30.

6. Ellis III E. Outcomes of patients with teeth in the line of mandibular angle fractures treated with stable internal fixation. J Oral Maxillofac Surg. 2002 Aug;60(8):863-5; discussion 866.

7. Anastassov DT, Vuvakis VM. Mandibular fracture complications associated with the third molar lying in the fracture line. Folia Med (Plovdiv). 2000;42(1):41-6.

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8. Anyanechi CE, Chukwuneke FN. Prognosis of teeth in the line of mandibular fracture: 5-year clinical and radiological follow-up. Níger J Med. 2013 Jan-Mar;22(1):61-3.

9. Gerbino G, Tarello F, Fasolis M, De Gioanni PP. Rigid fixation with teeth in the line of mandibular fractures.

Int J Oral Maxillofac Surg. 1997 June;26(3):182-6.

10. Bobrowski AN, Sonego CL, Chagas Junior OL. Postoperative infection associated with mandibular angle fracture treatment in the presence of teeth on the fracture line: a systematic review and meta-analysis.

Int J Oral Maxillofac Surg. 2013 Sept;42(9):1041-8.

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CaseReport

Surgical approach of impacted mandibular fourth molars:

case report

FELIPE AURÉLIO GUERRA1,2 | NATASHA MAGRO ÉRNICA1,3 | GERALDO LUIZ GRIZA1,3 | ELEONOR ALVARO GARBIN JÚNIOR1,3

ABSTRACT Supernumerary teeth are more frequent in the permanent dentition of the maxilla, and prevalent in male gender. Their presence may cause delay at adjacent teeth eruption, malocclusion, cystic formation, and root resorption. Since fourth molar presence is rare, early diagnosis is the key to accurate conduct and reduction of injuries at the time of its extraction. That is based on a thorough clinical evaluation and appropriate complementary exams. A twenty-one-year-old male patient, with no relevant medical history, presented for extraction of the third and fourth molars, with absence of pain or sensorial complaints. After clinical exam, radiographic, and computed tomography an analysis, the treatment plan was extraction of all third and fourth molars. Surgical procedure employed was effective in removing the included teeth, with adequate surgical time and no postoperative complications. Early diagnosis along with correct treatment planning through imaging exams such as computed tomography is of great value for success in the management of retained and supernumerary teeth.

Keywords: Impacted tooth. Supernumerary tooth. Oral surgery.

Universidade Estadual do Oeste do Paraná, Faculdade de Odontologia, Centro de Ciências Biológicas e da Saúde, Residência em Cirurgia e Traumatologia Bucomaxilofacial (Cascavel/PR, Brazil).

How to cite: Guerra FA, Érnica NM, Griza GL, Garbin Júnior EA. Surgical approach of impacted mandibular fourth molars: case report . J Braz Coll Oral Maxillofac Surg. 2019 Jan-Apr;5(1):41-5. DOI: https://doi.org/10.14436/2358-2782.5.1.041-045.oar

Especialista em Cirurgia e Traumatologia Bucomaxilofacial, Universidade Estadual do Oeste do Paraná (Cascavel/PR, Brazil).

Submitted: October 05, 2017 - Revised and accepted: April 18, 2018

Doutor(a) em Cirurgia e Traumatologia Bucomaxilofacial, Universidade Estadual Paulista, Faculdade de Odontologia de Araçatuba (Araçatuba/SP, Brazil).

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

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» Patients displayed in this article previously approved the use of their facial and intraoral photographs.

Contact address: Felipe Aurélio Guerra Av. Vital Brasil, 386, Casa 1, Bairro Areião – CEP: 13.414-044 – Piracicaba/SP E-mail: felipeaurelioguerra@gmail.com

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Surgical approach of impacted mandibular fourth molars: case report

INTRODUCTION Fourth molars are supernumerary teeth located in the distal region of third molars. 1 Males are the most affected, and the anterior maxillary region presents the highest incidence. Maxillary central incisors and molars are the most frequent supernumerary teeth. 2 These teeth may be present in both dentitions; however, the permanent is the most affected. Regarding the prevalence, 77.4% of individuals have one supernumerary tooth; 18.4% present two supernumerary teeth; 2.3% 3 teeth; and only 1.4% have 4 teeth beyond the regular dentition.3 The supernumerary molars affect only 0.18% of the population. 4 The molars do not have deciduous predecessors; this is important when discussing the etiology of supernumerary teeth. Thus, one of the most accepted theories is the hyperactivity of the dental lamina, which may give rise to a greater number of teeth while proliferating to form the tooth buds.

Within this context, the dichotomy theory, inherited factors and syndromes are also possible hypotheses.5 The classification of supernumerary molars is based on their shape and location. The first may be rudimentary, when the size and morphology do not resemble permanent or supplementary teeth. Regarding the location, they may be considered as paramolars, when beside the third molar; and distomolars, when located in their distal region. 6 Since fourth molars are seldom reported in the literature, 6 this study presents a case of extraction of third and fourth molars and presents considerations regarding the surgical technique employed.

CASE REPORT A 23-year-old Caucasoid male patient attended the dental clinic for extraction of third molars. Upon anamnesis he stated he did not have any diseases, allergies or harmful habits. A panoramic radiograph was requested (Fig 1) and revealed the presence of four third molars and two supernumerary molars (fourth molars) in the mandible. Considering the uniqueness of the case, a computed tomography was requested to better visualize the relation of teeth and adjacent structures. The upper sequence of coro-

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nal tomographic sections evidenced close contact between the inner alveolar nerve and the supernumerary tooth roots on the third quadrant; this proximity remained until the end of crown of tooth #38. The fourth quadrant, observed in the lower sequence, revealed a similar path (Fig 2).

The preoperative medication comprised 1 g of amoxicillin and 8 mg of dexamethasone. After antisepsis and placement of surgical drapes, the intraoperative period began by anesthetic block of the inferior alveolar nerve by the indirect technique, in which the anterior aspect of the ascending mandibular ramus is palpated in up-down direction, using the index finger. At the point of greatest depression, which consists of the retromolar fossa, the finger is turned so that the nail faces the sagittal plane. The nail center is the insertion point, about 1 cm above the occlusal plane of lower teeth. The needle is always inserted parallel to the occlusal plane of molars, deepening 5 to 6 mm and slowly injecting the anesthetic solution as it is introduced. This blocks the buccal nerve and then the lingual nerve. Afterwards, the needle is withdrawn without removing it from the mucosa, and the anesthetic syringe is directed to the opposite side, at the level of premolars. The needle is inserted until feeling bone contact and retreated a few millimeters, injecting the rest of the anesthetic tube, thus blocking the inferior alveolar nerve.6 The incision comprised a distal wedge, intrasulcular incision up to the mesiobuccal angle of the second molar and releasing incision. The third molar crown was sectioned in buccolingual and anteroposterior direction, to eliminate the existing impaction. After crown removal, the roots were sectioned. The supernumerary tooth was removed via the alveolus using elevators. Finally, suture was made using 5-0 nylon. The surgical sequence is shown in Figure 3. The same approach was used for both mandibular quadrants. The third upper molars were also extracted in the surgery. Postoperatively, the patient progressed satisfactorily, without complaints of pain or changes in sensitivity. The patient was followed at 7 and 15 days, and the suture was removed in the latter session.

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Guerra FA, Érnica NM, Griza GL, Garbin Júnior EA

Figure 1: Panoramic radiography.

Figure 2: Computed tomography. Coronal sections of the third and fourth quadrants, evidencing the proximity of the inferior alveolar nerve in relation to the teeth.

A

B

C

D

E

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Figure 3: A) Incision. B) Crown sectioning of the third molar. C) Aspect after crown removal. D) Sectioning of third molar root. E) Extraction of supernumerary molar. F) Suture.

