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College of Oral and Maxillofacial Surgery Volume 5, Number 3, 2019 - ISSN 2358-2782

Aquarium ©

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

Mandibular Advancement

Journal of the Brazilian

Maxillary Advancement with Mandibular

Total Arch Restoration (Implant Supported fixed bridge)

Airway Obstruction Airway Adenoids

Mandibular Advancement

Volume 5, Number 3, 2019

SIMPLES, © TRANSPARENTE & AMIGÁVEL. Patient education software ©

JBCOMS

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 13 14

A cycle that ends Gabriela Granja Porto The charms of COBRAC XXV and Belém do Pará: two opportunities for new experiences in one place José Rodrigues Laureano Filho CBCTBMF promove integração das Ligas Acadêmicas no COBRAC 2020 Belmiro Cavalcanti do Egito Vasconcelos Interview Emanuel Dias Articles

Bichectomy as facial aesthetic procedure: Prospective observational study

Raíssa Damasceno da Silva, Laís Dantas Fernandes Leite, Weber Céo Cavalcante, Arlei Cerqueira

Indication for extraction of impacted third molars: Cross-sectional study

Caio Gonçalves Silva, Victor Hugo Ferreira, Everaldo Pinheiro Lima, Suzana Celia Carneiro, Jefferson Figueiredo Leal, Belmiro Cavalcanti Vasconcelos

Evaluation of prevalence for B and C hepatitis virus on dentist

Prevalence of mandibular fractures of a tertiary hospital, reference in trauma of São Paulo

Airton Vieira Leite Segundo, Emerson Filipe de Carvalho Nogueira, Patrícia Élida Fernandes Rodrigues Carvalho, Maria Sueli Marques Soares

Eduardo Vasquez da Fonseca, Daniel Falbo Martins, Renato Cardoso, Manoel Roque Paraíso Santos Filho, Luciano Henrique Ferreira Lima

Removal of sialolite in Wharton’s duct by electrosurgery: case report

Rodrigo Souza Capatti, Lucas Rodarte Abreu Araújo, Marcela Silva Barboza

Conservative treatment of ameloblastoma in mandible: case report

Benign myoepithelioma of salivary gland in palate: case report

Camila Lopes Gonçalves, Felipe Eduardo Baires Campos, Luiz Felipe Cardoso Lehman, Roberta Rayra Martins Chaves, Flávia Leite Lima, Wagner Henriques de Castro

Rafael Saraiva Torres, Joel Motta Junior, Marcelo Vinicius de Oliveira, Valber Barbosa Martins, Gustavo Cavalcanti de Albuquerque

Tissue expansion as an option for reconstruction of craniofacial defects and alopecia area: Report of two cases Sylvio Luiz Costa de Moraes, Alexandre Maurity de Paula Afonso, Roberto Gomes dos Santos, Ricardo Pereira Mattos, Mariana Brozoski, Jonathan Ribeiro, Bruno Gomes Duarte, Bruno Costa Ferreira

Information for authors

Editorial

A cycle that ends

With a sense of accomplishment and gratitude, I end this cycle of management ahead JBCOMS. It was an honor to have participated, with Belmiro Vasconcelos, since its conception under direction of Nazareno Gil, to its consolidation in subsequent administrations, of Sylvio de Moraes and Laureano Filho. The journal was an old dream that became a solid reality today, thanks to the vision of colleagues who have been in the College board. The JBCOMS is a collective heritage. I am sure that the hard struggle for it to reach higher indexing levels in other databases will be maintained. It is still necessary to attract a greater number of original articles to meet this goal. For this, we need the continuous and intermittent, valuable collaboration from reviewers and authors.

How to cite: Porto GG. A cycle that ends. J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):4-5. DOI: https://doi.org/10.14436/2358-2782.5.3.004-005.edt

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):4-5

Editorial

In this context, I thank you for the confidence placed on me by Nazareno, Sylvio and Laureano. Believe me, I tried my best, alike the reviewers, who offered time and dedication; and the authors who contributed with published knowledge. Without you, the magazine would not make sense! To the new editor-in-chief, Sylvio de Moraes, I wish success in this new challenge, and be sure you can count on me whenever needed.

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

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):4-5

Carta do Letter from Presidente the President

The charms of COBRAC XXV and Belém do Pará: two opportunities for new experiences in one place Dear members of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology, Between June 09 and 12 2020 we will hold the XXV Brazilian Congress of Oral and Maxillofacial Surgery and Traumatology at the Hangar Convention Center in Belém – one of the largest and most modern in the country, close to touristic points and the city center, which is considered the most exotic in Brazil. The organizing committee of COBRAC XXV is preparing a scientific program with the very latest within our specialty, with more than 140 national and 16 international speakers (South Africa, Argentina, Chile, Colombia, Spain, United States, Guatemala, Dominican Republic and Venezuela). To register and enjoy all the Congress has to offer, you need to access the site www.cobrac.com.br/inscricao.php and fill the online form. After payment identification, you will have access to the participants area, in which you can submit papers, access documents and update your personal information. Registration includes access to activities of the scientific program, certification and participant materials. For colleagues who wish to present their work during COBRAC XXV, applications will be online, in the paper submission area of the event page. The deadlines for submission of materials and other dates should be consulted on the website www.cobrac.com.br/trabalhos.php, under ‘Instruction for Submission of Scientific Papers’. Free theme papers will be accepted for oral presentation or electronic poster; and in the scientific forum category, for oral presentation of finalized researches. It is important to pay attention to the theme choice, which should address areas of Oral and Maxillofacial Surgery and Traumatology and/or related to surgery.

How to cite: Laureano Filho JR. The charms of COBRAC XXV and Belém do Pará: two opportunities for new experiences in one place. J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):6-7. DOI: https://doi.org/10.14436/2358-2782.5.3.006-007.crt

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):6-7

Carta do Presidente

Posters will be presented in electronic format, providing greater interaction between the presenter and the audience, lower cost and greater flexibility for those preparing content and also to colleagues that access and view on the monitor. In early June, the top three papers in each category will be announced. To continue to compete, these papers should be re-presented by the same author/presenter, in place and time to be announced. The evaluation criteria are relevance of the subject; quality of material presented; presenter skill; and adherence to the presentation guidelines. Speaking a little about the city, Belém has a complex cuisine, full of ingredients and flavors different than we have already proved. It offers many typical dishes and juices of various flavors. One of the highlights of the region is the Ver-o-Peso market, known as the city heart. There, there is a wide variety of Amazonian ingredients, fishes, fruits and juices. The attraction of the place are the folk healers and their numerous powders, lotions and oils to cure everything you can imagine. But the Feliz Lusitânia complex in the historic center is the oldest part of Belém and is home to touristic points as the o Forte do Presépio, Casa das Onze Janelas, Museu de Arte Sacra and the Cathedral. Another tip is the Estação das Docas, which will complete 20 years of opening in 2020 and offers gastronomy, culture, fashion and events, in 500 meters of river shores of the ancient port of Belém. As the rain that falls every afternoon over Belém, much should still be expected, and we must go through a long way to perform an excellent congress. We have plenty of work ahead, but we are committed to providing the very best for the members of CBCTBMF. We wait for you in the largest congress of our specialty! Hugs to everyone!!!

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

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):6-7

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

www.omd.pt/congresso/2019

PLATINIUM SPONSOR

SILVER SPONSORS

GOLD SPONSORS

INT. MEDIA PARTNER

INSTITUTIONAL PARTNER

ORGANIZAÇÃO

CBCTBMF

CBCTBMF promotes integration of Academic Leagues in COBRAC 2020 2019-09-pagina-revista-ligas-academicas-cobrac2020-impressao.pdf 1 09/09/2019 10:09:53

CMY

Participants will have discounts on the College events and access to videos and lectures » The coordinator and vice-coordinator should be members of CBCTBMF. » It is necessary to prove the existence of the League by documentation related to the institution. To check all criteria and make the accreditation, visit www.bucomaxilo.org.br/site/credenciamento-das-ligas-academicas-cadastro.php.

Aiming at the integration of Surgery leagues, CBCTBMF launched a call for registration of Academic Leagues. The leagues are nuclei of students and health professionals, usually trained in universities or hospitals, aimed at scientific, educational, research, care, cultural and social activities, adding value to the training of participants. Besides the opportunity to acquire a wide knowledge in the field of Oral and Maxillofacial Surgery, the members of accredited leagues will have advantages as diffusion of their activities on the site; guaranteed participation and discounts to members in the College events; compete for awards for the actions promoted by CBCTBMF; and access to educational videos and preparatory classes. Some of the requirements to accredit the leagues are: » Having 20% of members associated with the College.

Belmiro Cavalcanti do Egito Vasconcelos - PhD in Dentistry, Universitat de Barcelona, Facultad de Odontología (Barcelona, Spain). - University of Pernambuco, Dental School, Department 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. CBCTBMF promotes integration of Academic Leagues in COBRAC 2020. J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):13. DOI: https://doi.org/10.14436/2358-2782.5.3.013.oar Submitted: August 22, 2019 - Revised and accepted: September 06, 2019

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):13

Interview

An interview with Emanuel Dias

» Associate Professor of Oral and Maxillofacial Surgery and Traumatology – University of Pernambuco. » Chief of the Maxillofacial Surgery and Traumatology Sector – Oswaldo Cruz University Hospital. » Former Dean of University of Pernambuco (1999-2006). » Former President of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology (2001-2003). » Former Vice-President of the Federal Dental Council (CFO) (2008-2012). » Former President of the Teaching Committee of the Federal Dental Council (CFO) (2003-2013). » Professor of Master, PhD and Postdoctoral Programs at the University of Pernambuco (UPE).

How to cite: Dias E, Porto GG. Interview with Emanuel Dias. J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):14-6. DOI: https://doi.org/10.14436/2358-2782.5.3.014-016.oar Submitted: August 27, 2019 - Revised and accepted: September 11, 2019

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):14-6

Dias E, Porto GG

Prof. Emanuel Dias, maxillofacial surgeon for 38 years, has held very important positions for the specialty, when he fought and contributed to its consolidation in Brazil. His wise and true standpoint about the specialty, particularly with regard to education and continued strengthening of the OMF surgery, is reported briefly in the following interview. The Oral and Maxillofacial Surgery and Traumatology has been developing, particularly in the last 40 years, an extremely important scientific and healthcare advance. It managed to combine, by the large dental schools, the undergraduate and graduate education to its development in major hospitals. It began to understand that the specialty would develop naturally as all medical surgical specialties within large hospital environments, which naturally led the professionals of the specialty, especially professors, to understand that multiprofessionality and multidisciplinarity of OMF surgery are unquestionable aspects. It is impossible to discuss and advance the OMFST without thinking about these aspects.

that determines a highly personalized facial esthetic standard. It is necessary to learn not to copy external models in an unrestricted manner; it is necessary to bring the knowledge to internal applicability, so that we can offer results within a functional esthetic perception of the type of people with whom we live. An important factor in the specialty that should be better addressed in residencies is tumors, large resections, tissue replacements, possibility of working with transplant patients or patients with incurable diseases such as AIDS. There are many patients who work with cancer protocol with chemotherapy or radiation, which we need to understand more so that we may actively participate. Specialty strengthening We still must discuss that we are in a country where more than 50,000 people die per year due to accidents. We are in a country where most major public hospitals have one OMF surgeon in the ER team, which was an extraordinary achievement. We need to be involved in national movements that work in the prevention of trauma, its etiology and the mechanisms of trauma. It is a great specialty that has a different team from other dental specialties, because they necessarily need an anesthesiologist, all supporting elements of hospitalization, collaboration of doctors in ICU, Cardiology, Hematology, Infectious Diseases, hospitals working with 24-hour laboratory, blood banks. This dimension cannot be ignored or put behind, because some wish to do procedures that can transform OMFST in a subarea, with limited importance. I believe that surgery is only one: it begins in studies of the types of patients, types of diseases, surgical techniques, from anesthesiology to large studies of techniques of major craniofacial disorders, and we must be involved in all this.

The OMF surgery and multidisciplinarity This environment involving other professions provided and provides, by large teaching hospitals, training in the long term. Large residencies of OMFST are currently held in 3 years of fulltime activity, leading residents to stay connected to other residencies and move in environments with different specialties, particularly medical. There is also the relationship with general examination of the patient, such as hospitalization, ICU, wards, nursing resources, complementary tests, the admission of other patients with underlying diseases or serious diseases, infectious or oral cancer, which requires a much greater preparation. There is also the relationship of OMF surgery with other dental specialties that are absolutely relevant, even though most are clinical, i.e. they are offered in clinics and offices. It is important to understand that we are in Brazil and we have proper illnesses or very classic of the country. We have many patients with important metabolic changes, some of which are characteristics of our tropical diseases. Notwithstanding, we have people who, as mentioned by Darcy Ribeiro, formed "a kind of new Rome", a mixture of races

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Technology and good clinical practice The speed of knowledge construction has been so rapid that some professionals seeking this knowledge, which can also be achieved so quickly by the available technologies, somehow neglect the clinical experience. Naturally, technological application, knowledge and the speed at which this knowledge is acquired will only be associated with good clinical practice if there is clinical experience. This means that it takes time, we need to operate, assist 15

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):14-6

Interview

new models should be applied in undergraduate and graduate. To discuss accords and internationalization sounds like an absolutely irreversible practice. I further advocate that the large training centers particularly occupy these large multidisciplinary spaces. I do not believe in specialist training in short time. At least 3 years are necessary within large hospital settings with good teams, which allows a solid learning, which surely form the basis of any surgeon for the future. This is my expectation; this is not a momentary vision, but the opinion of someone who is practicing the specialty for over 38 years and has been in all possible spaces in relation to education and assistance.

patients, be in places that provide an important movement of patients, so that the modern technology may be associated with the experience of each of us. One thing depends on the other. It is necessary to be updated and have time to use this action. Time really defines the quality of who is doing and applying this technology. Always operating, always treating and being in major centers that enable the examination of several patients with filled activities will provide a huge practice. Opinion of those who understand the subject I advocate that OMFST develops not only under the aspects of modern methodology and modern pedagogy for teaching and learning, but also that

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

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):14-6

OriginalArticle

Bichectomy as facial aesthetic procedure: Prospective

observational study RAÍSSA DAMASCENO DA SILVA1 | LAÍS DANTAS FERNANDES LEITE1 | WEBER CÉO CAVALCANTE1,2,3 | ARLEI CERQUEIRA1,2,3

ABSTRACT Objective: The objective of this study was to evaluate morbidity, possible sequels and the satisfaction of patients submitted to the bichectomy esthetic procedure. Methods: 16 patients undergoing the procedure were prospectively analyzed through a questionnaire, clinical examination and subjective photographs analysis. Results: This study revealed good results regarding patient satisfaction, with female patients showing satisfaction with the aesthetic result, while male patients noticed greater functional gain; in addition, it was observed low morbidity and low risk of complications, with only two cases of infections, treated with oral antibiotics. Conclusions: It was possible to conclude that bichectomy provides aesthetic improvements in the facial contour with safety and low morbidity. Keywords: Adipose tissue. Plastic surgery. Oral surgery. Cheek.

