Revista JBCOMS - Volume 5, Number 2, 2019 by Prod

Acesse o QR Code e Alinhe-se com o novo! Implant (Anterior Socket Grafting)

Maxillary Advancement with Mandibular

Total Arch Restoration (Implant Supported fixed bridge)

Journal of the Brazilian

College of Oral and Maxillofacial Surgery

Maxillary Advancement with Mandibular

Total Arch Restoration (Implant Supported fixed bridge)

Implant (Anterior Socket Grafting)

Volume 5, Number 2, 2019

Volume 5, Number 2, 2019 - ISSN 2358-2782

SAC: 0800 725 6363

Airway Obstruction Airway Adenoids

@clearcorrect.pro

Mandibular Advancement

Facial Asymmetry (Maxilla & Mandible)

Obstruction Adenoids

Facial Asymmetry (Maxilla & Mandible)

/clearcorrect.br

TAD Two Arch Protraction Plate

Anterior Tooth Implant

with Mandibular

TAD Two Arch Protraction Plate

Mandibular Adcancement Mandibular (CW rotation) Adcancement (CW rotation)

Aquarium para Cirurgia

PRECISAR

Aquarium para Cirurgia

O conteúdo do Aquarium para cirurgia foi desenvolvido sob as diretrizes de uma junta

TED

de cirurgiões bucomaxilofaciais. Aproveite estas acuradas animações 3D e ilustrações O conteúdo do Aquarium para cirurgia foi desenvolvido sob as diretrizes de uma junta para demonstrar procedimentos cirúrgicos complexos como enxerto ósseo, correção de

de cirurgiões bucomaxilofaciais. Aproveite estas acuradas animações 3D e ilustrações assimetria, avanço de mandíbula, implantes e mais. Aquarium está pronto para ambiente

para demonstrar procedimentos cirúrgicos complexos como enxerto ósseo, correção de de rede e apresenta impactantes imagens compatíveis com monitores de todos os

assimetria, avanço de mandíbula, implantes e mais. Aquarium está pronto para ambiente tamanhos e resoluções. Para saber mais, acesse www.dolphinimaging.com/aquarium ou

de rede e apresenta impactantes imagens compatíveis com monitores de todos os fale conosco: (11) 3286-0300 / contato@renovatio3.com.br. tamanhos e resoluções. Para saber mais, acesse www.dolphinimaging.com/aquarium ou

R 5 ANOS

rrect, Inc.

Maxillary Maxillary Advancement Advancement with Mandibular

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

Mandibular Advancement

JBCOMS

fale conosco: (11) 3286-0300 / contato@renovatio3.com.br. Management

Imaging

Aquarium ©

Labodental

Management

Imaging

Aquarium ©

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

4 6 8 10

How to conduct a systematic review: basic concepts Gabriela Granja Porto Letter from the President: Brazilian College of Oral and Maxillofacial Surgery promotes two important actions in May: scientific update and alert to the population. J Braz Coll Oral Maxillofac Surg José Rodrigues Laureano Filho Interview Gabriele Millesi Is Teleodontology a feature to be used in Buccomaxillofacial Surgery and Traumatology? Belmiro Cavalcanti do Egito Vasconcelos Articles

Pilot study of maxillofacial traumas in a reference hospital, Florianópolis/SC

Software developed for diagnostic recommendations and epidemiological analysis

Epidemiological study of facial injuries in Cacoal/RO, Brazil

Accuracy and cutting efficiency of surgical burs on crown sections

Intraoral scanning in the virtual planning for orthognathic surgery: case report

Mandibular multicystic ameloblastoma: case report and 10-year follow up

Carolina Leite Roquejani, Mariana Saideles Martins, José Nazareno Gil

Samara Andreolla Lazaro, Renato Sawazaki, Franklin David Gordillo Yépez, Geferson Toffolo, Roberto Rabello dos Santos

José Leozir Pedroso Júnior, Marco Aurélio Blaz Vasques, Rogério Bonfante Moraes, Carlos Alberto de Arruda Júnior, Diogo Loureiro de Freitas, Rafael Sacchetti

Patrícia Vittor de Souza, Francielle Silvestre Verner, Rodrigo Furtado de Carvalho, Thaís Cachuté Paradella, Jaiane Bandoli Monteiro, Maria da Graça Naclério Homem, Matheus Furtado de Carvalho

Flávio Wellington da Silva Ferraz, Daiane Betiatto, Thaís Samarina Sousa Lopes Mello, José Benedito Dias Lemos

Matheus Spinella de Almeida, Arthur Berny Castellano, André Luis Chiodi Bim, Luiz Henrique Godói Marola, José Nazareno Gil, Jonathas Daniel Paggi Claus

Osteonecrosis of maxilla associated with bisphosphonates: case report

Mandibular fracture after extraction of impacted third molar

Information for authors

Marcela Chiqueto Araujo, Geraldo Luiz Griza, Eleonor Álvaro Garbin Junior, Natasha Magro Érnica, Ricardo Augusto Conci

Alexandre Maranhão Menezes Neto, Eduardo Costa Studart Soares, Francisco Samuel Rodrigues Carvalho, Mariana Gomes Coutinho, Fábio Wildson Costa Gurgel

Editorial

How to conduct a systematic review: basic concepts Considering the lack of financial resources to fund scientific investigations in most Brazilian universities, a viable option found by many investigators is to develop systematic reviews. This type of study consists of a systematized scientific investigation, aiming to perform a critical and thorough literature review. It is located on the top of the levels of evidence pyramid, compared to other types of study (Fig. 1). Reviews with greater visibility are those that respond relevant clinical questions for the professional assisting the population. However, for this to be safe and truthful, they must be organized to avoid biases – both in the selection of studies and extraction and analysis of primary data – that may impair the result. Thus, in a schematic manner, the following main steps may be highlighted to achieve the goal of the review: » First, you should decide which question will guide the review, considering the PICO* strategy, depending on the type of study. » Following, to register the registrar review on the International Prospective Register of Systematic Review (PROSPERO). » Then, you should define the inclusion and exclusion criteria for selection of studies.

*PICO: P = Population; I = Intervention; C = Comparison; O = Outcomes. Depending on the type of study, other synonyms have been proposed for the PICO strategy, e.g. PICOS and PECO. The “S” added to PICO adds the type of study. The “E” (Exposition) is applied for observational studies.

How to cite: Porto GG. How to conduct a systematic review: basic concepts. J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):4-5. DOI: https://doi.org/10.14436/2358-2782.5.2.004-005.edt

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):4-5

Editorial

1) Systematic review of RCTs Individual RCT

2 3 4

2) Systematic review of cohort individual cohort 3) Systematic review of case-control individual case-control 4) Case series Low quality studies

5) Opinion of experts

SOURCE: Oxford Centre for Evidence-based Medicine Levels of Evidence (2001)

*RCT – Randomized Clinical Trial.

» The next step is to organize a search strategy as thorough as possible, on at least two databases, among which the main are the PubMed, Cochrane, Scopus and EMBASE. The grey literature should be observed, which is often not registered on these databases, and pay attention to papers found in duplicate. Other care in this topic concerns the selection of correct key words, which should be found on MeSH (PubMed). » Next, you must perform the selection of papers » After this, data are extracted, to compare the results of the different studies, for achievement of an overall estimate. » Finally, by observing that there are homogeneous studies (methodology and statistics), meta-analysis can be performed, which is a statistical technique especially designed to integrate the results of two or more independent studies on the same research. If this is not possible, the review can be performed without this last step. Following these steps, the possibility to achieve a well-performed and relevant systematic review is real. After all, there are many clinical questions with no evidence-based answers that may be helpful to the health professional delivering care.

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

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):4-5

Letter from the President

Brazilian College of Oral and Maxillofacial Surgery promotes two important actions in May: scientific update and alert to the population. J Braz Coll Oral Maxillofac Surg

How to cite: Laureano Filho JR. Brazilian College of Oral and Maxillofacial Surgery promotes two important actions in May: scientific update and alert to the population. J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):6-7. DOI: https://doi.org/10.14436/2358-2782.5.2.006-007.crt

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Dear members of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology, May was a month of great achievements for the CBCTBMF. First, I would like to share the challenge for the organization and success of the 24th edition of the International Conference on Oral and Maxillofacial Surgery (ICOMS), at the city of Rio de Janeiro. As you know, the Brazilian College of Oral and Maxillofacial Surgery and Traumatology was selected as a partner institution of the International Association of Oral and Maxillofacial Surgeons to host the event in Brazil. It has been many years of intense work with the scientific, social and organizing committees, which provided, during four days of event, the opportunity of personal contact with the worldâ&#x20AC;&#x2122;s greatest oral and maxillofacial specialists. We watched the speeches of 150 lecturers from important centers from all continents, besides 53 symposia, 15 conferences, four courses, five parallel symposia of institutions as IAOMS, AO, IBRA, SORG and the William Bell lectureship, and 53 sessions for presentation of scientific papers, with approximately 1,200 submitted papers. The scientific program included all areas of oral and maxillofacial surgery and the news in science, technology and research. We highlight some issues, as the treatment of dentoskeletal developmental facial deformities and congenital craniofacial deformities, facial transplantations, Oncology and reconstruction, and Oral Pathology. But the event also addressed updates on daily issues of the oral and maxillofacial surgeon, such as dental implants, TMJ surgery, sleep apnea, reconstruction of facial subunits, tissue bioengineering, cosmetic surgery and virtual planning. The programming also included research: different methods, their design, purpose, difficulties and solutions, and how to apply their results to the clinical practice; a symposium for authors, which addressed how to write a scientific paper, design a scientific experiment, report the studies and the ethics of publication; besides technology and innovations, such as pharmacogenetic testing for the use of drugs.

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):6-7

Letter from the President

May was also the month of the Yellow May campaign, when the CBCTBMF warned people about the prevention of facial trauma. In 2019, several Brazilian cities organized blitze with distribution of folders containing information about the importance of correct utilization of helmets. In Curitiba, specialization students in OMFST from Positivo University, professors, Military Police of Paraná and DETRAN-PR distributed folders and provided guidance to the population. In Manaus, a symposium on facial trauma was organized, with a campaign of traffic education for health professionals, residents and undergraduate students. In the state of Pernambuco, the CBCTBMF, together with the University of Pernambuco and DETRAN-PE, prepared a series of events throughout May. Once again, Chapter VII (Rio de Janeiro) had the participation of students from São José College on May 30, organizing actions and disseminating information related to facial trauma to drivers and motorcyclists, aiming to increase the awareness for a safer traffic for all. The importance of warning is related to the increasing number of motorcycles in the country. In Brazil, there are more than 26 million motorcycles in circulation, which is 3.5% greater than registered on April 2018. The proportion is one motorcycle for nearly eight inhabitants, and the number of motorcycles is already larger than the number of cars in 45% of Brazilian cities. We have a lot of work to do, but there is also a lot of willingness to keep up with advances in the specialty for members of the CBCTBMF.

A hug for all!!! José Rodrigues Laureano Filho President of the Brazilian College of Oral and Maxillofacial surgery and Traumatology

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):6-7

Interview

An interview with Gabriele Millesi

» Graduated in Medicine, University of Innsbruck (Austria). » Graduated in Dentistry, Medical University of Vienna (Austria). » Senior Collaborator at the Department of Cranial and Maxillofacial Surgery of the Medical University of Vienna (Austria). » Assistant Professor of the Department of Cranial and Maxillofacial Surgery of the Medical University of Vienna (Austria).

How to cite: Millesi G, Porto GG. Interview with Gabriele Millesi. J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):8-9. DOI: https://doi.org/10.14436/2358-2782.5.2.008-009.oar Submitted: May 17, 2019 - Revised and accepted: May 30,2019

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):8-9

Millesi G, Porto GG

Now that you will take over as president of the International Association of Oral and Maxillofacial Surgeons (IAOMS), what are your main goals? As new president of the International Association of Oral and Maxillofacial Surgeons (IAOMS), my main goal is to make the NextGen to participate! The IAOMS, as the most prominent and professional association in the global community of oral and maxillofacial surgery, has a huge potential to align international professionals and is a gate for high level education all over the world. The IAOMS is the link between regional associations and, becoming a member, the person realizes how important this networking is. The International Congress of ICOMS is the best opportunity to witness this.

Oral and maxillofacial surgery is well ahead because all the latest technologies – e.g. 3D planning, individualized plates, implants, laser cutting, navigation, etc. – depend on the bone structures, and this is our domain! No other specialty has this experience in the combined management of soft and hard tissue! In addition, our strength is our knowledge of occlusion in head and neck surgical procedures. The oral and maxillofacial surgery plays and will play a central role. What was your model or inspiration to become a maxillofacial surgeon? At the beginning of my medical studies, I had no idea what oral and maxillofacial surgery (OMFS) was. Thus, I think we have to speak out loud about what the maxillofacial surgeon can do! Coincidentally, I was working at an OMFS department at the University of Innsbruck, and there I realized it is a great specialty! From the skull base to the clavicle, from major to minor surgeries, inpatients or outpatients, from elective to life-saving surgeries! I believe that, once trained, every surgeon can find his place, either in a public hospital, academic setting or a private office! This freedom of choice is advantageous.

How is the training to become a maxillofacial surgeon in Austria? The training to become an oral and maxillofacial surgeon in Austria includes: 6-year medical course, 4-year dental course, plus 4 more years of training to become a surgeon. These 4 years include 9 months of overall training (which is required for any medical doctor) and 15 months of basic training in oral and maxillofacial surgery. After that, 24 months of specialization in oral and maxillofacial surgery (Oral Surgery, Implantology, Prosthodontics; Traumatology; Septic Surgery, Salivary Glands, Sinus Surgery; TMJ Surgery; Orthognathic Surgery; Tumor and Reconstructive Surgery, Craniofacial Surgery and Malformations). Then, the final exam!

Which qualities are needed for a successful career in maxillofacial surgery? You must have manual skills to become a surgeon, thus you have to be curious, ambitious and keen to learn, as in any field of Medicine. Look for a tutor and stay in the area; thus, you will be a good oral and maxillofacial surgeon. But, as in any other medical field, besides being a good professional, you should also have empathy for your patient.

How do you see the future of the specialty in Europe over the next 20 years?

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

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):8-9

CBCTBMF

Is Teleodontology a feature to be used in Buccomaxillofacial Surgery and Traumatology?

at a meeting of the Scientific Council of the Brazilian Medical Association, at the association headquarters in SĂŁo Paulo. Medical doctors discussed the measure, which may be changed. The first regulation of Telemedicine was made in 2002 and actually needed to be updated, to avoid a regulatory vacuum. Medical doctors discuss adjustments in teleconsultation, telediagnosis and guidelines for this practice, as well as robotic telesurgery, which should be very clear about procedures not evaluated by the CFM or those of experimental nature, being considered only in the context of clinical research, among many others. Dentistry and our specialty, Oral and Maxillofacial Surgery and Traumatology, also need to address this issue and discuss the possibility and relevance of distance consultation after a first presential consultation. Another topic that involves a warm debate

The term Teledentistry is commonly used in our field to indicate the work of higher education institutions and associations that produce digital content to support both the presential and distance learning. The professionals involved in the issue evaluate the best manner to apply information and communication technology resources in the development of educational content. The Federal Dental Council and some renowned universities in the country have debated and still address this issue, which involves the electronic exchange of information with reliability and confidentiality. However, currently with so many communication resources, which are increasingly available to everyone, the issue has increased. Recently, the Resolution n. 2227/18 of the Federal Medical Council (CFM), which updates the rules of Telemedicine in the country, was widely discussed

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):10-1

CBCTBMF

is the care – especially for solving doubts about the treatment – for patients by social and digital media, such as Facebook Messenger and WhatsApp, to cite just two examples. Another point to be evaluated is the care coverage in geographically remote areas: How would it occur, in the case of Dentistry and Oral and Maxillofacial Surgery and Traumatology? The issue involving a second opinion and distance consultation with a specialist should also be further discussed. A professional in a remote area can receive guidance from an oral and maxillofacial surgeon and perform emergency procedures until a more specialized care arrives. Which guidelines should be followed? The regulatory vacuum creates doubts and a vast field for unguided and possibly amateur actions. The Brazilian College of Oral and Maxillofa-

cial Surgery and Traumatology advocates the widest dialogue as possible on the subject with regulatory agencies, so that the entire society can benefit from the technological innovations that have emerged. The capillarization of Health access goes through these discussions; however, the focus of presential relationship with our patients (surgeon-patient relationship) cannot be lost. This is the most important and should be raised to the highest degree of importance. Teledentistry for discussion of cases between professionals and students is already being practiced in Brazil, as well as doubts about clinical cases between professionals. The doubt about distance consultations with patients is an ethical dilemma, and the current precepts are not clear and convincing. There is no doubt that, at this point, there is lack of in-depth discussion, to avoid injury to the patient.

Belmiro Cavalcanti do Egito Vasconcelos - PhD in Dentistry, Universitat de Barcelona, Facultad de Odontología (Barcelona, Spain). - University of Pernambuco, Dental School, Discipline of Oral and Maxillofacial Surgery and Traumatology (Camaragibe/PE, Brazil). - Scientific Director of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology.