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Surgical approach of impacted mandibular fourth molars: case report

DISCUSSION The frequency of supernumerary teeth in the permanent dentition reaches 0.1 to 3.8%, as compared to only 0.3 to 0.8% in the deciduous dentition. The prevalence is observed in the following descending order: mesiodens, upper molars, lower premolars, lower molars and upper premolars.5 Fourth molars are rarely observed, corresponding to 2% of supernumeraries;8 in the mandible, they affect only 0.02%. 9 In general, they present smaller size and altered form when compared to the third molars, being the most frequent rudimentary tooth (60.7%). The maxilla is more affected (62.3%) 5 and can reach a ratio of 7:1 when compared to the mandible. 10 Regarding gender, supernumeraries are more observed in males than females, at a ratio of 2.5:1. 5 The etiology of supernumerary teeth is not fully understood. Theories point as possible causes: proliferation of the dental lamina, disorders as Gardner syndromes and cleidocranial dysostosis, division of the tooth bud (dichotomy), inherited factors and history of trauma. 5 The development of complications, such as delayed eruption of adjacent teeth, malocclusion, formation of cysts or root resorptions, are associated with the presence of supernumerary teeth 1. Special attention should be given to the fourth molars, since their location may worsen cases of pericoronitis and formation of cysts, which are frequent occurrences in third molars.5 In the present case report, the 26-year-old patient female presented radiographic examination with third and fourth molars on the left side, foci of pain and infection. The left side had a fourth molar, but without any complaints. Surgery for extraction was performed under local anesthesia. The fourth molar

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on the left side was removed uneventfully; however, the third molar required bone removal and tooth sectioning to reduce the tooth size and minimize the risk of damage to adjacent structures. The tooth on the left side, though without symptomatology, was removed after patient consent. No postoperative complications were reported.1 The literature shows reports of impacted third and fourth molars sharing the same dental follicle and whose occlusal surfaces were contacting, with the roots in opposite direction – the so-called kissing molars. Computed tomography confirmed the proximity with the inferior alveolar canal and resorption of the lingual bone plate. The patient did not have any symptoms yet agreed with surgical removal of the impacted teeth. 11 The approach to be adopted in supernumerary molars depends on the present symptoms and complications inherent to the tooth permanence. Patients with complaint of pain in the region, affected adjacent teeth, pathological lesions and impactions affecting the permanent dentition should be extracted. The non-surgical approach is reserved for cases without complaints, with normal radiographic examinations and without possible injury to noble structures as the inferior alveolar nerve. The management should consider that the absence of symptoms does not indicate absence of disease, and the term asymptomatic is insufficient for diagnosis. 12

CONCLUDING REMARKS Agenesis of the third molars is an evolutionary mark, and fourth molars are rarely observed in the mandible Early diagnosis by radiographic examinations and computed tomography, combined with deep technical and anatomical knowledge, is the key to a safe and well-based treatment.

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Guerra FA, Érnica NM, Griza GL, Garbin Júnior EA

References:

1. Constantino A, Fonseca GM, Cantín M. Bilateral mandibular fourth molars: a case report. Rev Stomatol Chir Maxillofac Chir Orale. 2015 Nov;116(5):312-4.

2. Reddy GS, Reddy GV, Krishma IV, Regonda SK. Nonsyndromic bilateral multiple impacted supernumerary mandibular third molars: a rare and unusual case report. Case Rep Dent. 2013;2013:857147.

3. Bereket C, Çakir-Özkan N, Sener I, Bulut E, Bastan AI. Analyses of 1100 supernumerary teeth in a nonsyndromic Turkish population: a retrospective multicenter study. Niger J Clin Pract. 2015 Nov-Dec;18(6):731-8.

4. Cassetta M, Altieri F, Giansanti M, Di-Giorgio R, Calasso S. Morphological and topographical characteristics of posterior supernumerary molar teeth: an epidemiological study on 25,186 subjects. Med Oral Patol Oral Cir Bucal. 2014 Nov 1;19(6):e545-9.

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5. Neville B. Patologia oral e maxilofacial. 4ª ed. Rio de Janeiro: Elsevier; 2016.

6. Clementini M, Ottria L, Pandol C, Agrestini C, Barlattani A. Four impacted fourth molars in a young patient: a case report. Oral Implantol (Rome). 2012 Oct-Dec;5(4):100-3.

7. Marzola C. Anestesiologia. 5a ed. São Paulo: Pancast; 2017.

8. Shahzad KM, Roth LE. Prevalence and management of fourth molars: a retrospective study and literature review. J Oral Maxillofac Surg. 2012 Feb;70(2):272-5.

9. Ohata H, Hayashi K, Iwamoto M, Muramatsu K, Watanabe A, Narita M, et al. Three cases of distomolars. Bull Tokyo Dent Coll. 2013;54(4):259-64.

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10. Kara MI, Aktan AM, Ay S, Bereket C, Sener I, Bulbul M, et al. Characteristics of 351 supernumerary molar teeth in Turkish population. Med Oral Patol Oral Cir Bucal.

2012 May;17(3):e395-400.

11. Menditti D, Laino L, Cicciù M, Mezzogiorno A, Perillo L, Menditti M, et al. Kissing molars: report of three cases and new prospective on aetiopathogenetic theories. Int J Clin Exp Pathol. 2015;8(12):15708-18.

12. Dodson TB. How many patients have third molars and how many have one or more asymptomatic, disease-free third molars? J Oral Maxillofac Surg. 2012 Sept;70(9 Suppl 1):S4-7.

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CaseReport

Mandibular reconstruction after Pindborg tumor:

case report

HENRIQUE CLASEN SCARPARO1 | RONIELE LIMA DOS-SANTOS1 | ALEXANDRE MARANHÃO MENEZES NETO1 | FRANCISCO SAMUEL RODRIGUES CARVALHO1 | FABRICIO DE LAMARE RAMOS1 | FÁBIO WILDSON GURGEL COSTA1 | EDUARDO COSTA STUDART SOARES1

ABSTRACT Pindborg tumor, or calcifying epithelial odontogenic tumor (CEOT), is a rare, benign neoplasm with locally aggressive biological behavior. It has higher incidence between the third and fifth decades of life, with no predilection for race or sex. It presents radiographically with mixed pattern containing radiolucent areas with calcified structures.

The objective of this study was to present a clinical case of CEOT in a 42-year-old female patient, with a slight increase in volume in the posterior region of the mandible on the left side. An electronic data search was also carried out taking into account the last 10 years using the following electronic databases: PubMed, Cochrane database of systematic reviews, Embase, Medline and Electronic Journal Center. Imaging examinations demonstrated the presence of extensive radiolucent lesion with areas of scattered calcifications. The patient was submitted to an incisional biopsy of the lesion whose diagnosis was of CEOT. The patient was submitted to resection of the tumor, posterior reconstruction of the affected site with autogenous graft and implant-supported prosthesis. The patient was asymptomatic, under clinical-imaging follow-up for 2 years, with no signs of recurrence of the lesion, besides rehabilitation in which satisfactory aesthetic-functional results were obtained.

Keywords: Mandible. Mandibular reconstruction. Mandibular neoplasms.

Universidade Federal do Ceará, Hospital Universitário Walter Cantídio, Serviço de Cirurgia e Traumatologia Bucomaxilofacial (Fortaleza/CE, Brazil).

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How to cite: Scarparo HC, Dos-Santos RL, Menezes Neto AM, Carvalho FSR, Ramos FL, Costa FWG, Soares ECS. Mandibular reconstruction after Pindborg tumor: case report. J Braz Coll Oral Maxillofac Surg. 2019 Jan-Apr;5(1):46-52.

DOI: https://doi.org/10.14436/2358-2782.5.1.046-052.oar

Contact address: Alexandre Maranhão Menezes Neto Rua Capitão Francisco Pedro, 1016, apto. 303 – CEP: 60.430-372 – Fortaleza/CE E-mail: alexandremaranhaobucomaxilo@gmail.com

Submitted: November 06, 2017 - Revised and accepted: April 18, 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.