Universidade Federal da Bahia, Faculdade de Odontologia (Salvador/BA, Brazil). Universidade Federal da Bahia, Serviço de Cirurgia e Traumatologia Buco-Maxila-Faciais (Salvador/BA, Brazil). 3 Obras Sociais Irmã Dulce, Hospital Santo Antônio (Salvador/BA, Brazil). 1

How to cite: Silva RD, Leite LDF, Cavalcante WC, Cerqueira A. Bichectomy as facial aesthetic procedure: prospective observational study. J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):17-23. DOI: https://doi.org/10.14436/2358-2782.5.3.017-023.oar

Submitted: August 11, 2018 - Revised and accepted: May 26, 2019 » 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: Arlei Ciqueira Av. Tancredo Neves, 620, sala 2423/2424 – Caminho das Árvores – Salvador/BA CEP: 41.820-020 – E-mail: arleic@ufba.br, arlei.bucomaxilo@gmail.com

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):17-23

Bichectomy as facial aesthetic procedure: Prospective observational study

INTRODUCTION The valuation and search for esthetics is a strong tendency in current society.1 In the field of work of dentists, the esthetic reference is traditionally the smile. However, the evaluation of facial pattern, expression lines, facial contours and possible improvements has become a common practice among dentists. 2,3 The midface occupies a central position in the facial profile and plays an important role in defining the personal image. Visual criteria for a harmonious midface depend, among others, on prominent zygomatic eminences and well-defined jaw line, particularly in the angle. 4 The buccal fat pad was first described in 1732 by Heister, who imagined that this structure had a glandular nature, calling it malar gland. 4,5 In 1802, the French anatomist Marie FranĂ§ois Xavier Bichat described in more detail an encapsulated mass of adipose tissue which, along with the zygomatic bone, provides bilateral volume to the face 3-8. Due to its adjacent anatomical location and abundant blood supply, the buccal fat has been used in the reconstruction of intraoral defects, autologous fat transplantation and increase of malar region in patients with Down syndrome. 4,9 The technique described by Egyedi12 uses the buccal fat for closure of oroantral fistulae. Poeschl et al.13 used fat graft in 161 patients with orosinusal fistula with resolution of all cases, evidencing the efficacy of the technique. More recently, the buccal cheek fat pad achieved great importance in the field of facial cosmetic surgery, with special attention to thinning or modification of facial contours and malar prominence.4,9 Besides the esthetic indication, its removal may be justified to solve the bite trauma on the buccal mucosa10,14. Surgical removal of this fat pad is named buccal fat pad removal and provides the patient with a more youthful appearance, with thinner and defined traces.3,5 In skilled hands, with specific training, the surgical technique is simple. By intraoral access, its scar is apparently imperceptible and postoperative care is similar to tooth extraction. 2,3 However, as with any surgery, relevant complications can occur, such as parotid duct injury with formation of mucoceles, facial nerve injury, excessive resection (fenestration of the face), trismus, infection, bruising and facial asymmetry.4,5,14

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Despite the popularity of the technique, there is scarce scientific data on the safety, esthetic and functional benefit and patient satisfaction. Thus, the aim of this study was to prospectively evaluate a series of cases of cosmetic surgery of buccal fat pad removal, concerning the morbidity, possible sequels and patient satisfaction, aiming to contribute data to the literature. MATERIAL AND METHODS This study was approved by the Institutional Review Board of the Federal University of Bahia. The study aimed to prospectively evaluate patients who sought care at the Oral and Maxillofacial Surgery Service for buccal fat pad removal procedure for esthetic or functional purposes between May 2016 and July 2017. A convenience sample was used, adopting the following inclusion criteria: patients of both genders, who sought for buccal fat pad removal procedure. The study excluded patients with systemic conditions that could interfere with the healing process or history of previous local surgery. Patients who agreed to participate were photographed with a digital camera Canon Rebel T 5i, in a standardized manner, using circular flash, in an environment with artificial lighting, at a distance of 1.52 m, before the procedure and at three months postoperatively (Fig 1). The procedures were performed by the researcher specialist in oral and maxillofacial surgery on an outpatient setting under local anesthesia without sedation. After infiltrative terminal anesthesia on the cheek region, the buccal nerve and posterior superior alveolar nerve could also be anesthetized. An incision was made, measuring up to 1 cm, located in the upper portion of the cheek, close to the second molar and after the parotid papilla (Fig 2). Using a plier, by the blunt divulsion technique, the buccinator muscle is transfixed and the underlying fat tissue is exposed to the oral cavity and pulled until its subcutaneous pedicle is located and then completely removed. Finally, the wound is irrigated with saline and suture is performed with one or two simple stitches. After discharge, all participants used nonsteroidal anti-inflammatory drugs and analgesic of peripheral action at home, for three days.

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):17-23

Silva RD, Leite LDF, Cavalcante WC, Cerqueira A

Figure 1: Protocol for preoperative images (A, B and C) and 3 months postoperatively (D, E and F).

was assigned for the variables pain, edema, ecchymosis, hematoma, infection, duct injury and nerve injury. To evaluate the esthetic result, two clinical methods were used. The patients expressed their satisfaction on a scale of 0 to 10, and two examiners, knowledgeable about the treatment, analyzed the photographs mounted on a digital album. The esthetic result was considered positive when the changes were noticeable by the two examiners.

The follow-up included re-evaluation one week after the procedure to assess the morbidity and occurrence of complications; and a new evaluation was performed three months after the procedure to evaluate the esthetic and functional result and patient satisfaction. On that occasion, the participants were again photographed and interviewed with questions regarding the procedure morbidity. To characterize the morbidity, a scale of 0 to 5

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):17-23

Bichectomy as facial aesthetic procedure: Prospective observational study

Figure 2: Surgical technique employed. Up to 1-cm incision, blunt dissection to expose the buccal fat pad, fat traction and sectioning of the pedicle. Suture with one or two simple stitches.

RESULTS During the study period, 16 patients sought the Oral and Maxillofacial Surgery service to perform the buccal fat pad removal surgery, being 13 females and 3 males. All participants met the inclusion criteria, and none was dropped at the study onset or completion. The age range varied from 22-30 years, with a mean of 26 years. When asked about the motivation for the procedure, among the 16 patients, 13, all female, sought for esthetic benefit and 3, male, reported functional complaint, characterized by biting the cheek, besides the esthetic complaint. During the study, there were two cases of postoperative infection, one diagnosed after request of ultrasound examination. Both cases were treated with oral antibiotics (azithromycin). No nerve or parotid duct injury was recorded.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

The patients reported a mean score for pain equal to 1.4, considered mild; edema was assigned a mean score of 2.4; bruising and hematomas achieved mean of 0.1 on a scale of 0 to 5. The patients in this case series were satisfied with the results and noticed significant differences in facial contour. On a scale of 0 to 10, the participants assigned a mean satisfaction of 9. Male patients were less satisfied in relation to esthetics; however, they were very pleased with the functional gain, reducing or eliminating the oral mucosa biting (Tab. 1). The subjective analysis of photographs, after discussion between the authors about the personal impression, considered that the changes were not noticeable in six cases, while in all others a subtle result was noticed.

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):17-23

Silva RD, Leite LDF, Cavalcante WC, Cerqueira A

Table 1: Data evaluated in the study: Pain, Edema, Bruising and Hematomas (Grade 0-5); Infection, Duct or Nerve injury (Presence (+) or absence (-)); and satisfaction score (0 to 10).

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Age

Gender

Pain

Edema

Bruising

Hematoma

Infection

Duct injury

Nerve injury

Satisfaction

24 28 36 23 22 30 26 25 22 23 24 25 26 27 29 27 26,1

F F M M F F F M F F F F F F F F 13/03

3 2 1 0 3 0 3 0 4 1 3 0 0 1 1 1 1,4

3 3 1 1 5 0 5 3 3 2 3 1 2 2 1 3 2,4

0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0,1

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0,0

+ + 2

8 10 5 10 10 10 9 7 10 9 9 10 9 9 10 9 9,0

DISCUSSION The buccal fat pad is a well-defined anatomical structure which, together with the zygomatic bone, is responsible for facial contours, providing a protuberance or luminescence in the malar region, and is closely related to the masticatory space.5,6,8 Nicolich and Montenegro5 and Junior et al.6 complemented that the size of this fat pad minimally corresponds to the degree of body fat or weight of the patient. The goal of buccal fat pad removal is to achieve better definition of the angularity of facial skeletal features and mandibular contour, seeking increase in facial esthetics3,5,11. In this study, patients sought this procedure mostly for esthetic purposes. According to Matarasso,11 removal of the buccal fat pad can be considered at any age for the treatment of lipodystrophy or pseudo hernia. However, Stevão3 recommends this for patients over 18 years, non-smokers and aware of the results that can be achieved by surgery. The patients in this study had

a mean age of 26 years and were non-smokers, corroborating the indication of Stevão3. The esthetic motivation of the sample justifies the selection and guidance as to the results of the procedure and may be little noticed by others. Usually, there are no functional problems related to this procedure.14 Esthetics is the most frequent complaint: only 3 patients reported functional complaint related to mucosal bite, thus in this study there were also functional complaints. The buccal fat pad removal seeks the physical and psychological welfare.2 According to the literature, this procedure allows changes in the facial contour, thinner lines, sharper cheeks, more prominent zygomatic area with consequent increase in self-esteem.3,5 According to Gracindo, 1 surgeries most sought within one year were lips and cheeks, influenced by the appearance of celebrities as the actress Angelina Jolie and singer Beyoncé - according to reports of the patients themselves.

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):17-23

Bichectomy as facial aesthetic procedure: Prospective observational study

in facial contour.2,5,10,11 According to Stevão,3 the results can be seen after four to six months, when the residual edema is resorbed. In this study, we adopted a three-month period for evaluation (photographic records, evaluation of morbidity and satisfaction), and at this time the patients were satisfied. Jackson 14 notes that in some patients the results are good, but in others, particularly those with rounder faces or men, disappointing results can be obtained. According to Matarasso,4 most patients reported subtle change. The study results were satisfactory: the female patients reported significant difference in facial contour, while males reported no esthetic gain, but noted functional gain, reducing biting of the buccal mucosa. These findings suggest that buccal fat pad removal, despite the slight difference observed by the authors, presents good results in the patients’ opinions. Although the photographic record used in this study has methodological limitations, such as the two-dimensional representation of a three-dimensional model, it was able to evaluate the changes achieved by buccal fat pad removal. The analysis of images by the authors may present a practical limitation, since no esthetic improvements were noticed in cases where participants were fully satisfied. Some questions remain: much is questioned about the appearance of these patients in the long term and how shall be their appearance in middle or old age. Therefore, further studies with larger size and long-term follow-up are still required and can be performed by monitoring the present sample of individuals or by adding new participants.

Candidates for this surgery usually have facial rounding or some esthetic irregularity.3,11 These findings agree with the presented patients because, in this sample, all reported dissatisfaction with the facial volume, besides the desire to resemble famous people. In this regard, the results of buccal fat pad removal were satisfactory. The esthetic buccal fat pad removal can be associated with other procedures as liposuction and orthognathic surgery.4,7,9,14 In this study, buccal fat pad removal was carried out individually, with no association with any other procedure. The removal of fat tissue can be performed by external or intraoral approach, and the external approach is more dangerous.5 For Mataraso4 and Muresan and Matarasso,7 the incision must have 2.5cm. In this case series, incisions of up to 1cm were made, which agrees consistent with Stevão,3 being enough for the procedure and certainly decreasing the morbidity. Surgical complications as pseudo-herniation, lipodystrophy and trismus were described, though rare. Infections, stenosis or rupture of the parotid duct and bruises are more frequent. The most commonly reported serious surgical complication is facial nerve damage. 5,6,11 In this study, there were two cases of postoperative infection, being one with abscess diagnosed by ultrasound and handled by puncture. Both patients were treated with oral antibiotics. Stevão 3 prescribes antibiotic, analgesic and cryotherapy. In the study of Matarasso11, the patients received broad spectrum antibiotics and mouthwash with hydrogen peroxide in average concentration postoperatively and were encouraged to exercise their jaws. Considering clinical trials of antibiotic prophylaxis in oral surgeries,15,16,17 this study used only non-steroidal anti-inflammatory drugs and simple analgesics. However, the incidence of two cases of infection, even without major complications, may indicate the use of prophylactic antibiotics, only in the perioperative period. Patients undergoing buccal fat pad removal wait on average two to three months to notice the change

CONCLUSION The buccal fat pad removal is a relatively safe procedure; its postoperative care is similar to that of tooth extraction. The patients were satisfied with the functional and especially the esthetic outcome of buccal fat pad removal.

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):17-23

Silva RD, Leite LDF, Cavalcante WC, Cerqueira A

References:

1. Gracindo GCL. A moralidades das intervenções cirúrgicas com fins estéticos de acordo com a bioética principialista. Rev Bioét. 2015;23(3):524-34. 2. Quispe PGD, Lupa LC. Cirugia estética de mejillas. Rev Act Clin. 2014;48:2538-41. 3. Stevão E. Bichectomy or Bichatectomy: a small and simples intraoral surgical procedure with great facial results. Adv Dent Oral Health. 2015;1(1):1-4. 4. Matarasso A. Buccal Fat Pad Excision: aesthetic improvement of the midface. Ann Plast Surg. 1991 May;26(5):413-8. 5. Nicolich F, Montenegro C. Extracción de la bola de Bichat: una operación simple con sorprendentes resultados. Folia Dermatol Peru. 1997;8:1-5. 6. Bernardino Junior R, Sousa GC, Lizardo FB, Bontempo DB, Guimarães PP, Macedo JH. Corpo adiposo da bochecha: um caso de variação anatômica. Biosci J Uberlandia. 2008;24(4):108-13. 7. Muresan H, Matarasso A. Evaluation and Treatment of the Buccal Fat Pad. QMP’s Plastic Surgery Pulse News. 2009;7(1):1-3.

8. Shrivastava G, Padhiary S, Pathak H, Panda S, L Shitaprajna. Buccal Fat Pad to Repair Intraoral Defects. Int J Sci Res Pub. 2013;2(3):1-4. 9. Bohluli B, Aghagoli M, Sarkarat F, Malekzadeh M, Moharamnejad N. Facial Sculpturing by Fat Grafting. Textbook Adv Oral Maxillofac Surg. 2013;3:813-28. 10. Guryanova RA, Guryanov AS. Ct anatomy of buccal fat dap and its role in volumetric alterations of face. The International Archives of the Photogrammetry, Remote Sensing and Spatial Information Sciences. 2015;XL-5/W6:33-6. 11. Matarasso A. Managing the Buccal Fat Pad. Aesthet Surg J. 2006 May-Jun;26(3):330-6. 12. Egyedi P. Utilization of the Buccal Fat Pad for Closure of Oro-Antral and/ or Oro-Nasal Communications. J Maxillofac Surg. 1977 Nov;5(4):241-4. 13. Poeschl P, Baumann A, Russmueller G, Poeschl E, Klug C, Ewers R. Closure of Oroantral Communications With Bichat’s Buccal Fat Pad. J Oral Maxillofac Surg. 2009 July;67(7):1460-6. 14. Jackson T. Buccal Fat Pad Removal. Aesthetic Surg J. 2003;23:484-5.

15. Aragon-Martinez OH, Isiordia-Espinoza MA, Tejeda Nava FJ, Aranda Romo S. Dental Care Professionals Should Avoid the Administration of Amoxicillin in Healthy Patients During Third Molar Surgery: Is Antibiotic Resistence the Only Problem? J Oral Maxillofac Surg. 2016 Aug;74(8):1512-3. 16. Prajapati A, Prajapati A, Sathaye S. Benefits of not Prescribing Prophylactic Antibiotics After Third Molar Surgery. J Maxillofac Oral Surg. 2016 June;15(2):217-20. 17. Milani BA, Bauer HC, Sampaio-Filho H, Horliana AC, Perez FE, Tortamano IP, et al. Antibiotic therapy in fully impacted lower third molar surgery: randomized threearm, double-blind, controlled trial. Oral Maxillofac Surg. 2015 Dec;19(4):341-6.

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):17-23

OriginalArticle

Indication for extraction of impacted third molars:

Cross-sectional study

ABSTRACT Introduction: Removal of third impacted asymptomatic molars has been the subject of considerable controversy. Therefore, this study aims to verify the indication of removal of lower third molars by oral and maxillofacial surgeons after evaluating radiographic images. Methods: This was an observational cross-sectional study developed with professionals participating in the XXIII Brazilian Conference on Oral and Maxillofacial Surgery (COBRAC-2015) held in Salvador, Bahia, Brazil, in which the participants were divided into groups according to the level of training. Results: The results show that most oral and maxillofacial surgeons tend to indicate the removal of asymptomatic impacted third molars (ITMs), and this decision-making is independent of the level of training, and the number of years of experience does not influence it. Conclusions: It can be concluded that there is insufficient evidence in the current literature to determine routine prophylactic removal of asymptomatic ITMs. The indication or not of removal of asymptomatic ITMs should take into account the patients acceptance as well as the clinical knowledge of the professional to guide the decision making. Keywords: Molar, third. Tooth, impacted. Surgery, oral.

Universidade do Pernambuco, Faculdade de Odontologia, Setor de Cirurgia e Traumatologia Bucomaxilofacial (Camaragibe/PE, Brazil). Hospital da Restauração, Departamento Cirurgia e Traumatologia Bucomaxilofacial (Recife/PE, Brazil). 3 Sindicato dos Odontologistas de Pernambuco, Curso de Especialização em Implantodontia (Recife/PE, Brazil). 1

How to cite: Silva CG, Ferreira VH, Lima EP, Carneiro SC, Leal JF, Vasconcelos BC. Indication for extraction of impacted third molars: Cross-sectional study. J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):24-8. DOI: https://doi.org/10.14436/2358-2782.5.3.024-028.oar

Submitted: February 17, 2019 - Revised and accepted: May 26, 2019 » 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: Caio Gonçalves Silva Av. Gal. Newton Cavalcanti, 1.650, Tabatinga – Camaragibe/PE CEP: 54.753-220 – E-mail: caiocgsilva@gmail.com

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):24-8

Silva CG, Ferreira VH, Lima EP, Carneiro SC, Leal JF, Vasconcelos BC

INTRODUCTION The surgical removal of an impacted tooth is one of the most common procedures performed by a maxillofacial surgeon in the dental office. 1,2 The third molars are the most commonly impacted teeth, with a mean global rate of impaction of 24%.3 Impacted third molars (ITM) may be associated with pathological disorders as pericoronitis, root resorption, gingivitis, periodontitis, caries and development of cysts and tumors.4 The prophylactic removal proposed by some authors5,6 aims to prevent the development of these lesions and avoid this procedure at a more advanced stage of life, when the risk of postoperative complications is higher.4 ITM removal surgery is usually a simple procedure performed under local anesthesia in an outpatient setting. However, for a variety of reasons, some patients require hospital care under general anesthesia or intravenous sedation to perform these extractions. 1,4,5 Every procedure for the removal of ITM presents risks for the patient, including temporary or permanent nerve damage, alveolitis, infection, bleeding, swelling, pain and trismus. Moreover, this surgery is often perceived by the patient as an intensely frightening situation, and in some cases an unnecessary surgical procedure, since the tooth is shown as fully erupted in the mouth and does not have clinical and radiographic signs of associated injury. 1,7 8 The removal of asymptomatic ITM has been subject of considerable controversy. Some authors advocate the removal as beneficial for patients to prevent the risk of future bone injury. 5,6 Conversely, the removal of third molar may result in various types of morbidities, thus clinical monitoring of ITM is recommended.7 Thus, the objective of this study is to verify the indication of removal of third molars by the maxillofacial surgeons after evaluating radiographic images.