How to cite: Vasconcelos BCE. Is Teleodontology a feature to be used in Buccomaxillofacial Surgery and Traumatology? J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):8-9. DOI: https://doi.org/10.14436/2358-2782.5.2.010-011.oar Submitted: April 17, 2019 - Revised and accepted: May 14, 2019

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):10-1

21 a 23 de Maio de 2020. MaringĂĄ. PR. Brasil

Palestrantes

Presidente do Congresso - Gustavo Giordani

Eric Van Dooren

Carlos Alexandre CĂ˘mara

Marcelo Calamita

Florin Cofar

Nazariy Mykhaylyuk

Daniel Machado

Ertty Silva

Fabiano Marson

Felipe Villa Verde

Marcelo Giordani

Marcelo Kyrillos

Marcelo Moreira

Marcos Pitta

Thiago Ottoboni

Victor Clavijo

Ronaldo Hirata

Sidney Kina

Luis Calicchio

Paulo Vinicius Soares

congresso.dentalpress.com.br

EXCELÊNCIA EM DTM As Disfunções Temporomandibulares englobam diferentes patologias e são altamente prevalentes. Diagnosticar e tratar essas condições exige não só uma sólida formação, mas educação continuada para que os conhecimentos científicos e clínicos possam ser mais bem sedimentados e atualizados. Desta forma, é com muita alegria que anunciamos nosso primeiro programa de educação continuada em DTM e Dor Orofacial.

TIPO TEÓRICO

CORPO DOCENTE 2º MÓDULO: DE 05 A 08 DE AGOSTO TEMA: PATOLOGIAS MUSCULARES

Paulo Conti

Betânia Alves

Bruno Furquim

05.08.2019 - SEGUNDA

06.08.2019 - TERÇA

Rafael Silva

Thalita Pereira Queiroz

Daniel Bonotto

06.08.2019 - TERÇA

07.08.2019 - QUARTA

08.08.2019 - QUINTA

Paulo Cunalli 14.10.2019 - SEGUNDA

Daniela Franzen

Priscila Brenner Hilgenberg

Daniela Gonçalves

José Geraldo Speciali

17.10.2019 - QUINTA

18.10.2019 - SEXTA

3º MÓDULO: DE 14 A 18 DE OUTUBRO TEMA: DORES NEUROPÁTICAS E COMORBIDADES

Juliana Stuginski 14.10.2019 - SEGUNDA 15.10.2019 - TERÇA

18.10.2019 - SEXTA

*Programação sujeita a alterações

(44) 99898-4875

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CURSOS.DENTALPRESS.COM.BR

16.10.2019 - QUARTA

FIL | LISBOA | 14 | 15 | 16 | NOV | 2019

CONFERENCISTAS ESTRANGEIROS CONFIRMADOS GRE

ANTONIS CHANIOTIS

ENDODONTIA

ESP

JUAN CARLOS PÉREZ VARELA

ORTODONTIA

ESP

DAVID HERRERA

PERIODONTOLOGIA

BRA

JULIANA RAMACCIATO

TERAPÊUTICA MEDICAMENTOSA

BRA

DUDU MEDEIROS

FOTOGRAFIA

DNK

LARS BJØRNDAL

CARIOLOGIA

BRA

FERNANDO BORBA DE ARAÚJO ODONTOPEDIATRIA

ITA

LEONARDO TROMBELLI

PERIODONTOLOGIA

ITA

FILIPPO GRAZIANI

PERIODONTOLOGIA

ITA

LUCA CORDARO

IMPLANTOLOGIA

BRA

FRANK KAISER

PRÓTESE REMOVÍVEL

ESP

MARIANO SANZ

PERIODONTOLOGIA

AUT

GABOR TEPPER

REABILITAÇÃO ORAL

BRA

OSWALDO SCOPIN

PRÓTESE FIXA

ITA

GIOVANNI LODI

MEDICINA ORAL

GRE

PANOS N. PAPAPANOU

PERIODONTOLOGIA

TUR

HANDE ŞAR SANCAKLI

DENTISTERIA ESTÉTICA

ITA

PASQUALE VENUTI

DENTISTERIA ESTÉTICA

USA

HOMA H. ZADEH

PERIODONTOLOGIA

BRA

PAULO FERNANDO CARVALHO

PERIODONTOLOGIA

ARG

HUGO ALEJANDRO ALBERA

REABILITAÇÃO ORAL

ESP

PEDRO BARRIO FERNANDEZ

MEDICINA ORAL

ESP

JOSÉ MARIA SUÁREZ FEITO

OCLUSÃO

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ORGANIZAÇÃO

Original Article

Pilot study of maxillofacial

traumas in a reference hospital, Florianópolis/SC CAROLINA LEITE ROQUEJANI1 | MARIANA SAIDELES MARTINS2 | JOSÉ NAZARENO GIL3,4

ABSTRACT Introduction: Many traumas affect the face, which generates emotional and physical consequences. Objective: This study aimed to assess facial fractures in the medical records of patients treated at the Service of Oral and Maxillofacial Surgery of the Hospital Governador Celso Ramos (Florianópolis/SC, Brazil), from January 2015 to January 2016. Methods: 82 medical records with 121 fractures were analyzed. The data were organized, tabulated and analyzed descriptively. Results: Fractures occurred primarily among men (80%) in the age range of 21 to 30 years (31%), with mean age of 42 years; whereas for women the mean age was 46 years. The most frequent cause was aggression (38%). In women, the main etiology was motorcycle accident (31%), while in men it was aggression (44%). The most affected bone was the mandible (33%) in both sexes, mainly the mandibular angle (30%). Most fractures occurred on Friday (13%) and in February (23%). Conclusion: Aggression was the most prevalent etiology, and occurred mainly in young adults. Most cases of facial trauma could be avoided or mitigated by means of educational measures encouraging respect for traffic laws and strategies to deal with stressful situations. Keywords: Face. Fractures, bone. Maxillofacial injuries.

Universidade Federal de Santa Catarina, Curso de Graduação em Odontologia (Florianópolis/SC, Brazil).

How to cite: Roquejani CL, Martins MS, Gil JN. Pilot study of maxillofacial traumas in a reference hospital, Florianópolis/SC. J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):17-23. DOI: https://doi.org/10.14436/2358-2782.5.2.017-023.oar

Universidade Federal de Santa Catarina, Centro de Ciências da Saúde, Departamento de Odontologia (Florianópolis/SC, Brazil).

Submitted: November 18, 2017 - Revised and accepted: December 11, 2018

Universidade Federal de Santa Catarina, Centro de Ciências da Saúde, Departamento de Patologia (Florianópolis/SC, Brazil).

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

Hospital Universitário Professor Polydoro Ernani de São Thiago, Programa de Residência em Cirurgia e Traumatologia Bucomaxilofacial (Florianópolis/SC, Brazil).

Contact address: Carolina Leite Roquejani Rua Felipe Schmidt, 100, Centro, Florianópolis/SC — CEP: 88.130-100 E-mail: carolina_roquejani@hotmail.com

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):17-23

Pilot study of maxillofacial traumas in a reference hospital, Florianópolis/SC

INTRODUCTION Due to its anatomical location, the face is poorly protected in cases of trauma, making it highly susceptible to fractures.1 This type of disorder causes serious emotional consequences and physical deformities to the patient, in addition to the economic impact demanded by the complex treatments required.2 Since most facial fractures can be prevented, it is necessary to achieve more knowledge about their characteristics, to produce preventive strategies that will reduce the occurrence of trauma and promote more acceptable esthetic and functional results.2 To achieve in-depth knowledge about such fractures, it should be considered that, even though this injury presents a pattern of occurrences in society, its epidemiology may vary depending on the population studied.3 According to the World Health Organization, traumas are among the leading causes of morbidity and mortality. Also, according to Motta et al,5 facial traumas were among the most frequent diagnoses in patients from a general emergency room. This encouraged the present study of these disorders at the region of Florianópolis/Santa Catarina, analyzing the facial fractures treated at Hospital Governador Celso Ramos during the year 2015, with special attention to age, gender, etiology, type of fracture and date of occurrence, since this information are still scarcely available in Brazil and do not meet the need for scientific knowledge of professionals in the field.4,6

METHODS This descriptive study analyzed the facial fractures registered on the records of patients assisted by the Oral and Maxillofacial Surgery and Traumatology service at Hospital Governador Celso Ramos, at the city of Florianópolis/SC, during the period January 2015 to January 2016. This study was approved by the Institutional Review Boards of UFSC (#1.539.133) and Hospital Governador Celso Ramos (#1.649.913). Data were collected by consultation to the patients’ records. The collected variables included gender, age, date of occurrence of fracture, fractured bone and etiology. The etiologies were grouped in the following categories: aggression, car or motorcycle accident, fall from own height, fall, sports trauma, FAB (firearm bullet), work accident, running over, iatrogenic and horse kick. The fractures were classified as fractures of the mandible (angle, condyle, body, symphysis/parasymphysis, ramus, alveolar process), zygomatic bone or arch, orbit, maxilla, NOE (naso-orbito-ethmoidal), nasal and frontal sinus. Data were collected, organized and submitted to descriptive statistical analysis. RESULTS The study analyzed the records of 82 patients, which revealed the occurrence of 121 facial bone fractures. The most affected age range was 21 to 50 years (77%). Most fractures occurred between 21 and 30 years (31%) (Tab. 1).

Table 1: Occurrence of fractures in relation to age.

11-20 years 21-30 years 31-40 years 41-50 years 51-60 years 61-70 years 71-80 years Total

9 25 20 18 7 2 1 82

11 31 24 22 9 2 1 100

SOURCE: Oral and Maxillofacial Surgery and Traumatology Service (OMFST) of Hospital Governador Celso Ramos (HGCR).

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Roquejani CL, Martins MS, Gil JN

The main etiologic factor in men was aggression (44%), and motorcycle accidents in women (31%) (Tab. 2). The 31 patients who reported aggression had age between 20 and 55 years, with mean age of 37 years for aggression with standard deviation of zero. The 13 patients victims of motorcycle accidents presented mean age of 34 years, with standard deviation of zero (Tab. 3).

The mean general age of patients was 44 years, being 42 years for men and 46 years for women, both with standard deviation of zero. The greatest number of fractures occurred in men (80%). Aggression was the main general etiology (38%), followed by motorcycle accident (16%). Sports traumas were also significant, adding up to 10%.

Table 2: Occurrence of etiologies in relation to gender. Female (n)

Male (n)

Total

2 5 3 2 2 1 0 0 0 1 0 16

13 30 19 13 13 6 0 0 0 6 0 100

29 8 9 3 2 7 2 3 2 0 1 66

44 12 14 5 3 9 3 5 3 0 2 100

31 13 12 5 4 8 2 3 2 1 1 82

Aggression Motorcycle accident Car accident Fall from own height Fall Sports trauma FAB* Work accident Running over Iatrogenic Horse kick Total geral

*Firearm bullet. SOURCE: Oral and Maxillofacial Surgery and Traumatology Service (OMFST) of Hospital Governador Celso Ramos (HGCR).

Table 3: Relationship between age and etiologic factor. Number of cases

Mean age

Minimum age

Maximum age

31 13 12 5 4 8 2 3 2 1 1 82

37 34 36 47 41 27 43 32 25 73 69 44

20 20 16 30 26 18 42 35 20 73 69 16

55 49 56 65 57 37 44 29 30 73 69 73

Aggression Motorcycle accident Car accident Fall from own height Fall Sports trauma FAB* Work accident Running over Iatrogenic Horse kick Total geral

*Firearm bullet. SOURCE: Oral and Maxillofacial Surgery and Traumatology Service (OMFST) of Hospital Governador Celso Ramos (HGCR).

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Pilot study of maxillofacial traumas in a reference hospital, Florianópolis/SC

Table 4: Occurrence of type of fracture in relation to gender.

Mandible Alveolar process Zygomatic bone Zygomatic arch Orbit Maxilla NOE* Frontal sinus Nasal Total

Female

Male

Total

8 2 7 3 3 1 0 0 1 25

32 3 18 9 14 9 4 4 3 96

40 5 25 12 17 10 4 4 4 121

*Naso-orbit-ethmoidal fracture. SOURCE: Oral and Maxillofacial Surgery and Traumatology Service (OMFST) of Hospital Governador Celso Ramos (HGCR). Table 5: Occurrence of main etiological factors, according to the most fractured bones. Etiological factor

MANDIBLE Aggression Car accident Motorcycle accident Fall Sports trauma Others ZYGOMATIC BONE Aggression Car accident Motorcycle accident Sports trauma Others ZYGOMATIC ARCH Aggression Car accident Motorcycle accident Fall from own height Fall Sports trauma Work accident ORBIT Aggression Car accident Motorcycle accident Fall FAB* Work accident

40 15 4 6 4 3 8 25 8 4 4 5 4 12 4 2 2 1 1 1 1 17 3 4 3 4 1 2

Among the 121 fractures analyzed, 33% occurred in the mandible and 21% in zygomatic bone. The most affected anatomical site in the mandible was the angle (30%), followed by the body (26%). The mandible was the most affected bone in men (32 cases). Among the 25 fractured diagnosed in women, 8 affected the mandible (Tab. 4). Aggression was the most common etiology in cases of mandibular fracture, maxilla, nose, zygomatic arch and bone. Fall and car accident were the main causes of orbit fracture. Car accident was also the main cause of frontal sinus fracture, while alveolar process fractures occurred mainly due to fall from own height (Tab. 5). The greatest number of fractures occurred on Fridays (23%), during the month of February (13%). DISCUSSION Facial lesions predominantly affected males (80%), compatible with studies in the literature. 2,3,6-10 The male to female ratio found was 4.1: 1, values that may change, as reported by Chalya et al,2 who observed a ratio of 2.7: 1, and Amarista et al, 11 who reported 6.1: 1. There was predominance of males in facial fractures; however, the profile of this trauma is heterogeneous and its epidemiology changes according to the specific characteristics of each population. 3 Men present greater risk to facial fractures, because their behaviors make them more susceptible to this injury. This male vulnerability is attributed to the greater social freedom of young men, such as:

*Firearm bullet. SOURCE: OMFST Service of HGCR.

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Roquejani CL, Martins MS, Gil JN

working outside home; greater car mobility; engaging in high-risk activities such as physical contact sports; their more aggressive nature; association of alcohol/drug use and driving; and lack of compliance with traffic laws. 3,4,9,11,13 However, there is a tendency of increase in the number of females victims of facial trauma. This is related to changes in the social behaviors played by women, who are taking increasingly active positions in society, working outside home and playing sports, besides the increase in the number of female drivers and cases of urban violence. 3,9 Adult patients aged 21 to 50 years represent the age range with greater predominance of fractures. This occurs because they are the most socially and economically active part of the population, being exposed to physical contact sports, interpersonal violence, work accidents and disrespect to traffic laws. 4,9,11,13,14,15 The peak prevalence occurred between 21 and 30 years (31%), reflecting the several psycho-socio-economic conflicts faced by young individuals and their greater exposure to urban violence.4,7,16 The low occurrence in individuals aged 51 to 80 years (12%) and between 11 and 20 years (11%) is assigned to the low pattern of activity of these age ranges, and the minimum age for attendance at Hospital Governador Celso Ramos is 16 years.4,7 In this study, the main etiology was aggression (38%), in agreement with previous studies; 3,6,17 however, the investigation conducted by Maliska, Lima Júnior and Gil 6 at the University Hospital of the Federal University of Santa Catarina, also at Florianópolis/SC, presented traffic accidents as the main etiology (48%), followed by aggression (36%), in agreement with studies in the literature.12,13,18,19 This difference may indicate a gradual change in the main etiologic pattern, from traffic accident to interpersonal violence. This may be explained by changes in traffic laws, which are demanding the use of seatbelt, airbags, helmets and special clothing for motorcyclists, reduction of speed limits in specific regions and laws that discourage the association of alcohol/drugs and driving. The stricter surveillance of these laws, with greater population awareness on the traffic behavior, combined to the increased urban violence and use of alcohol/drugs, may be the cause of changes observed in the etiologic pattern. 4,7

In this study, the mandible was the most affected bone (33%), mainly at the angle region (30%). Despite the variation in the most affected fracture site, the mandible is often indicated as the main fractured bone, possibly because it is the only moving bone in the face, being more vulnerable to impacts 2,3,6,7,12. However, different results than the present study are also observed in the literature, as the study of Gassner et al,16 which indicated dentoalveolar fracture as the most common. Fractures in the mandible, zygomatic arch, maxilla and nasal bone occurred mainly due to aggression. The nasal and zygomatic bones are structures with prominent position in the face, making them more vulnerable to traumas, especially in cases of aggression and traffic accidents. In situations of interpersonal aggression, the mandible is among the most frequent targets, which explains the difference observed in the present study between the quantity of mandibular fractures caused by aggression and the other fractures presenting the same etiology. 3 Aggression and work accident were the only etiologies mentioned in all categories of fractured bones, even though 31 individuals suffered trauma due to aggression, and only 3 cases of work accidents were reported. This leads to the question about the frequency and aggressivity o these occurrences in society, if workers have access to satisfactory safety standards and perform correct utilization of safety gear during work. Facial fractures occurred predominantly on Fridays (23%) and Saturdays (20%), which are considered favorable for night activities, with greater possibility of use of alcohol and illicit drugs, which increases the risk of fractures. Daytime leisure activities, travel and sports activities, especially related to soccer, played on these days also contributed to the large number of fractures occurred. Chrcanovic et al13 concluded that the greatest number of fractures occurred during weekends, since most soccer matches are played on these days, which would increase the risk of violence among fans watching the matches. There is a predominance of facial fractures between December and March, with greater concentration in February, probably due because Carnival occurs in this month. In summer months, residents and tourists enjoy greater freedom for outdoor ac-

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Pilot study of maxillofacial traumas in a reference hospital, Florianópolis/SC

for public awareness campaigns directed at young people, to stimulate psychological strategies to deal with hostile situations, aiming to minimize the interpersonal violence; and establishment of effective educational measures to raise the awareness about the importance of using the seatbelt or helmet, respecting traffic laws and reducing the alcohol consumption, to reduce the cases of facial fractures and also the public costs with such disorders.

tivities and to participate in highly active nightlife, often with alcohol and/or drugs, which may increase the aggressiveness and the number of drunk drivers, thus increasing the cases of fracture due to aggression and traffic accidents. However, different results can be found in the literature, as in the survey conducted in Vitória/ES that showed peak occurrence of fractures between July and September.20 The future expectation for facial fractures is a gradual increase in the occurrence of fractures due to aggression, concomitantly with a decrease in the number of fractures due to traffic accidents, which would imply an increase in the difference between the occurrence of main etiologies and also a significant increase in the number of women suffering this type of fracture. The analysis of data confirms the growing need

CONCLUSION Greater dissemination of literature on facial fractures is necessary, to provide foundation for the production of preventive measures to reduce the increasing cases of such disorders. Thus, this study indicates the need to perform more extended studies on facial fractures, including a greater number of patients.