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J Braz Coll Oral Maxillofac Surg. 2019 Jan-Apr;5(1):46-52

Scarparo HC, Dos-Santos RL, Menezes Neto AM, Carvalho FSR, Ramos FL, Costa FWG, Soares ECS

INTRODUCTION The calcifying epithelial odontogenic tumor (CEOT), or Pindborg tumor, is a rare benign odontogenic neoplasm. It was first described in 1955 by Jens J. Pindborg.1 This lesion represents less than 1% of all odontogenic tumors, preferably affecting patients between the third and fifth decades of life, without gender predilection, and occasional cases of malignancy were described in the literature.2,4 Several studies investigated the pathogenesis of CEOT; however, it remains controversial.4,5 Its main clinical manifestation is the increase in volume, usually without associated symptomatology. The most affected site is the posterior mandibular region, and approximately 25% of cases occur in the maxilla.3 It can present in intraosseous (94%) or extraosseous (6%) manifestations, usually with slow and painless growth.4,6,7 The radiographic presentation is varied and may contain radiolucent areas, with calcified structures of varying sizes and densities. When associated with impacted teeth, these radiopacities are close to the coronal portion.8,9 Histopathologically, the most common pattern presents polyhedral epithelial cells with well-defined borders and prominent intercellular bridges. Amyloid substances and Liesegang calcified concentric rings are the most classical findings.10 The Pindborg tumor is locally aggressive. Studies show that, depending on the lesion size, it can be treated by enucleation or by surgical resection with free margins.10 This procedure may involve conservative enucleation, marginal, segmental or partial resection (larger and more aggressive tumors), or very rarely composite resection (in the presence of malignant transformation).1,6,7 A local recurrence rate of 14% is reported and the prognosis is considered as good.3 Therefore, this paper presents a case report of CEOT treated by surgical excision with application of Carnoy solution, posterior reconstruction with autogenous graft and rehabilitation with implants, and also presents a literature review of the last 10 years about the reconstructions used for treatment of this lesion. For that purpose, an electronic data search was conducted on June 2016, considering the last 10 years and using the following electronic databases: PubMed, Cochrane Database of Systematic Reviews, Cochrane Controlled Randomized Con-

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

trolled Trials, Embase, Medline and Electronic Journal Center. The following search entries were used: “Pindborg”, “calcifying epithelial odontogenic tumor”, “excisional biopsy” and/or “Pindborg”, “treatment” and/or “Pindborg”, “resection” and/or “Pindborg”, “Carnoy solution” and/or “Pindborg”, “recurrence” and/or “Pindborg”. The search included any type of study in which surgical treatment was performed to remove the Pindborg tumor associated with bone reconstruction. Studies published in languages other ​​ than English, papers that did not inform the type of treatment and animal studies were excluded. The electronic search retrieved 111 references, among which 37 were animal studies and 8 were not published in English language. Thus, 66 articles were selected for reading. Analysis of abstracts and reading of the full texts retrieved 10 papers that addressed the surgical removal of Pindborg tumor.

CASE REPORT A 42-year-old female patient, without systemic disorders, attended the dental office for routine examination with the following chief complaint: “I discovered a lump in my mandible three months ago”.

Extraoral physical examination did not show any noticeable changes. Oral examination revealed a painless swelling at the region of teeth 45 to 48, without change in color of the adjacent mucosa (Fig 1). Imaging exam-

Figure 1: Preoperative intraoral clinical aspect.

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Mandibular reconstruction after Pindborg tumor: case report

compatible with amyloid material (Fig 3B), characteristic of the Pindborg tumor.

A biomodel was used for surgical planning and reconstruction plate modeling (Fig. 4A). The patient was then submitted to surgery in a hospital environment, under general anesthesia and by intraoral access. We decided to extract the teeth 44, 45 and 47 because they were affected by the lesion. Surgical resection was performed, including a marginal portion of apparently healthy bone, and Carnoy solution was applied to the surgical site. A 2.0 system plate with high profile was fixed on the base to reinforce the bone remnant (Fig 4B). After 14 days, a second surgery was performed for mandibular reconstruction using an iliac crest bone graft (Fig 5A, B). The patient has been submitted to clinical and imaging follow-up for two years, without signs of lesion recurrence, with rehabilitation by implant-supported denture, which retrieved satisfactory esthetic and functional results (Fig 6A, B).

inations revealed a multilocular, radiolucent area with well-defined margins and limits, associated with teeth 44, 45 and 47, causing a slight increase in the buccal volume and on the mandibular base (Fig 2A, B). Considering the clinical and radiographic findings, the following diagnosis hypotheses were suggested: CEOT, calcifying odontogenic cyst, ameloblastoma, ossifying fibroma, keratocystic odontogenic tumor and dentigerous cyst.

An incisional biopsy was performed under local anesthesia, and the specimen was referred to an Oral Pathology laboratory. The histopathological analysis revealed polyhedral odontogenic epithelial cells and prominent intercellular junctions with cell pleomorphism, organized as anastomosed strands within a fibrous stroma with hemorrhage areas (Fig 3A). Congo red staining was positive interspersed between the odontogenic epithelial cells, evidencing deposition of eosinophilic material, either globular or amorphous,

A

Figure 2: A) Cone-beam computed tomography and panoramic reconstruction. B) Three-dimensional reconstruction of computed tomography.

B

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Scarparo HC, Dos-Santos RL, Menezes Neto AM, Carvalho FSR, Ramos FL, Costa FWG, Soares ECS

A

B

Figure 3: A) Histopathological section of Pindborg tumor (HE/20x). B) Histopathological section of Pindborg tumor (HE/40X).

A

Figure 4: A) 3D surgical biomodel. B) High-profile 2.0 system plate.

B

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Mandibular reconstruction after Pindborg tumor: case report

A

A

B

B

Figure 5: A) Iliac graft positioned with 2.0 system screws. B) Postoperative panoramic radiograph.

Figure 6: A) Final occlusion. B) Two-year postoperative panoramic radiograph.

DISCUSSION The Pindborg tumor is an extremely rare odontogenic epithelial neoplasm first described in 1955 by Jens J. Pindborg,1,7,9,10 representing less than 1% of all odontogenic tumors. Its prevalence affects a broad age range; however, most reported cases comprise patients between the third and fifth decades of life, and it does not present gender predilection.6,8,9 It manifests with slow and asymptomatic, yet locally invasive growth. Aggressive lesions exhibit bone destruction and tumor calcification. Usually, it is diagnosed during routine dental examination, possibly affecting the maxilla or mandible, yet the most affected site is the posterior mandibular region, predominantly at the premolar and molar regions.4,6,8

Its most common histopathological characteristic is the presence of pleomorphic polyhedral epithelial cells and prominent intercellular bridges, as well as amyloid substances and Liesegang calcified concentric rings.1,3,5,6 The differential diagnosis of CEOT include the calcifying odontogenic cyst, ameloblastoma, ossifying fibroma, ameloblastic fibro-odontoma, myxoma, odontogenic tumor keratocystic and dentigerous cyst.1,8 The type of treatment depends on the size and anatomical location of the CEOT.6.2 The current literature reports only three cases of malignant CEOT and one case presenting microscopic characteristics of malignant potential, published in the English-lan-

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Scarparo HC, Dos-Santos RL, Menezes Neto AM, Carvalho FSR, Ramos FL, Costa FWG, Soares ECS

consider the volume of bone loss and consequently the amount of bone required for reconstruction, the type of bone defect presented by the patient, the surgical-prosthetic planning, geometric conformation of the ridge, general conditions of the patient and good three-dimensional positioning of the anchorages to withstand the occlusal forces.6 The iliac crest is the preferred donor site for large reconstructions.5,6 Besides allowing easy surgical access due to its anatomical location, it provides a large amount of bone, both cortical and cancellous. In the present case, the iliac crest graft, together with a high-profile 2.0 system plate, proved to be a good treatment modality, without postoperative complications.

The biomodel was used to facilitate the surgical planning. Biomodels allow simulation of osteotomies and resection techniques, as well as complete planning of the most diverse types of oral and maxillofacial surgery. This tends to reduce the surgical time and consequently the period of anesthesia, as well as the risk of infection, with improved outcomes.6

CONCLUDING REMARKS Even though it is a rare lesion, the calcifying epithelial odontogenic tumor presents several treatment options. Among these, surgical resection and reconstruction with titanium plate and application of Carnoy solution, together with iliac crest graft and subsequent prosthetic rehabilitation with implants, proved to be an efficient treatment modality, since esthetic and functional results were satisfactorily obtained. The patient in the present case is under clinical follow-up, without signs of lesion relapse.

guage literature.1,4 Odontogenic malignant tumors are extremely rare. Malignancy is confirmed based on the following criteria: histological findings of infiltrative growth, atypical cytologic features and focal necrosis or clear evidence of distant metastatic dissemination.10 In the present case, the treatment consisted of surgical tumor resection, including the marginal portion of apparently healthy bone, together with reconstruction with plate and iliac crest graft. However, although there are no reports in the literature, Carnoy solution was used in the present patient to assure a greater safety that there would be no lesion relapse. The present search found an article that reported the case of a patient with Pindborg tumor in the posterior mandibular region, in which the same treatment modality was used. However, in the present case, we decided to use an autogenous iliac crest graft, besides subsequent rehabilitation with implants.