Salvador/BA, in the period from August 25 to 29 2015, in which some professionals of Oral and Maxillofacial Surgery and Traumatology who were present were addressed during the event and answered a questionnaire indicating the removal of third molars, after evaluating radiographic images. The study was conducted in accordance with Resolution 466/2012 of the National Health Council, Ministry of Health, related to ethics in research involving human subjects, and was approved by the Institutional Review Board of Hospital da Restauração (report n. 2.753.179). For data collection, a questionnaire was designed including age, gender, title (resident/specialized, specialist, master, doctor), training time in the field and a series of four hypothetical clinical cases on which each professional evaluated radiographic images with different types of dental impactions in the mandible and expressed indication or not for extraction (Fig 1). The radiographic images were obtained from the database of a radiology clinic in Recife/PE. For data collection, the team was calibrated for application of the questionnaire and for acquisition of a random sample of participants during the event. After data collection, the Microsoft Excel was used to tabulate the data and for statistical calculations. RESULTS The study analyzed 170 questionnaires that met the inclusion criteria of the research. Among professionals participating in the study, 71.1% were males and mostly specialists. The percentage of participants in relation to the training course in the specialty of Oral and Maxillofacial Surgery is shown in Figure 2. Sixty-four percent opted to remove the impacted tooth as a prophylactic measure, since most cases presented were young patients. However, the percentage of indication for extraction varied according to the clinical situation presented. The total of indications per case is observed in Table 1. The total indications for extraction in each clinical situation did not vary significantly between professionals with different training levels, as shown in Figure 3.

METHODS This observational cross-sectional study was carried out during the XXIII Brazilian Congress of Oral and Maxillofacial Surgery (COBRAC 2015) in

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):24-8

Indication for extraction of impacted third molars: Cross-sectional study

Figure 1: Radiographic images to assess the extraction of the impacted lower third molar: A) young patient without comorbidities, asymptomatic (case 1); B) elderly patient without comorbidities, asymptomatic (case 2); C) young patient without comorbidities, asymptomatic (case 3); D) young patient without comorbidities, asymptomatic (case 4).

Level of training Specialized

Specialized

Specialists

Specialists Masters

Masters

Doctors

Doctors Case Case

Figure 2: Percentage of participants, according to the level of training.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Case Case

Figure 3: Percentage of indication for removal of impacted third impacted third molars, by level of education in each clinical case.

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):24-8

Silva CG, Ferreira VH, Lima EP, Carneiro SC, Leal JF, Vasconcelos BC

Table 1: Percentage of indications or contraindications for removal of impacted third molars, per clinical case.

Case 1 Case 2 Case 3 Case 4

Yes

62% 15% 93% 85%

38% 85% 7% 15%

DISCUSSION The management related to removal of symptomatic ITM is well described in several oral and maxillofacial surgery books. However, it remains a dilemma for the surgeon on how to proceed in case of na asymptomatic impacted tooth.7,8 The ITM can be associated with pathological disorders as pericoronitis, root resorption, periodontal problems, caries and development of cysts and tumors. 1,4,9 Other reasons for the prophylactic removal of asymptomatic ITM include the prevention of lower incisor crowding, preparation for orthognathic surgery or radiotherapy.4 Many dentists and their patients believe that removing asymptomatic ITM is justified to avoid future complications at a later stage of life in which the therapeutic and surgical management is more complex, and the risk of postoperative complications increases. 4,9 According to studies by Metts et al.7 and Huang et al.10, patients are largely influenced by recommendations of their dentists who indicated removal of ITM for prophylactic reasons. Thus, the indication of prophylactic extraction should be based on literature, both to provide the best treatment for the patient and also for legal support in case of possible complications in the postoperative period, which can lead to lawsuits. The Brazilian Congress of Oral and Maxillofacial Surgery and Traumatology (COBRAC) is the biggest event of the specialty in Brazil, with participation of great specialists from the country, as well as personalities with worldwide recognition, due to the work they develop within the field of oral and maxillofa-

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

cial surgery. In this sense, we can infer the relevance of the present study, because it was conducted with high-level professionals with high scientific knowledge and working based on what is best in the literature. This study included a total of 170 professionals from questionnaires, which were participants in the aforementioned congress. Among these, 49 had PhD (29%), 40 were masters (24%), 60 were specialists (35%) and 21 were residents or trainees (12%). By data analysis, most professionals surveyed tend to indicate the extraction of asymptomatic ITM. However, when comparing the approach between young and elderly patients, we observed that professionals tend to be more conservative in relation to elderly patients but indicate more often the prophylactic extraction in young patients. This trend follows the report of the study of Petrosyan and Ameerally,11 which described a criterion for prophylactic removal of third molars. According to the authors, in young patients, the extraction of ITM and its contralateral should be performed prophylactically, if the latter is present partially erupted. The authors justify their behavior arguing that young patients have minimal chances of postoperative serious complications, in addition to a faster recovery. Similarly, Talwar et al. 12 mention that young patients submitted to extraction of third molars have low morbidity, low prevalence of postoperative complications and minimal impact on quality of life, concluding that the indication of this type of surgery in patients with that age would bring more benefits than harm.

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):24-8

Indication for extraction of impacted third molars: Cross-sectional study

of asymptomatic and uncomplicated ITM remains controversial. The current approach to deal with the ITM is based on clinical judgment, periodic evaluation by some professionals and early extraction by others, and there is no consensus of surgeons in the management of ITM.1,4,15,16 Considering the lack of evidence, the indication for removing or not asymptomatic ITM must consider the acceptance of patients and clinical knowledge of the professional to guide the decision-making.

The indication of ITM removal in the older age group was also decreased in the study Ethunandan et al. 13 Factors as decreased bone elasticity, risk of osteoporosis, bone atrophy and increased potential for tooth ankylosis supported the decision. The study of Camargo et al. 14 evaluated the decision-making between maxillofacial surgeons in relation to ITM surgery and observed that the group with the shortest experience tended to recommend extractions with increasing frequency. The conclusion of these authors is different from data observed in this study, because there was no significant difference in the management of clinical cases presented in different stages in the specialty. There is insufficient evidence in the current literature to determine the routine prophylactic removal of asymptomatic ITM. 4,7 The management

CONCLUSION The decision-making regarding the surgical removal of asymptomatic impacted third molar is independent of the level of professional training. There is insufficient evidence to support or refute the removal of asymptomatic impacted third molars.

References:

1. Balaguer-Martí JC, Aloy-Prósper A, Peñarrocha-Oltra A, Peñarrocha-Diago M. Non surgical predicting factors for patient satisfaction after third molar surgery. Med Oral Patol Oral Cir Bucal. 2016 Mar 1;21(2):e201-5. 2. Kumar KS, Sargunam AED, Ravindran C, Giri G. Intra-alveolar extraction of impacted distoangular mandibular third molars: a novel technique. Indian J Dent Res. 2018 Mar-Apr;29(2):252-3. 3. Ryalat S, AlRyalat SA, Kassob Z, Hassona Y, Al-Shayyab MH, Sawair F. Impaction of lower third molars and their association with age: radiological perspectives. BMC Oral Health. 2018 Apr 4;18(1):58. 4. Ghaeminia H, Perry J, Nienhuijs MEL, Toedtling V, Tummers M, Hoppenreijs TJM, et al. Surgical removal versus retention for the management of asymptomatic disease-free impacted wisdom teeth. Cochrane Database Syst Rev. 2016 Aug 31;(8):CD003879. 5. White RP Jr, American Association of Oral and Maxillofacial Surgeons House of Deletates. Progress report on third molar clinical trials. J Oral Maxillofac Surg. 2007 Mar;65(3):377-83. 6. Renton T, Al-Haboubi M, Pau A, Shepherd J, Gallagher JE. What has been the United Kingdom’s experience with retention of third molars? J Oral Maxillofac Surg. 2012 Sept;70(9 Suppl 1):S48-57.

7. Mettes TD, Ghaeminia H, Nienhuijs ME, Perry J, van der Sanden WJ, Plasschaert A. Surgical removal versus retention for the management of asymptomatic impacted wisdom teeth. Cochrane Database Syst Rev. 2012 June 13;(6):CD003879. 8. Rodríguez Sánchez F, Rodríguez Andrés C, Arteagoitia Calvo I. Does Chlorhexidine Prevent Alveolar Osteitis After Third Molar Extractions? Systematic Review and Meta-Analysis. J Oral Maxillofac Surg. 2017 May;75(5):901-914. 9. Baensch F, Kriwalsky MS, Kleffmann W, Kunkel M. Third Molar Complications in the Elderly-A Matched-Pairs Analysis. J Oral Maxillofac Surg. 2017 Apr;75(4):680-6. 10. Huang GJ, Cunha-Cruz J, Rothen M, Spiekerman C, Drangsholt M, Anderson L, et al. A prospective study of clinical outcomes related to third molar removal or retention. Am J Public Health. 2014 Apr;104(4):728-34. 11. Petrosyan V, Ameerally P. Changes in demographics of patients undergoing third molar surgery in a hospital setting between 1994 and 2012 and the influence of the National Institute for Health and Care Excellence guidelines. J Oral Maxillofac Surg. 2014 Feb;72(2):254-8.

12. Talwar R, Haug R, Gonzalez M, Perrott D. The AAOMS age-related third molar study. J Oral Maxillofac Surg. 2004 Aug;62(1):34-35. 13. Ethunandan M, Shanahan D, Patel M. Iatrogenic mandibular fractures following removal of impacted third molars: an analysis of 130 cases. Br Dent J. 2012 Feb 24;212(4):179-84. 14. Camargo IB, Melo AR, Fernandes AV, Cunningham LL Jr, Laureano Filho JR, Van Sickels JE. Decision making in third molar surgery: a survey of Brazilian oral and maxillofacial surgeons. Int Dent J. 2015 Aug;65(4):169-77. 15. Msagati F, Simon EN, Owibingire S. Pattern of occurrence and treatment of impacted teeth at the Muhimbili National Hospital, Dar es Salaam, Tanzania. BMC Oral Health. 2013 Aug 6;13:37. 16. Mayrink G, Nicolai B, Aboumrad Júnior JP. Comparative study of dipyrone and paracetamol pain control after third molar extraction. J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):32-7.

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):24-8

OriginalArticle

Evaluation of prevalence for B and C

virus on dentist

hepatitis

AIRTON VIEIRA LEITE SEGUNDO1 | EMERSON FILIPE DE CARVALHO NOGUEIRA2 | PATRÍCIA ÉLIDA FERNANDES RODRIGUES CARVALHO3 | MARIA SUELI MARQUES SOARES4

ABSTRACT Objective: The aim of the present work was to determine the seroprevalence of hepatitis type B and type C in the dentists of Caruaru (Pernambuco, Brazil). Methods: The sample comprised 80 professionals who underwent blood collection for serological tests (HBsAg and anti-HCV) to hepatitis type B and type C, and submitted to an interview about their time of graduation, checking vaccination against hepatitis type B, previous blood transfusion and use of individual protection equipment. Results: In relation to the seroprevalence, two cases of hepatitis type B and one case of hepatitis type C were confirmed, representing a rate of 2,5% and 1,25%, respectively. The average of time of graduation was 17,35 years. Fifty two percent of the professionals report biologic material accident. The results showed that 75% had complete hepatitis type B vaccination. Conclusion: It is concluded that dental surgeons in the city of Caruaru presented low prevalence of hepatitis B and C virus infection, and that ¼ of the professionals did not present regular hepatitis B vaccination. Keywords: Hepatitis. Dentists. Occupational risks. Hepatitis virus.

Hospital Regional do Agreste, Departamento de Cirurgia Bucomaxilofacial (Caruaru/PE, Brazil). Universidade de Pernambuco, Departamento de Cirurgia (Recife/PE, Brazil). Faculdade Pernambucana de Saúde, Departamento de Medicina (Recife/PE, Brazil). 4 Universidade Federal da Paraíba, Departamento de Clínica e Odontologia Social (João Pessoa/PB, Brazil). 1

How to cite: Leite Segundo AV, Nogueira EFC, Carvalho PEFR, Soares MSM. Evaluation of prevalence for B and C hepatitis virus on dentist. J Braz Coll Oral Maxillofac Surg. 2019 SeptDec;5(3):29-33. DOI: https://doi.org/10.14436/2358-2782.5.3.029-033.oar

Submitted: March 17, 2019 - Revised and accepted: July 17, 2019 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. Contact address: Airton Vieira Leite Segundo Av. Agamenon Magalhães, 444, Empresarial Difusora – Sala 530, Maurício de Nassau Caruaru/PE – CEP: 55.012-290 – E-mail: airtonsegundo@hotmail.com

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):29-33

Evaluation of prevalence for B and C hepatitis virus on dentist

INTRODUCTION The hepatitis B virus (HBV) remains a global public health problem, with more than one third of the world’s population infected.1 The prevalence of HBV infection is higher among dentists than in the general population, especially among those who have surgical specialties.2 The hepatitis C virus (HCV) is also an important infectious agent due to the large number of human pathologies associated with its infection, which is worsened by the prospect of a further rise as a threat to public health in the coming years. 3 It is believed that approximately 170 million people are persistently infected and at least 80% will develop serious diseases, including chronic hepatitis, cirrhosis or liver cancer.4 Most researchers believe that dentists acquire the virus through a cut in fingers contaminated by blood or saliva from the patient. Since nasopharyngeal secretions carry the virus, the possibility of acquiring the infection by aerosol, though remote, still exists. Thus, dentists have a high risk of exposure to hepatitis due to numerous contacts with patients and use and disposal of cutting instruments. 5 Considering that these professionals are included in the contamination risk by HBV and HCV, and considering the importance of knowledge of epidemiological data on these diseases, this research investigated the prevalence of seropositivity for these viruses among dentists in the city of Caruaru, Pernambuco, Brazil.

made in clinics that were closed. In case of failure, the respondent was deleted and replaced by another by drawing lots, to complete the determined sample. Data were collected in two stages: the first, by applying a structured questionnaire with personal data, training time, vaccination against hepatitis, personal protective equipment use and history of accidents with sharp instruments. This questionnaire was applied exclusively by the author, to achieve homogeneity of answers, and calibration was performed on five dentists to assess its applicability as a data collection instrument. At the second time, a blood sample was collected from each respondent and submitted to laboratory analysis for the presence of antigens and antibodies to hepatitis B and C. Blood samples were collected and placed in tubes for specific serological tests, cooled and immediately identified. To diagnose the presence of hepatitis B and C, laboratory tests were made from the obtained blood samples. Thus, the blood was centrifuged at 3,500 rpm for 5 minutes, and the serum was separated to perform the tests HBsAg (surface antigen) for the diagnosis of hepatitis B; and anti-HCV (viral antibody) for HCV research, both by enzyme immunoassay method. All tests were performed on third-party laboratory. The results were crossed with information from questionnaires and supplemented with qualitative and quantitative analyses, determining seropositivity rates. Descriptive analysis was performed using Microsoft Excel 2010™ program.

METHODS The project was submitted to the Institutional Review Board of Associação Caruaruense de Ensino Superior/PE, and was approved under number 011/07. This study was conducted in the period from 2010 to 2013 in the city of Caruaru (Pernambuco, Brazil), with a sample of 80 dentists, randomly included. The participants were drawn among dentists working in the city of Caruaru, regularly recorded in the Pernambuco Regional Dental Council, who agreed to join the study and signed an informed consent form. The study excluded professionals who were not at work, who died or left the profession during the research. Respondents received the researcher in their offices, during business hours. A new attempt was

RESULTS Among the total sample, 43 professionals (53.75%) were males and 37 (46.25%) were females, aged 26-68 years. The training ranged from 1 to 40 years. The research revealed that 60 professionals (75%) showed complete hepatitis B vaccination, receiving three doses. Ten (12.5%) received two doses, one (1.25%) received one dose, three (3.75%) were not vaccinated and six (7.5%) were unable to inform the vaccination status (Fig 1 ). When assessing the existence of prior blood transfusion, it was found that two dentists (2.5%) had transfusion history. With respect to the own knowledge infection with hepatitis, two workers (2.5%) were knowledgeable about infection with hepatitis, one hepatitis B and

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):29-33

Leite Segundo AV, Nogueira EFC, Carvalho PEFR, Soares MSM

occurrence of needlestick accidents, 42 professionals (52.5%) suffered accidents with this type of material during clinical practice. With respect to seroprevalence, two cases of hepatitis B and one case of hepatitis C were confirmed, representing prevalences of 2.5% and 1.25%, respectively. One professional was 50 years old and referred history of blood transfusion. The other two cases were aged 46 and 55, and mentioned they neglected the use of cap and goggles. The three cases had more than 20 years of graduation and all had history of needlestick accidents.