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Roquejani CL, Martins MS, Gil JN

References:

1. Bisson JL, Shepherd JP, Dhuia M. Psychological sequelea of facial trauma. J Trauma. 2015 Dec;43(3):496-70. 2. Chalya PL, Mchembe M, Mabula JB, Kanumba ES, Gilyoma JM. Etiological spectrum, injury characteristics and treatment outcome of maxillofacial injuries in a Tanzanian teaching hospital. J Trauma Manag Outcome. 2011 June;5(1):7-12. 3. 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 Out;76(5):565-74. 4. 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. Braz J Otorhinolaryngol. 2006 Abr;72(2):211-6. 5. Motta MM. Análise epidemiológica das fraturas faciais em um hospital secundário. Rev Bras Cir Plas. 2009;24(2):162-9. 6. Maliska MC, Lima Júnior SM, Gil JN. Analysis of 185 maxillofacial fractures in the state of Santa Catarina, Brazil. Braz Oral Res. 2008 Oct;23(3):268-74. 7. Silva JJL, Lima AAUS, Melo IFS, Maia RCL, Pinheiro Filho TRC. Trauma facial: análise de 194 casos. Rev Bras Cir Plást. 2011 Fev;26(1):37-41. 8. Almahdi HM, Higzi MA. Maxillofacial fractures among Sudanese children at Khartoum Dental Teaching Hospital. BMC Res Notes. 2016 Feb;9(120):10-3.

9. Macedo JL, Camargo LM, Almeira PF, Rosa SC. Perfil epidemiológico do trauma de face dos pacientes atendidos no pronto-socorro de um hospital público. Rev Col Bras Cir. 2008 Out;35(1):9-13. 10. Samieirad S, Aboutorabzade MR, Tohidi E, Shaban B, Khalife H, Hashemipour MA, et al. Maxillofacial fracture epidemiology and treatment plans in the Northeast of Iran: a retrospective study. Med Oral Patol Oral Cir Bucal. 2017 Sept 1;22(5):e616-24. 11. Amarista RFJ, Bordoy SMA, Cachazo M, Dopazo JR, Vélez H. The epidemiology of mandibular fractures in Caracas, Venezuela: Incidence and its combination patterns. Dent Traumatol. 2017 Dec;33(6):427-32. 12. Bonavolontà P, Dell’aversana Orabona G, Abbate V, Vaira LA, Lo Faro C, Petrocelli M, et al. The epidemiological analysis of maxillofacial fractures in Italy: The experience of a single tertiary center with 1720 patients. J Craniomaxillofac Surg. 2017 Aug;45(8)1319-26. 13. Chrcanovic BR, Freire-Maia B, Souza LN, Araújo VO, Abreu MHNG. Facial fractures: A 1-year retrospective study in a hospital in Belo Horizonte. Braz Oral Res. 2004;18(4):322-8. 14. Alves LS, Aragão I, Sousa MJ, Gomes E. Pattern of maxillofacial fractures in severe multiple trauma patients: a 7 year prospective study. Braz Dent J. 2014 Nov;25(6):461-4. 15. Zamboni RA, Wagner JCB, Volkweis MR, Gerhardt EL, Buchmann EM, BaVaresco CS. Epidemiological study of facial fractures at the Oral and Maxillofacial Surgery Service, Santa Casa de Misericórdia Hospital Complex, Porto Alegre - RS - Brazil. Rev Col Bras Cir. 2017 Sept;44(5):491-7.

16. Gassner R, Tuli T, Hächl O, Rudisch A, Ulmer H. Cranio-maxillofacial trauma: a 10 year review of 9542 injuries. J Craniomaxillofac Surg. 2003 Feb;31(1):51-61. 17. Halsey MJC, Hoppe IC, Granick MS, Lee ES. A singleCenter review of radiologically diagnosed maxillofacial fractures: Etiology and distribution. Craniomaxillofac Trauma Reconstr. 2017 Mar;10(1):44-47. 18. Brasileiro BF, Cortez AL, Aspirino L, Passeri LA, Moraes M, Mazzonetto R. Traumatic subcutaneous emphysema of the face associated with paranasal sinus fractures: a prospective study. J Oral Maxillofacial Surg. 2005 Aug;63(8):1080-7. 19. Cabrini GMA, Gabrielli MFR, Marcantoio E, HochuliVieira EMA. Fixation of mandibular fractures with 2.0 mm miniplates: Review of 191 cases. J Oral Maxillofacial Surg. 2003 Apr;61(4):430-6. 20. Botacin WG, Nakasome LF, Coser RC, Cançado RP. Epidemiologia dos procedimentos de um serviço público de CTBMC. J Braz Coll Oral Maxillogac Surg. 2018,4(2):38-44.

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):17-23

Original Article

Software developed for diagnostic recommendations

and epidemiological analysis SAMARA ANDREOLLA LAZARO1 | RENATO SAWAZAKI1 | FRANKLIN DAVID GORDILLO YÉPEZ1 | GEFERSON TOFFOLO2 | ROBERTO RABELLO DOS SANTOS2

ABSTRACT Introduction: Numerous advantages are derived from the use of electronic medical records, such as fast access to information and the simultaneous use of data. Objective: The objective of the study was to develop an electronic medical record software with a system of diagnostic recommendations and statistical analyzes in the area of Oral and Maxillofacial Surgery. Methods: In the system of diagnostic recommendations, the degree of similarity was performed using the Cosine method, and to verify the similarity between the Pearson variables, graphs were elaborated from a descriptive analysis. Results: The recommendations system had a 93.3% accuracy score in the diagnoses. The time to generate each graph in the software was 6.21 seconds. Conclusions: The developed software proved to be effective for decision making based on the diagnostic recommendations and statistical analysis generated by the program. Diagnostic recommendations were 93.3% effective. Continuous improvements in the process of software development and use are necessary to achieve user expectations. Keywords: Dentistry. Electronic health records. Face. Oral and maxillofacial surgeons.

Universidade de Passo Fundo, Faculdade de Odontologia (Passo Fundo/RS, Brazil).

How to cite: Lazaro SA, Sawazaki R, Yépez FDG, Toffolo G, Santos RR. Software developed for diagnostic recommendations and epidemiological analysis. J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):24-9. DOI: https://doi.org/10.14436/2358-2782.5.2.024-029.oar

Universidade de Passo Fundo, Instituto de Ciências Exatas e Geociências (Passo Fundo/RS, Brazil).

Submitted: January 04, 2018 - Revised and accepted: November 15, 2018 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. Contact address: Samara Andreolla Lazaro Faculdade de Odontologia Universidade de Passo Fundo, BR 285, São José Passo Fundo/RS – CEP: 99.052-900 E-mail: samara_andreolla@hotmail.com

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):24-9

Lazaro SA, Sawazaki R, Yépez FDG, Toffolo G, Santos RR

INTRODUCTION The word Prontuário (Portuguese word for medical record) comes from the Latin promptuariu, which means place to keep what should be at hand, what may be needed at any moment.1 One of the oldest known documents is the papyrus assigned to the Egyptian physician Imhotep, who is considered the patriarch of Medicine. According to some Egyptologists, the two most important Egyptian medical papyruses currently known are those of Ebers and Edward Smith: the first address internal medicine and pharmacology, including spells and occult explanations for diseases of unknown etiology; while the second describes wounds and surgical treatment, with little content about religious spells or magic rituals.2 The Dental Ethics Code establishes the obligation of preparation and maintenance, in a legible and updated form, of patient records and their conservation, either physical or digital.3 We have entered a time when the use of computers, tablets and smartphones allows digital capture of nearly all information. The challenge is not how to collect these data, but how we can safely integrate and use such great amount of data, by systems of support to clinical decision, to improve the clinical outcomes. Computer-based systems that can host all scientific and clinical data are fundamental to generate knowledge, which is the directly relevant endpoint for better understanding and management of the disease of each patient. Alike computing, science and medicine continue to converge. This conversion of data into knowledge and sharing of such knowledge has become a crucial component to achieve an accurate medicine and customized patient care.4 A dental software system is a tool that provides easy use and fast exchange of information, combined with easy achievement of knowledge; it provides agility, practicality and optimization of the working time5. Additionally, statistical management softwares are important resources for decision making in oral and maxillofacial procedures, as epidemiological databases. The wide array of work of the oral and maxillofacial surgeon increases the need for utilization of technologies to aid the routine, considering that technology advances rapidly, clearly demonstrating the benefits of digital inclusion in society.6

Thus, the objective of the present study was to develop a dental record software for the Residency Program in Oral and Maxillofacial Surgery and Traumatology of University of Passo Fundo (UPF/HC/ SMS), to allow the generation of diagnostic suggestions to support the decision making, presenting fast functionality, providing generation of statistical data for research and publications. METHODS This was a descriptive study. The study was approved by the Institutional Review Board of University of Passo Fundo (UPF), protocol n. CEP 133133/2017. The software design was divided into five stages: Stage 1: Survey of requirements Specification of the main features for the system, identification and definition of the needs to solve the proposed problem. Software called Odontosys. Stage 2: Modeling Definition of what was necessary for data storage and analysis of record documents. Stage 3: Development Development of an electronic record for data collection from patients assisted in the fields of work of the Residency Program in Oral and Maxilofacial Surgery and Traumatology. The interface for interaction with the user occurred by the WEB platform. For internal development, the following technologies were used: databank MySQL, programming language (PHP), AJAX, Bootstrap and JavaScript. The application and the databank were hosted on the UPF server. This stage comprised the registry of basic information and entry of the main elements of a patient record (Fig 1). Stage 4: Generation of statistical graphs and recommendation Several statistical graphs were generated by filtering some parameters (Fig 2). Data were analyzed by descriptive analysis, by means (standard deviation) for quantitative variables and n (%) for categorical variables.

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):24-9

Software developed for diagnostic recommendations and epidemiological analysis

Figure 1: Development of electronic record.

Figure 2: Folder ‘Statistics’ and its functions for graphics generation.

variables was analyzed by the Pearson coefficient. Figure 3 exemplifies the recommendation process. The process of recommendations exposes the five possible diagnoses found in decreasing order, according to the degree of similarity (Fig 4).

For the system of diagnostic recommendations, the following variables were analyzed and correlated: chief complaint, anatomical region, signs, symptoms and etiology. The calculation to achieve the degree of similarity employed the Cosine method, and the similarity between

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):24-9

Lazaro SA, Sawazaki R, Yépez FDG, Toffolo G, Santos RR

Stage 5: Evaluation and usability of the software To analyze the usability of the software concerning its ability to perform an epidemiological survey, the study employed a convenience sample: overall, the study included 495 records from patient assisted in the period January 1st 2014 to July 31st 2017.

For the recommendation system, following the guidance of the company that developed the software, 254 attendances were included to compose the database, adding up to 296 diagnoses. Later, 141 attendances and 195 diagnoses were included, to control the system efficiency. The study excluded registries with incomplete variables, cancelled or without diagnosis.

Figure 3: Process of diagnostic recommendations.

Figure 4: Example of recommendations system.

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):24-9

Software developed for diagnostic recommendations and epidemiological analysis

RESULTS The study included 495 records of patient attendance in the period January 1st 2014 to July 31st 2017. For analysis of the recommendation system, only 395 registries were considered as valid. The control group for the recommendation system demonstrated that the software was assertive in 182 diagnoses and non-assertive in only 13 cases, because there were no registries in the database to allow comparison of the degree of similarity. As a result, there were 93.3% of correct responses. The mean time for data computing and generating a graph on the software was 6.21 seconds.

patient will receive more efficient and safer care, due to the correct diagnosis. Also, the larger the database, the more assertive the recommendations.9-11 As exemplified in the present study, whose database allowed a percentage of 93.3% of correct answers in the diagnostic suggestions, the correct diagnosis will lead to decision making concerning the therapeutic approaches to injuries, as well as public health strategies. Studies evidence that a critical step to achieve an accurate medicine is to integrate old and new data into validated information, and convert this information into knowledge directly applicable to the diagnosis, prognosis or treatment. This implies the development of an integrated knowledge environment to that may institutionally capture information, grow, accumulate and organize new information, making it accessible to healthcare providers. The accumulated knowledge of scientific research and clinical data contained in electronic health records will be shared and shall affect the discovery of new therapeutic methods the application of precision drugs.12 This opens possibilities for real-time sharing of high-quality information on clinical patients between physicians and institutions. The collective experience of physicians around the world may be stored in a structured knowledge base, available to support the diagnosis based on pattern recognition. The similarity analysis may support this process by calculating the degree of correspondence between a patient’s pattern and the patterns of other patients in the knowledge base who already have a diagnosis.8 The prevalence of disease by parameters such as age, gender, race and geo-temporal distribution can be obtained from several sources, including published reports, large electronic health records repositories, administrative claim data, social media and environmental data (e.g. climate). These sources can feed a knowledge base of the next-generation diagnostic support system. Patient demographics automatically extracted from the electronic health record may customize the previous probability estimates. Few typical findings of a particular disease are invariably present in all cases. The probability of a particular symptom, sign, or specific abnormality found in a certain disease is available from published reports and can be used by next-generation diagnostic support systems. Indeed, as the knowledge base of the next-generation diagnostic support system expands, the collective body of structured standards provided by physicians can serve as a living epidemiological data-

DISCUSSION Currently, information is the greatest resource available to achieve growth and development and thereby enable the future. Thus, the use of electronic records is necessary in the professional routine. Software development on the WEB platform allows to users access on desktop and mobile devices connected to the internet, at anytime and anywhere. However, the disadvantages of access to the online page are the need for browsing in mobile or network data and their quality, which can lead to a delay in loading functions.7 Several dental softwares are available on the market, such as Dental Office (São Paulo/BR), which provides analysis of patient profile as to gender and age, patient flow control and profit; Dentalis Software® (São Paulo/ BR), which allows teaching institutions to perform statistical analysis of procedures accomplished; XDental Controle® (Brasília/BR), which presents a survey of individual statistics concerning the dental plaque control. Most dental softwares available focus on statistical analyses of financial flow, with insufficient data collection to contribute with scientific evidence to generate studies and decision making in public health strategies. However, although interactive diagnostic support systems have been commercially available for six decades, they are not yet widely used. Professionals intuitively apply the recognition of patterns when evaluating a patient. Creating a rational diagnosis requires placement of clinical patterns in the context of previous probability of disease; however, professionals often present a flawed probabilistic reasoning. The difficulties in diagnosis are reflected by the high rates of fatal and costly diagnostic errors.8 Using the recommendation system, it can be expected to avoid certain clinical errors and, in general, the

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):24-9

Lazaro SA, Sawazaki R, Yépez FDG, Toffolo G, Santos RR

the essential principles of software development, aiming to meet the demands of software enhancement by the diagnostic recommendation system and epidemiological scientific analysis.

base, providing real-time statistics on the incidence of symptoms, signs and diseases.8 These factors justify and strengthen the need to use electronic records on the routine of professionals who always attempt to be connected to the new technologies, with several enhancements in their professional life. Technology plays a paramount function to enhance the systems, which is the software development cycle, its stages, activities and responsibilities of each person involved in this process of development, aiming to maintain the project aligned to the needs of users and expectations of sponsors.13 Thus, the software developed in the present study has contributed to solve such questions, also following

CONCLUSION According to the aspects analyzed, the designed software was effective for decision making based on diagnostic recommendations and statistical analysis generated by the software; the diagnostic recommendations presented 93.3% of effectiveness; continuous improvement in the process of software development and utilization is necessary to meet the user’s expectations.

References:

1. Houaiss A, Villar MS, Franco FMM. Dicionário Houaiss de língua portuguesa. Rio de Janeiro: Objetiva; 2009. Prontuário; p. 1561. 2. Castiglioni A. A history of medicine. Nova York: [s.n.], 1947. 3. Odontologia CFD. Código de Ética Odontológica: Resolução No. 118 de 11 de maio de 2012. Rio de Janeiro: CFO; 2012. 4. Castaneda C, Nalley K, Mannion C, Bhattacharyya P, Blake P, Pecora A, et al. Clinical decision support systems for improving diagnostic accuracy and achieving precision medicine. J Clin Bioinforma. 2015 Mar 26;5:4. 5. Martins C, Lima SM. Advantages and disadvantages of electronic health record for health institutions. Rev Admin Saúde. 2014 Apr-June;16(63):61-3.

6. Santos OS, Carvalho GP. Prontuários eletrônicos em odontologia e obediência às normas do CFO. Rev Odontol Bras Central. 2014;23(66):166-71. 7. Menachemi N, Collum TH. Benefits and drawbacks of electronic health record systems. Risk Manag Healthc Policy. 2011;4:47-55. 8. Cahan A, Cimino JJ. A learning health care system using computer-aided diagnosis. J Med Internet Res. 2017 Mar 8;19(3):e54. 9. Berner ES, Maisiak RS, Cobbs CG, Taunton OD. Effects of a decision support system on physicians’ diagnostic performance. J Am Med Inform Assoc. 1999 Sept-Oct;6(5):420-7. 10. Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ. 2005 Apr 2;330(7494):765.