Among the reconstruction modalities, autogenous bone is considered among the best options.5,6 The autogenous graft is biologically considered the gold standard for reconstruction of maxillary and mandibular ridges, because of advantages as antigenic and angiogenic properties, and because it is the only to maintain the osteo-reparative, osteogenic, osteoinductive and osteoconductive properties, besides reducing the costs and providing more bone. The major disadvantage of this type of graft is the greater morbidity to the patient, besides the need for two surgeries.5,6 Despite the wide possibility of intra- or extraoral graft donor sites, 6 selection of the donor area should

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Mandibular reconstruction after Pindborg tumor: case report

References:

1. Rydin K, Sjostrom M, Warfvinge G. Clear cell variant of intraosseous calcifying epithelial odontogenic tumor: a case report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol. 2016;122(4):e125-30.

2. Shetty SJ, Pereira T, Desai RS. Peripheral clear cell variant of calcifying epithelial odontogenic tumor: case report and review of the literature. Head Neck Pathol.

2016;10(4):481-5.

3. Mariano RC, Oliveira MR, Silva AC, Ferreira DH, Almeida OP. Guided bone regeneration following surgical treatment of a rare variant of Pindborg tumor: a case report. J Oral Sci. 2014;56(1):95-8.

4. Chen Y, Wang TT, Gao Y, Li TJ. A clinicopathologic study on calcifying epithelial odontogenic tumor: with special reference to Langerhans cell variant. Diagn Pathol. 2014 Feb 20;9:37.

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

5. Wadhwan V, Sharma P, Bansal V. A rare case of hybrid odontogenic tumor: Calcifying epithelial odontogenic tumor combined with ameloblastoma. J Oral Maxillofac Pathol. 2015 May-Aug;19(2):268.

6. Foroughi R, Amini Shakib P, Babaei Darzi A, Seyedmajidi M, Jamaatlou N. Calcifying epithelial odontogenic tumor: report of a recurrent destructive case with review of literature. J Dent (Tehran). 2015 Jan;12(1):78-84.

7. Rani V, Masthan MK, Aravindha B, Leena S. Aggressive calcifying epithelial odontogenic tumor of the maxillary sinus with extraosseous oral mucosal involvement: a case report. Iran J Med Sci. 2016 Mar;41(2):145-9.

8. Caliaperoumal SK, Gowri S, Dinakar J. Pindborg tumor. Contemp Clin Dent. 2016 Jan-Mar;7(1):95-7.

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9. Priya S, Madanagopaal LR, Sarada V. Pigmented Pindborg tumor of the maxilla: a case report. J Oral Maxillofac Pathol. 2016 Sept-Dec;20(3):548.

10. Costa Mendes L, Sauvigne T, Guiol J. [Morbidity of autologous bone harvesting in implantology: Literature review from 1990 to 2015]. Rev Stomatol Chirurg Maxillo-facial Chirurg Oral. 2016;117(6):388-402.

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OriginalArticle

Treatment of bilateral fracture in

severely displaced atrophic mandible LORENZZO DE ANGELI CESCONETTO1 | ANDRÉ VÍTOR ALVES ARAÚJO1,2 | ANTONIO DIONIZIO ALBUQUERQUE NETO1 | DANIEL ASSUNÇÃO CERQUEIRA1,2 | ANTONIO AUGUSTO CAMPANHA1

ABSTRACT Introduction: The mandibular atrophy leads to a decrease in bone mass, which makes the bone more vulnerable to fracture. Numerous methods are proposed for the treatment of this condition. The use of 2.4 locking plates system, is the most common nowadays. Case report: A 79-year-old female patient, presenting a fracture in the bilateral mandibular body region, undergone surgical reduction and rigid internal fixation of the fracture, through an extraoral approach with a 2.4 locking plate system. Conclusion: The treatment of atrophic mandibular fractures represents a challenge for the maxillofacial surgeon, due to the peculiarities presented by the intense bone loss.

Keywords: Mandible. Fracture fixation. Atrophy.

Hospital Municipal Dr. Mário Gatti, Serviço de Cirurgia e Traumatologia Bucomaxilofacial (Campinas/SP, Brazil).

1

How to cite: Cesconetto LA, Araújo AVA, Albuquerque Neto AD, Cerqueira DA, Campanha AA. Treatment of bilateral fracture in severely displaced atrophic mandible. J Braz Coll Oral Maxillofac Surg. 2019 Jan-Apr;5(1):53-7.

DOI: https://doi.org/10.14436/2358-2782.5.1.053-057.oar

Especialista em Cirurgia e Traumatologia Bucomaxilofacial, Hospital Municipal Dr. Mário Gatti (Campinas/SP, Brazil).

2

Submitted: January 30, 2018 - Revised and accepted: May 24, 2018

Contact address: Lorenzzo De Angeli Cesconetto Rua Francisco Bueno Lacerda, 250, apto 36-B, Campinas/SP – CEP: 13.036-265 E-mail: lorenzzodac@hotmail.com - andrearaujo.odonto@hotmail.com

» 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.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Treatment of bilateral fracture in severely displaced atrophic mandible

INTRODUCTION The life expectancy of the elderly population has dramatically increased due to health advances and lifestyle changes. The elderly population (aged 60 and over) in Brazil totaled 19.6 million in 2010, probably reaching 41.5 million in 2030 and 73.5 million in 2060.1 Mandibular atrophy leads to a decrease in bone mass, making the bone more vulnerable to fracture. It can be considered the final stage of edentulism (total loss of teeth). Tooth loss leads to several biological processes, until loss of the alveolar process.2 The reduction of fracture fragments and fracture consolidation are impaired by bone atrophy, small contact area contact between fractured segments, reduction of the bone repair capacity and lack of anatomical reference points to guide the alignment of fragments.3 Luhr et al4 developed a classification system for fractures of atrophic mandibles based on bone height at the fracture site: bone fractures with less than 20mm height are considered atrophic; Class I are fractures with bone height 16 to 20 mm; Class II from 11- to 15-mm height; and Class III, less than 10-mm height.

Therapy for atrophic jaw fractures may be open or closed. The conservative treatment includes the use of circumandibular ligatures in existing prostheses, Gunning splints or external fixation. Surgical treatment includes several modalities using the most varied types of rigid internal fixation.2,3,5,6

CASE REPORT A 79-year-old female patient presented for evaluation by the Oral and Maxilofacial Surgery and Trau-

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

matology team 17 days after having been ran over by a bike, with the chief complaint of facial asymmetry and difficulty in mastication. She had a history of hypertension and diabetes. Upon examination, bone crepitation was observed in the mandibular body region bilaterally, associated with pain upon manipulation. The patient was completely edentulous in both arches and mentioned paresthesia in the inferior alveolar nerve region bilaterally.

Computed tomography of the face was requested, which revealed a fracture line in the body region bilaterally, with severe anterior displacement in anteroposterior and craniocaudal directions (Fig 1).

On the tomographic examination the alveolar ridge presented 7-mm height, scored as Luhr Class III.4 Due to the degree of mandibular atrophy, it was decided to surgically reduce the fracture and use rigid internal fixation. The procedure was performed under general anesthesia with nasotracheal intubation. The access of choice was submandibular bilaterally, extending to the submental region. After accessing the fractured region, surgical reduction with fracture simplification was performed using three bicortical screws. Then, fixation was performed using a reconstruction plate of the 2.4 locking system on the lateral mandibular border, with four screws in the right body region, three in the left body and five in the symphyseal region (Fig 2). The surgical wound was sutured by planes and no drains were placed.

Computed tomography was obtained in the immediate postoperative period, which revealed that the bone fragments were aligned, and the rigid internal fixation material was well positioned (Fig 3).