Proportion (%)

hepatitis C. Among these respondents, 18 dentists (22, 5%) had assisted patients known to have hepatitis B or C during their working life. In this study, it was also observed that the use of protective equipment in its complete set (cap, goggles, mask and glove) was used only by 21 professionals (26.25%). A total of 68.75% used it, except goggles. Other 53.75% said they did not wear cap, or were using only goggles, mask and gloves. Meanwhile, 1.25% said they did not use mask and gloves, i.e. only used cap and glasses (Fig 2). Concerning the

3 doses

2 doses

1 doses

0 doses

Unaware Figure 1: Sample distribution according to the vaccination schedule.

Proportion (%)

Vaccination scheme

O, GO, M, GL

O, M, GL

O, GO

GO, M, GL

PPE used

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Figure 2: Sample distribution according to use of PPE (C = cap; GO = goggles; M = mask; GL = glove).

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):29-33

Evaluation of prevalence for B and C hepatitis virus on dentist

DISCUSSION The professional activity of dentists exposes them to a large number of pathogenic microorganisms, including this professional in the risk group of occupational infections. This fact is a major concern, and the professional and health team should perform a safe clinical practice, adopting current standards of infection control. The most important pathogens to which dentists are susceptible include HBV and HCV. The stability of this virus and the possibility that a small amount of blood or secretions containing the agent is capable of transmitting the infection justify the hypothesis that HBV can be transmitted by inhalation of droplets, aerosols or by manual transport of infected particles to the mouth 6. The surface antigen of hepatitis B (HBsAg) in serum is used to detect the presence of active disease and status of chronic carrier7. Considering this hypothesis, there is a high risk of occupational infection of the dentist, emphasizing the importance to establish preventive biosecurity measures in the routine of these professionals. In a research8 conducted on a sample of 585 people in the city of Resende (Rio de Janeiro, Brazil), among health professionals (29.74%) and users (71.36%), it was observed that four participants were reagents anti -VHC and 18 anti-HBc. Among these, 15 were reactive for anti-HBs antibodies. Among health professionals, 68.8% were positive for anti-HBs, and 63.9% of participants reported being vaccinated against hepatitis B, demonstrating a prevalence of 0.68% for HCV and 3.08% for anti-HBc in the region. The literature has published studies on the occupational hazards of dentists in relation to hepatitis.1,2,3,4,5,8,9 The indices obtained from the serology study were 2.5% for hepatitis B and 1.25% for hepatitis C. The Ministry of Health6 describes the prevalence of hepatitis in Pernambuco as 3.3% for HBV and 2.3% for HCV. Thus, it appears that the prevalence of seropositivity in professionals of this study is consistent with rates collected from the local population, although there is the risk of occupational acquisition among these professionals. This low prevalence of infection with HBV and HCV in the study group can be explained by the vaccination rate and the use of personal protective equipment. Nogueira et al.9 described the experience in a dental school to reduce occupational risk related to

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

hepatitis B. This study included 242 students entering the institution with copies of vaccination cards, and it was observed that 100% were vaccinated, and 87.2% had vaccination records of three doses. Anti-HBs seroconversion was confirmed in 91.3% of students. Among the 20 individuals whose serology was negative, 9 students were monitored and repeated the basic vaccination and anti-HBs test, being that 8 seroconverted and 1 was considered non-responder, increasing the frequency of immune students to 95%. The remaining 11 (55%) did not have registry or there were no data about them in the analyzed documents. Camilo 10 conducted a study on the dentists at the Dental School of the Federal University of Rio de Janeiro and observed that there were no significant differences in the prevalence of HCV infection in dentists (1/231) compared with the control group (1/307). However, HBV serology results for individuals in the same sample showed a higher rate of infection in dentists (24/231) than in the control group (18/307). In this study, it is observed that the distribution of age/graduation time of respondents varied widely, covering all age groups. This is relevant because, as older professionals began operations in a time of dentistry in which PPE were not used and consequently contact with contaminated material was more significant. The literature reports that the number of infected professionals decreased over time and that older professionals had very high rates of infection compared to the current. Among the three cases identified in the present study, a professional infected with HCV had a history of blood transfusion, with the possibility of having contracted the virus in that transfusion. The other two cases were dentists who were aged 46 to 55 years, and during the interview, they said they used only mask and glove as personal protective equipment, overlooking the cap and goggles. Thus, occupational infection in dentists usually occurs due to needlestick accidents and/or by contact with contaminated body fluids and may result in complications in acute or chronic forms. Conversely, the opposite is also true about the possibility of transmission of infectious diseases by health professionals to their patients. In the current study, half of professionals reported needlestick accidents while working.

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):29-33

Leite Segundo AV, Nogueira EFC, Carvalho PEFR, Soares MSM

tient as a potential disease carrier. Proper protocols of infection and sterilization control must be followed to reduce the risk of infection. The dentists are at greater risk of exposure than other specialists in the medical area due to their exposure to ultrasonic aerosol. Thus, they should put emphasis on special prevention and protection against hepatitis. 13

According to the data obtained, the full vaccination rate of hepatitis was 75%. This result shows that a considerable percentage of individuals are susceptible to infection by hepatitis B. It is noteworthy that, even with the three recommended doses, the mean seroconversion is 95%, and there may be the need for a fourth dose.11,12 Among the positive HBsAg professionals, one patient had the three doses and the other did not receive any dose. In the first case, the professional may have contracted the disease before vaccination or there was no seroconversion. Thus, all health specialties that involve contact with mucosa, blood or blood contaminated with body fluids must ensure compliance with standard precautions and other methods to minimize the risk of infection.5 The role that a dentist may play in the prevention of hepatitis is to consider each and every pa-

CONCLUSION It is concluded that dentists in the city of Caruaru (Pernambuco, Brazil) showed a low prevalence of infection with hepatitis B and C, with presence of seropositivity professionals with over 20 years of graduation. Half of the professionals reported needlestick accidents, and a large number of professionals did not have complete vaccination for hepatitis B.

References:

1. Lavanchy D. Worldwide epidemiology of HBV infection, disease burden, and vaccine prevention. J Clin Virol. 2005 Dec;34 Suppl 1:S1-3. 2. Ferreira RC, Guimarães ALS, Pereira RD, Andrade RM, Xavier RP, Martins AMEBL. Vacinação contra hepatite B e fatores associados entre cirurgiões-dentistas. Rev Bras Epidemiol. 2012;15(2):315-23. 3. Negro F. Epidemiology of hepatitis C in Europe. Dig Liver Dis. 2014;46:5158-64. 4. Siravenha LG, Siravenha LQ, Madeira LDP, OliveiraFilho AB, Machado LFA, Feitosa RNM, et al. Detection of HCV Persistent Infections in the Dental Pulp: A Novel Approach for the Detection of Past and Ancient Infections. PLoS One. 2016 Oct 26;11(10):e0165272. 5. Dahiya P, Kamal R, Sharma V, Kaur S. “Hepatitis” Prevention and management in dental practice. J Educ Health Promot. 2015 May 19;4:33.

6. Brasil. Ministério da Saúde. Sistema Nacional de Vigilância em Saúde. Relatório de Situação: Pernambuco. 2ª ed. Brasília, DF: Ministério da Saúde; 2006. 7. Narasimhan M, Hazarey VK, Saranya V. Prevalence of Hepatitis B surface antigen in dental personnel. J Oral Maxillofac Pathol. 2015 Jan-Apr;19(1):34-6. 8. Silva AE, Ferreira OC Jr, Sá RSA, Correia AL Jr, Silva SGC, Carvalho Netto MAL, et al. HBV and HCV serological markers in health professionals and users of the Brazilian Unified Health System network in the city of Resende, Rio de Janeiro, Brazil. J Bras Patol Med Lab. 2017;53(2):92-9. 9. Nogueira DN, Ramacciato JC, Motta RHL, FonsecaSilva AS, Flório FM. Strategy to control occupational risk for Hepatitis B: impact on the vaccination and seroconversion rates in dentistry students. Rev Gaúch Odontol. 2018;66(1):8-14.

10. Camilo RS. Prevalência das hepatites B e C nos cirugiões-dentistas da Faculdade de Odontologia da UFRJ [tese]. Rio de Janeiro: Universidade Federal do Rio de Janeiro; 1998. 11. Informe Técnico Institucional. Vacina contra hepatite B. Rev Saúde Pública 2006; 40(6):1137-40. 12. Ferreira CT, Silveira TR. Hepatites virais: aspectos da epidemiologia e da prevenção. Rev Bras Epidemiol. 2004;7(4):473-87. 13. Dahiya P, Kamal R, Sharma V, Kaur S. “Hepatitis” Prevention and management in dental practice. J Educ Health Promot. 2015 May 19;4:33.

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):29-33

OriginalArticle

Prevalence of mandibular fractures of a tertiary

reference in trauma of São Paulo hospital,

EDUARDO VASQUEZ DA FONSECA1 | DANIEL FALBO MARTINS1 | RENATO CARDOSO1 | MANOEL ROQUE PARAÍSO SANTOS FILHO1 | LUCIANO HENRIQUE FERREIRA LIMA2

ABSTRACT Introduction: The mandibular region presents a high rate of involvement in facial trauma, generating functional and aesthetic damages. Objectives: The aim of this study is to outline the profile of patients with mandibular fractures treated at the Conjunto Hospitalar do Mandaqui, focusing on its etiology, age/sex ratio and anatomic region affected. Method: An epidemiological survey of patients diagnosed with mandibular fractures attended at the Conjunto Hospitalar do Mandaqui from January 2011 to January 2019 through the analysis of medical records and imaging tests. Results: From the 434 patients with maxillofacial trauma treated during the study period, 353 (81%) presented mandibular fracture with characteristics for inclusion in the study. The age group ranged from 2 to 78 years, male/female ratio was approximately 8:2. The main etiologies were traffic accidents (36.64%), aggressions (33.99%) and falls (15.58%). The most affected anatomic regions were the mandibular angle (26.72%), the mandibular body (24.22%) and the mandibular head (17.12%), and the coronoid process region was the least affected (0.42%). Conclusion: The prevalence and causes of mandibular fractures reflect the pattern of facial trauma of a population, and may help in the development of preventive measures, mainly to improve public policies for traffic safety and crime control. Keywords: Epidemiology. Mandibular fractures. Traumatology.

Conjunto Hospitalar do Mandaqui, Departamento de Cirurgia Bucomaxilofacial (São Paulo/ SP, Brazil). Pontifícia Universidade Católica de Minas Gerais, Departamento de Odontologia (Belo Horizonte/MG, Brazil).

How to cite: Fonseca EV, Martins DF, Cardoso R, Santos Filho MRP, Lima LHF. Prevalence of mandibular fractures of a tertiary hospital, reference in trauma of São Paulo. J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):34-9. DOI: https://doi.org/10.14436/2358-2782.5.3.034-039.oar

Submitted: February 07, 2019 - Revised and accepted: August 09, 2019 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. Contact address: Manoel Roque Paraíso Santos Filho Rua Butantã, 408, ap. 805, Pinheiros – São Paulo/SP CEP: 05.424-000 – E-mail: manoelctbmf@gmail.com

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):34-9

Fonseca EV, Martins DF, Cardoso R, Santos Filho MRP, Lima LHF

INTRODUCTION The face is a region of great importance for social life. It is used to show emotions, communicate, and it is where most of our sensory organs are located. Thus, injuries that affect the maxillofacial complex, besides the physical and functional sequels, also affect the personal and social relationships of the individual, and therefore are stigmatizing traumas.1 Mandibular fractures are the most common among facial fractures. They may occur in isolation or in combination with other facial injuries. The pattern of mandibular fractures is established in the literature of several countries and these statistics vary from one country to another, thus being evident that some of the variations can be assigned to social, cultural and environmental factors. 2,3,4 Most epidemiological studies put the mandible as the facial bone most affected by fractures, 5,6,7 corresponding to 36% to 70% of facial bone fractures; 8 others consider to be the second most frequently fractured body site, behind the fractures of nasal bones. 9,10 Despite having a dense and sturdy bone structure, the reason for this high prevalence may result from the fact that the mandible is projected in the lower facial third, making it vulnerable to the direct action of mechanical forces, besides its open arch shape, 5,8 in addition to noticeable process of atrophy after tooth loss. 8,9 The treatment of complex maxillofacial fractures remains a challenge for maxillofacial surgeons, requiring skill and a high level of expertise. Such epidemiological information can also be used to guide the future financing of public health programs for prevention. 11 For that purpose, researchers12 have conducted several studies on population groups from all continents, all with the common objective to attempt to elucidate the nature of mandibular fractures. The incidence of maxillofacial trauma varies according to the geographical location where the sample was collected, distribution and socioeconomic trends in the population studied, as well as the traffic laws and seasonal variations.1

Maxillofacial Surgery and Traumatology residency program at the Conjunto Hospitalar do Mandaqui (CHM). The study was approved by the Institutional Review Board of Conjunto Hospitalar do Mandaqui, Brazil (CAAE No. 04664918.500005551), with due consent of all involved organizations. Among the total of 434 patients with maxillofacial trauma, 353 were collected in a specific clinical form. The data (etiology, age, gender, topography) were collected from the medical records of patients in the period from January 01 2011 to January 01 2019. These data were entered into the trauma survey form. The collected data were expressed in tables and graphs (Microsoft Excel-2010) and then analyzed. The literature review included the following health databases: MEDLINE, LILACS, SciELO and BBO. The keywords used were: traumatology, epidemiology and mandibular fractures. The study was conducted at the Complexo Hospitalar do Mandaqui, which is a general teaching hospital at the tertiary level, being reference to trauma patients in the Brazilian Public Health System (SUS). Population and sample The study sample consisted of records of patients with mandibular fractures in the period January 01 2011 to January 01 2019. Inclusion criteria » Patients diagnosed with mandibular fractures treated at SUS. » Patients’ records filled properly. » Acceptance of proposed therapy. » Patients who agreed to participate and signed the informed consent form. Exclusion criteria » Incomplete patient records. » Non-acceptance of the proposed therapy. » Refusal to participate. » Patients treated outside the period proposed in this study. Data analysis Data were collected to fill the pre-established protocol with the information considered relevant for the study and are presented as graphs.

METHODS The study retrospectively evaluated the medical records of all trauma patients treated at the Oral and

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):34-9

Prevalence of mandibular fractures of a tertiary hospital, reference in trauma of SĂŁo Paulo

RESULTS Concerning gender, it was observed that 298 (84.42%) patients in the sample were males (Fig. 1). Concerning the age group, the most prevalent was between 21 to 30 years, including 121 (34.28%) patients, followed by the age group between 11 and 20 years of age, represented by 83 (23.51%) patients ( Fig. 2), and a minor involvement associated with the age between 0 and 10, by 8 (2.26%) patients, followed by the age group over 60 years old, which was formed by a sample of 14 (3.97%) patients. Regarding etiology, the most frequent report was car accidents with 129 (36.54%) patients, fol-

lowed by physical aggression with 120 (33.99%) patients and 55 falls (15.58%). The least significant etiological factor was work accident, represented by 10 (2.83%) patients. There were 8 (2.27%) patients with other causes (pathological fractures, following third molar extraction, etc.) (Fig. 3). Concerning the affected site, it was observed that 128 (26.72%) patients had fracture on the angle region, 116 (24.22%) on the mandibular body and 82 (17.12%) on the condyle. Among the affected sites in the mandibular region, fracture at the coronoid process region was only found in 2 (0.42%) patients (Fig. 4).

GENDER

MALE

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

FEMALE

Figure 1: Percentage distribution of patients according to gender.

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):34-9

Fonseca EV, Martins DF, Cardoso R, Santos Filho MRP, Lima LHF

AGE RANGE

0-10 YEARS

11-20 YEARS

21-30 YEARS

31-40 YEARS

41-50 YEARS

51-60 YEARS

MORE THAN 60 YEARS

WORD ACCIDENTS

CUNSHOT WOUND

OTHER CASES

Figure 2: Percentage distribution of patients by age.

ETIOLOGY

TRAFFIC ACCIDENT

PHYSICAL AGRESSION

FALLS

SPORTS ACCIDENTS

Figure 3: Percentage distribution of patients concerning the etiology.

nd yle

ss Ma

ibu

lar

pre ce

ch an Br Co ro

gle An

dy Bo

s sym ph ysi

Pa ra

Sy mp hy si

TOPOGRAPHY

Figure 4: Percentage distribution of patients by site involved.