11. Ballard DW, Vemula R, Chettipally UK, Kene MV, Mark DG, Elms AK, et. al. Optimizing clinical decision support in the electronic health record. Appl Clin Inform. 2016 Sept 21;7(3):883-98. 12. Friedman CP, Wong AK, Blumenthal D. Achieving a Nationwide Learning Health System. Sci Transl Med. 2010 Nov 10;2(57):57cm29. 13. Paula Filho WP. Alguns fundamentos da Engenharia de software. Rio de Janeiro: LTC; 2000.

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):24-9

Original Article

Epidemiological study of facial injuries in

Cacoal/RO, Brazil

ABSTRACT Introduction: The face is a region that is often the target of trauma of a wide variety of etiologies, which, when is not identified and treated, can lead to severe functional, emotional and aesthetic sequelae. The medical literature refers to traffic accidents and urban violence as the main causes. Objective: To raise the epidemiological profile of face trauma in the region of Cacoal/RO, Brazil, which does not present any study of this subject. Methods: Retrospective study of 414 patients with facial fracture diagnosis. Age, sex, fractured facial bones, treatment and the cause of the accident were considered. Results: Males predominated, with 79.7% of the cases, and the most affected age group was between 18 and 39 years, with 63.2% of the cases. The motorcycle traffic accidents were the main responsible for the injuries (51.9%) and the mandible was the most affected bone (41.48%). Conclusion: In view of this, we observed the importance of collecting data on the epidemiological profile of the population and suggesting a continuous research to provide support and guidance to public policies of population education, as well as the prevention of trauma, influencing the health of the population. Keywords: Epidemiology. Traumatology. Fractures, bone. Oral and maxillofacial surgeons.

Hospital Regional de Cacoal (Cacoal/RO, Brazil).

How to cite: Pedroso Júnior JL, Vasques MAB, Moraes RB, Arruda Júnior CA, Freitas DL, Sacchetti R. Epidemiological study of facial injuries in Cacoal/RO, Brazil. J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):30-5. DOI: https://doi.org/10.14436/2358-2782.5.2.030-035.oar

Especialista em Cirurgia e Traumatologia Bucomaxilofacial, Hospital Regional de Cacoal (Cacoal/RO, Brazil).

Mestre em Ciências Odontológicas, área de concentração em Cirurgia e Traumatologia Bucomaxilofacial, Universidade Federal de Uberlândia (Uberlândia/MG, Brazil).

Submitted: February 22, 2018 - Revised and accepted: September 15, 2018

Mestre em Ciências Odontológicas, área de concentração em Cirurgia e Traumatologia Bucomaxilofacial, Universidade de São Paulo (São Paulo/SP, Brazil).

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

Contact address: José Leozir Pedroso Júnior Rua Antônio de Paula Nunes, 1512 - Centro, Cacoal/RO – CEP: 76.963-784 E-mail: dr.joseleozir@gmail.com

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):30-5

Pedroso Júnior JL, Vasques MAB, Moraes RB, Arruda Júnior CA, Freitas DL, Sacchetti R

INTRODUCTION Traumas are very importance in the contemporary society. According to data from the World Health Organization, they are among the main causes of death and morbidity in the world, causing an average of 16,000 daily deaths as a result.1 Facial trauma is observed daily in emergency hospitals. Studies conducted in the South 2 and Southeast 3 regions of Brazil reveal that it mostly affects the younger population, mainly due to traffic accidents and physical aggression. Thorough study on the epidemiology of facial trauma is fundamental to allow patients to undergo the most appropriate treatment. Consequently, evaluation of the prevalence and etiology of facial fractures allows a more accurate and appropriate care. According to Eggensperger et al, 4 traumatic injuries have been identified as the main cause of reduction in productivity, including fewer years of work, as compared to heart disease and cancer in combination. The state of Rondônia has 1.7 million inhabitants, representing approximately 0.85% of the Brazilian population,5 and the city of Cacoal covers the state macroregion II as a health reference, assisting a population of 803,621 inhabitants, according to data from 2015.6 Considering the lack of data and research on the epidemiology of facial trauma in the Northern region of Brazil, this study investigated the epidemiological profile of patients submitted to maxillofacial trauma surgery at the Regional Hospital of Cacoal/Rondônia, Brazil, during the period April 1, 2011 to October 31, 2015. METHODS This study was approved by the Institutional Review Board of the Biomedical Sciences School of Cacoal, under number CAAE 50282915.7.0000.5298. The study consisted of a retrospective evaluation, by analysis of records and emergency care reports of patients treated by the Oral and Maxillofacial Surgery and Traumatology team of the Regional Hospital of Cacoal, Rondônia, Brazil, in the period April 1, 2011 to October 31, 2015.

Data were collected using a form addressing the following variables: date and time of attendance and trauma, age, gender, origin, lesion characteristics, associated lesions, type of anesthesia, fracture site, treatment and cause of accident – which was subdivided into physical assault (including interpersonal violence and bites), firearm accident (FAA), running over (including car, truck, motorcycle, bike and bus), car accident (including collision with other vehicles, light poles, walls, houses), motorcycle accidents, sports (including various sports, including martial arts), bike accidents, falls from their own heights, and non-fall impacts (the latter category included trauma due to direct collision with furniture, facilities, internal and external to the patients’ homes). The following exclusion criteria were considered: patients without personal identification, without SUS card, who were not registered in the hospital’s records, patients treated by the OMFST department and presenting other diseases or injuries than bone fractures, and patients with facial trauma yet without bone fracture on the face. Thus, information obtained directly from the records were registered on the study form, and data were tabulated and analyzed on the Excel software (Microsoft), version 2007. The variables were presented as tables and graphs, with absolute and relative frequencies. For continuous variables, the means, standard deviations and medians were calculated. RESULTS The study evaluated 414 records of patients with diagnosis of facial fracture, in whom 511 facial fractures were found. The majority (330 patients) were males (79.71%), with 84 females (20.28%), with a ratio close to 4:1. Both groups had higher prevalence in the age range 18 to 39 years (63.2%, n=262) (Fig 1). Traffic accidents were the most common etiological factor for both males and females, accounting for 269 cases (64.9%), with predominance of motorcycle accidents (51.9%, n=215), followed by physical aggression (7.9%, n=33) and work accidents (7.4%, n=31) (Tab. 1).

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):30-5

Epidemiological study of facial injuries in Cacoal/RO, Brazil

highest fracture rate, it was subdivided by anatomical region: parasymphysis (29.4%, n=86), condyle (19.5%, n=57), angle (18.8%, n=55) and body (15.75%, n=46) (Table 2, Fig 2).

The most affected facial bones, in decreasing order, were: mandible (41.48%, n=212), zygomatic bone (24.65%, n=126) and nasal bones (18.39%, n=94) ) (Tab. 3). Since the mandible presented the

Patients (n)

Sex and age 500 400 300 200 100 0

0 to 17 years 18 to 39 years 40 to 59 years 44 218 62 15 44 19

M F

> 60 years 10 2

Total

414

Figure 1: Graph with distribution of cases of maxillofacial fractures according to sex and age.

Table 1: Causes of maxillofacial injuries. Etiology

Car accident Motorcycle accident Bike accident Work accident Physical aggression Fall from own height Firearm accident Accident with animals Sports trauma Others Total

24 215 30 31 33 22 6 24 26 3 414

5,7% 51,9% 7,2% 7,4% 7,9% 5,3% 1,4% 5,7% 6,2% 0,7% 100%

Type of fracture

Mandible Zygoma Nasal bones Maxilla Dentoalveolar in maxilla Orbit floor Frontal TOTAL

212 126 94 42 21 9 16 511

41,48% 24,65% 18,39% 8,21% 4,1% 1,76% 3,13% 100%

Table 2: Topography of maxillofacial fractures.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):30-5

Pedroso JĂşnior JL, Vasques MAB, Moraes RB, Arruda JĂşnior CA, Freitas DL, Sacchetti R

Table 3: Distribution of cases of maxillofacial fractures according to etiology and age. Age (years)

Etiology

Traffic Aggression Work Sports Total

0 to 17

18 to 39

40 to 59

> 60

20 7 1 6

198 17 18 18

42 7 11 2

9 2 1 0

0,3%

18,8% 5,1% 29,4% 8,9%

Figure 2: Topography of mandibular fractures.

DISCUSSION Epidemiological studies are necessary to determine the demands of any population, influencing the improvement of quality of life and health of citizens. According to Thomson et al.7, the epidemiology of maxillofacial trauma may provide information on how people are injured and how the geographic area, socioeconomic status, traffic and social behavior can influence this type of trauma. Also, the follow-up of trends in the occurrence of maxillofacial trauma allows adjustments in professional training and development. 7 Among the several types of trauma, facial trauma stands out due to its emotional and functional repercussions and possibility of permanent deformities 8. Accidents involving the face presented increased prevalence in the last four decades, and the

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

269 33 31 26 359

medical literature refers to the increase in car accidents and urban violence as the main causes of trauma, especially in young individuals. 8,9 Patients aged 18 to 39 years were the age group with highest prevalence among victims of facial trauma, agreeing with other studies.2,8,9,10 This applies for both sexes, yet with statistically significant predominance in men: male=79.71% and female=20.28%, approximate ratio of 4:1. There was higher prevalence of young people due to the easy access to motor vehicles, concomitantly with the intake of alcoholic beverages, besides being people within the economically active population, who play some social role, being more prone to trauma in daily life.9,10 This study agrees with the report of Chrcanovic et al,15 who verified that the main etiological agent was traffic accident, mainly motorcycle accident, accounting for 51.9% of cases. Several authors reported traffic accidents as the main etiological factor.4,7,11 However, other predominant etiological factors were observed in some countries, such as physical aggression, in Australia,12 Hong Kong13 and United States.14 The location of fractures depends on the mechanism and intensity of trauma. 3 Chrcanovic et al, 15 after analysis of 1,326 facial fractures in 911 patients, reported that the mandible was the facial bone most frequently fractured, followed by the zygomatic complex and the nose. In the present study, mandibular fractures were the most common among all types of facial fractures (41.48%), as reported in previous studies. 2,3,9,15-28 This high prevalence is probably due to the kinematics of many traumas, since the mandible is the only moving bone and is anatomically prominent on the face. However, other samples present higher frequency of zygoma fractures 11 and nasal fractures.29

19,5%

15,7%

Total

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):30-5

Epidemiological study of facial injuries in Cacoal/RO, Brazil

CONCLUSION Within the limits of this study and based on the epidemiological significance of the results achieved, it can be concluded that facial traumas assisted at Cacoal/ RO mainly affect male individuals, aged 18 to 39 years, with predominance of motorcycle traffic accidents and mandibular fracture. This type of study is important to direct the public policies to the most affected population profile, aiming at the prevention of trauma, improving the health and quality of life of the population.

Among the mandibular fractures, the parasymphysis was the most affected anatomical region (29.4%), followed by the condyle (19.5%) and angle (18.8%). However, this prevalence was different in other studies, in which the mandibular angle, 3,14 condyle 23,24 and body26 were the most affected regions. It should be highlighted that the early surgical management of facial trauma provides the best results, besides contributing to promote faster return to professional activities and family life.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):30-5

Pedroso Júnior JL, Vasques MAB, Moraes RB, Arruda Júnior CA, Freitas DL, Sacchetti R

References:

1. Krug EG, Sharma GK, Lozano R. Commentaries: The global burden of injuries. Am J Public Health. 2000;90(4):523-7. 2. Maliska MCDS, Lima Júnior SM, Gil JN. Analysis of 185 maxillofacial fractures in the state of Santa Catarina, Brazil. Braz Oral Res. 2009 JulySept;23(3):268-74. 3. Tino MT, Freitas RR. Epidemiologia do trauma maxilofacial num hospital universitário terciário da cidade de São Paulo. Rev Bras Cir Cabeça Pescoço. 2010;39(2):139-45. 4. Eggensperger NM, Danz J, Heinz Z, Iizuka T. Occupational maxillofacial fractures: a 3-year survey in central Switzerland. J Oral Maxillofac Surg. 2006;64(2):270-6. 5. IBGE. Censo Demográfico. Brasília, DF: IBGE; 2010. 6. Resolução nº 011/CIB/RO Porto Velho, 19 de março de 2015. Diário Oficial [do] Estado de Rondônia. 2015 Abr 7. Disponível em: www.jusbrasil.com.br/ diarios/89330843/doero-07-04-2015-pg-24> 7. Thomson WM, Stephenson S, Kieser JA, Langley JD. Dental and maxillofacial injuries among older New Zealanders during the 1990s. Int J Oral Maxillofac Surg. 2003;32(2):201-5. 8. Bull JP. Disabilities caused by road traffic accidents and their relation to severity scores. Accid Anal Prev. 1985 Oct;17(5):387-97. 9. Oliveira CMCS, Santos JS, Brasileiro BF, Santos TS. Epidemiologia dos traumatismos buco-maxilofaciais por agressões em Aracaju/SE. Rev Cir Traumatol Buco-Maxilo-Fac. 2008;8(3):57-68. 10. Wulkan M, Parreira JG Jr, Botter DA. Epidemiologia do trauma facial. Rev Assoc Med Bras. 2005;51(5):290-5. 11. Naveen Shankar A, Naveen Shankar V, Hegde N, Sharma, Prasad R. The pattern of the maxillofacial fractures - A multicentre retrospective study. J Craniomaxillofac Surg. 2012 Dec;40(8):675-9. 12. Cabalag MS, Wasiak J, Andrew NE, Tang J, Kirby JC, Morgan DJ. Epidemiology and management of maxillofacial fractures in an Australian trauma centre. J Plast Reconstr Aesthet Surg. 2014 Feb;67(2):183-9.

13. Wong JY, Choi AW, Fong DY, Wong JK, Lau CL, Kam CW. Patterns, aetiology and risk factors of intimate partner violence-related injuries to head, neck and face in Chinese women. BMC Womens Health. 2014 Jan 10;14:6. 14. Morris C, Bebeau NP, Brockhoff H, Tandon R, Tiwana P. Mandibular fractures: An analysis of the epidemiology and patterns of injury in 4,143 fractures. J Oral Maxillofac Surg. 2015 May;73(5):951.e1-12. 15. Chrcanovic BR, Freire-Maia B. Facial fractures: a 1-year retrospective study in a hospital in Belo Horizonte. Braz Oral Res. 2004;18(4):322-8. 16. Martin Junior, Keim FS, Tiaraju E, Helena DS. Aspectos epidemiológicos dos pacientes com traumas maxilofaciais operados no hospital geral de Blumenau, SC de 2004 a 2009. Arq Int Otorrinolaringol (Impr.). 2010 Apr-June;14(2):192-8. 17. 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. 18. Eskitascioglu T, Özyazgan I, Çoruh A, Günay GK, Yontar Y, Altiparmak M. Fractures of the mandible: a 20-year retrospective analysis of 753 patients. Ulus Travma ve Acil Cerrahi Derg. 2013;19(4):348-56. 19. Goulart TR, Colombo L, Moraes M, Asprino L. What is expected from a facial trauma caused by violence? J Oral Maxillofac Res. 2014;5(4):1-7. 20. Kambalimath HV, Agarwal SM, Kambalimath DH, Singh M, Jain N, Michael P. Maxillofacial injuries in children: a 10 year retrospective study. J Maxillofac Oral Surg. 2013;12(2):140-4. 21. Bali R, Sharma P, Garg A, Dhillon G. A comprehensive study on maxillofacial trauma conducted in Yamunanagar, India. J Inj Violence Res. 2013;5(2):108-16. 22. Exadaktylos AK, Eggensperger NM, Eggli S, Smolka KM, Zimmermann H, Iizuka T. Sports related maxillofacial injuries: the first maxillofacial trauma database in Switzerland. Br J Sports Med. 2004;38(6):750-3. 23. Van Den Bergh B, Karagozoglu KH, Heymans MW, Forouzanfar T. Aetiology and incidence of maxillofacial trauma in Amsterdam: a retrospective analysis of 579 patients. J Cranio-Maxillofacial Surg. 2012;40(6):e165-9.

24. Brasileiro BF, Passeri LA. Epidemiological analysis of maxillofacial fractures in Brazil: a 5-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006 July;102(1):28-34. 25. Carvalho TBO, Cancian LRL, Marques CG, Piatto VB, Maniglia JV, Molina FD. Six years of facial trauma care: an epidemiological analysis of 355 cases. Braz J Otorhinolaryngol. 2010 SeptOct;76(5):565-74. 26. Mijiti A, Ling W, Tuerdi M, Maimaiti A, Tuerxun J, Tao YZ, et al. Epidemiological analysis of maxillofacial fractures treated at a university hospital, Xinjiang, China: a 5-year retrospective study. J Cranio-Maxillofacial Surg. 2014;42(3):227-33. 27. Lins MA, Albuquerque GC, Oliveira AL, Martins VB, Fayad FT, Oliveira MV, et al. Epidemiology of facial trauma in a hospital in the municipality of ManausAmazonas. J Braz Coll Oral Maxillofac Surg. 2018 Jan-Abr;4(1):28-32. 28. Heitor BS, Goldenberg DC, Bastos E, Fonseca A, Kanashiro E, Daniel FR, et al. Tratamento cirúrgico das fraturas de face em pacientes pediátricos: características clínicas em um centro de trauma terciário. Rev Bras Cir Craniomaxilofac. 2009;12(2):47-9. 29. Bataineh AB. Etiology and incidence of maxillofacial fractures in the north of Jordan. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998;86(1):31-5. 30. Motamedi MHK, Dadgar E, Ebrahimi A, Shirani G, Haghighat A, Jamalpour MR. Pattern of maxillofacial fractures: a 5-year analysis of 8,818 patients. J Trauma Acute Care Surg. 2014 Oct;77(4):630-4.