The patient was followed for one year, without complications from the surgical procedure.

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Cesconetto LA, AraĂşjo AVA, Albuquerque Neto AD, Cerqueira DA, Campanha AA

Figure 1: 3D reconstruction of computed tomography, evidencing bilateral mandibular body fracture with severe displacement.

There is loss of continuity of the alveolar ridge on the intraoral image, due to severe displacement of the fracture.

Figure 2: Transoperative image of mandibular fixation with the 2.4 locking plate system, evidencing the correct adaptation of the plate.

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Treatment of bilateral fracture in severely displaced atrophic mandible

Figure 3: 3D reconstruction of computed tomography postoperatively, demonstrating correct reduction of the fractured segments and satisfactory fixation. The intraoral image exhibits the correct contour of the alveolar ridge after the surgical procedure.

DISCUSSION The treatment of fractures in atrophic mandibles in edentulous patients is challenging for the oral and maxillofacial surgeon, due to the unfavorable biological and biomechanical conditions.2 The surgical approach under general anesthesia is often affected by the poor overall status of an elderly patient. Consequently, it is mandatory to decide the treatment correctly since its onset. Advances in the management of polytraumatized patients and in the anesthesia of elderly patients have reduced the surgical risk in these cases.7 The extraoral access provides direct and wide visualization of the surgical field and allows accurate approximation of the fragments.6 Some authors suggest that the intraoral access prevents visible scars

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

and lesions on facial nerve branches; however, this increases the risk of infection and lesion to the inferior alveolar nerve.2,5 The selection criterion should be based on the surgeon’s preference and experience, observing the type of fracture and general conditions of the patient. Rigid internal fixation can be obtained by open reduction techniques and provides greater comfort for the patient, due to the early function of mandibular movements.2 Some authors suggest the accomplishment of supraperiosteal dissection in fractures in atrophic mandibles, stating that this allows better blood supply to the traumatized region. The major disadvantage of this dissection is the impaired visualization, which complicates the fracture reduction and fixation difficult.2.5

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Cesconetto LA, Araújo AVA, Albuquerque Neto AD, Cerqueira DA, Campanha AA

they were condylar fractures. Among the cases, 62% were treated using 2.4 locking system reconstruction plates, 29% with 2.0 locking miniplates and 2 cases with 2.7 locking system reconstruction plates. Success was observed in 96.5% of cases, with non-union in only one case.

Novelli et al2 treated 16 fractures in edentulous patients, being 8 with the 2.0 locking miniplate system and the other 8 with the 2.4 locking system.

There was only one case of complication, in which the plate presented exposure when the 2.4 locking system was used. The use of miniplates was limited to cases scored as Luhr I and II4, while thicker plates were used in cases scored as Luhr III. The treatment of fractures in Luhr Class III4 atrophic mandibles is based on the use of 2.4 or 2.7-mm locking plates, by extraoral access, and may or may not be associated with the use of immediate graft2,3,5,6,9,10.

CONCLUDING REMARKS The treatment of fractures in atrophic mandibles is challenging for the oral and maxillofacial surgeon. The evolution of rigid internal fixation devices provided greater surgical predictability and allowed early recovery of masticatory functions. The degree of mandibular atrophy should be assessed to choose the most appropriate fixation system, since better results are obtained with the 2.4 locking plate system in Luhr II and III cases.

The evolution of fixation materials allowed the recent development of locking plate systems. This system provides important advantages in the treatment of fractures in atrophic mandibles, especially the possibility of small imperfections on the plate contour. Haug et al8 demonstrated that fracture stability is not decreased when locking system plates are used with up to 4 mm of the bone surface.

Van Sickels and Cunningham9 suggest that mandibular atrophy smaller than or equal to 5 mm requires some means to promote osteogenesis, which may involve bone grafting or morphogenetic bone protein (rh-BMP-2). The autogenous bone grafts increase the operative morbidity due to the need of a second surgical area.5,9,10 Luhr et al4 treated 84 fracture sites in atrophic mandibles in 65 patients with compressive plates, without bone grafting, observing absence of complications in 81 cases. There were 2 cases of non-union and 1 case of osteomyelitis.

Most articles in the literature that investigate fractures in edentulous patients present a small case series, due to the low incidence.3 Franciosi et al3 performed a retrospective 20-year study of patients assisted at Hospital Italiano de Buenos Aires. They observed 18 edentulous patients with mandibular fracture, totaling 35 fracture lines. Among these, 6 lines were treated conservatively because

References:

1. Ervatti LR, Borges GM, Jardim AP. Informação Demográfica e socioeconômica 3. Mudança Demográfica no Brasil no início do Século XXI. Subsídios para as Projeções da População. Brasília, DF: IBGE; 2015.

Estudos & Análises, n. 3.

2. Novelli G, Sconza C, Ardito E, Bozzetti A. Surgical treatment of the atrophic mandibular fractures by locked plates systems: our experience and a literature review. Craniomaxillofac Trauma Reconstr. 2012 June;5(2):65-74.

3. Franciosi E, Mazzaro E, Larranaga J, Rios A, Picco P, Figari M. Treatment of edentulous mandibular fractures with rigid internal fixation: case series and literature review. Craniomaxillofac Trauma Reconstr.

2014 Mar;7(1):35-42.

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4. Luhr HG, Reidick T, Merten HA. Results of treatment of fractures of the atrophic edentulous mandible by compression plating: a retrospective evaluation of 84 consecutive cases. J Oral Maxillofac Surg. 1996 Mar;54(3):250-4; discussion 254-5.

5. Ellis E 3rd, Price C. Treatment protocol for fractures of the atrophic mandible. J Oral Maxillofac Surg. 2008 Mar;66(3):421-35.

6. Flores-Hidalgo A, Altay MA, Atencio IC, Manlove AE, Schneider KM, Baur DA, et al. Management of fractures of the atrophic mandible: a case series. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015 June;119(6):619-27.

7. Marciani RD. Invasive management of the fractured atrophic edentulous mandible. J Oral Maxillofac Surg.

2001 July;59(7):792-5.

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8. Haug RH, Street CC, Goltz M. Does plate adaptation affect stability? A biomechanical comparison of locking and nonlocking plates. J Oral Maxillofac Surg. 2002 Nov;60(11):1319-26.

9. Van Sickels JE, Cunningham LL. Management of atrophic mandible fractures: are bone grafts necessary?

J Oral Maxillofac Surg. 2010 June;68(6):1392-5.

10. Madsen MJ, Haug RH, Christensen BS, Aldridge E. Management of atrophic mandible fractures. Oral Maxillofac Surg Clin North Am. 2009 May;21(2):175-83.

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CaseReport

Nasolabial cyst – diagnosis and surgical treatment:

Case report

MARCOS ANTONIO TORRIANI1,2 | ÂNGELO NIEMCZEWSKI BOBROWSKI3,4 | RAFAEL JOBIM RODRIGUES3,4 | RAQUELE SOARES MATOS5 | STEFANY RODRIGUES SANTOS5 | TANIELLEY VIERA MACHADO5 | CAROLINE KOMMELING CASSAL3

ABSTRACT The nasolabial cyst is an uncommon lesion of soft tissue, with nonodontogenic origin and uncertain pathogenesis. Its occurrence is usually unilateral and has a predilection for female patients (4: 1). Clinically is characterized by a volume increase in the nasolabial area causing elevation of the bridge of the nose and the upper lip projection. In this paper, the authors report the case of a 68-year-old female patient, complaining of swelling in the right nasolabial fold region, approximately 2 years of evolution, without reported episodes of painful symptoms, with clinical features compatible with the nasolabial cyst. Intranasal aspiration of the cystic content was carried out, and immediately performed the injection of radiographic contrast and profile and occlusal radiographs, to locate the lesion. Then, we proceeded to surgical enucleation of the lesion. The diagnosis of nasolabial cyst was confirmed after histopathological examination. After 45 days the patient was discharged, with full clinical recovery without functional and aesthetic complications.

Keywords: Biopsy. Nonodontogenic cysts. Jaw cysts.

Universidade Federal de Pelotas, Faculdade de Odontologia, Departamento de Cirurgia e Traumatologia Bucomaxilofacial (Pelotas/RS, Brazil).