Â© Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):34-9

Prevalence of mandibular fractures of a tertiary hospital, reference in trauma of São Paulo

DISCUSSION Trauma is a major public health problem in all countries, regardless of socioeconomic development, and is the third leading cause of mortality in the world, preceded only by cancer and cardiovascular diseases.13 The mandible is the only mobile bone in the face and is of paramount importance for functional activities as mastication, speech, swallowing and maintenance of dental occlusion, besides contributing to facial esthetics. Despite its high density, the mandible is prone to fractures, since it is an open arch, located at the lower facial region, related to hyperextensive and hyperflexive mechanisms of the head in car accidents and atrophy with age.4 Mandibular fractures account for most fractures in the facial skeleton and may be related to social, cultural, economic and environmental factors.13,14,15 The results of this study of patients with mandibular fractures who were treated at the Complexo Hospitalar do Mandaqui, SP, largely agree with the literature. Regarding the variable gender, the male to female ratio was 8: 2, similar to data in the literature, in which this ratio ranges from 3:1 to 5:1,11 since males are more exposed to the etiological factors associated with trauma. The study of Mayrink et al. 15 used a sample quantitatively similar to that employed in this study and obtained a similar male to female ratio. In regions where females have less social participation, such as the Middle East, this proportion reaches up to 11:1;4 however, some studies have reported an increased number of females with this fracture pattern, due to the greater participation of females in activities outside home, physical activities, car driving and increased urban violence.13 With respect to age, the literature indicates the age group of 21-30 years as the most affected by this trauma, which is in accordance with this study and can be justified by being an economically active age range, thus more susceptible.11,12,16 The elderly and children are little affected because they are most of the time in their homes and accompanied by caregivers.13 According to some authors, 7,14,17 the mandibular angle is the most affected anatomical region, which

confirms the findings presented in this epidemiological survey. However, other authors report the mandibular body, 10,18 symphysis/parasymphysis9,11 and condyle. 19 Therefore, the topography is not unanimous and varies across regions. Many studies indicate car accidents as the leading cause of mandibular fractures,12,13,16,20 since Brazil is in fifth place with regard to car accidents, being preceded by India, China, the United States and Russia,15 which was restated and presented in this study as the main cause. Also, another fact pointed out by other authors and worth mentioning is that the constant increase of the national population, especially in large urban centers, associated with social inequality and current stress levels, which are related to increased physical aggression among people assuming an important role in the etiology of facial trauma,11,21-24 observed in this survey as the second most common cause, with a slight difference from the first, as reported in the recent study of Mayrink et al.15 Therefore, with the data obtained in this survey, it is possible, by the evaluation of etiological factors most related to trauma, to create policies or approaches to solve or reduce this problem, particularly with regard to the impact of car accidents and physical aggressions. CONCLUSION Mandibular fractures occur in people of all ages and genders, in a variety of social contexts. The etiology often reflects changes in facial trauma patterns over the years. It is assumed that such epidemiological surveys, as the present, are useful for government agents and health professionals involved in the planning of future prevention and treatment programs. The analysis of results allowed to conclude that, in the observed sample: » The mean age ranged from 21 to 30 years. » The most affected gender was male, corresponding to 84.42% of the sample. » The most prevalent etiology was car accident. » The most affected anatomical region was the mandibular angle (26.72%).

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Fonseca EV, Martins DF, Cardoso R, Santos Filho MRP, Lima LHF

References:

1. Cardoso SO, Aragão-Neto AC, Pires ELM, Lôbo JS, Silva JJ, Vieira FLT. Análise epidemiológica do trauma mandibular em unidade de alta complexidade localizada em recife - PE. Odontol. Clín.-Cient. (Online). 2016;15(1):49-53. 2. Bamjee Y, Lownie JF, Cleaton-Jones PE, Lownie MA. Maxillofacial injuries in a group of South Africans under 18 years of age. Br J Oral Maxillofac Surg. 1996 Aug;3(4):298-302. 3. Abbas I, Ali K, Mirza YB. Spectrum of mandibular fractures at a tertiary care dental hospital in Lahore. J Ayub Med Coll Abbottabad. 2003;15(2):12-4. 4. Sarmento DJS, Cavalcanti AL, Santos JA. Características e distribuição das fraturas mandibulares por causas externas: estudo retrospectivo. Pesq Bras Odontoped Clin Integr. 2007;7(2):139-44. 5. Andrade Filho EF, Fadul RJ, Azevedo A, Rocha MAD, Santos RA, Toledo SR, et al. Fraturas de mandíbula: análise de 166 anos. Rev Ass Med Bras. 2000;46(3):272-6. 6. Vasconcellos RJH, Oliveira DM, Santos KPC, Calado MV. Métodos de tratamento das fraturas mandibulares. Rev Cir Traumatol Buco-Maxilo-Fac. 2001;1(2):21-7. 7. Sakr K, Farag IA, Zeitoun IM. Review of 509 mandibular fractures treated at the University Hospital, Alexandria, Egypt. Br J Oral Maxillofac Surg. 2006 Apr;44(2):107-11. 8. Raimundo RC, Guerra LAP, Antunes AA, Carvalho RWF, Santos TS. Fraturas de mandíbula: análise retrospectiva de 27 casos. Rev Cir Traumatol Buco-MaxiloFac. 2008;8(1):57-62. 9. Patrocínio LG, Patrocínio JA, Borda BHC, Bonatti BS, Pinto LF, Vieira JV, et al. Fratura de mandíbula: análise de 293 pacientes tratados no Hospital de Clínicas da Universidade Federal de Uberlândia. Rev Bras Otorrinolaringol. 2005;71(5):560-5.

10. Horibe EK, Pereira MD, Ferreira LM, Andrade Filho EF, Nogueira A. Perfl epidemiológico de fraturas mandibulares tratadas na Universidade Federal de São Paulo - Escola Paulista de Medicina. Rev Assoc Med Bras. 2004;50(4):417-21. 11. Sbardelotto BM, Garbin Júnior EA, Oliveira GR, Griza GL, Fleig CN, Sinegalia AC. Prevalência de fraturas mandibulares no serviço de residência em cirurgia bucomaxilofacial do Hospital Universitário do Oeste do Paraná. Arc Oral Res. 2013;9(3):269-78. 12. 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. 13. Botacin WG, Nakasome LF, Coser RC, Cancado RP. Epidemiology of OMFS surgical procedures of a public hospital. J Braz Coll Oral Maxillofac Surg. 2018 MayAug;4(2):38-44. 14. Motta Júnior J, Giovanini JG, Borges HOI, Higasi MS, Stabile GAV. Fraturas Mandibulares: Estudo Prospectivo de 52 Casos. Ciênc Biol Saúde. 2010;12(1):25-30. 15. Mayrink G, Avila NGA, Belonia JB. Epidemiological survey of face trauma in a public hospital in Vitória/ES (Brazil). J Braz Coll Oral Maxillofac Surg. 2018 SeptDec;4(3):42-7. 16. Montovani JC, Campos LMP, Gomes MA, Moraes VRS, Ferreira FD, Nogueira EA. Etiologia e incidência das fraturas faciais em adultos e crianças: experiência em 513 casos. Rev Bras Otorrinolaringol. 2006;72(2):235-41. 17. Gabrielli MAC, Gabrielli MFR, Marcantonio E, HochuliVieira E. Fixation of mandibular fractures with 2.0mm miniplates: review of 191 cases. J J Oral Maxillofac Surg. 2003 Apr;61(4):430-6. 18. Ellis III E, Moos KF, El-Attar A. Ten years of mandibular fractures: an analysis of 2137 cases. Oral Surg Oral Med Oral Pathol. 1985;59(2):120-9.

19. Matos FP, Arnez MFM, Sverzut CE, Trivellato AE. A retrospective study of mandibular fracture in a 40-month period. Int J Oral Maxillofac Surg. 2010 Jan;39(1):10-5. 20. Jardim ECG, Faverani LP, Gullineli JL, Queiroz TP, Magro-Filho O, Garcia-Júnior IR. Epidemiologia das fraturas mandibulares em pacientes atendidos na região de Araçatuba. Rev Bras Cir Cabeça Pescoço. 2009;38(3):163-5. 21. Ogundare BO, Bonnick A, Bayley N. Pattern of mandibular fractures in an urban major trauma center. J Oral Maxillofac Surg. 2003 June;61(6):713-8. 22. Atilgan S, Erol B, Yaman F, Yilmaz N, Ucan MC. Mandibular fractures: a comparative analysis between young and adult patients in the southeast region of Turkey. J Appl Oral Sci. 2010;18(1):17-22. 23. Cavalcanti AL, Damaceno de Lima IJD, Leite RB. Perfil dos Pacientes com Fraturas Maxilo-Faciais Atendidos em um Hospital de Emergência e Trauma, João Pessoa, PB, Brasil. Pesqui Bras Odontopediatria Clín Integr. 2009 Set-Dez;9(3): 339-45. 24. Massuia PDS, Silveira FGL, Assunção LF, Garcia ERBR, Sanches VM. Epidemiologia dos traumas de face do serviço de cirurgia plástica e queimados da Santa Casa de Misericórdia de São José do Rio Preto. Rev Bras Cir Plást. 2014;29(2):221-6.

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):34-9

CaseReport

Removal of sialolite in Wharton’s duct by electrosurgery:

case report

RODRIGO SOUZA CAPATTI1 | LUCAS RODARTE ABREU ARAÚJO1 | MARCELA SILVA BARBOZA1

ABSTRACT Sialolithiasis accounts for 30% of salivary gland morbidity. Characterized by the interruption of normal salivary flow due to the formation of calcified structures along the duct or in the glandular parenchyma, this condition, often underdiagnosed, can lead to pain, edema and infection of the affected region. The treatment methods cited in the literature are based on the characteristics of the lesion and vary between surgical and conservative. The present study presents a case report of the use of electrosurgery for the treatment of sialolithiasis in submandibular gland with immediate elimination of signs and symptoms reported by the patient, and absence of postoperative complications. Postoperative surgery and healing were satisfactory; there were no complaints on the part of the patient, which evolved without symptomatology during the follow-up period. The removal of intra-oral sialoliths using electrosurgery showed control of trans and postoperative hemorrhage and low morbidity. Keywords: Oral surgical procedures. Maxillofacial abnormalities. Salivary duct calculi.

Pontifícia Universidade Católica de Minas Gerais, Departamento de Odontologia (Belo Horizonte/MG, Brazil).

How to cite: Capatti RS, Araújo LRA, Barboza MS. Removal of sialolite in Wharton’s duct by electrosurgery: case report. J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):40-4. DOI: https://doi.org/10.14436/2358-2782.5.3.040-044.oar Submitted: March 06, 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: Lucas Rodarte Abreu Araújo Rua Lassance Cunha, 260, sala 04, Centro – Sete Lagoas/MG CEP: 35.700-006 – E-mail: lucasrodarte@hotmail.com

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):40-4

Capatti RS, Araújo LRA, Barboza MS

INTRODUCTION The sialolithiasis is the most common disease of salivary glands in adults, 1 being characterized by the formation of calcified structures inside the duct of glands or in the parenchyma, called salivary stones or sialoliths. Among the diseases that affect the salivary glands, sialolithiasis accounts for 30% of cases. 2 The etiology of sialolith may be divided into two major groups: salivary retention due to the morphological configuration of glandular ducts; and the saliva composition itself, such as pH and increased calcium concentration. 3-5 It occurs at a frequency of 12 in every 1,000 individuals, mainly adults (rarely occurring in children), there is no ethnic predilection and is more common in males. 6 In general, sialoliths measure 5 to 10 mm in their largest diameter. However, several studies report larger stones, with up to 56 mm 7. When they are larger than 10 mm, they are considered rare and classified as giant calculi. 8 Among the most common locations of sialolith, the submandibular gland accounts for 83% to 94% of cases, followed by the parotid (4% to 10%) and sublingual (1% to 7%), rarely reaching minor salivary glands. 9,10 The frequencies of these locations are explained by some authors because of the anatomical characteristics of the submandibular gland: tortuous, long and ascending duct, 11 and its positioning in relation to the excretory canal, besides the viscosity of saliva produced.12 Calculi are rigid bodies, of varying shape, yellow color and usually solitary in the affected region. 6 The symptoms may be reported as swelling and pain in the affected gland region; however, sialolithiasis may remain asymptomatic in many cases, diagnosed during routine examination.10 In cases of total obstruction of salivary flow, the patient can report constant pain and eventual purulent drainage in the region.13 The diagnosis is often defined by imaging studies such as panoramic and occlusal radiographs – the most commonly used exams – in which the sialolith appears as a radiopaque image in the areas of affected glands. 6 The appropriate treatment depends on the affected gland, location, and calculus size, and can vary from conservative approaches - such as hydration of the patient, and gland massage and drops of

acidic fruit (lime) – to surgical procedures, for larger calculi located in the glandular parenchyma. 14,15 Moreover, electrosurgery is an effective alternative compared to other incision methods, in relation to hemostasis and morbidity of the surgical procedure. 17 This study reports a case of sialolithiasis in submandibular gland removed by conservative electrosurgery, besides discussing the literature on the subject. CASE REPORT A female patient, of mixed Caucasoid-African descent, aged 25 years, attended a private clinic complaining of “swelling under the tongue and pain on swallowing”. In anamnesis, she did not report any systemic change nor any harmful habit. On clinical examination, edema was observed on the right sublingual region (Fig 1A), also noticed by extraoral observation. During palpation, a rigid consistency was noted, with interruption of salivary flow and painful symptoms. The patient reported pulpotomy in tooth 47 about 5 years earlier (she did not know the exact time) and therefore endodontic complications were suspected. Pulp sensitivity test was performed, which did not reveal changes, thus endodontic disorder was ruled out. No other clinical changes that could be associated were observed. In the first visit the patient brought a panoramic radiograph, which confirmed the absence of other changes and the presence of radiopaque area in teeth 42 to 44 (Fig 1B). An occlusal mandibular radiograph was requested, which evidenced the presence of a radiopaque body in the duct area, allowing a conclusive diagnosis of sialolithiasis of Wharton’s duct (Fig 1C). The selected treatment was removal by electrosurgery. After local anesthesia, the sialolith position was identified by palpation and transfixation was performed with nylon suture (4-0) immediately after the foreign body, to prevent it from penetrating deeper into the duct toward the gland during the procedure. An incision was made parallel to the duct, with approximately 15 mm, near the left sublingual caruncle, using an electric scalpel with small straight knife electrode, 67 mm (BP-100 Plus Transmai, São Paulo, Brazil) (Fig 2A). After slight tissue divulsion using 2.1 mm ball type electrode coupled to the electric scalpel, the sialolith was located and removed,

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):40-4

Removal of sialolite in Wharton’s duct by electrosurgery: case report

biotic (amoxicillin 1g), analgesics (sodium dipyrone 500mg) and rinse with 0.12% chlorhexidine digluconate. The suture was removed after 10 days, with good local healing and normalization of salivary flow (Fig 3B).

measuring approximately 12 x 5 mm (Fig 2B). The duct was flushed with saline and then a simple suture was performed joining the epithelial edges without collapsing the duct and keeping the orifice clear (Fig. 3A). The drug protocol used included anti-

Figure 1: A) Initial clinical intraoral image of the mouth floor, showing the preoperative aspect of the mucosa. B) Panoramic radiograph showing radiopaque image close to the region of teeth 43 and 44, suggesting sialolith. C) Occlusal radiograph showing radiopaque image lingual to teeth 44 and 45, suggesting sialolith.

Figure 2: A) Intraoral clinic image of the mouth floor, showing the appearance of the mucosa and sialolith after incision and divulsion of tissues with electric scalpel. B) Sialolith image after removal, showing its dimensions.

Figure 3: A) Intraoral clinical image of the mouth floor, showing the appearance of mucosa in the immediate postoperative period. B) Final intraoral clinical image of the mouth floor, showing the appearance of mucosa at 10 days postoperatively.

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):40-4

Capatti RS, Araújo LRA, Barboza MS

DISCUSSION Among the diseases of salivary glands, sialolithiasis accounts for 30% of cases. 2 The frequency of 12 in every 1000 individuals6 suggests that this morbidity is present in the daily clinic of the dentist, often undiagnosed by the professional. Most sialoliths are diagnosed in adult men; however, the present case was observed in a female patient. This gender predilection is not as significant as the patient age, and it rarely occurs in children.1 According to Arunkumar et al, 8 sialoliths greater than 10 mm are considered giant, but they may range from 5 to 56 mm 7. Symptoms as swelling and pain of the affected region in the gland may be related to the lesion size and its ability to block salivary flow in the region, while smaller calculi can remain asymptomatic for long periods and are only diagnosed in routine tests.10 The patient had complaints of slight increase in volume and pain in the sublingual region, which justified the complementary tests to define the diagnosis. Although the best method for precise location of sialoliths is cone beam computed tomography, images of the most commonly used tests to diagnose this type of change are the occlusal and panoramic radiographs. 6 The intention to request both exams is justified by the need of clinical treatment and general evaluation of the jaws (panoramic radiograph), besides the diagnosis of possible change in the sublingual or submandibular gland regions (occlusal radiography). The submandibular gland is affected in 83-94% of cases of sialolithiasis, 9-11 which agrees with the present report. Definition of the best treatment for sialolithiasis depends on the lesion characteristics: size, lo-

cation (glandular parenchyma or duct) and affected gland. Conservative treatments as gland massage, hydration, and use of moist heat secretagogues are reserved for smaller sialoliths, resulting in spontaneous expulsion of the calculus. 9 According to the present case, care related to duct dissection and sutures is essential to prevent postoperative complications, such as stenosis and fibrosis in the duct area, besides formation of saliva retention regions.16 The proposed surgical treatment is justified by the lesion size and increase in volume during clinical examination, 14,15 as well as preventive antibiotic therapy, which was given due to the presence of purulent exudate at the examination.13 The use of electric scalpel, compared to other sectioning methods, has better performance in relation to hemostasis at the operated region,17 which improves the field visualization and consequently access to the surgical area. Since 1914, the medicine uses this method to incise or promote tissue hemostasis tissue; also, the patients experience minimal or no postoperative morbidity.18 Electrosurgery has applications in several techniques in dentistry, even though it is rarely used. Regular users know from experience that, when applied in accordance with the principles, it is possible to obtain satisfactory and predictable wound healing.19 FINAL CONSIDERATIONS As described in the literature, there are several proposed methods for the treatment of this type of injury. Surgical removal by electrosurgery is an effective alternative, whose results are elimination of the signs and symptoms and restoration of normal function of the affected gland.