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):30-5

Original Article

Accuracy and cutting efficiency of surgical burs

on crown sections

ABSTRACT Introduction: Manufacturers of surgical burs do not provide information about the lifetime of these materials, making it difficult for the dentist to choose the most efficient burs. Objective: To compare the accuracy and the cutting efficiency of two types of tungsten carbide burs in mandibular third molar crown sections. Methods: Half of the twenty homologous teeth were sectioned with a Zecrya bur, whereas a Talon 12 Surg bur was used in the contralateral teeth. The accuracy and the cutting efficiency were analyzed through the section thickness and the wear on the bur tip. The results were compared with 1-way ANOVA and Tukey test, with a significance level of 0.05. Results: The two burs suffered a reduction on their area after twenty cuts. However, on the stereomicroscopy examination, the Talon 12 Surg suffered a large deformation after the twentieth cut and a significant wear at its active tip (p <0.05) observed at the scanning electron microscopy examination; the same intensity of damage was not observed in the Zecrya bur. Conclusions: The Zecrya and Talon 12 Surg burs have durability for twenty dental sections. However, Zecrya presented higher cutting accuracy and less wear than Talon 12 Surg. Keywords: Tungsten. Molar, third. Tooth wear.

Universidade Federal de Juiz de Fora, Departamento de Odontologia (Governador Valadares/MG, Brazil).

How to cite: Souza PV, Verner FS, Carvalho RF, Paradella TC, Monteiro JB, Homem MGN, Carvalho MF. Accuracy and cutting efficiency of surgical burs on crown sections. J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):36-43. DOI: https://doi.org/10.14436/2358-2782.5.2.036-043.oar

Universidade Estadual Paulista, Departamento de Materiais Odontológicos e Prótese (São José dos Campos/SP, Brazil).

Submitted: August 03, 2018 - Revised and accepted: February 07, 2019

Universidade de São Paulo, Departamento de Cirurgia, Prótese e Traumatologia Maxilo-Faciais (São Paulo/SP, Brazil).

» 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: Matheus Furtado de Carvalho Universidade Federal de Juiz de Fora, Faculdade de Odontologia Rua José Lourenço Kelmer, São Pedro - Juiz de Fora/MG – CEP: 36.036-330 E-mail: matheus.furtado@ufjf.edu.br

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):36-43

Souza PV, Verner FS, Carvalho RF, Paradella TC, Monteiro JB, Homem MGN, Carvalho MF

INTRODUCTION The extraction of mandibular third molars is indicated in cases of dental impaction; by orthodontic indication; malpositioning in the dental arch; in case of advanced periodontal disease, caries and/or extensive fractures; and when associated with pathological lesions or involved in maxillary fractures.1,2 The sectioning of dental crowns divides the tooth into smaller fragments, avoiding extensive ostectomies and reducing the postoperative discomfort. This is performed using rotary burs with laminated active tips able to cut and remove dental structure 3. Most of these drills are composed of a solid, high-melting (2,780°C) carbon-tungsten metallic alloy that does not undergo deformation, presents white-greyish color and exhibits an almost permanent shine. 4 However, it is believed that its repeated use, associated with sterilizations, causes wear on their surface, reducing the cutting efficiency.5,6,7 During selection of burs, the dentist should consider not only the material composition, but also the mechanism of action in contact with different surfaces. Some studies evaluated the wear of non-surgical burs in contact with restorative materials as amalgam and ceramics; 5,8,9 others evaluated the wear of surgical burs in contact with human bone during drilling for placement of dental implants6,7,10. However, no study was found evaluating the surgical tungsten carbide burs for sectioning of human teeth, thus justifying the need of this study.

extraction. Pairs of homologous teeth with buccolingual dimension smaller than 9 mm or greater than 11 mm were excluded from the sample, and only one tooth had dimension larger than 11 mm. Study material The study employed tungsten carbide burs Zecrya and Talon 12 Surg (Tri-Hawk, Tri-Hawk Inc., Morrisburg, Canada) with the same diameter as the active point. The teeth were embedded in self-curing acrylic resin (Jet, Classical, São Paulo / SP, Brazil) in the center of polyvinylchloride (PVC) tube with 3-cm height and 4-cm diameter, after identification of buccal, lingual, mesial and distal surfaces, with exposure of the cervical line of the crown, which is considered the depth limit for the action of burs. The experimental part of the study was conducted at the Prosthesis Laboratory of São Paulo State University (UNESP) at São José dos Campos, using a specific device for specimen immobilization, coupling of high-speed handpiece (Kavo extra-torque 605, São Paulo / SP, Brazil) and direction of sectioning (Fig 1). Sample groups The tooth pairs were divided into two groups (right and left sides). The Zecrya bur was used at one side, and the Talon 12 Surg bur was used on the contralateral side (Fig 2). Tooth sectioning Sectioning was performed in continuous movement, contacting the burs on the specimens, running 6 mm in buccolingual direction, under constant irrigation with distilled water, using a high-speed handpiece at 350,000 rpm. After each section, the burs were cleaned with isopropyl alcohol (Álcool Santa Cruz Ltda, Guarulhos, São Paulo, Brazil), in an ultrasonic cleaner for five minutes, and then sterilized in autoclave. Analysis of bur accuracy The accuracy was quantitatively evaluated in mm using a stereomicroscope (Stereo Discovery V20, Zeiss, Göttingen, Germany), comparing the original thickness of 1.2 mm of active point of burs with the thickness of tooth wear after sectioning (Fig 3).

METHODS Achievement of sample This study was approved by the Institutional Review Board of the Federal University of Juiz de Fora (CAAE #79758317.4.0000.5147). The initial sample was composed of 42 teeth (21 pairs of homologous mandibular third molars) that served as specimens for sectioning. The teeth had intact surfaces, without dental caries or fractures, and were obtained by donation from the patients, after indication of extraction and signing an informed consent form, in accordance with the Declaration of Helsinki. To standardize the extent of sectioning, the tooth dimensions were measured using a digital caliper (Mitutoyo Absolute, Suzano / SP, Brazil) after

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):36-43

Accuracy and cutting efficiency of surgical burs on crown sections

Figure 1: Device for immobilization of specimen and coupling of high-speed handpiece: A) lateral view; and B) frontal view.

Figure 2: Direction of burs for tooth sectioning: A) Zecrya bur; and B) Talon 12.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):36-43

Souza PV, Verner FS, Carvalho RF, Paradella TC, Monteiro JB, Homem MGN, Carvalho MF

1.356 mm

Figure 3: Micrograph representing the thickness of tooth sectioning: sectioning with bur Zecrya on specimen 1.

Analysis of wear of burs The wear in mm 2 of the active point area of the bur was quantitatively evaluated by stereomicroscopy after each section; and qualitatively, in descriptive manner, by scanning electron microscopy, using a microscope (Inspect S50, FEI, Brno, Czech Republic) under high vacuum, at 55× and 200× magnifications, at different moments: before the first use (T0) and after the first (T1), fifth (T5), tenth (T10), 15th (T15) and 20 th (T20) sections. The burs were positioned with the same surface turned upward for microscopic analysis, to compare the wear on the same surface. Statistical analysis Quantitative data on the accuracy and wear of burs were plotted on tables for descriptive analysis (means and standard deviations). Data were ana-

lyzed by the parametric test one-way analysis of variance (ANOVA) and complementary Tukey test, at a significance level of 0.05. The analysis was performed on the software SPSS, version 23.0. RESULTS Quantitative analysis When analyzing tooth wear, the Talon 12 Surg bur showed significant variation in section thickness at the 20 th cut (p<0.05), which was not observed for the Zecrya drill, regardless of the number of utilizations (Table 1). Analysis of bur wear by stereomicroscopy showed that both Talon 12 Surg and Zecrya had reduction in the active point, decreasing with the increased number of sections, with the most significant values on the 15h and 20th utilizations (p<0.05) (Table 2).

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):36-43

Accuracy and cutting efficiency of surgical burs on crown sections

Table 1: Tooth grinding after the 1st, 5th, 10th, 15th and 20th utilization of burs. Bur

Numbers of utilization of burs

Mean (mm)

Standard deviation

Talon 12

1 5 10 15 20

1,34a 1,32ab 1,25b 1,31ab 1,56c

0,00 0,03 0,05 0,05 0,05

1 5 10 15 20

1,33a 1,32a 1,32a 1,22a 1,15a

0,00 0,03 0,27 0,20 0,06

Lower limit

1,34 1,28 1,18 1,24 1,50 < 0,05 1,33 1,28 0,99 0,97 1,08 > 0,05

P valor

Zecrya

95% confidence interval for the mean

P valor

Minimum

Maximum

1,35 1,36 1,31 1,37 1,63

1,34 1,27 1,16 1,26 1,50

1,35 1,35 1,28 1,39 1,64

1,34 1,36 1,65 1,47 1,22

1,33 1,27 1,10 1,04 1,09

1,34 1,35 1,78 1,57 1,24

Upper limit

P value – one-way ANOVA, with post-hoc Tukey test. Mean values followed by different letters were different from each other (p < 0.05).

Table 2: Wear of active point area before utilization of burs and after 1, 5, 10, 15 and 20 sections. Bur

Numbers of utilization of burs

Mean (mm²)

Standard deviation

Talon 12

0 1 5 10 15 20

4,95a 4,89a 4,70b 4,67b 4,47c 4,42c

0,02 0,12 0,17 0,04 0,07 0,02

0 1 5 10 15 20

11,94 11,80b 11,74b 11,65c 11,60cd 11,53d

P value

Zecrya

95% confidence interval for the mean

Minimum

Maximum

Lower limit

Upper limit

4,92 4,87 4,48 4,62 4,39 4,39

4,98 4,90 4,92 4,71 4,55 4,45

4,93 4,88 4,48 4,64 4,41 4,40

4,98 4,91 4,88 4,73 4,58 4,45

11,90 11,79 11,69 11,58 11,53 11,49

11,99 11,80 11,79 11,72 11,67 11,56

11,90 11,80 11,71 11,55 11,52 11,49

11,98 11,81 11,81 11,71 11,67 11,55

< 0,05 a

0,03 0,02 0,04 0,06 0,06 0,03

P value

< 0,05

P valor - one-way ANOVA with post-hoc Tukey test. Mean values followed by different letters were different from each other (p < 0.05).

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):36-43

Souza PV, Verner FS, Carvalho RF, Paradella TC, Monteiro JB, Homem MGN, Carvalho MF

Qualitative analysis Figure 4 illustrates the micrographs of Talon 12 Surg bur at 55× and 200× magnifications, obtained by SEM at different moments. After the 10th section (Fig. 4G-H), the bur showed greater wear on its edges, which was well evidenced on the 20th cut (Fig. 4K-L), with a great change.

Figure 5 illustrates the micrographs of Zecrya at 55× and 200× magnifications, obtained by SEM at the same moments, evidencing that the bur did not show clear wear on its edges even after the 20th use (Fig 5K-L).

Figure 4: SEM micrographs of bur Talon 12 Surg before the first section (A, B), after the first (T1) (C, D), fifth (T5) (E, F), tenth (T10) (G, H), fifteenth (T15) (I, J) and twentieth (T20) (K, L) sectioning: 55x (A, C, E, G, I, K) and 200x magnifications (B, D, F, H, J, L).

Figure 5: SEM micrographs of bur Zecrya before the first section (A, B), after the first (T1) (C, D), fifth (T5) (E, F), tenth (T10) (G, H), fifteenth (T15) (I, J) and twentieth (T20) (K, L) sectioning: 55x (A, C, E, G, I, K) and 200x magnifications (B, D, F, H, J, L).

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):36-43

Accuracy and cutting efficiency of surgical burs on crown sections

DISCUSSION The accomplishment of tooth section is influenced by some factors, depending on the quality of materials, such as the bur and handpiece, as well as the surgical technique, peculiar to each operator.11,12 Therefore, all sections were performed by the same operator. The two types of burs (Talon 12 Surg and Zecrya) belong to the same manufacturer and were tested in the laboratory of the American Dental Association and passed the tests referenced by the American National Standards Institute. 11 Tooth sectioning should be performed on three quarters of the crown, to weaken the structure and allow tooth cleavage without compromising adjacent structures as the lingual nerve. After measuring the buccolingual distance of all teeth, an extension of 6 mm was standardized for all sections. Tooth sectioning was performed on human teeth, aiming to reproduce a reliable resistance as that found during clinical practice. Some studies employed bovine teeth as specimens, which have similar dental structure as the human tooth; and the machinable glass ceramics Macor, which presents similar hardness and thermal properties as dental enamel. 9,12 The wear of a bur can be accelerated by the use of different washing and sterilizing agents.13 To reproduce the clinical routine, the burs were cleaned by ultrasound and sterilized after each section. Penel et al 14 evaluated the manual and ultrasonic cleaning methods, observing the superiority of ultrasonic cleaning.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Table 1 shows that the Zecrya bur showed greater precision of tooth sectioning, since the thickness of sections showed smaller variations than those promoted by Talon 12 Surg. This is interesting for the dentist, since very wide sections can impair the tooth cleavage, by allowing complete rotation of elevators in the slots, promoting inadequate sections, which complicates the tooth extraction. The most important findings of this study were those related to wear of the bur area identified by stereomicroscopy and the wear observed at the bur edges by SEM analysis. Table 2 shows that Talon 12 Surg had a wear of 10.75% compared to its initial area, compared to only 3.93% for the Zecrya drill, thus suggesting a longer durability for Zecrya in relation to Talon 12 Surg. Figures 4 and 5 also highlight this finding, identifying deformation at the edges of Talon 12 Surg after the 20th use, not found on SEM images of Zecrya. This information is important for dentists, proving that, despite the differences found, both have durability of at least twenty sections, guiding the professional for the correct use of the surgical material, aiming at better patient care. Further studies using more than twenty sections should be conducted, involving a greater number of surgical burs, leading them to exhaustion (fracture) due to repeated use, thus determining the lifetime of this important surgical tool. CONCLUSION Both the Zecrya and Talon 12 burs presented durability for 20 sections on mandibular third molars. However, Zecrya exhibited higher accuracy and less wear than Talon 12 Surg.

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):36-43

Souza PV, Verner FS, Carvalho RF, Paradella TC, Monteiro JB, Homem MGN, Carvalho MF

References:

1. Cruz JN, Rothen M, Spiekerman C, Drangsholt M, McClellan L, Huang GJ. Recommendations for third molar removal: a practice-based cohort study. Am J Public Health. 2014 Apr;104(4):735-43. 2. Patel S, Mansuri S, Shaikh F, Shah T. Impacted mandibular third molars: a retrospective study of 1198 cases to assess indications for surgical removal, and correlation with age, sex and type of Impaction-a single institutional experience. J Maxillofac Oral Surg. 2017 Mar;16(1):79-84. 3. Sharma S, Shankar R, Srinivas K. An epidemiological study on the selection, usage and disposal of dental burs among the dental practioner’s. J Clin Diagn Res. 2014 Jan;8(1):250-4. 4. Zaoxue Y, Mei C, Pei KS. Nanosized tungsten carbide synthesized by a novel route at low temperature for high performance electrocatalysis. Sci Rep. 2013;3:1646. 5. Angham CA. The effectiveness of a new diamond and carbide fissure burs in cutting amalgam and composite materials. J Bagh College Dentistry. 2017 Jan;20(2):26-9.

6. Koo K, Kim M, Kim H, Wikesjö UME, Yang J, Yeo I. Effects of implant drill wear, irrigation, and drill materials on heat generation in osteotomy sites. J Oral Implantol. 2015 Apr;41(2):e19-23. 7. Allsobrook OF, Leichter J, Holborrow D, Swain M. Descriptive Study of the longevity of dental implant surgery drills. Clin Implant Dent Relat Res. 2011 Sept;13(3):244-54. 8. Di Cristofaro RGR, Giner, Mayoral JR. Comparative study of the cutting efficiency and working life of carbide burs. J Prosthodont. 2013 July;22(5):391-6. 9. Ercoli C, Rotella M, Funkenbusch PD, Russell S, Feng C. In vitro comparison of the cutting efficiency and temperature production of 10 different rotary cutting instruments. Part I: Turbine. J Prosthet Dent. 2009 Apr;101(4):248-61. 10. Bernardes RA, Húngaro MA, Vivan RR, Baldi JV, Vasconcelos BC, Bramante CM. Scanning electronic microscopy analysis of the apical surface after of rootend resection with different methods. Scanning. 2015 Mar-Apr;37(2):126-30.

11. American National Standard. American Dental Association Specification No. 23-1982, Dental Excavating Burs. J Am Dent Assoc. 1970 Oct;81(4):961-9. 12. Watanabe I, Ohkubo C, Ford JP, Atsuta M, Okabe T. Cutting efficiency of air turbine burs on cast titanium and dental casting alloys. Dent Mater. 2000 Nov;16(6):420-5. 13. Jochum RM, Reichart PA. Influence of multiple use of Timedur-titanium cannon drills: thermal response and scanning electron microscopic findings. Clin Oral Implants Res. 2000 Apr;11(2):139-43. 14. Penel L, Iost Um, Libersa JC. Cleaning implantation burs. Observations using scanning electron microscopy. Bull Group Int Rech Sci Stomatol Odontol. 2001 JanApr;43(1):11-3.