Doutor em Cirurgia e Traumatologia Bucomaxilofacial, Pontifícia Universidade Católica do Rio Grande do Sul (Porto Alegre/RS, Brazil).

3 Universidade Federal de Pelotas, Serviço de Cirurgia e Traumatologia Bucomaximofacial, Hospital Escola da Universidade Federal de Pelotas (Pelotas/RS, Brazil).

4 Especialista em Cirurgia e Traumatologia Bucomaximofacial, Universidade Federal de Pelotas (Pelotas/RS, Brazil).

5 Universidade Federal de Pelotas, Faculdade de Odontologia (Pelotas/RS, Brazil).

1

How to cite: Torriani MA, Bobrowski ÂN, Rodrigues RJ, Matos RS, Santos SR, Machado TV, Cassal CK. Nasolabial cyst – diagnosis and surgical treatment: Case report. J Braz Coll Oral Maxillofac Surg. 2019 Jan-Apr;5(1):58-63.

DOI: https://doi.org/10.14436/2358-2782.5.1.058-063.oar

2

Submitted: September 28, 2017 - Revised and accepted: February 28, 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: Rafael Jobim Rodrigues E-mail: rafaeljobim@bol.com.br - raquelesm@yahoo.com.br

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Torriani MA, Bobrowski ÂN, Rodrigues RJ, Matos RS, Santos SR, Machado TV, Cassal CK

INTRODUCTION The nasolabial cyst is a rare soft tissue lesion of non-odontogenic origin.1 Its prevalence reaches 0.7% among the maxillary cysts, and its occurrence is usually unilateral, presenting bilaterally in only 10% of cases.2 The prevalence is been higher in patients of African descent, presenting predilection for females (4:1)3,4 and higher occurrence between the fourth and fifth decades of life.5 The first report of a nasolabial cyst is assigned to the Austro-Hungarian anatomist Emil Zuckerkandl6. Many names have been used to describe this cyst, including Klestadt cyst, nasoalveolar cyst, buccal nasal cyst, mucous cyst of the nose, nasal ala cyst, maxillary cyst, subalar cyst and nasoglobular cyst. Currently, the term “nasolabial cyst” is the most commonly used.7,8 The pathogenesis of this lesion is uncertain and, among the various theories for its origin, the most accepted was proposed by Bruggemann in 1920, which suggests that the nasolabial cyst arises from epithelial remnants of the lower anterior part of the nasolacrimal duct, due to histological similarities.2,7 Other theories assume that it is a fissural cyst or that it originates from deposition of epithelium of the nasolacrimal duct.9 Upon clinical examination, it is characterized by an increase in volume in the nasolabial region, raising the nasal ala and projecting the upper lip;10 spontaneous drainage of the cyst into the nasal or oral cavity is responsible for the variation in lesion size. This lesion is located in soft tissues, making the radiographic findings scarce. Radiographic imaging using contrast may aid the diagnosis by showing the lesion size and its proximity to surrounding structures.

Gross examination of an entirely resected nasolabial cyst shows a spherical to oval cyst, colored pink to tan, with soft to firm rubbery texture and smooth surface. The section reveals variable cystic and fibrous areas filled with clear viscous fluid, while necrosis, hemorrhage and purulence are only expected in secondarily infected cysts.11 The diagnosis is confirmed by histology, and the characteristic histological finding is respiratory columnar pseudostratified ciliated epithelium with goblet cells.1

CASE REPORT The 68-year-old female Caucasoid patient attended an Oral and Maxillofacial Surgery and Trau-

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

matology Clinic complaining of increase in volume at the right nasolabial fold region, with approximately two years of evolution, without episodes of pain symptomatology.

Extraoral examination revealed a volumetric increase in the right globulomaxillary region, with loss of evidence of the nasolabial fold and increased volume in the intranasal region (Fig 1). The nodule measured approximately 1 cm, was soft and mobile. No changes were observed on intraoral clinical examination. The cystic content was aspired intranasally, followed by immediate injection of non-ionic radiographic contrast Iopamiron 300® (iopamidol 612 mg/ ml) in equal amount into the cavity. Lateral and occlusal radiographs were immediately obtained to locate the lesion (Fig 2) and to observe its relationship with neighboring structures.

Figure 1: Image showing increase in volume on the nasolabial fold, nasal ala and intranasal regions.

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Nasolabial cyst – diagnosis and surgical treatment: Case report

tic texture, brownish color, irregular shape and surfaces. The histological sections revealed a cystic capsule fragment composed of dense fibrous connective tissue, presenting intense vascularization, moderate cellularity and mild, predominantly mononuclear inflammatory infiltrate. The fibrous capsule was lined ciliated cylindrical pseudostratified columnar epithelium, which occasional goblet cells.

The suture was removed after seven days, when the patient presented good intraoral healing. However, the intranasal site ruptured and presented a small secretion of blood clot remnants upon removal.

After 20 days the patient presented significant improvement and was discharged, after 45 days, presenting full clinical recovery, without esthetic or functional disorders.

The radiographic result by this technique, is an important diagnostic predictor, since it evidences that the lesion affects exclusively soft tissue, and the location and shape were compatible with this type of cyst. Immediately after radiography the lesion was surgically enucleated, with intraoral access under local anesthesia. A semilunar mucosal incision was made in the buccal sulcus, At the anterior region of the right maxilla, followed by posterior divulsion of tissues until complete disclosure and subsequent removal of the lesion (Fig 3). Afterwards, intraoral continuous suture (Catgut 3.0) and extraoral suture (nylon 5.0) were performed, with a small transfixation of the nasal mucosa.

Macroscopic examination revealed a soft tissue fragment measuring 18 x 12 x 2 mm, of fibroelas-

Figure 2: Radiographic images after contrast injection.

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Torriani MA, Bobrowski Ă&#x201A;N, Rodrigues RJ, Matos RS, Santos SR, Machado TV, Cassal CK

Figure 3: Surgical technique showing the pre- and post-excision aspect of the surgical wound, aspect and dimensions of cystic capsule, and suture.

A

B

Figure 4: A) Delicate fibrous connective tissue capsule lined by epithelium with few layers (40x magnification). B) lining epithelium varying from stratified pavement to ciliated pseudostratified cylindrical (200x magnification).

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Nasolabial cyst – diagnosis and surgical treatment: Case report

DISCUSSION This case report illustrates the most common characteristics found in the nasolabial cyst; despite the difference in ethnicity predilection,3 it coincides with the female predilection,3,4 corroborating previous studies.2,9 Nasal ala elevation and upper lip projection were clinically observed, which are determinants for the diagnosis of nasolabial cyst, as well as absence of symptoms and history characteristic of infection of dental origin.10 It should be highlighted that several lesions may occur in soft tissues at this facial site; therefore, the differential diagnosis should be careful. However, only the nasolabial cyst occurs exclusively in this area.

Nasolabial cysts are non-toxic soft tissue lesions and may remain undetected, unless they are infected or associated with facial deformities. For this reason, the patients often delay in searching for treatment because, since they do not present pain symptomatology and exhibit slow evolution, there is no immediate concern, often leading to years before treatment.12 The nasolabial cyst is asymptomatic, unless there is nasal obstruction, infection or deformity.7,13,14,15 As reported by El- Din et al16 nasolabial cysts may range in size from 1 to 5 cm and can lead to erosion of the underlying bone if growing to a large size. Therefore, the sooner the correct diagnosis and treatment, the less trauma to the patient.

The diagnosis of nasolabial cyst is nearly exclusively clinical, and bidigital palpation of the region is fundamental. The diagnosis may be difficult because this is a relatively rare lesion and differential diagnosis may include many other conditions that affect the anterior maxilla, including odontogenic cysts, periapical granulomas, and abscesses. The pulp vitality test of adjacent teeth is essential for adequate diagnosis and should be performed in the first attendance to differentiate from periapical lesions, and teeth in the region should respond positively to the vitality test in the presence of nasolabial cyst. However, this test could not be performed in the present case because the patient was edentulous.