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):40-4

Removal of sialolite in Wharton’s duct by electrosurgery: case report

References:

1. Iqbal A, Gupta AK, Natu SS, Gupta AK. Unusually large sialolith of Wharton’s duct. Ann Maxillofac Surg [Internet]. 2012 [Access in: 2016 Feb 2];2(1):70-3. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?arti d=3591092&tool=pmcentrez&rendertype=abstract 2. Oliveira Filho MA de O, Almeida LE, Pereira JA. Sialolito Gigante Associado à Fístula Cutânea. Rev Cir Traumatol Buco-maxilo-facial. 2008;8(2):35-8. 3. Leung AK, Choi MC, Wagner GA. Multiple sialoliths and a sialolith of unusual size in the submandibular duct: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999 Mar [Access in: 2016 Mar 10];87(3):331-3. Available from: http://www.ncbi.nlm. nih.gov/pubmed/10102595 4. Silva-Junior GO, Picciani BLS, Andrade VM, Ramos RT, Cantisano MH. Asymptomatic large sialolith of Wharton’s duct: a case report. Int J Stomatol Occlusion Med [Internet]. 2010 [Access in: 2016 Jan 20];3(4):20810. Available from: http://link.springer.com/10.1007/ s12548-010-0062-4 5. Manzi FR, Gurgel F, Oliveira W, Silva AI V, Marigo H. Diagnóstico diferencial de sialolito na glândula parótida: relato de caso clínico. Rev ABRO. 2007;8(2):17-24. 6. Neville BW, Damm DD, Allen CM, Bouquot JS. Patologia oral e maxilofacial. 3a ed. Rio de Janeiro: Elsevier; 2009. 992 p. 7. Rauso R, Gherardini G, Biondi P, Tartaro G, Colella G. A case of a giant submandibular gland calculus perforating the floor of the mouth. Ear Nose Throat J. 2012 Jun;91(6):E25-7.

8. Arunkumar K V, Garg N, Kumar V. Oversized submandibular gland sialolith: a report of two cases. J Maxillofac Oral Surg [Internet]. 2015 Mar [2016 Oct 26];14(Suppl 1):116-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25838684 9. Jaeger F, Andrade R, López Alvarenga R, Fernandes Galizes B, Figueiredo Amaral MB. Sialolito gigante no ducto da glândula submandibular. Rev Port Estomatol Med Dent Cir Maxilofac. 2013;54(1):33-6. 10. Manzi FR, Silva AI V, Dias FG, Ferreira EF. Sialolito na Glândula Submandibular? Rev Odontol Bras Cent. 2010;19(50):270-4. 11. Branco BLC, Cardoso AB, Caubi AF, Pena GN. Sialolitíase: relato de caso. Rev Cir e Traumatol Bucomaxilo-facial. 2003;3(3):9-14. 12. Freitas A, Rosa E, Souza F. Radiologia Odontológica. 6a ed. São Paulo: Artes Médicas; 2004. 833 p. 13. Landgraf H, Assis AF, Klüppel LE, Oliveira CF, Gabrielli MAC. Extenso sialolito no ducto da glândula submandibular? Relato de caso. Rev Cir Traumatol Buco-maxilo-facial. 2006;6(2):29-34. 14. Gabrielli MAC, Gabrielli MFR, Paleari AG, Conte Neto N, Silva LMC, Dantas JFC. Tratamento de sialolitíase em glândulas submandibulares? Relato de dois casos. Robrac. 2008;17(44):110-6. 15. Cottrell D, Courtney M, Bhatia I, Gallagher G, Sundararajan D. Intraoral removal of a giant submandibular sialolith obstructing Wharton’s duct: a case report. J Mass Dent Soc [Internet]. 2011 [Access in: 2016 July 15];60(2):14-6. Available from: http://www.ncbi.nlm.nih. gov/pubmed/22128471

16. Mandel L, Alfi D. Diagnostic imaging for submandibular duct atresia: Literature review and case report. J Oral Maxillofac Surg [Internet]. 2012 [Access in: 2016 Aug 20];70(12):2819-22. Available from: http://dx.doi. org/10.1016/j.joms.2012.02.032 17. Hasar ZB, Ozmeric N, Ozdemir B, Gökmenoglu C, Baris E, Altan G, et al. Comparison of Radiofrequency and Electrocautery With Conventional Scalpel Incisions. J Oral Maxillofac Surg [Internet]. 2016 [Access in: 2017 Jan 20];2136-41. Available from: http://www.sciencedirect.com/science/article/pii/ S0278239116304906 18. Osman FS. Dental electrosurgery: general precautions. J Can Dent Assoc. 1982 Oct [Access in: 2017 Jan 10];48(10):641. Available from: https://www.ncbi.nlm. nih.gov/m/pubmed/6754035/ 19. Bashetty K, Nadig G, Kapoor S. Electrosurgery in aesthetic and restorative dentistry: a literature review and case reports. J Conserv Dent. 2009 [Access in: 2016 Sept 2]; 12(4):139-44. Available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC2879725/

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):40-4

CaseReport

Conservative treatment of ameloblastoma in mandible:

case report

ABSTRACT Ameloblastomas are slow-growing benign odontogenic tumors, locally invasive, that can reach varied proportions according to the time of evolution. The treatment of ameloblastomas has been controversial among surgeons. A patient with ameloblastoma in the mandible, treated by resection with conservative safety margin and of adjuvant therapies. After 4 years of follow-up without recurrence, the surgical defect reconstruction was performed by means of autogenous free graft from iliac crest and implant-supported dental prosthesis. After 9 years of follow up, the patient has no signs of recurrence and no esthetic and functional changes. Keywords: Ameloblastoma. Mandibular reconstruction. Mouth rehabilitation. Conservative treatment.

Universidade Federal de Minas Gerais, Programa de Residência em Cirurgia e Traumatologia Bucomaxilofacial, Hospital das Clínicas (Belo Horizonte/MG, Brazil).

How to cite: Gonçalves CL, Campos FEB, Lehman LFC, Chaves RRM, Lima FL, Castro WH. Conservative treatment of ameloblastoma in mandible: case report. J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):45-50. DOI: https://doi.org/10.14436/2358-2782.5.3.045-050.oar

Universidade Federal de Minas Gerais, Programa de Mestrado em Estomatologia (Belo Horizonte/MG, Brazil).

Submitted: 20/03/2018 - Revised and accepted: 03/09/2018 » 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: Camila Lopes Gonçalves Av. Marechal Mascarenhas de Moraes, 607, apto. 702, Centro – Vitória/ES CEP: 29.010-330 – E-mail: camila_clg@hotmail.com

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):45-50

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Conservative treatment of ameloblastoma in mandible: case report

INTRODUCTION Ameloblastoma (AM) is a benign epithelial odontogenic tumor, locally invasive and presenting slow growth. Its most common site is the mandible, especially in body and ramus regions. The AM has no gender predilection and affects patients of different ages, with peak prevalence in the third and fourth decades of life, being uncommon in people under 19 years.¹ Generally, the AM presents clinically as a painless swelling, resulting from expansion or destruction of the jaws.¹ The proportion of facial asymmetry caused by the lesion is related to the period of neoplasm evolution.¹ On radiographic or tomographic examination, the AM usually exhibits a unilocular or multilocular osteolytic image, lined by a radiopaque or hyperdense halo, besides expansion of the cortical bone. There may be impacted teeth, displacement and/or resorption of dental roots associated with the tumor.² The most common histopathological types of AMs are follicular and plexiform.² Other types as acanthomatous, granular cells, basal and desmoplastic cells, though rare, can also be observed. The histopathology of ameloblastoma consists basically of proliferation of epithelial cells that are arranged in varying patterns, which sometimes are present in the same tumor. The treatment of AMs is controversial. Due to its aggressive behavior and high tendency to relapse, the classic treatment is tumor resection with a safety margin in normal tissues. However, more conservative therapeutic approaches - including enucleation,³ curettage,¹ marsupialization4 or resection with smaller safety margins - have been proposed, particularly associated with supporting therapies as chemical cauterization (Carnoy’s solution),5 peripheral ostectomy1 cryotherapy (liquid nitrogen).1,4 The aim of this paper is to discuss the possibility for conservative treatment of ameloblastoma, by presenting the case of a patient affected by the tumor in the jaw, treated by lesion resection with a minimal safety margin and oral rehabilitation, with bone graft and implant-supported dentures, who did not present signs of neoplasm relapse after 9-year follow-up. The patient signed an informed consent in accordance with Resolution N. 466 of the National Health Coun-

cil, of December 12 2012, allowing publication of images in scientific journals. CASE REPORT A male patient, aged 22 years, attended the Oral and Maxillofacial Surgery and Traumatology Service of the Clinics Hospital at the Federal University of Minas Gerais for evaluation of asymptomatic lesion in the mandible. He reported no pain symptomatology, paresthesia, dysesthesia or hypoesthesia, and had no comorbidities. Extraoral and intraoral physical examination revealed no noticeable changes (Fig. 1A). However, the CT scan showed extensive hypodense image in the region of the symphysis and left mandibular body, multiloculated, with aspect of destruction and bone expansion, associated with teeth 31, 32, 33, 34, 35 and 41 (Fig 1B). An incisional biopsy confirmed the diagnosis of conventional AM (Fig 1C). By intraoral surgical access under general anesthesia, the tumor was removed using a minimal marginal resection of the mandible, with safety margin ranging between 5 and 10 mm, maintaining the lower border of the mandible, extracting the associated teeth and also tooth 42 (Fig 1D). Adjutant therapies as peripheral ostectomy over the entire lesion extent and application of Carnoy’s solution (3ml of chloroform, 6 ml of absolute ethanol, 1 ml of glacial acetic acid and 1 g of ferric chlorite) were performed for 5 minutes on the entire surgical field. After 4-year follow-up, with quarterly visits in the first year, at each semester in the second, and yearly from the third year, the clinical and imaging examinations should no lesion relapse. The patient was then submitted to a mandibular reconstruction procedure consisting of placing, by extraoral surgical access (submental), a free autogenous iliac crest bone graft, fixed with 2.0 System titanium plates (Fig 2). At five months after grafting, the region was rehabilitated by an implant-supported denture using four implants: three Cone Morse platform implant with 3.75 diameter and 13 mm mm length in the grafted area; and one implant in the position of molars, platform Cone Morse, with 5 mm diameter and 11 mm length (Fig 3A and 3B). After nine years of surgery for tumor resection, there were no signs of relapse and the patient was pleased with the treatment results (Fig 3B and 3C).

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):45-50

GonĂ§alves CL, Campos FEB, Lehman LFC, Chaves RRM, Lima FL, Castro WH

MENTUAL FORAMEN

Figure 1: A) Intraoral preoperative image, showing normal aspect. B) Computed tomography showing a hypodense image, well defined, multilocular, in the region of symphysis and left mandibular body. C) Lesion composed of nests and cords of odontogenic epithelial cells with solid growth pattern. Individually, the epithelial cells in the periphery were columnar, hyperchromatic, and arranged in palisade and similar to ameloblasts. In the central portion, cells presented loose arrangement similar to stellate reticulum of the enamel organ. Note cystic degeneration in focal areas. The stroma is fibrous and represented by vascularized connective tissue. D) Marginal resection of the mandible, with preservation of the base bone.

Figure 2: Surgical reconstruction of defect with free autogenous iliac crest bone graft, 4 years after tumor resection.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):45-50

Conservative treatment of ameloblastoma in mandible: case report

DISCUSSION In 2017, the classification of AMs was revised and simplified by the World Health Organization. These tumors were divided into ameloblastoma, unicystic ameloblastoma and extraosseous/peripheral ameloblastoma. The adjective “solid/multicystic” for conventional ameloblastoma was removed because it had no biological significance and could lead to confusion with the unicystic ameloblastoma. The desmoplastic ameloblastoma was reclassified as a histological subtype, and not as a clinical-pathological disorder.6 The treatment of AMs varies between more radical forms – as tumor resection, together with a significant amount of normal tissue, used as safety margin – to more conservative approaches, which include enucleation, curettage, marsupialization (unicystic AM) and resection with a minimal safety margin. In this case, we chose a conservative approach, combined with supporting therapy, considering the anatomical location of the tumor, histological type, size, clinical aspects and patient’s expectations after being informed about the possible treatment options. The literature reveals a 3.15 higher risk for relapse when AMs are treated conservatively. The relapse rate of AMs varies between 55 and 90% after conservative treatments and between 15 and 25% after more radical treatments1. However, we understand that, in selected cases of localized lesions of the mandible, which apparently respect the base cortical bone, the patient should be offered a more conservative treatment, keeping it under close and regular monitoring. Considering the local aggressiveness and high propensity for relapse of AM, its classic treatment recommended in the literature is radical tumor resection with a safety margin. The safety margin is prescribed in different manners, according to several authors. Gortzak et al.3 proposed a safety margin of 1 cm of apparently healthy bone, Gardner et al.7 suggested a marginal resection with 1.5 cm of mandibular bone apparently not compromised by the tumor, and removal of soft tissue margin in cases of tumors with basal cortical expansion. Williams8 proposed a resection with 2 cm of margin of normal bone and adequate margin of soft tissues free of tumor, as established by freezing biopsy. Other authors recommend bone margins even greater than 2 cm, for an appropriate resection.9

Figure 3: A) Intraoral aspect after rehabilitation with implants. B) CT scan showing implants placed and no relapse nine years after tumor resection. C) Axial mandibular section nine years after tumor resection, indicating no relapse.

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):45-50

Gonçalves CL, Campos FEB, Lehman LFC, Chaves RRM, Lima FL, Castro WH

usually respecting the periosteum as a barrier. Because of its benign nature, some surgeons believe that the initial treatment of AM should always be conservative, with radical treatment being reserved for relapses.1 Even when it occurs, relapse is initially small, discrete and localized, which facilitates further treatment when diagnosed early.5 Thus, we emphasize that the postoperative follow-up of patients treated for AM is imperative and should be as long as possible, regardless of the treatment modality employed. In the case of AMs in the maxilla, the resection with safety margin becomes the best indication for treatment because, in this bone, these tumors become dangerous and more difficult to treat due to the cancellous bone, proximity to the orbit, nasal fossa, pterygomaxillary and infratemporal spaces. Moreover, the relapse can escape between the ethmoid labyrinth and reappear at the cranial base.1,5 Variations in treatment techniques of ameloblastomas are observed, for the best benefit for patients. Before decision making regarding the treatment of ameloblastoma, factors as clinical and histopathological presentation of the tumor, lesion size, anatomical site involved, patient’s age, rate and condition of expected relapse, and possible physical, functional and psychological impacts, should be considered by the surgeon.10 It is clear that there are many variables in choosing the ideal treatment for AMs, which explains the great controversy on the subject in the literature. This case demonstrates that, when properly indicated, the conservative treatment combined with adjutant therapies, long-term follow-up and proper dental rehabilitation can assure the patient, in addition to curing the disease, a better quality of life after treatment.

In the case of AMs, more conservative treatment options should be considered, particularly when supporting therapies such as peripheral ostectomies, cryotherapy and chemical cauterization (Carnoy’s solution) can be provided. In this clinical case, the area of marginal mandibular resection was designed to involve all bone affected by the tumor, based on observation of a recent CT scan. The lateral limits of resection in alveolar bone ranged between 5 and 10 mm. However, it did not advance to the base bone beyond the tumor margins. Even though tooth 42 was not associated with the neoplasm, it was removed as a safety margin, even because its socket would be included in the peripheral ostectomy area. Peripheral ostectomy was performed around the surgical site, especially the mandibular base, after tumor removal. Finally, chemical cauterization was performed in the bone bed, using Carnoy’s solution for 5 minutes. Scientific evidence suggests that some treatment protocols for AMs should be revised.3 Authors who studied the growth pattern of large AMs in the mandible observed the presence of tumor cells in the bone marrow, at a maximum distance of 5 mm from the tumor mass. They also observed expansion and invasion of cortical bone by the lesion. The mucoperiosteal layer was affected, but not perforated, with the periosteum apparently acting as a kind of effective barrier against the tumor. There was no neoplasm in the inferior alveolar nerve and soft tissue above the periosteum. Finally, the present authors suggest a safety margin of 1 cm, observed from the tumor radiography.3 Especially in cases of AMs, we understand that curative surgery is the priority in patient treatment. However, we must reflect on the functional, esthetic and psychological sequels that can result from a more aggressive treatment, and the high morbidity and complexity of reconstructive surgery. Almeida et al.1, in a meta-analysis, found no statistically significant difference regarding the relapse rates between marginal bone resection with preservation of continuity and segmental resection of the jaw. These findings advocated the therapeutic option for this case. Therefore, during surgery, maintenance of the base portion of the mandible when it is not affected by the tumor is mandatory. Preservation of the mandibular line is essential to ensure the facial symmetry and facilitate dental rehabilitation. The AM does not change its biological behavior and there is no scientific evidence that relapse complicates the treatment1. This tumor has strong affinity with bone and rarely migrates into the soft tissues,

FINAL CONSIDERATIONS For the treatment of conventional ameloblastoma in the mandible, the surgeon should consider the accomplishment of a more conservative curative surgery, especially when supporting therapies may be employed. The patient’s cure with the lowest functional, esthetic and psychological disorder as possible should guide the therapeutic choice. ACKNOWLEDGMENTS We thank Professor Ricardo Alves Mesquita for his help in the case documentation.