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):36-43

Case Report

Intraoral scanning in the virtual planning for orthognathic surgery:

case report

FLÁVIO WELLINGTON DA SILVA FERRAZ1 | DAIANE BETIATTO1 | THAÍS SAMARINA SOUSA LOPES MELLO1 | JOSÉ BENEDITO DIAS LEMOS2

ABSTRACT The protocol for surgical virtual planning in orthognathic surgery requires the replacement of teeth from the computed tomography (CT) by the teeth of the digitized plaster models, aiming at the fabrication of a composite skull. In the classic protocols, the plaster models are scanned in a three-dimensional surface optical scanner or scanned by means of CT. With the development of the intraoral optical scanner, the possibility of using this method for surgical planning was considered, dispensing the plaster models. However, there are two main issues: the precision of the transversal dimension and a way to obtain the final occlusion virtually. Thus, the present article aims to present a clinical case of Class III dentofacial deformity due to anteroposterior atresia of the maxilla and mandibular laterognatism, in which intraoral scanning was used to replace the teeth in the skull, aiming at obtaining the composite skull. The final occlusion was achieved by moving and color mapping of the virtual models, and making the surgical guides. The adaptation of the surgical guides occurred without adjustment, and the final clinical occlusion was within the standards, showing good accuracy of the protocol. Keywords: Orthognathic surgery. Maxillomandibular abnormalities. X-ray computed tomography.

Universidade de São Paulo, Hospital Universitário, Serviço de Cirurgia e Traumatologia Bucomaxilofacial (São Paulo/SP, Brazil).

How to cite: Ferraz FWS, Betiatto D, Mello TSSL, Lemos JBD. Intraoral scanning in the virtual planning for orthognathic surgery: case report. J Braz Coll Oral Maxillofac Surg. 2019 MayAug;5(2):44-50. DOI: https://doi.org/10.14436/2358-2782.5.2.044-050.oar

Universidade de São Paulo, Hospital Universitário, Divisão de Odontologia (São Paulo/SP, Brazil).

Submitted: February 22, 2018 - Revised and accepted: June 06, 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: Flávio Wellington da Silva Ferraz Rua Cristiano Viana, 401, sl. 1401, Pinheiros – São Paulo/SP – CEP: 05.411-000 E-mail: flavio.ferraz@hc.fm.usp.br

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):44-50

Ferraz FWS, Betiatto D, Mello TSSL, Lemos JBD

INTRODUCTION The surgical correction of complex dentofacial deformities remain a challenge in the clinical routine of oral and maxillofacial surgeons. The current surgical procedures aim to restore harmony, esthetics and function, by accurate surgical planning. Traditionally, the diagnosis of dentofacial deformities and surgical planning were performed by predictive tracing and surgery on dental casts. The tracings were obtained by contouring the facial scaffold on the lateral cephalogram on acetate paper. These tracings were then trimmed and moved to assess the possible outcomes. With these data, surgery was performed on the dental casts mounted on a semi-adjustable articulator, and surgical guides were fabricated using acrylic resin.1 With the easy access of oral and maxillofacial surgeons and patients to multislice computed tomographies (CT) and cone beam computed tomographies (CBCT), different protocols were established for virtual surgical planning of orthognathic surgeries. Computed tomography imaging is the gold standard for observation of bone structures. However, a significant disadvantage of CT is the lack of accuracy on representation of the tooth surfaces2. Dental casts mounted on semi-adjustable articulators are reliable copies of patients’ teeth; however, these casts have no bone support, which is one limitation of traditional surgical planning: the lack of visualization of bone structures in the planning and treatment of complex craniomaxillofacial deformities.3 In 2003, Gateno et al.3 reported the first clinically applicable method for accurate interpretation of the craniofacial skeleton. Their method was basically divided into three stages; the first was CT of the patient’s dental casts; the second, CT of the patient using bite guide and fiducial markers, to create a bone model of the craniomaxillofacial skeleton; and the third was to incorporate the digitized dental casts into the patient’s initial cranial CT, creating a composite cranial model for virtual surgical planning. Gateno et al3 and Xia et al4 proposed the Computer-Aided Surgical Simulation (CASS) protocol for virtual surgical planning, which includes five steps: 1) creation of composite skull; 2) guidance of the composite skull in natural head positioning (NHP); 3) analysis and diagnosis of dentofacial deformity; 4) virtual simulation of orthognathic surgery; and 5) transfer of obtained data for preparation of surgical guides, for posterior surgery on the patient.4,5 Subsequently, Swennen et al6 developed a technique to achieve the virtual 3D model of the patient with accu-

rate dental data based on triple CBCT scanning (first, from the patient; second, patient with the bite guide; and third, of the guide alone). Both methods aimed to eliminate the need for dental cast surgery and achieve better surgical accuracy.6 The increased utilization of intraoral optical scanner in orthodontic and prosthetic planning raised the possibility to use this method for surgical planning, eliminating the dental casts. However, there are two main issues: the accuracy of transverse dimension and how to achieve the final occlusion virtually7. This study presents the case of a 21-year-old male patient with dentofacial deformity, who was submitted to intraoral scanning instead of dental casts, to replace the teeth in the skull. The composite skull was entirely virtually fabricated, eliminating the laboratory steps for virtual surgical planning of orthognathic surgery, thus avoiding possible errors due to material or technique distortion. CASE REPORT The 21-year-old male patient, of Asian descent, was assisted at the Oral and Maxillofacial Surgery and Traumatology service of University Hospital of São Paulo, with esthetic and functional complaints, masticatory and speech difficulties. Clinical examination evidenced that the patient presented Pattern III due to severe maxillary deficiency, mandibular laterognathism, right maxillary midline deviation of 1.5 mm and good maxillary and mandibular inclination in frontal view (Fig 1A to 1C). On oral examination, the patient presented Angle Class III canine and molar relationship, short crowns, teeth 11 and 21 with 7-mm length and probable altered passive eruption. During smile, he presented 3-mm gingival exposure in the anterior superior region. Following the protocol of Gateno et al,3 the composite skull was obtained in three stages, with a main modification in the first part, in which the dental casts were obtained by intraoral scanning using the Trios 3Shape appliance (3Shape A/S Holmens Kanal 7.4 1060 Copenhagen, Denmark), of the upper and lower dental arches, to obtain the digital casts (Fig 2D to 2F). On the second stage, a multislice computed tomography of the patient was obtained using a pink wax bite guide (two folded wax sheets with a gauze in the middle to avoid distortion), in centric relation, achieving a bone model of the craniomaxillofacial skeleton. The third stage aimed to incorporate the dental arches obtained by intraoral scanning into the initial CT skull, creating an entirely virtual composite skull model (Fig 1D to 1F)

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):44-50

Intraoral scanning in the virtual planning for orthognathic surgery: case report

Figure 1: Postoperative views: A) right profile smiling, B) frontal smiling, C) left profile at rest. Composite skull without movement of segments, in views: D) sagittal right, E) coronal, F) sagittal left. Composite skull after movement of segments, in views: G) sagittal right, H) coronal, I) sagittal left.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):44-50

Ferraz FWS, Betiatto D, Mello TSSL, Lemos JBD

of mandibular rami (Figs 1G to 1I). Final occlusion was obtained by color mapping (Fig. 2G and 2H). Surgical guides were obtained on a 3D printer, obtaining adequate adjustment in all surgical stages, thus showing the accuracy of the technique proposed for this clinical case. The superimposition of virtual models with the postoperative tomography after one month demonstrated deviations smaller than 1 mm for the chosen reference points, proving the efficacy of the new proposed protocol (Fig 2A to 2C; 3A to 3I). The case report was submitted and approved by the Institutional Review Board of the University Hospital of USP, and the patient signed an informed consent form

for later virtual surgical planning (Fig 1G to 1I). This modification in the initial protocol aimed to suppress the laboratory steps for virtual surgical planning of orthognathic surgery, thus avoiding possible errors due to distortion of impression materials or technique. Using the Dolphin Imaging 3D software v. 11.9 (Dolphin Imaging Software, Canoga Park, California, USA), virtual surgical planning was obtained proposing 7 mm of maxillary advancement, with 1-mm superior repositioning and correction of 1.5-mm maxillary midline deviation to the left, by Le Fort I osteotomy of the maxilla; 1.4 mm advancement of the mandible in the region of lower incisors by bilateral sagittal osteotomy

Figure 2: Views of final occlusion at one month postoperatively: A) lateral right, B) frontal, C) lateral left. Views of occlusion obtained by intraoral scanning, after movement of segments, simulating the final occlusion: D) sagittal right, E) coronal, F) sagittal left. Color mapping for visualization of grinding areas, to achieve the final occlusion: G) upper arch, H) lower arch.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):44-50

Intraoral scanning in the virtual planning for orthognathic surgery: case report

Figure 3: One-month postoperative evaluation: A) right profile smiling, B) frontal smiling, C) left profile at rest. Composite skull with movement of segments, final occlusion: D) sagittal right view, E) coronal view, F) sagittal left view, G) coronal view. H) Computed tomography (CT) at one month postoperatively, in coronal view. I) Superimposition of preoperative composite skull in final occlusion (coronal view) and at one month postoperatively (coronal view), evidencing deviations smaller than 1 mm on the selected reference points.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):44-50

Ferraz FWS, Betiatto D, Mello TSSL, Lemos JBD

DISCUSSION Dental casts are reliable copies of the patient’s teeth. Besides the diagnosis and good adaptation of surgical guides, they allow comparisons to establish a dynamic analysis of the evolution of clinical cases. The possibility of digitizing dental casts, or even performing intraoral scanning of the patient’s dental arch, is becoming a routine in the dental clinic.8 The main advantages of the digital cast are accuracy, fast achievement of data for diagnosis and planning, easy storage and possibility of information transfer using virtual communication means.8,9 Some disadvantages of digital casts include the fabrication costs, lack of familiarity with the analysis of digital casts, impossibility of mounting on the articulator and the impossibility of using the touch.8 The recent technological advances in healthcare and the easy access to CT scans for diagnosis of dentofacial deformities and planning of orthognathic surgeries led to a groundbreaking advance in virtual diagnosis, planning, treatment and outcome evaluation. However, for this paradigm shift and replacement of traditional orthognathic surgical planning to virtual planning by surgeons, both the imaging system and the 3D virtual planning on the software should be easy to use, accessible and available at a relatively low cost.3,4 Several studies comparing plaster casts with digital casts concluded that digital casts are clinically acceptable,

despite some statistically significant linear variations, with mean differences of 0.03 to 0.4mm. It is assumed that the possible causes for the variability of results between different studies may be due to errors in examiner technique, material properties and the unavoidable differences between the softwares used.10 In the present case, these differences were not noticed, since the guides had satisfactory fitting in the dental arches. Regarding the protocol, the method presented good accuracy and precision, with differences of at most 1 mm in anteroposterior, vertical and transverse directions, yet without clinical significance on the esthetic and final occlusal results. The guide was well adapted in all surgical stages, showing that there were no transverse distortions in measurements obtained by the intraoral optic scanning, without clinically significant changes in the final occlusion of the patient.

CONCLUSION The surgical guides were adapted without the need for adjustments, and the final clinical occlusion was within normal standards, evidencing the good precision of the protocol. Superimposition of the surgical planning and postoperative tomography demonstrated high level of accuracy for the selected reference points, demonstrating the efficacy of the suggested protocol, as well as of the surgical process.

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):44-50

Intraoral scanning in the virtual planning for orthognathic surgery: case report

References:

1. Bell WH, editor. Modern practice in orthognathic and reconstructive surgery. Philadelphia, WB Saunders; 1992. 2. Santler G, Karcher H, Ruda C. Indications and limitations of three-dimensional models in cranio-maxillofacial surgery. J Craniomaxillofac Surg. 1998 Feb;26(1):11-6. 3. Gateno J, Xia J, Teichgraeber JF, Rosen A. AÂ new technique for the creation of a computerized composite skull model. J Oral Maxillofac Surg. 2003 Feb;61(2):222-7. 4. Xia JJ, Gateno J, Teichgraeber JF, Christensen AM, Lasky RE, Lemoine JJ, et al. Accuracy of the computer-aided surgical simulation (CASS) system in the treatment of patients with complex craniomaxillofacial deformity: a pilot study. J Oral Maxillofac Surg. 2007 Feb;65(2):248-54.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

5. Xia JJ, Gateno J, Teichgraeber JF. New clinical protocol to evaluate craniomaxillofacial deformity and plan surgical correction. J Oral Maxillofac Surg. 2009 Oct;67(10):2093-106. 6. Swennen GRJ, Mollemans W, Schutyser F. Threedimensional treatment planning of orthognathic surgery in the era of virtual imaging. J Oral Maxillofac Surg. 2009 Oct;67(10):2080-92. 7. Patzelt SBM, Emmanouilidi A, Stampf S, Strub JR, Att W. Accuracy of full-arch scans using intraoral scanners. Clin Oral Investig. 2014 July;18(6):1687-94. 8. Shastry S, Park JH. Evaluation of the use of digital study models in postgraduate orthodontic programs in the United States and Canada. Angle Orthod. 2014 Jan;84(1):62-7.

9. Mullen SR, Martin CA, Ngan P, Gladwin M. Accuracy of space analysis with emodels and plaster models. Am J Orthod Dentofacial Orthop. 2007 Sept;132(3):346-52. 10. Fleming PS, Marinho V, Johal A. Orthodontic measurements on digital study models compared with plaster models: a systematic review. Orthod Craniofac Res. 2011 Feb;14(1):1-16.

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):44-50

Case Report

Mandibular multicystic ameloblastoma:

case report and 10-year follow up

ABSTRACT Ameloblastomas are local invasive benign tumors that demand complex and multidisciplinary treatment, mainly due to the possibility of its expansion and resorption of adjacent structures. Following diagnosis, some questions about treatment longevity and success should be highlighted. As recurrence is an important concern, the type and timing of the graft are major decisions, and it must be decided in agreement with the patient, taking some factors in consideration: tumor dimensions and localization, anatomical characteristics and health conditions of the patient, and professional experience. The present article reports a case of a female patient with volume increase in posterior left mandible, diagnosed as multicystic ameloblastoma, submitted to a surgical sequence, from biopsy to esthetic and functional rehabilitation with dental implants and prosthesis. Actually the patient is in clinical and radiographic follow-up of 10 years, with maintenance of graft and implant stability, and no signs of recurrence. The events chronology and the complications faced in this particularly case allow a relevant discussion regarding treatment sequence, reconstruction options and rehabilitation. Keywords: Ameloblastoma. Jaw neoplasms. Dental implants. Bone transplantation.

Universidade Federal de Santa Catarina, Departamento de Cirurgia e Traumatologia Bucomaxilofacial (Florianópolis/SC, Brazil).

How to cite: Almeida MS, Castellano AB, Bim ALC, Marola LHG, Gil JN, Claus JDP. Mandibular multicystic ameloblastoma: case report and 10-year follow up. J Braz Coll Oral Maxillofac Surg. 22019 May-Aug;5(2):51-7. DOI: https://doi.org/10.14436/2358-2782.5.2.051-057.oar

Submitted: March 19, 2018 - Revised and accepted: August 06, 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: Matheus Spinella de Almeida Rua Pastor William Richard Schisler Filho, 884, ap. 1003, Itacorubi, Florianópolis/SC CEP: 88.034-100 – E-mail: matheuspinella@gmail.com

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):51-7

Mandibular multicystic ameloblastoma: case report and 10-year follow up

INTRODUCTION Ameloblastoma is the most common benign tumor among the jaw neoplasms. Despite its benign nature, it is a locally aggressive lesion that can cause complex sequelae to the patients.1,2,3 In addition to tumor diagnosis and elimination, the major challenge during ameloblastoma treatment is the patient rehabilitation in all aspects: esthetic, functional, and even psychological. Depending on the lesion location and extent, the treatment requires the collaboration of several specialties for the restoration of teeth, bone, gingiva and other tissues, allowing patient rehabilitation as close as possible to their natural condition. 4,5 Mandibular reconstruction is often necessary after tumor resection, aiming to maintain the esthetics, symmetry and sufficient bone for later rehabilitation. Autogenous grafts are the most common option, with the advantage of bone incorporation, which provides the necessary continuity, strength and function for the mandible for later rehabilitation, including masticatory function. Currently, two types of autogenous grafts are the most used: non-vascularized free grafts and microvascular free grafts. 6,7,8 Removable dentures may be used to rehabilitate the masticatory function; however, the anatomical alteration caused by previous surgeries makes their use uncomfortable. Endosseous implants are being used to avoid these problems, since they allow the placement of fixed prostheses, with stable results in the long term. 9,10 Thus, this paper reports a case of mandibular ameloblastoma with long-term follow-up. The chronology of facts and complications allows a relevant discussion regarding the treatment sequence, options for reconstruction and rehabilitation.

multilocular radiolucent image with well-defined limits, occupying the entire mandibular height from the alveolar crest to the lower base, with an impacted tooth in the center of the lesion (Fig 1A). The patient was submitted to incisional biopsy, diagnosed as multicystic ameloblastoma (Fig 2). Considering the result, a computed tomography (CT) was requested to establish the lesion limits, including a safety margin of 1.5 cm. Based on the CT, a biomodel was fabricated by stereolithography to facilitate the surgical planning, especially preparation of the reconstruction plate and selection of the screw size. Segmental mandibulectomy of approximately 10 cm was performed under general anesthesia, including removal of two premolars within the safety margin. The mandibular segments were fixed with a 2.4-mm reconstruction plate. The bone defect was reconstructed with two blocks of ipsilateral iliac crest bone graft and particulate bone (Fig 1B). At three weeks postoperatively the patient presented an infection, which was treated by extraoral abscess drainage and antibiotic therapy. The infection regressed and the symptoms were resolved at three months postoperatively. Then, the rehabilitation planning was initiated. Radiographic evaluation at nine months postoperatively revealed significant resorption of the bone graft, estimated at 50% of the initially placed volume, with sign of bone discontinuity yet without evidence of lesion relapse. The patient was submitted to another reconstruction one year after the first surgery by extraoral incision and contralateral iliac crest reconstruction. Transoperatively, fracture of the reconstruction plate was observed and, since there was no material available for replacement (Fig 3A), together with the new bone reconstruction, it was decided to maintain maxillomandibular block (MMB) for a period of three weeks (Fig 3B). The aim of the MMB was to neutralize the mobility of the fractured mandible and thus contribute to the graft outcome. After a healing period of four months after grafting, a new tomography was requested, which revealed good maintenance of bone volume and mandibular continuity, thus allowing planning of the next stage, namely the dental rehabilitation. Three

CASE REPORT A 36-year-old Caucasoid female patient presented with significant volume increase on the left mandibular angle, with evolution of approximately nine months, without painful symptomatology or change in sensitivity. Intraoral examination revealed increased volume on the mandibular left molar edentulous region, with firm palpation and expansion of cortical bone. The panoramic radiograph revealed

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):51-7

Almeida MS, Castellano AB, Bim ALC, Marola LHG, Gil JN, Claus JDP

In the last clinical and radiographic follow-up, ten years after tumor resection, there were no signs of lesion relapse, with maintenance of bone graft (volume and continuity) and stability of the implants and peri-implant tissues (Fig. 4).

external hex implants were placed under local anesthesia. After four months of osseointegration, the implants were reopened for placement of healing abutments and the patient was referred for fabrication of fixed crowns.