Nasolabial cysts are not obvious on simple radiographs, because their characteristics are not specific, i.e. since it is a soft tissue cyst, the radiographic image does not provide any characteristic findings (without bone erosion), requiring radiograph and utilization of contrast to identify and assess the cyst extent.17

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The utilization of contrast is of an important approach to evaluate the lesion dimensions and its relationship with adjacent structures. Since the nasolabial cyst usually does not show signs on routine radiographic techniques, puncture of the cystic content with immediate contrast injection in the cavity and achievement of radiograph aids the surgical planning,3 being a low-cost, simple and fast procedure. The spread of bacteria to other facial planes occurs only when the cyst wall breaks, because the volume of contrast injected is greater than the amount of cystic fluid aspirated18. This demonstrates the importance of observing the volume of aspirated contents for subsequent injection in equal quantity.

This cystic lesion should always be considered in the diagnosis of soft tissue buccal swelling in the alar region. Thus, after clinical and radiographic examination, the treatment of choice is conservative surgical excision. Histological analysis will confirm the nasolabial cyst, and relapse is rare after proper management of the lesion.

CONCLUDING REMARKS Knowledge on the clinical and pathological characteristics of the nasolabial cyst is important for the dentist to allow the correct diagnosis, which demands a surgical treatment that is easily accomplished and presents great resolution. Computed tomography, magnetic resonance imaging and simple radiograph are the safest means to correctly diagnose the nasolabial cyst. However, the high cost of computed tomography and magnetic resonance imaging, as well as the electromagnetic and radiation exposure to the patient, make the use of contrast-enhanced plain radiograph, which can be performed in the office, the most viable choice for both dentist and patient. Thus, aspiration of cystic content and immediate injection of an equal amount of contrast for radiographic imaging constitute an important diagnostic aid and surgical guide.

Surgery is mainly done for esthetic reasons and secondary complications, such as infection or bleeding. To our knowledge, malignant transformation of a nasolabial cyst is not reported in the literature.10 Surgical treatment of the reported case was necessary due to the possible aforementioned complications; in addition, the cyst growth could interfere with adaptation of the maxillary denture used by the patient, causing esthetic and speech disorders and feeding difficulties.

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References:

1. Kuriloff DB. The nasolabial cyst-nasal hamartoma. Otolaryngol Head Neck Surg. 1987 Mar;96(3):268-72.

2. Wesley RK, Scannell R, Nathan LE. Nasolabial cyst: presentation of a case with a review of the literature.

J Oral Maxillofac Surg. 1984 Mar;42(3):188-92.

3. Van Bruggen AP, Shear M, du Prees IJ, Van Wyk DP, Beyers D, Leeferink GA. Nasolabial cysts. A report of 10 cases and a review of the literature. J Dent Assoc S Afr. 1985 Jan;40(1):15-9.

4. Bull TR, McNeill KA, Milner G, Murray SM. Naso-alveolar cysts. J Laryngol Orol. 1967 Jan;81(1):37-44.

5. Vasconcelos RF, Souza PE, Mesquita RA. Retrospective analysis of 15 cases of nasolabial cyst.

Quintessence Int. 1999 Sept;30(9):629-32.

6. Zuckerkandl E. Normale und pathologische Anatomie der Nasenhöhle und ihrer pneumatischen Anhänge. 2nd ed. Vienna, Austria: Braumüller; 1893. v. 1.

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7. Venkatesh VK, Satelur K, Yerlagudda K. Nasolabial cysts-report of four cases including two bilateral occurrences and review of literature. Indian J Dent.

2011 Oct-Dec;2(4):156-9.

8. Aquilino RN, Bazzo VJ, Faria RJA, Eid NLM, Bóscolo FN. Nasolabial cyst: presentation of a clinical case with CT and MR images. Braz J Otorhinolaryngol.

2008 May-June;74(3):467-71.

9. Tiago RS, Maia MS, Nascimento GM, Correa JP, Salgado DC. Nasolabial cyst: diagnostic and therapeutical aspects. Braz J Otorhinolaryngol. 2008 Jan-Feb;74(1):39-43.

10. Su CY, Chien CY, Hwang CF. A new transnasal approach to endoscopic marsupialization of the nasolabial cyst. Laryngoscope. 1999 July;109(7 Pt 1):1116-8.

11. Toribio Y, Roehrl MH. The nasolabial cyst: a nonodontogenic oral cyst related to nasolacrimal duct epithelium. Arch Pathol Lab Med. 2011 Nov;135(11):1499-503.

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12. Boffano P, Gallesio C, Campisi P, Roccia F. Diagnosis and surgical treatment of a nasolabial cyst. J Craniofac Surg. 2011 Sept;22(5):1946-8.

13. Patil AR, Singh AP, Nandikoor S, Meganathan P. Bilateral nasolabial cysts - case report and review of literature Indian J Radiol Imaging. 2016 Apr-June;26(2):241-4.

14. Sato M, Morita K, Kabasawa Y, Harada H. Bilateral nasolabial cysts: a case report. J Med Case Rep. 2016 Apr;10(1):246.

15. Allard RHB. Nasolabial cyst Review of the literature and report of 7 cases. Int J Oral Surg. 1982 Dec;11(6):351-9.

16. El-Din K. El-Hamd AA. Nasolabial cyst: a report of eight cases and a review of the literature. J Laryngol Otol .

1999 Aug;113(8):747-9.

17. Rallan NS, Rallan M, Singh NN, Gadiputi S. Nasolabial cyst mimicking inflammatory cyst. BMJ Case Rep. 2013 Apr 15;2013.

18. Campbell RL, Burkes EJ Jr. Nasolabial cyst: report of case. J Am Dent Assoc. 1975 Dec;91(6):1210-3.

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Information for authors

Information for authors

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.

• The publication categories include original papers (systematic reviews, clinical trials, experimental studies and case series with at least 9 clinical cases) and case reports.

• The manuscripts submitted to the Journal will be analyzed by the Editorial Board, which decides if the paper is acceptable for publication.

• The declarations and opinions expressed by the author(s) do not necessarily correspond to those of the editor(s) or publisher(s), who will not take responsibility over them. Neither the editor(s) nor the publisher offers guarantee of any product or service announced in this publication, or any statement of their respective manufacturers. Each reader should determine if he or she should act according to the information presented in the publication. The Journal or announcers are not responsible for any harm caused by the publication of mistaken information.

• The submitted manuscripts should be original, not previously published nor under consideration by another journal. The manuscripts will be analyzed by the editor and consultants and are subject to editorial review. The authors should follow the guidelines described below.

• The manuscripts should be submitted in Portuguese.

GUIDELINES FOR MANUSCRIPT SUBMISSION • The manuscripts should be submitted through the website: www.dentalpressjournals.com.br.

• The manuscripts should be written in a concise, clear and correct manner, in formal language, avoiding colloquial expressions.

• Whenever applicable, the text should be organized as follows: Introduction, Material and Methods, Results, Discussion, Conclusions, References, and Figure Legends.

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• The manuscripts should have at most 2,500 words, including the abstract, references and legends of figures and tables (yet excluding data on the tables).

• A maximum of four authors are allowed for case reports and six authors for research manuscripts.

If more authors are included, the participation of each author in the manuscript must be informed.

• The figures should be submitted as separate files.

• The figure legends should also be included within the text, to guide the final formatting of the paper.

• Title page: this page should contain only the manuscript title, in Portuguese and English languages, which should be as informative as possible, composed of at most 8 words. This page should not include information related to the identification of authors (e.g. full author names, academic degrees, institutional affiliations and/or administrative roles). This should only be included in specific fields in the manuscript submission website.

Therefore, this information shall not be visible for the reviewers.

ABSTRACT • Structured abstracts, in Portuguese and English, with 200 words or less, are preferred.

• Structured abstracts should contain the following sections: INTRODUCTION, presenting the study objective; METHODS, describing how it was conducted; RESULTS, describing the primary outcomes; and CONCLUSIONS, reporting the study conclusions and clinical implications of the outcomes.

• The abstracts should also present 3 to 5 keywords, also in Portuguese and English, which should comply with DeCS (http://decs.bvs.br/) and MeSH (www.nlm.nih.gov/mesh).

INFORMATION ON ILLUSTRATIONS • The illustrations (graphs, drawings, etc.) should be limited to up to 6 figures, for original manuscripts; or up to 3 figures, for case reports. They should preferably be prepared in appropriate softwares, e.g. Excel, Word, etc.