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):45-50

Conservative treatment of ameloblastoma in mandible: case report

References:

1. Almeida RAC, Andrade ES, Barbalho JC, Vajgel A, Vasconcelos BC. Recurrence rate following treatment for primary multicystic ameloblastoma: systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2016 Mar;45(3):359-67. 2. Neville BW, Damm DD, Allen CM, Chi AC. Patologia Oral e Maxilofacial. 4a ed. Rio de Janeiro: Elsevier; 2016. 3. Gortzak RAT, Latief BS, Lekkas C, Slootweg PJ. Growth characteristics of large mandibular ameloblastomas: report of 5 cases with implications for the approach to surgery. Int J Oral Maxillofac Surg. 2006 Mar;35(8):691-5.

4. Seintou A, Martinelli-Klay C, Lombardi T. Unicystic ameloblastoma in children: systematic review of clinicopathological features and treatment outcomes. Int J Oral Maxillofac Surg. 2014 Apr;43(4):405-12. 5. Jahrad H, Sarah S, Mark M. Argument for the conservative management of mandibular ameloblastomas. Br J Oral Maxillofac Surg. 2016 Nov;54(9):1001-5. 6. Wright-John M, Vered M. Update from the 4th Edition of the World Health Organization Classification of Head and Neck Tumours: Odontogenic and Maxillofacial Bone Tumors. Head Neck Pathol. 2017 Mar;11(1): 68-77.

7. Gardner DG, Pecak AM. The treatment of ameloblastoma based on pathologic and anatomic principles. Cancer. 1980 Dec;46(11):2514-9. 8. Williams THP. Management of ameloblastoma: A changing perspective. J Oral Maxillofac Surg. 1993 Oct;51(10):1064-70. 9. MacIntosh RB. Aggressive surgical management of ameloblastoma. Oral Maxillofac Surg Clin North Am. 1991;3:73-97. 10. Amaral SM, Lehman LFC, Campos FEB, Cunha JF, Gomez RS, Castro WH. Ameloblastoma unicístico na mandíbula: relato de caso clínico. J Braz Coll Oral Maxillofac Surg. 2016 Jan-Abr;2(1):61-7.

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):45-50

CaseReport

Benign myoepithelioma of salivary gland in palate:

case report

RAFAEL SARAIVA TORRES1 | JOEL MOTTA JUNIOR1 | MARCELO VINICIUS DE OLIVEIRA1 | VALBER BARBOSA MARTINS1 | GUSTAVO CAVALCANTI DE ALBUQUERQUE1

ABSTRACT Myoepithelioma are rare tumors that represent at least 1% of salivary gland tumors. The majority is benign and the parotid gland is the most common site of the tumor, followed by the palate and submandibular gland. There is no predominance between the gender and the average age is 62 years old. It appears as a mass of slow growth, generally encapsulated, painless, which leads to a delay in diagnosis. Its malignant variant, even rarer, is characterized by invasion and local destruction, metastasis is rare. The aim of this work is report a case of benign myoepithelioma on the palate, in a female patient, presenting a 15-day increase in volume in the posterior region of the palate, approximately 2.5 cm in the larger diameter, sessile, painless, consistency resilient to palpation, presenting unchanged lining mucosa, which first diagnose was pleomorphic adenoma. An excisional biopsy of the lesion was performed, presenting a trans-surgical appearance of multiple blisters. Results: Histopathological analysis reached the diagnosis of benign myoepithelioma and no recurrence was observed after 2 years of removal of the lesion. The benign myoepithelioma is a rare tumor that if treated correctly, through surgical excision, presents minimal recurrence. Keywords: Myoepithelioma. Palate. Salivary gland neoplasms.

Universidade do Estado do Amazonas, Serviço de Cirurgia e Traumatologia Bucomaxilofacial (Manaus/AM, Brazil).

How to cite: Torres RS, Motta Junior J, Oliveira MV, Martins VB, Albuquerque GC. Benign myoepithelioma of salivary gland in palate: case report. J Braz Coll Oral Maxillofac Surg. 2019 SeptDec;5(3):51-5. DOI: https://doi.org/10.14436/2358-2782.5.3.051-055.oar Submitted: March 22, 2018 - Revised and accepted: September 02, 2018 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. » Patients displayed in this article previously approved the use of their facial and intraoral photographs. Contact address: Rafael Saraiva Torres Rua Dom Jackson D. Rodrigues, 733, Residencial Arezzo, bl. 01, apt. 303 – Manaus/AM CEP: 69.085-833

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):51-5

Benign myoepithelioma of salivary gland in palate: case report

INTRODUCTION Myoepitheliomas was first described in 1943 1,2. Most authors in the past considered it as an extreme variant of pleomorphic adenoma with predominant myoepithelial differentiation. 1 However, since 1991, the WHO classified the myoepithelioma as a distinct tumor, since these tumors were relatively more aggressive than pleomorphic adenoma. 2 Myoepithelioma is a rare tumor with less than 100 cases reported in the literature.2 It is a benign salivary gland tumor and most common in the parotid,1-5 accounting for less than 7% of salivary gland tumors. The minor salivary glands and submandibular glands may also be affected, as well as the hard and soft palate. 1 There is controversy about the classification of myoepithelioma, yet it may be divided into benign and malignant. The morphology of the tumor cell is varied with fusiform, plasmacytoid, epithelioid or clear cells. 2,3 These tumors occur in any age group from the first to the eighth decade of life, with peak incidence in the third and fourth.1-5 Only four cases have been reported in pediatric patients below 12 years of age.2 The benign lesion shows varied morphological growth pattern, and may be solid, myxoid or reticular with myoepithelial differentiation, differing from pleomorphic adenoma because it does not present a ductal component. 2 Clinically, it appears as a slow growing mass, generally encapsulated, circumscribed, with 1 to 5 cm in its largest diameter, usually asymptomatic and without gender predilection.1,2,3,6 The malignant myoepithelioma is also a very rare condition, accounting for less than 2% of salivary gland carcinomas, and the most common site is the major salivary glands, particularly the parotid. However, there are reports of involvement of hard palate. 7 Most cases occur in adults, especially in women, with rare reports in children.8 Over 50% of lesions originate from premalignant lesions: pleomorphic adenoma and benign myoepithelioma. It is characterized by local invasion and destruction, rarely presenting metastasis.7 Total surgical removal of the lesion with a margin of unaffected normal tissue is not the first treatment choice for benign myoepitheliomas. The

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

patients should undergo regular follow-up exams to rule out local relapse. Even though the prognosis of benign myoepitheliomas is very favorable, almost 7% of malignant transformation has been reported. 9,10 The objective of this study is to report a case of benign myoepithelioma treated by surgical excision with two-year postoperative follow-up, without evidence of relapse, to advise health professionals regarding the responsibility for the diagnosis. CASE REPORT A female patient aged 31 years old, of African descent, attended the Oral and Maxillofacial Surgery and Traumatology service complaining of a mass located on the palate, with evolution of 15 days, without pain complaints. The patient reported no systemic disorders or allergies. Upon physical examination, a nodular lesion was observed, resilient to palpation, presenting mucosal lining without alteration, with approximately 2.5 cm in its largest diameter, precisely in the division between hard and soft palate (Fig 1A). A CT scan was requested, which did not reveal any change in bone structures adjacent to the lesion (Fig 1B). According to clinical data of the lesion, the previous suspected diagnosis was pleomorphic adenoma. Surgical removal was performed in an outpatient setting under local anesthesia. Intra- and extraoral antisepsis was performed local anesthesia was applied with 4% articaine with epinephrine 1:100,000. A linear incision was performed on the palatal mucosa of the lesion with a number 15 scalpel, followed by dissection and dilatation until complete removal of the lesion, not involving the overlying mucosa. During the dilatation, the coated capsule was ruptured, and the macroscopic aspect was similar to multiple glands. A safety margin of approximately 5 mm around the lesion was removed. After removal, suture was performed with resorbable Catgut (Fig 2). Histological analysis showed multiple fragments of unmodeled dense connective tissue, showing clusters of oval cells with eosinophilic cytoplasm in plasmacytoid morphologic configuration, interpreted as neoplastic cells of myoepithelial origin compatible with benign myoepithelioma. The patient was followed for two years postoperatively, without signs of relapse (Fig 3).

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):51-5

Torres RS, Motta Junior J, Oliveira MV, Martins VB, Albuquerque GC

Figure 1: A) Intraoral aspect, evidencing lesion in the region between the hard and soft palate. Arrows indicate the limits of the lesion. B) CT scan showing no bone destruction on the palate or adjacent structures.

Figure 2: A) Incision on the lesion. B) Divulsion after incision of the lesion. C) Tumor removal. D) Macroscopic appearance (similar to multiple glands). E) Histopathological aspect (multiple unmodeled dense connective tissue fragments, showing clusters of oval cells with eosinophilic cytoplasm in plasmacytoid morphological configuration). F) Closure of the surgical site with Catgut suture.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):51-5

Benign myoepithelioma of salivary gland in palate: case report

Silveira et al2 stated that an aspect of interest about myoepitheliomas is the little information about their biological behavior, because of their low frequency. They are benign neoplasms whose relapse is usually associated with incomplete excision. They are rarely malignant; however, its transformation into myoepithelial carcinoma may occur in tumors with long-term evolution or cases of multiple relapses.8 Because of this, many papers consider it to be more aggressive than pleomorphic adenomas,1,2,6 while another study found no difference in the proliferative activity between myoepitheliomas and pleomorphic adenomas.2 The myoepithelioma should be distinguished from other salivary gland tumors, as well as their malignant variant and other soft tissue tumors that mimic myoepithelioma. Cytologically, there are four different types of myoepithelioma: spindle, plasmacytoid, epithelioid and clear cells. The pattern found in the present case was plasmacytoid. Surgical excision is the treatment of choice for myoepithelioma, with all the surveyed papers confirming this procedure. The relapse rate is extremely low if the entire lesion is removed. The patient in question has been followed for two years and no signs of relapse were observed. Ostrosky et al3 also stated that, due to the malignant transformation of the remaining primary disease, or due to regions that were initially malignant and were not included in the resection, this benign tumor should be removed with at least one small safety margin wherever possible, if its location permits. It is very important that both surgeon and pathologist should have experience with salivary gland tumors, since the lack of information may lead to the chance of misdiagnosis, followed by wrong management, thus causing damage, especially to the patient. The reviewed literature correlates the lack of experience of the pathologist and dentist, and mistakes during the surgical procedure as the major causes of wrong diagnosis of this pathology. 3,10

Figure 3: Aspect at 24 months postoperatively.

DISCUSSION Myoepitheliomas is a rare tumor, accounting for approximately 1.5% to 2% of all tumors of major and minor salivary glands8, primarily affecting the parotid gland,1,2,3,5,6 followed by tumors in minor salivary glands, e.g. located in the palate. 2 Some studies report that this neoplasm constitutes a rare type of pleomorphic adenoma. 9,10 However, according to Simpson et al,10 it differs from pleomorphic adenoma since it exhibits little or no duct component. There are few cases reported in the literature, approximately less than 100. It can affect a wide age range, from 9 to 85 years, with higher incidence in the third decade of life. 8 In the present case, the patient was in the fourth decade of life. 2,10 It affects males and females alike; however, studies indicate higher prevalence in males, different from the present case.2,3 Alike the present case, these tumors present as circumscribed, well-defined and encapsulated lesions, with resilient texture, painless and slow growing. 8 Politi et al9 state that only tumors in the parotid present capsule, in contrast to the present case, since a tumor with capsule though thin, was observed on the palate. The most common diagnosis is usually pleomorphic adenoma, as reported by Ostrosky et al3 and Padmaja et al,1 coinciding with the diagnostic hypothesis suggested in the case.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

FINAL CONSIDERATIONS Myoepithelioma is an extremely rare tumor and thus its diagnosis is often challenging. It is very important that professionals should be familiar with such diseases to achieve a correct diagnosis and effective treatment. The chances of relapse are minimal if the correct treatment, namely surgical excision, is successfully performed.

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):51-5

Torres RS, Motta Junior J, Oliveira MV, Martins VB, Albuquerque GC

References:

1. Padmaja RK, Anita PJ, Bhaswanth P, Fazil S. Plasmacytoid Myoepithelioma of the Hard Palate in a Child - A Rare Case Report Journal of Clinical and Diagnostic Research. 2015 Oct;9(10):ED01-2 2. Silveira EJD, Pereira ALA, Fontora MC, Souza LB, Freitas RA. Myoepithelioma of minor salivary gland Na immunohistochemical analysis of four cases. Rev Bras Otorrinolaringol. 2006;72(4):528-32. 3. Ostrosky A, Villa DM, González M, Klurfan F. Benign myoepithelioma: presentation of a case report. Rev Esp Cir Oral Maxilofac. 2007 SeptOct;29(5):336-41. 4. James J, Sciubba DMD, Robert B. Myoepithelioma of Salivary Glands: Report of 23 Cases. Cancer. 1982 Feb 1;49(3):562-72.

5. Barnes L, Appel BN, Perez H, El-Attar AM. Myoepithelioma of the head and neck: case report and review. J Surg Oncol. 1985 Jan;28(1):21-8. 6. Gore CR, Panicker NK, Chandanwale SS, Singh BK. Myoepithelioma of minor salivary glands - A diagnostic challenge: Report of three cases with varied histomorphology. J Oral Maxillofac Pathol. 2013 May-Aug;17(2):257-60. 7. Ludtke IN, Ramos GHA, Pedruzzi PAG, Bernades MVAA, Mauro FHO, Jung J. Um raro caso de mioepitelioma maligno de palato duro Rev Bras Cir Cabeça Pescoço. 2015 Out-Dez;44(4):185-6. 8. El-Naggar AK, Chan JKC, Grandis JR, Takata T, Slootweg PJ. WHO Classification of Head and Neck Tumours. 4th ed. Lyon: WHO; 2017. v. 9.

9. Politi M, Toro C, Zerman N, Mariuzzi L, Robiony M. Myoepithelioma of the parotid gland: Case report and review of literature. Oral Oncology Extra. 2005;41(6):104-8. 10. Simpson RHW, Jones H, Beasley A. Benign myoepithelioma of the salivary glands: a true entity? Histopathology. 1995 July;27(1):1-9.

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):51-5

CaseReport

Tissue expansion as an option for reconstruction of craniofacial defects and alopecia area:

Report of two cases

ABSTRACT The repair of defects by restoring the cranial vault in some cases is difficult because of the scalps inextensible tissue, which results in the unavoidable exposure of neighboring areas, or even the material used in the reconstruction, which represents a potential risk of infection and consequent surgical losses. The purpose of this article is to describe the technique of scalp expansion as an adjuvant step for the correction of cranial vault contour and the alopecia area, associated with trauma and as a sequela of previous surgical time. We used non-customized 480ml silicone expanders (SILIMED - Comércio de Produtos Médico-Hospitalares, LTDA - Rio de Janeiro - Brazil), with external valve, on the scalp to enable correction of cranial vault and alopecia area associated with craniofacial trauma sequelae. Expansion procedures, techniques and recommendations for insertion and removal of the expander are described. The previous tissue expansion of the scalp is a feature that allows adequate recoating of the craniofacial region to be reconstructed, avoiding exposure of the biomaterial and allowing the correction of alopecia area. Keywords: Tissue expansion. Skull. Reconstruction.