Figure 1: A) Initial radiograph. B) Immediate postoperative radiograph.

Figure 2: A) Histopathological image obtained on light microscope with 200x magnification, evidencing a lesion composed of long anastomosed cords, islands and nests of neoplastic epithelial cells in a stroma of loose connective tissue. B) Histopathological image with 400x magnification demonstrating a single layer of columnar cells with inverted polarization.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):51-7

Mandibular multicystic ameloblastoma: case report and 10-year follow up

Figure 3: A) Transoperative image exhibiting the plate fracture. B) Postoperative radiograph of the second bone graft surgery: observe the screws and maxillomandibular block, to aid the graft healing.

Figure 4: A) 10-year follow-up occlusal photograph. B) 10-year follow-up radiograph, evidencing the stability of endosseous implants and autogenous graft without signs of relapse.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):51-7

Almeida MS, Castellano AB, Bim ALC, Marola LHG, Gil JN, Claus JDP

DISCUSSION Ameloblastoma is a benign odontogenic neoplasm with locally aggressive evolution, usually manifesting between the third and fifth decades of life. The prevalence is similar in men and women. The mandible is the most affected bone, especially the posterior region, associated or not to an impacted third molar. Clinically, it presents as a slow- growing mass, with tooth mobility, occlusal disorders, paresthesia and pain.1 Luo and Li2 published a study in 2009 evaluating 1,309 cases of odontogenic tumors, which revealed that the lesion most frequently diagnosed was keratocystic odontogenic tumor (38.73%). Ameloblastoma was the second most common pathology (36.52%), with 91.21% of cases in the mandible, mostly affecting the posterior region (83.94%). A retrospective study conducted between 1993 and 2008 evaluated 340 cases of ameloblastomas, being 197 (57.9%) related to males and 143 (42.1%) to females.3 The mandible was the most affected bone, with 311 cases (91.5%), while the maxilla was affected in 8.5% of lesions. Regarding the subtype, the authors found solid ameloblastoma in 65% of cases, followed by unicystic in 28%, desmoplastic in 6.4% and peripheral in 0.6%. The posterior mandibular region was affected in 90% of tumors. Ameloblastoma presents a relatively high relapse rate, which according to the literature can range from 15.9% to 20.6%. It is known that tumor relapse is directly associated with the lesion subtype, tumor evolution and treatment method. Tumors with follicular, granular or acanthomatous histological pattern appear to have higher recurrence rate; while desmoplastic, plexiform and unicystic subtypes present lower potential of relapse. 4 According to the recent literature, about 58% of relapses are diagnosed within the first 5 years of follow-up, but relapses have been described after 30 years of follow-up.5 Eckdart et al,6 in 2009, published a study reporting a relapse rate of 25.49%, with 44% of relapses occurring after the first 5 years. Also, the authors reported that, in patients undergoing bone reconstruction, the relapse was 28%. A serious problem with the diagnosis and therapy of ameloblastoma is that the incisional biopsy may not always represent the complete histological status. Mixed forms may occur histologically, and

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

differentiation between lesion subtypes is nearly impossible and may lead the professional to undertreatment. 4,6 Surgical resection of ameloblastomas often leads to large mandibular defects, with significant negative impact on the patientsâ&#x20AC;&#x2122; quality of life. The mandible, which is affected more frequently, is considered one of the most important facial bones, since besides the masticatory function it is very important for speech, breathing, facial esthetics and social interaction. Alloplastic materials as plates and screws have been frequently used for mandibular reconstruction; however, when used in isolation, late complications as fractures and infections led to the abandonment of such reconstruction, with increased indication of free bone grafts. 7 The success of bone graft is important for the rehabilitation of these patients, since besides restoring the bone continuity and facial contour, it allows functional reestablishment. Historically, non-vascularized free grafts have been regularly used since the 1960s, when the concepts of bone physiology were developed. In some cases, they may be performed by intraoral access; however, the literature reports higher success rate when extraoral access is used on a second surgery. The most probable reason for this fact is the possibility of contamination by the intraoral access, which can be avoided with clean surgery by extraoral access.8 Recently, mandibular reconstruction using vascularized bone graft has been reported, presenting as main advantages: 1) vascularization allows grafting on the same surgical procedure; 2) soft tissue can be provided simultaneously; 3) the graft may be indicated even in irradiated areas; 4) dental implants can be simultaneously fixed. 9 In a study conducted by Pogrel et al.8, 68 mandibles were reconstructed, being 29 with non-vascularized grafts and 39 with microvascular grafts. The success rate of reconstruction using microvascular graft was 94.9%, while in cases receiving non-vascularized graft the success rate was 76%. It was also observed that graft failure is directly related to its size: grafts smaller than 6 cm presented success rate of 83%; for grafts larger than 12 cm, the success rate was 25%. Considering these results, the authors do not recommend non-vascularized grafting in regions/defects larger than 6 cm, in which the microvascular graft should be the first option.

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):51-7

Mandibular multicystic ameloblastoma: case report and 10-year follow up

dental rehabilitation allows the patient to masticate again and considerably improves the speech, swallowing and esthetics. Anatomical changes resulting from tumor resection â&#x20AC;&#x201C; such as alteration of masticatory muscles, loss of proprioception, transformation of the buccal space and irregularities in bone contour â&#x20AC;&#x201C; impair the adaptation of removable dentures. Endosseous implants emerged as a solution to this problem, since they allow more complete rehabilitation by implant-supported dentures. 9,10

Currently, the vascularized graft is the most indicated in cases with indication for immediate reconstruction, in patients with history of irradiation, extensive defects or inadequate soft tissue. The non-vascularized bone graft presents a high success rate in non-irradiated patients, who present satisfactory soft tissue and bone defects smaller than 6 cm. 8,9 There is lack of studies in the literature about the success rate of bone grafts after mandibulectomy for the treatment of mandibular tumors. In a study conducted by Chiapasco et al, 9 29 patients submitted to tumor resection were evaluated, followed by reconstruction with free bone graft and subsequent implant placement. Among these, 16 were rehabilitated with a total of 60 implants, with a mean follow-up of 94 months after denture placement, with a success rate of 93.3%. Dental rehabilitation is very important to achieve the desired results concerning the restoration of esthetics and function. The satisfactory

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

FINAL CONSIDERATIONS Despite the limitations of this isolated report of one case, the 10-year follow-up and complications registered during its evolution allow to emphasize that the correct diagnosis and planning are fundamental for the treatment success. When well indicated, the non-vascularized free bone graft from the iliac crest, followed by implant placement and subsequent fixed denture, may be a safe option for patients diagnosed with ameloblastomas.

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):51-7

Almeida MS, Castellano AB, Bim ALC, Marola LHG, Gil JN, Claus JDP

References:

1. Gardner DG, Heikinheimo K, Shear M, et al: Ameloblastomas. In: Barnes L, Eveson JW, Reichart PA, editors. World Health Organization Classification of Tumours. Pathology and genetics of head and neck tumours. Lyon: International Agency for Research on Cancer; 2005. p. 296 2. Luo HY, Li TJ. Odontogenic tumors: a study of 1309 cases in a Chinese population. Oral Oncol. 2009 Aug;45(8):706-11. 3. Siar CH, Lau SH, Ng KH. Ameloblastoma of the jaws: a retrospective analysis of 340 cases in a Malaysian population. J Oral Maxillofac Surg. 2012 Mar;70(3):608-15. 4. Amaral SM, Lehman LFC, Campos FEB, Cunha JF, Gomez RS, Castro WH. Ameloblastoma unicístico na mandíbula: relato de caso clínico. J Braz Coll Maxillofac Surg. 2016 Jan-Abr;2(1):61-7.

5. Ferretti C, Polakow R, Coleman H. Recurrent ameloblastoma: report of two cases. J Oral Maxillofac Surg. 2000;58:800-4. 6. Eckardt AM, Kokemuller H, Flemming P, Schultze A. Recurrent ameloblastoma following osseous reconstruction - a review of twenty years. J Craniomaxillofac Surg. 2009 Jan;37(1):36-41. 7. Schlieve T, Hull W, Miloro M, Kolokythas A. Is immediate reconstruction of the mandible with nonvascularized bone graft following resection of benign pathology a viable treatment option? J Oral Maxillofac Surg. 2015 Mar;73(3):541-9. 8. Pogrel MA, Podlesh S, Anthony JP, Alexander J. A comparison of vascularized and nonvascularized bone grafts for reconstruction of mandibular continuity defects. J Oral Maxillofac Surg. 1997 Nov;55(11):1200-6

9. Chiapasco M, Colleti G, Romeo E, Zaniboni M, Brusati R. Long-term results of mandibular reconstruction with autogenous bone grafts and oral implants after tumor resection. Clin Oral Implants Res. 2008 Oct;19(10):1074-80. 10. Cuesta-Gil M, Ochandiano Caicoya S, Riba-García F, Duarte Ruiz B, Navarro Cuéllar C, Navarro Vila C. Oral rehabilitation with osseointegrated implants in oncologic patients. J Oral Maxillofac Surg. 2009 Nov;67(11):2485-96.

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):51-7

Case Report

Osteonecrosis of maxilla associated with bisphosphonates:

case report

MARCELA CHIQUETO ARAUJO1 | GERALDO LUIZ GRIZA1,2 | ELEONOR ÁLVARO GARBIN JUNIOR1,3 | NATASHA MAGRO ÉRNICA1,3 | RICARDO AUGUSTO CONCI1,4

ABSTRACT Bisphosphonates have fundamental biological effects on calcium metabolism, inhibiting calcification and bone resorption, and may present with different types of adverse reactions, such as osteonecrosis of the jaw. This paper presents the case report of a patient who developed osteonecrosis of the maxilla after administration of bisphosphonates and received surgical treatment associated with antibiotic therapy to resolve the condition. In one postoperative year the patient had healed intra-oral tissues, with no signs of infection or disease. The prevention of osteonecrosis of the maxilla is still the best option for those patients who use bisphosphonates and present some predisposition to the development of the disease. Keywords: Osteonecrosis. Maxillary diseases. Oral surgery.

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

How to cite: Araujo MC, Griza GL, Garbin Junior EA, Érnica NM, Conci RA. Osteonecrosis of maxilla associated with bisphosphonates: case report. J Braz Coll Oral Maxillofac Surg. 2019 MayAug;5(2):58-63. DOI: https://doi.org/10.14436/2358-2782.5.2.058-063.oar

Doutor em Implantodontia, Universidade Estadual Paulista Júlio de Mesquita Filho (Araraquara/SP, Brazil).

Submitted: May 04, 2018 - Revised and accepted: September 26, 2018

Doutor(a) em Cirurgia e Traumatologia Bucomaxilofacial, Universidade Estadual Paulista Júlio de Mesquita Filho (Araraquara/SP, Brazil).

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

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

» Patients displayed in this article previously approved the use of their facial and intraoral photographs. Contact address: Marcela Chiqueto-Araujo Rua Paraná, 2465 – Centro, Cascavel/PR – CEP: 85.812-011 E-mail: marcela_chiqueto@hotmail.com

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):58-63

Araujo MC, Griza GL, Garbin Junior EA, Érnica NM, Conci RA

CASE REPORT A 55-year-old female patient with diabetes attended the dental clinic at the State University of Western Paraná with complaint of “exposed bone” in the maxilla, reporting that the process had initiated one year after extractions of teeth 11, 12, 21 and 22. Clinical examination revealed that, besides strong halitosis, there was necrotic bone tissue exposed at the anterior maxilla (Fig 1). The patient reported metastatic breast cancer 4 years before and chemotherapy including intravenous administration of bisphosphonates for 19 months, with monthly administrations of 4 mg. Radiographic examination revealed an irregular radiolucent area with diffuse limits in the anterior region of the maxillary alveolar process (Fig 2A). Tomography of the face showed bone sequestration in the lesion region (Fig 2B). Based on the diagnosis of BIJO, oral antibiotic therapy was initiated with clindamycin 300 mg (6/6h) started immediately and maintained for 7 days after the procedure; 0.12% chlorhexidine mouthwash; surgical debridement and wound closure by first intention. The surgical treatment was performed at the University Hospital of Western Paraná (HUOP) under general anesthesia, with total removal of the lesion. The surgical procedure was performed as follows: local anesthetic infiltration, incision on the maxillary alveolar ridge followed by two releasing incisions, mucoperiosteal raising, removal of necrotic bone block, topical irrigation with povidone iodine and closure of the region by first intention with 4-0 nylon suture (Fig 3). Postoperative follow-up was performed at the outpatient clinic of HUOP. One year after the procedure, the patient had healed intraoral tissues with normal aspect, without signs of infection or disease, indicating the treatment success.

INTRODUCTION Bisphosphonates (BFs) present fundamental biological effects on the calcium metabolism, inhibiting bone calcification and bone resorption. Therefore, they have been used since 1960 in the treatment of bone metastases, multiple myeloma, lung cancer, Paget’s disease and control of calcium metabolism diseases.1 This type of drug may cause different types of adverse reactions, such as osteonecrosis of the jaws – which is characterized by bone exposure in the maxilla or mandible that does not heal within eight weeks, in patients receiving or who received treatment with BFs and were not submitted to irradiation in the head and neck region.2 Bisphosphonate-induced jaw osteonecrosis (BIJO) still presents uncertain etiology; however, the best hypothesis is alteration of bone turnover, associated with specific characteristics of the jaws, such as mucous lining, risk of infection and trauma.3 Also, some factors predispose to the development of BIJO, including the type, administration via and length of use of BFs; simultaneous administration with other drugs; and accomplishment of invasive intraoral procedures.4 Clinically, the BIJO presents as necrotic bone exposure of varying sizes, and may become symptomatic after infection or inflammation of adjacent tissues, with higher prevalence in the mandible than the maxilla. Radiographically, the lamina dura is thickened and there is increase of periodontal ligament in the alveolar bone at the initial point.5 The treatment of BIJO varies according to lesion staging, including pain control, antibiotic therapy, mouthwashes, interruption of BFs, hyperbaric chamber therapy, laser therapy and surgical debridement.6 This paper reports the case of a patient with osteonecrosis in the anterior maxilla after administration of BFs.

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):58-63

Osteonecrosis of maxilla associated with bisphosphonates: case report

Figure 1: Exposure of necrotic bone at the anterior maxilla.

Figure 2: A) Radiographic examination evidencing radiolucent area at the anterior maxilla. B) Axial section of computed tomography evidencing bone sequestrum in the maxilla.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):58-63

Araujo MC, Griza GL, Garbin Junior EA, Érnica NM, Conci RA

Figure 3: A) Incision for exposure of necrotic area. B) Removed necrotic bone block. C) Immediate postoperative final aspect. D) Intraoral tissues one year after the procedure.

DISCUSSION The literature demonstrates that most patients who present osteonecrosis of the jaws are females, between the fourth and eighth decades of life3,9 – as in the present case, of a 55-year-old female. Only two studies reported higher prevalence of BIJO in males; however, they agreed that the most affected age group would be between 40 and 83 years.4,5 A plausible explanation for the increased number of diagnoses in women would be the increased yearly incidence of osteoporosis, with subsequent prescription of BFs for treatment. The higher frequency of multiple myeloma and breast cancer may also explain the higher incidence of osteonecrosis in women.7 The authors unanimously stated that most patients who used bisphosphonates and developed osteonecrosis of the jaws were being treated for malignant hypercalcemia associated with multiple myelomas and breast cancer – followed by osteoporosis and prostate cancer

– with pamidronate or zoledronate.7,8,9 This study corroborates the reviewed literature by presenting the case of a patient who used intravenous zoledronate for the treatment of breast cancer. The literature agrees that, before starting therapy with BFs, regardless of the disease, all patients should be advised on the risk of developing osteonecrosis of the jaws and its signs and symptoms, and should be previously evaluated by a dental professional, who should instruct patients on oral hygiene and prophylaxis of dental and periodontal disorders, besides establishing the diagnosis and previous treatment of any intraoral infectious foci.7,8 In the present case, the patient had not been referred to the dentist before starting bisphosphonate therapy, and did not received any instruction about the risk of developing osteonecrosis of the jaws, as well as its signs and symptoms. These factors probably contributed to development of the disease.