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Information for authors

» Case report Title (Portuguese/English); Abstract/Keywords; Introduction (Introduction + Proposition); Case report; Discussion; Concluding remarks; References (10 references, at most – by order of citation in the text); Maximum 3 figures.

• Their respective legends should be clear and concise. The approximate point in the text in which the images should be inserted as figures should be indicated. Tables and charts should be consecutively numbered in Arabic numbers. The figures should be referred in the text using Arabic numbers.

MANDATORY DOCUMENTS All manuscripts should be accompanied by the following documents:

Figures • The digital images should be sent in JPG or TIFF format, with at least 7cm width and 300dpi resolution.

• They should be submitted as separate files.

• If a figure has been previously published, its legend should mention the original source.

• All figures should be cited in the text.

Institutional review board If applicable, the manuscripts should mention the Institutional Review Board approval.

Copyright transfer Assigning the manuscript copyright to Dental Press, in case the manuscript is published.

Graphs and cephalometric tracings • These should be cited in the text as figures.

• The authors should send the files containing the original versions of graphs and tracings, in the softwares used for their preparation.

• The submission of images in bitmap format (not editable) is not recommended.

• The submitted drawings may be enhanced or redesigned by the journal production, as indicated by the Editorial Board.

Conflict of interest If there is any interest of the authors concerning the study objective, it should be explicitly mentioned.

Human rights and animal protection If applicable, the authors should mention the compliance with international institutions for protection and the Helsinki declaration, following the ethical guidelines of the human/animal institutional review board. In case of studies on humans, the authors should mention the approval by the Institutional Review Board, according to Resolution 466/2012 CNS-CONEP.

Tables • The tables should be self-explanatory and should complement, but not duplicate the text.

• Tables should be numbered in Arabic numbers, in order of appearance in the text.

• Each table should have a short title.

• If a table has been previously published, a footnote should be included mentioning the original source.

• The tables should be submitted as text files (e.g.

Word or Excel), and not as graphs (non-editable image).

Permission to use copyrighted images Illustrations or tables, either original or modified, from copyrighted material should be accompanied by permission of utilization granted by the copyright owners and the original author (and the legend should properly refer the source).

Informed consent The patients have right to privacy, which should not be violated without an informed consent. Identifiable photographs of individuals should be accompanied by a consent form signed by the person or the parents or caretakers, in case of underage individuals. These authorizations should be kept indefinitely by the manuscript author. A cover letter should be submitted stating that all patients’ consents were obtained and are stored by the corresponding author.

TYPES OF MANUSCRIPTS » Research paper (original article) Title (Portuguese/English); Abstract/Keywords; Introduction (Introduction + Proposition); Methods; Results; Discussion; Conclusions; References (15 references, at most – by order of citation in the text); Maximum 6 figures.

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Information for authors

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

- All references should be cited in the text.

- To enhance reading, the references should be cited in the text indicating only their numbers.

- The references should be indicated in the text by superscript Arabic numbers in order of appearance.

- The abbreviations of journal titles should be formatted according to the publications “Index Medicus” and “Index to Dental Literature”.

- The authors are responsible for the accuracy of references, which should contain all data necessary for their identification.

- The references should be presented at the end of the text completion, following the Vancouver guidelines (http://www.nlm.nih.gov/bsd/uniform_requirements. html).

- Use the examples below:

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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Notice to Authors and Consultants Registration of Clinical Trials

2. Portal for promoting and registering clinical trials With the purpose of providing greater visibility to validated Clinical Trial Registers, WHO launched its Clinical Trial Search Portal (http://www.who. int/ictrp/network/en/index.html), an interface that allows simultaneous searches in a number of databases. Searches on this portal can be carried out by entering words, clinical trial titles or identification number. The results show all existing clinical trials at different stages of implementation with links to their full description in the respective Primary Clinical Trials Register.

The quality of information available on this portal is guaranteed by the producers of the Clinical Trial Registers that form part of the network recently established by WHO, i.e., WHO Network of Collaborating Clinical Trial Registers. This network will enable interaction between the producers of the Clinical Trial Registers to define the best practices and quality control. Primary registration of clinical trials can be performed at the following websites: www.actr.org.au (Australian Clinical Trials Registry), www.clinicaltrials.gov and http://isrctn.org (International Standard Randomized Controlled Trial Number Register (ISRCTN). The creation of national registers is underway and, as far as possible, registered clinical trials will be forwarded to those recommended by WHO. WHO proposes that as a minimum requirement the following information be registered for each trial. A unique identification number, date of trial registration, secondary identities, sources of funding and material support, the main sponsor, other sponsors, contact for public queries, contact for scientific queries, public title of the study, scientific title, countries of recruitment, health problems studied, interventions, inclusion and exclusion criteria, study type, date of the first volunteer recruitment, sample size goal, recruitment status and primary and secondary result measurements.

1. Registration of clinical trials Clinical trials are among the best evidence for clinical decision making. To be considered a clinical trial a research project must involve patients and be prospective. Such patients must be subjected to clinical or drug intervention with the purpose of comparing cause and effect between the groups under study and, potentially, the intervention should somehow exert an impact on the health of those involved.

According to the World Health Organization (WHO), clinical trials and randomized controlled clinical trials should be reported and registered in advance.

Registration of these trials has been proposed in order to (a) identify all clinical trials underway and their results, since not all are published in scientific journals; (b) preserve the health of individuals who join the study as patients and (c) boost communication and cooperation between research institutions and other stakeholders from society at large interested in a particular subject. Additionally, registration helps to expose the gaps in existing knowledge in different areas as well as disclose the trends and experts in a given field of study.

In acknowledging the importance of these initiatives and so that Latin American and Caribbean journals may comply with international recommendations and standards, BIREME recommends that the editors of scientific health journals indexed in the Scientific Electronic Library Online (SciELO) and LILACS (Latin American and Caribbean Center on Health Sciences) make public these requirements and their context. Similarly to MEDLINE, specific fields have been included in LILACS and SciELO for clinical trial registration numbers of articles published in health journals.

At the same time, the International Committee of Medical Journal Editors (ICMJE) has suggested that editors of scientific journals require authors to produce a registration number at the time of paper submission.

Registration of clinical trials can be performed in one of the Clinical Trial Registers validated by WHO and ICMJE whose addresses are available at the ICMJE website.

To be validated, the Clinical Trial Registers must follow a set of criteria established by WHO.

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Notice to Authors and Consultants - Registration of Clinical Trials

open access basis. Thus, following the guidelines laid down by BIREME / PAHO / WHO for indexing journals in LILACS and SciELO, Dental Journal of the Brazilian College of Oral and Maxillofacial Surgery will only accept for publication articles on clinical research that have received an identification number from one of the Clinical Trial Registers, validated according to the criteria established by WHO and ICMJE, whose addresses are available at the ICMJE website http://www.icmje.org/about-icmje/faqs/ clinical-trials-registration/. The identification number must be informed at the end of the abstract.

Consequently, authors are hereby recommended to register their clinical trials prior to trial implementation.

Currently, the Network of Collaborating Registers is organized in three categories: » Primary Registers: Comply with the minimum requirements and contribute to the portal; » Partner Registers: Comply with the minimum requirements but forward their data to the Portal only through a partnership with one of the Primary Registers; » Potential Registers: Currently under validation by the Portal’s Secretariat; do not as yet contribute to the Portal.

3. Journal of the Brazilian College of Oral and Maxillofacial Surgery Dental Journal of the Brazilian College of Oral and Maxillofacial Surgery endorses the policies for clinical trial registration enforced by the World Health Organization - WHO (http://www.who.int/ictrp/en/) and the International Committee of Medical Journal Editors - ICMJE (# http://www.wame.org/wamestmt. htm#trialreg and http://www.icmje.org/clin_trialup. htm), recognizing the importance of these initiatives for the registration and international dissemination of information on international clinical trials on an

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Yours sincerely, Gabriela Granja Porto, CD, MS, Dr Editor-in-chief, Journal of the Brazilian College of Oral and Maxillofacial Surgery E-mail: gabiporto99@yahoo.com

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