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):58-63

Osteonecrosis of maxilla associated with bisphosphonates: case report

Some treatments for BIJO are described in the literature, especially those involving invasive procedures as sequestrectomy, bone resection, curettage, minor oral surgeries and microvascular surgery.8 Ruggiero et al4 recommended the following treatment for BIJO: 1) Initial stage: daily oral antimicrobial rinse or irrigation with 0.12% chlorhexidine digluconate and clinical follow-up; 2) Developing stage: antimicrobial therapy based on culture and sensitivity analysis, with concomitant analgesia and daily oral rinse or irrigation with 0.12% chlorhexidine digluconate; 3) Advanced stage: surgical fragmentation of necrotic bone, antimicrobial therapy (oral or intravenous), analgesia and daily rinses with 0.12% chlorhexidine digluconate. In the present case, treatment success was achieved by a radical surgical procedure, different than the common approach in the literature, namely conservative treatment.

Another important factor for prevention of BIJO is the interruption of bisphosphonate therapy, in agreement with the oncologist, in case the patient needs any oral surgical procedure. This interruption should occur at least 3 months before surgery and extend for at least 3 months thereafter.9 BFs have been increasingly used due to the increasing number of indications for treatment of several conditions, being effective and efficient. Ruggiero reported the common use of pamidronate and zoledronate in patients with osteonecrosis of the jaws.2,4 The triggering factor of such disease is still discussed in the literature, since the mechanism of action of these drugs on the bone structures is not yet well explained. According to Dimitrakopoulos et al,6 tooth extractions are the most significant factor for the occurrence of disease, corroborating the present findings. The incidence of BIJO at any location is four times higher in cancer patients than in the general population.9 It should be investigated whether this higher incidence is related to the patient’s general condition, altered bone metabolism, radiotherapy or use of any other drug. In the present case, the patient had metastatic breast cancer, a condition related to BIJO. However, such study should consider the fact that patients without cancer submitted to BF treatment for osteoporosis may also present BIJO.7 The most common clinical findings of BIJO are pain, poor or late tissue repair, spontaneous or postoperative soft tissue collapse, often after extraction, leading to intraoral and/or extraoral bone exposure, areas of bone necrosis and osteomyelitis and, in most cases, affecting the mandible more often than the maxilla5,7 – which was different in the present case. There is an important discussion about the causal association between BFs and the onset of osteonecrosis in patients previously submitted to extractions. This dental procedure is cited as the main local risk factor for BIJO, followed by trauma and behaviors that cause bone damage.6 In this case, the patient underwent tooth extractions, suggesting that local trauma may have been the cause for the occurrence of osteonecrosis.

FINAL CONSIDERATIONS The management of patients with bisphosphonate-induced osteonecrosis has been widely discussed. In the literature, there are reports of marginal or segmental bone resections, sequestrectomy, use of hyperbaric oxygen and antibiotic therapy. It is important to consider the possibility to change the drug; however, the patient’s general status, well-being and risk-benefit relationship should be assessed by a multidisciplinary team. Since the treatment with BFs in cases of malignant neoplasms is fundamental, the medical doctors should perform a careful evaluation when prescribing these drugs for the treatment of osteoporosis and especially osteopenia, since other prophylactic and even therapeutic measures may be used to reverse these metabolic changes. BIJO is still a relatively new consequence in patients who use BFs, directly affecting their quality of life. Therefore, careful clinical evaluation by both the medical and dental doctors is fundamental for the establishment of prevention, since so far there are no effective therapeutic measures for the treatment of BIJO, thus prevention is the best option.

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):58-63

Araujo MC, Griza GL, Garbin Junior EA, Érnica NM, Conci RA

References:

1. American Association of Oral and Maxillofacial Surgeons. American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaws. J Oral Maxillofac Surg 2007;65(3):369-76. 2. Ruggiero SL, Woo SB. Biophosponate-related osteonecrosis of the jaws. Dent Clin North Am. 2008;52(1):111-28. 3. Sawatari Y, Marx RE. Bisphosphonates and bisphosphonate induced osteonecrosis. Oral Maxillofac Surg Clin North Am. 2007 Nov;19(4):487-98, v-vi. 4. Ruggiero SL, Mehrotra B, Rosemberg TJ, Engroff SL. Osteonecrosis of the jaws associated with the use of bisphosphonates: a review of 63 cases. J Oral Maxillofac Surg. 2004 May;62(5):527-34.

5. Bagan JV, Jimenez Y, Murillo J, Hernandez S, Poveda R, Sanchis JM, et al. Jaw osteonecrosis associated with bisphosphonates: multiple exposed areas and its relationship to teeth extractions. Study of 20 cases. Oral Oncol. 2006 Mar;42(3):327-9. Epub 2005 Nov 4. 6. Dimitrakopoulos I, Magopoulos C, Karakasis D. Bisphosphonate - induced avascular osteonecrosis of the jaws: a clinical report of 11 cases. Int J Oral Maxillofac Surg. 2006 July;35(7):588-93. 7. Migliorati CA, Casiglia J, Epstein J, Jacobsen PL, Siegel MA, Woo SB. Managing the care of patients with bisphosphonate-associated osteonecrosis: an American Academy of Oral Medicine position paper. J Am Dent Assoc. 2005 Dec;136(12):1658-68.

8. Fliefel R, Tröltzsch M, Kühnisch J, Ehrenfeld M, Otto S. Treatment strategies and outcomes of bisphosphonate-related osteonecrosis of the jaw (BRONJ) with characterization of patients: a systematic review. Int J Oral Maxillofac Surg. 2015 Feb;44(5):568-85. 9. López-D’alessandro E, Mardenlli F, Paz M. Oral bisphosphonate associated osteonecrosis of maxillary bone: a review of 18 cases. J Clin Exp Dent. 2014 Dec;6(5):530-4.

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):58-63

Case Report

Mandibular fracture after extraction of

impacted third molar ALEXANDRE MARANHÃO MENEZES NETO1 | EDUARDO COSTA STUDART SOARES1 | FRANCISCO SAMUEL RODRIGUES CARVALHO2 | MARIANA GOMES COUTINHO1 | FÁBIO WILDSON COSTA GURGEL1

ABSTRACT Mandibular fractures resulting from extraction of impacted third molars are rare and cause postoperative morbidity to the patient. This study aims to present a clinical case of a mandibular fracture that occurred after an impacted tooth had been removed. The 19-year-old female patient sought care with a history of pain during mastication. After anamnesis and clinical examination, the presence of a fracture in the region of left mandibular angle was observed. The patient underwent an open reduction and fracture osteosynthesis with fixation plates through an intraoral approach. After a follow-up of 2 years, there were no pain complaints and satisfactory aesthetic and functional results. In this context, the present case highlights the importance of surgical planning and a long-term follow-up in cases of fracture after extraction of third molars, even this complications being uncommon. Keywords: Mandibular fractures. Postoperative complications. Unerupted tooth.

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

How to cite: Menezes Neto AM, Soares ECS, Carvalho FSR, Coutinho MG, Gurgel FWC. Mandibular fracture after extraction of impacted third molar. J Braz Coll Oral Maxillofac Surg. 2019 MayAug;5(2):64-9. DOI: https://doi.org/10.14436/2358-2782.5.2.064-069.oar

Universidade de Fortaleza, Programa de Pós-Graduação de Odontologia (Fortaleza/CE, Brazil).

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

Submitted: May 17, 2018 - Revised and accepted: August 06, 2018

» Patients displayed in this article previously approved the use of their facial and intraoral photographs. Contact address: Alexandre Maranhão Menezes Neto Rua Capitão Francisco Pedro, 1016, apto 303, Rodolfo Teófilo - Fortaleza - Ceará CEP: 60.430-372 E-mail: alexandremaranhaobucomaxilo@gmail.com

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):64-9

Menezes Neto AM, Soares ECS, Carvalho FSR, Coutinho MG, Gurgel FWC

INTRODUCTION The extraction of impacted third molars is among the procedures most commonly performed by oral and maxillofacial surgeons.1 There are several reasons for indication of extraction, including pericoronitis, caries or periodontal disease, besides preparation for orthognathic surgery and orthodontic treatment.2 The most frequent complications in this type of procedure are alveolitis, infection, neurological dysfunction, hemorrhage, trismus and edema, with prevalence ranging from 0.2% to 6% of cases. 1-5 Mandibular fracture is the most severe postoperative complication and causes the highest morbidity. 2,5 This type of complication is rare, with reported prevalence ranging from 0.0034 to 0.0075%.2,3,5 When compared to the prevalence of mandibular fractures resulting from tooth extraction, third molar-related fractures appear first, followed by impacted second molars and canines. 1 The prevalence of late mandibular angle fracture occurring postoperatively after surgical removal of a mandibular third molar is lower than 0.005%. 5 Some factors may contribute to the risk of fracture of the mandibular angle after extraction of impacted third molars, such as presence of bone surrounding the impacted tooth, 6 impaction level, 1,6,7 dental and root anatomy,6 previous local infection,8 sex, 6 age,6,8 bruxism,8 athletic activities, postoperative time6,8 and inadequate surgical technique. 1 These fractures may occur intraoperatively or postoperatively. 1 The treatment option depends on the clinical characteristics of the fracture and the professional’s technical experience. This paper presents a case of mandibular angle fracture resulting from extraction

of an impacted third molar, and to discusses its clinical and therapeutic aspects. CASE REPORT A 19-year-old female patient, ASA I, was referred to the oral and maxillofacial surgery and traumatology service at Walter Cantídio University Hospital, Federal University of Ceará, complaining of severe pain at the site of extraction of tooth 38. She reported that, during the procedure, she heard a slight click at the mandibular region. Physical examination revealed edema in the left mandibular angle region (Fig. 1), pain on palpation, presence of maxillomandibular block by heavy elastics in the premolar region bilaterally, and silk suture in the alveolus of teeth 38 and 48. The surgical wounds of the alveoli presented no signs of infection or dehiscence (Fig 2). Imaging examination revealed an area of peripheral ostectomy performed during extraction of tooth 38, approaching the base region of the left mandibular angle (Fig 3), and fracture line on the left mandibular angle region, with slight displacement of the fractured sides (Fig 4). Considering the clinical condition, the surgical team decided to perform open reduction and osteosynthesis of the mandibular angle fracture. Initially, the procedure consisted of placing the patient in horizontal supine position under general anesthesia. After nasotracheal intubation and antisepsis of the surgical site, mandibular buccal intraoral access was performed, with reduction and fixation of two 2.0 mm system plates at the mandibular angle region (Fig 5). After 2-year follow-up, the patient presented significant improvement in local pain, as well as correct reduction of fracture or any occlusal complaint (Fig 6). Imaging examination evidenced adequate reduction of the fracture line (Fig 7).

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):64-9

Mandibular fracture after extraction of impacted third molar

Figure 1: Preoperative extraoral physical examination, evidencing slight edema at the left mandibular angle region.

Figure 2: Preoperative intraoral physical examination: patient with heavy elastics placed by the surgeon who performed extraction of impacted third molars, right after suspicion of fracture due to extraction. The occlusion was similar to the preoperative, and the patient did not notice any alteration.

Figure 3: Preoperative panoramic radiograph. Note the area of peripheral ostectomy performed during extraction of tooth 38, approaching the base region of the left mandibular angle.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Figure 4: Preoperative posteroanterior mandibular radiograph, exhibiting facture line on the left mandibular angle region, with slight displacement of fractured sides.

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):64-9

Menezes Neto AM, Soares ECS, Carvalho FSR, Coutinho MG, Gurgel FWC

Figure 5: Intraoperatively: exposure of mandibular angle fracture; positioning of 2.0 mm system plates at the mandibular angle region, after fracture reduction and contention.

Figure 6: Occlusion two years after surgery: note the stable occlusion, without complaints related to the fracture.

Figure 7: Panoramic and Towne radiographs, two years after surgery: note the anatomical reduction in buccolingual direction at the mandibular angle region.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):64-9

Mandibular fracture after extraction of impacted third molar

DISCUSSION Mandibular fractures are complications that may occur due to extractions of impacted third molars, with prevalence lower than 1%.2,3,4 This paper discusses the case of a fracture in a patient younger than 20 years, which is an uncommon occurrence according to previous studies. The several factors that may imply an increased prevalence of mandibular fracture include increasing age as a predictor factor, with higher prevalence in the group aged 36 to 60 years.3,4 It is considered that there is an increase in the frequency of mandibular fractures in men, possibly due to the stronger masticatory forces and increased risk of trauma3. Males with average age 40 years and complete dentition are considered the group with the highest risk of mandibular fracture.2,9 Reduced elasticity, risk of osteoporosis, bone atrophy, higher potential for bone ankylosis, higher prevalence of pathologies and prolonged healing are factors that contribute to an increased risk of mandibular fractures in older patients.3,9 The degree and extent of impaction, according to the classification by Pell and Gregory,8 are also directly related to mandibular fracture.3,9,10 Fully impacted teeth, classes B/C and types II/III teeth in relation to the anterior border of the mandibular ramus are more frequently associated with mandibular fractures.3,7,8 In the present case, according to the classification by Pell and Gregory,8 the patient presented class 2B.3,9,10 A correlation has been suggested between preoperative infection associated to the impacted tooth and predisposition to postoperative mandibular fracture.3,6,9 In a series of cases of mandibular fracture due to extraction of impacted third molar, preoperative infection was observed in all 130 patients.3 In the present case, the patient reported a previous episode of infection associated to the impacted tooth, corroborating the findings in the literature. The current literature demonstrates that postoperative fractures are more frequent than intraoperative, usually occurring two to three weeks after surgery.1,3,8,9 Some authors suggest that mandibular intraoperative fractures occur due to inadequate use of surgical instruments, excessive force and inadequate surgical technique.3,8 Intraoperative fractures are more associated with extractions of teeth with

impaction class II/III and type C, according to the classification of Pell and Gregory. 3,8 The fracture occurring in the present case may have been caused by inadequate force on a previously weakened mandibular bone after ostectomy during surgery. The position of the third molar, which occupied a large space within the bone, also contributed to weaken the mandibular angle, as well as the reduction of bone support, especially at the external oblique line region, potentiating the force applied by the instrument on a previously fragile bone. The postoperative diagnosis of mandibular fractures resulting from extractions of third molars can be challenging, since in most cases the patient does not present disocclusion and a fracture line easily evident on radiographs.6,8 In the present case, the patient reported pain on palpation in the operated region, and the fracture line was not easily identified on the panoramic radiograph. The mandibular fracture was only diagnosed after posteroanterior radiograph of the mandible and the patient’s report stating that she felt a slight click during surgery. The treatment of mandibular fractures after extraction of impacted third molars is mostly conservative, with liquid/pasty diet and closed reduction.1,3,9 The literature mentions that only 30% of fractures are treated by open reduction and internal fixation.3 In the present case, the patient was initially treated with liquid/pasty diet and maxillomandibular block. Surgical treatment was performed after definitive diagnosis of mandibular fracture. Mandibular fractures after third molar extraction should be largely predictable, even if unavoidable. Informed consent from the patient informing the risk of fracture is mandatory. Also, postoperative instructions on characteristics as pain, edema, “cracking noise” and altered bite two to three weeks after extraction aids the diagnosis and early treatment of this type of complication.1,3,9 FINAL CONSIDERATIONS In summary, open reduction and osteosynthesis with plates was an effective treatment for mandibular angle fracture due to postoperative complication of impacted third molar extraction. In the present case, after 2-year follow-up, the patient did not present any complaint involving the fracture site.

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Menezes Neto AM, Soares ECS, Carvalho FSR, Coutinho MG, Gurgel FWC

References:

1. Silva WS, Silveira RJ, Andrade MGBA, Franco A, Silva RF. Is the late mandibular fracture from third molar extraction a risk towards malpractice? Case report with the analysis of ethical and legal aspects. J Oral Maxillofac Res. 2017 Apr-June;8(2):e5. 2. Cankaya AB, Erdem MA, Cakarer S, Cifter M, Oral CK. Iatrogenic mandibular fracture associated with third molar removal. Int J Med Sci. 2011;9(7):547-53. 3. Ethunandan M, Shanahan D, Patel M. Iatrogenic mandibular fracture following removal of impacted third molars: an analysis of 130 cases. Br Dent J. 2012 Feb 24;212(4):179-84. 4. Xu JJ, Teng L, Jin XL, Lu JJ, Zhang C. Iatrogenic mandibular fracture associated with third molar removal after mandibular angle osteotectomy. J Craniofac Surg. 2014 May;25(3):e263-5.

5. Pires RW, Bonardi JP, Faverani LP, Momesso GAC, Munõz XMJP, Silva AFM, et al. Late mandibular fracture occurring in the postoperative period after third molar removal: systematic review and analysis of 124 cases. Int J Oral Maxillofac Surg. 2017 Jan;46(1):46-53. 6. Cutilli T, Bourelaki T, Scarsella S, Fabio DD, Pontecorvi E, Cargini P, et al. Pathological (late) fractures of the mandibular angle after lower third molar removal: a case series. J Med Case Rep. 2013;30:121. 7. Ruela WS, Almeida VL, Rivera LML, Santos PL, Porporatti AL, Freitas PHL, et al. Is there association between the presence of lower third molar and mandibular angle fractures: a meta-analysis? J Oral Maxillofac Surg. 2017;76. 8. Pell G J, Gregory BT. Impacted mandibular third molars: Classification and modified techniques for removal. Dent Digest. 1933;39(9):330-8.

9. Wagner KW, Otten JE, Schoen R, Schmelzeisen R. Pathological mandibular fractures following third molar removal. Int J Oral Maxillofac Surg. 2005 Oct;34(7):722-6. 10. Xu S, Huang J-J, Xiong Y, Tan Y-H. How is third molar status associated with the occurrence of mandibular angle and condyle fractures? J Oral Maxillofac Surg. 2017 July;75(7):1476.e1-15.

J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):64-9

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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» 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.

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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

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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