Hospital São Francisco na Providência de Deus, Serviço de Cirurgia e Traumatologia Bucomaxilofacial, Crânio-Maxilo-Facial e Reparadora da Face (Rio de Janeiro/RJ, Brazil). Universidade Federal Fluminense, Serviço de Emergência do Hospital Universitário Antônio Pedro (Niterói/RJ, Brazil). 3 Centro Universitário São José (UNISJ, Rio de Janeiro/RJ, Brazil). 4 Hospital Federal de Bonsucesso, Serviço de Cirurgia e Traumatologia Bucomaxilofacial (Rio de Janeiro/RJ, Brazil). 5 Centro Universitário Serra dos Órgãos, Programa de Residência em Cirurgia e Traumatologia Bucomaxilofacial (Teresópolis/RJ, Brazil). 6 Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Cirurgia, Estomatologia, Patologia e Radiologia (Bauru/SP, Brazil). 1

How to cite: Moraes SLC, Afonso AMP, Santos RG, Mattos RP, Brozoski M, Ribeiro J, Duarte BG, Ferreira BC. Tissue expansion as an option for reconstruction of craniofacial defects and alopecia area: Report of two cases. J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):56-63. DOI: https://doi.org/10.14436/2358-2782.5.3.056-063.oar

Submitted: July 17, 2018 - Revised and accepted: August 15, 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: Sylvio Luiz Costa de Moraes Rua: Conde de Bonfim, 211, sala 213, Tijuca – Rio de Janeiro/RJ CEP: 87.140-000 – E-mail: sdmoraes@yahoo.com.br

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):56-63

Moraes SLC, Afonso AMP, Santos RG, Mattos RP, Brozoski M, Ribeiro J, Duarte BG, Ferreira BC

INTRODUCTION Patients submitted to surgical procedures that result in loss of bone tissue evolve with retraction and/or atrophy of adjacent soft tissue. 1 Thus, it is necessary to recover the extent of soft tissue in the region, to allow adequate coverage of the area to be repaired, preventing complications as exposure of biomaterial, potential risk of infection and loss of the surgical goal. 2 However, the repair of soft tissue defects represents a significant challenge for repair surgery, 3 since the reconstruction of cranial contour, in some cases, is extremely difficult, due to the limited extensibility of the scalp, leading to the need of rotation flaps, which can result in cranial exposure of surrounding areas or even of the material used for contour reconstruction. 3 Techniques as local flaps, regional or distant, or free pedicles3,4 are described, but do not solve the issue of limited expansibility of the scalp. 3,4 The concept of tissue expansion for reconstruction of defects in the maxillofacial region was first proposed by Neuman in 1957 5,6 and later developed by Manders et al. in 1984 Radovan in 1984 and also by Van Rappard et al. in 1988.4 The scalp expansion technique is based on gradual tissue increase by a tissue expander located between the subgaleal plane and the pericranium. 7 The expander selection depends on the area to be reconstructed, the defect size,3,5,7 the existing “hollow effect”, and also an occasional surrounding area of alopecia,3,4 which can be repaired by advance of the hairy area of expanded tissue, thus covering the defect after resection of the glabrous skin area (Fig. 1A, 1B, 1C). The purpose of this paper is to describe the scalp expansion technique as a method of cranial vault contour correction and alopecia area associated with trauma, and/or as a sequel of previous surgical procedure.

Figure 1: A) Soft tissue retraction in the frontal region, resulting from craniofacial trauma that led to frontal bone loss. Tissue expander positioned in the occipital region to allow previous advance of scalp hair to reposition the hairline area. B) Area corresponding to the scalp loss. C) Reconstruction of the frontal region contour with biomaterial and anatomical repositioning of the hairline area, according to the characteristics of the patient’s face. D) Photograph 18 months postoperatively.

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):56-63

Tissue expansion as an option for reconstruction of craniofacial defects and alopecia area: Report of two cases

CASE REPORT Procedure for tissue expansion The expanders used by the authors were made of silicone with 480ml volumetric capacity, reference 830-480-3 (SILIMED - Comércio de Produtos Médico-Hospitalares, LTDA - Rio de Janeiro - Brazil), stock type, which may have semi-implanted (external) or implanted valves. The authors preferred to use the external valve for ease of handling. To use the expander, two operative times are necessary: » The first operative time aims at expander placement. Therefore, it is a unique, essential procedure. » The second operative time intends to remove the expander and also to perform cranioplasty and reconstruction of the hairy area. Therefore, it is an associated procedure.

compression without exceeding the incision limits, forming a “rectangular niche”, a “tunnel” for expander placement, as shown in Figures 2C and 2D. Before placing the expander and accommodating it in the created niche, two maneuvers should be performed: » First: making an “underwater inflation test” using a bowl with 0.9% saline covering the expander and then inflating it with air injected from a 60ml syringe, thus determining possible defects (perforations), followed by expander deflation using the same syringe. » Second: transfixation of incisions with nylon suture 3-0 (Black Nylon Monofilament – Ethicon – Johnson & Johnson do Brazil Ind. e Com. de Prod. para a Saúde, Ltda) without completing the knot, leaving them not stressed. The sutures should be sufficiently long to allow the introduction and accommodation of expander in the created niche. After this step, the sutures must be tied, properly occluding the incisions. The outer valve should exit through a small incision, by “counter opening”, lateral to the expander placement region. Then, initial injection of 5% of the total volumetric capacity8 of the expander is made to avoid “dead spaces” and excessive compression of the suture region.9 The authors recommend starting the expansion from the tenth day postoperatively to allow proper tissue healing, free from the action of tensile forces in the incision areas. Due to the limited extensibility of the scalp, it is recommended to inject 5% of the total volumetric capacity of the expander daily, allowing slow and gradual tissue expansion. The number of injections depends on the volume deemed necessary for adequate coverage of the biomaterial for contour reconstruction and/or alopecia area to be corrected. Between fifteen and twenty days of injections are usually required to obtain the desired expansion. The initial expansion should be considered in the total count of days. Using the external valve expander, the expansion will not depend on patient hospitalization. The expansion may be performed by the patient, relative or other health professional as instructed.

Expander insertion technique The initial incisions for expander placement must be performed adjacent to the area to be reconstructed, considering the flap planning to be used later. Under general anesthesia and orotracheal intubation, two incisions are performed with conventional scalpel blade 23 (Feather Safety Razor CO., Ltd. 3-70, Ohyodo Minami 3-chome, Kita-KU, Osaka, 531-0075 – Japan). The first and second incisions should have extension corresponding to the expander width plus 1.0 cm on each side and are parallel. These parallel incisions must be distant from each other, considering the greater defect distance plus 2.0 cm in each end,1 i.e. the distance between incisions is equal to the long axis of the defect plus four centimeters (defect in centimeters + four centimeters) (Fig 2A, 2B, 2C and 2D). If one of the incisions should be performed in the area near the hair implantation line, it should start at least 2.0 cm from the hair implantation line to prevent any noticeable and thus unesthetic scar. The authors recommend that the expander should not be directly positioned over the resulting defect of a prior craniotomy, since the progressive expansion may cause brain compression. The expander should be placed in a remote area at least 5.0 cm lateral to the defect (Fig 3). Between the parallel incisions previously made, detachment of the avascular region localized between the subgaleal plan and pericranium should be performed, allowing tissue dissection with lower

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):56-63

Moraes SLC, Afonso AMP, Santos RG, Mattos RP, Brozoski M, Ribeiro J, Duarte BG, Ferreira BC

Figure 2: A) Yellow dotted line = expander width; black lines = first and second incisions, parallel to each other and 1cm longer than the expander width. B) Red dotted line = defect long axis plus 2cm on each side; black lines = first and second incisions. C) Frontal view of surgical access for expander placement. External valve observed by counter opening. D) Posterior view of surgical access for expander placement. External valve observed by counter opening. E) 24-month postoperative image.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):56-63

Tissue expansion as an option for reconstruction of craniofacial defects and alopecia area: Report of two cases

Completion of reconstruction The cranial vault contour is then reconstructed, using the biomaterial fixed by titanium microplates and microscrews and repair of possible alopecia regions. The internal suture the scalp is performed with Vicryl 2-0 (Polyglactin 910 Suture - Ethicon - Johnson & Johnson do Brasil Ind. e Com. de Prod. para a Saúde, Ltda), and skin suture with metal sutures staplers SW 35 (VICARE SKIN Stapler - Victor Medical Instruments CO. Ltd. Changzhou - China. Ref PDSS35G). The use of vacuum drain with “counter opening” output with previously passed and fixed suture, and siphoning, avoids the formation of bloody collections and will be removed when the collection in 24 hours is smaller than 30 ml, which usually occurs on the second day postoperatively. At the time of drain removal, the knot is completed in the suture left in the small access to the externalization of the drain.

Conversely, the internal valve expander requires strict routine antisepsis, as well as knowledge of anatomical reference, important for proper transcutaneous insertion of the syringe needle in the valve region, which may require hospitalization for patients who live in remote areas, or daily outpatient visit to perform the injection for expansion. Expander removal technique In the second operative time, the access is usually performed through the scar from the neurosurgical procedure performed during the initial care immediately after trauma. The access allows expander extraction, thereby providing a scalp extension that enables wound closure without stress (Fig. 4). Due to adherence of the pericranium to the dura mater, the authors do not recommend detachment of these structures, to prevent meningeal lesions.

Ex er

nd ial an t Cr efec d

Figure 3: Red dotted line = 5cm distance between the cranial defect and the expander; black lines = first and second incisions.

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):56-63

Moraes SLC, Afonso AMP, Santos RG, Mattos RP, Brozoski M, Ribeiro J, Duarte BG, Ferreira BC

Figure 4: A) Access for expander removal and reconstruction of temporoparietal region contour. B) Detail of removed expander.

RESULTS The cases presented in this paper involve two male patients (Fig. 1 and 2), aged 28 and 26 years, respectively. The etiological factors were car accident (double crash) and motorcycle accident, respectively. The first patient (Fig 1) reported that he was using the safety belt at the time of the accident. The second patient (Fig 2) reported that he was not using a helmet at the time of the accident. Both patients had multiple trauma (presenting systemic trauma, such as traumatic brain injury [TBI], chest injuries, abdominal and orthopedic trauma), and required long hospital stay to recover and, after emergency care, they underwent neurosurgical procedures that resulted in craniotomy, with loss of cranial bone segment. The reason for the loss of the cranial segment is unknown. The first patient (Fig 1) had associated facial fractures and the second patient (Fig 2) had no facial fractures yet presented a Superior Orbital Fissure Syndrome (SOFS) as a sequel of cranioencephalic trauma. Concerning the present injuries, the first patient (Fig. 1) had frontal bone loss and extensive alopecia area, resulting from surgery that followed the initial care. The second patient (Fig 2) showed bone loss at the temporoparietal region and small area of alopecia, also due to the initial neurosurgical procedure.

Both patients underwent scalp expansion. In the first patient (Fig 1) an expander with total capacity of 500 ml was used, to which 480 ml were injected. In the second patient (Fig 2) an expander with total capacity of 480 ml was used, to which 360 ml were injected. Concerning reconstruction, both had the bone loss areas reconstructed with custom biomaterials. In the first patient (Fig 1) an HTR®-PMI prosthesis was used (Hard Tissue Replacement Patient-matched Implant - BIOMET MICROFIXATION, 1520 Tradeport Drive Jacksonville, FL 32218 - USA), and the second patient (Fig. 2) received a castor oil polymer prosthesis (Poliquil Polímeros Químicos, Rua Pedro José Laroca, 150 / B - 5° Distrito Industrial - 14808300 - Araraquara - São Paulo - Brazil). The prostheses were fixed with titanium miniplates and miniscrews. In the same surgery, the expanded areas, besides fully covering the prostheses, were used to correct the alopecia areas. DISCUSSION Tissue expanders revolutionized reconstructive surgery, allowing correction of scars7 and defects by flaps of the same color and texture 5,6 with better functional and esthetic results. One of the advantages of the use of expanders is the adequate defect coverage with minimal morbidity to the donor area, besides good vascularization of the flap skin.

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Tissue expansion as an option for reconstruction of craniofacial defects and alopecia area: Report of two cases

about the sequence of maneuvers for daily expansion, which occurs in cases of patients who are discharged and kept in outpatient control. Therefore, patients and families should have access to daily demonstration of saline injection maneuvers for expansion. The authors recommend delivering written instructions in accessible language to the patient’s family. It is noteworthy that patients with difficulty in understanding, either by neurologic or cognitive reasons, are indicated to receive the internal valve expander and maintenance of hospitalization. Combined treatment modalities are often necessary to obtain better results in various deformities, especially in craniofacial deformities. 4 Lesions in this location are a great challenge, since they involve multiple anatomical structures, and the use of expanders is presented as an effective option for reconstruction.

The Cranial, Oral and Maxillofacial Surgery and Traumatology and Face Repair Service of Hospital São Francisco (HSF, Rio de Janeiro) uses tissue expansion for such cases since 2003, with encouraging results. Cherry et al.10 demonstrated that advanced flaps of expanded tissue last 117% longer compared with random flaps advanced from unexpanded skin. Authors as Dos Santos Rubio et al 11 reported expansion on the frontal region, positioning the expander over the defect region, yet using a custom polymethyl methacrylate prosthesis between the expander and the brain tissue to prevent undesirable compression. The authors believe that this procedure requires a larger initial approach, which can be avoided by placing the expander laterally to the bone defect, as described in other studies. 7,8 The selection of the expander is determined by the craniofacial contour defect size. 5 The outer valves are much easier to handle; however, attention should be given to positioning of the valve outlet, avoiding areas under pressure during sleep. Proper positioning of the expander in relation to the defect area is an important step in the reconstruction technique. The transfixion of sutures prior to expander placement brings safety to avoid the risk of accidental punctures. The slow and gradual expansion enables painless expansion without risk of tissue suffering for the patient. As a method limitation, the authors highlight the possible lack of understanding by the patient

FINAL CONSIDERATIONS Tissue expansion is indicated for the treatment of multiple disorders. It is a safe and effective treatment option in cases of reconstruction of the craniofacial region, presenting a unique potential to preserve both the shape and function, preventing further scarring and decreasing the morbidity related to the need for a donor area. The previous tissue expansion of the scalp, in cases of secondary correction of cranial vault contour defects, is a safe treatment option, allowing proper coverage of the craniofacial region to be reconstructed, avoiding biomaterial exposure and correction of alopecia areas.

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Moraes SLC, Afonso AMP, Santos RG, Mattos RP, Brozoski M, Ribeiro J, Duarte BG, Ferreira BC

References:

1. Merlino G, Carlucci S. Role of systematic scalp expansion before cranioplasty in patients with craniectomy defects. J Craniomaxillofac Surg. 2015 Oct;43(8):1416-21. 2. Matsuno A, Tanaka H, Iwamuro H, Takanashi S, Miyawaki S, Nakashima M, et al. Analyses of the factors influencing bone graft infection after delayed cranioplasty. Acta Neurochir (Wien). 2006 May;148(5):53540; discussion 540. Epub 2006 Feb 9. 3. Handschel J, Schultz S, Depprich RA, Smeets R, Sproll C, Ommerborn MA, et al. Tissue expanders for soft tissue reconstruction in the head and neck area-requirements and limitations. Clin Oral Investig. 2013 Mar;17(2):573-8. 4. Carloni R, Hersant B, Bosc R, Le Guerinel C, Meningaud JP. Soft tissue expansion and cranioplasty: For which indications? J Craniomaxillofac Surg. 2015 Oct;43(8):1409-15. 5. McCarn K, Hilger PA. 3D analysis of tissue expanders. Facial Plast Surg Clin North Am. 2011 Nov;19(4):75965, x.

6. Lasheen AE, Saad K, Raslan M. External tissue expansion in head and neck reconstruction. J Plast Reconstr Aesthet Surg. 2009 Aug;62(8):e251-4. 7. Mobley SR, Sjogren PP. Soft tissue trauma and scar revision. Facial Plast Surg Clin North Am. 2014 Nov;22(4):639-51. 8. Moraes SLC, Afonso AMP, Santos RGD, Mattos RP, Duarte EBG. Reconstruction of the Cranial Vault Contour Using Tissue Expander and Castor Oil Prosthesis. Craniomaxillofac Trauma Reconstr. 2017 Sept;10(3):216-24. 9. Swenson RW. Controle da expansão do tecido na reconstrução facial. In: Baker SR. Retalhos Locais em Reconstrução Facial. 2a ed. Rio de Janeiro: DiLivros; 2009. p. 671-93. 10. Cherry GW, Austad E, Pasyk K, McClatchey K, Rohrich RJ. Increased survival and vascularity of random-pattern skin flaps elevated in controlled, expanded skin. Plast Reconstr Surg. 1983 Nov;72(5):680-7.

11. Santos Rubio EJ, Bos EM, Dammers R, Koudstaal MJ, Dumans AG. Two-Stage Cranioplasty: Tissue Expansion Directly over the Craniectomy Defect Prior to Cranioplasty. Craniomaxillofac Trauma Reconstr. 2016 Nov;9(4):355-60.

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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.

• The manuscripts should have at most 2,500 words, including the abstract, references and legends of figures and tables (yet excluding data on the tables). • A maximum of four authors are allowed for case reports and six authors for research manuscripts. If more authors are included, the participation of each author in the manuscript must be informed. • The figures should be submitted as separate files. • The figure legends should also be included within the text, to guide the final formatting of the paper. • Title page: this page should contain only the manuscript title, in Portuguese and English languages, which should be as informative as possible, composed of at most 8 words. This page should not include information related to the identification of authors (e.g. full author names, academic degrees, institutional affiliations and/or administrative roles). This should only be included in specific fields in the manuscript submission website. Therefore, this information shall not be visible for the reviewers. ABSTRACT • Structured abstracts, in Portuguese and English, with 200 words or less, are preferred. • Structured abstracts should contain the following sections: INTRODUCTION, presenting the study objective; METHODS, describing how it was conducted; RESULTS, describing the primary outcomes; and CONCLUSIONS, reporting the study conclusions and clinical implications of the outcomes. • The abstracts should also present 3 to 5 keywords, also in Portuguese and English, which should comply with DeCS (http://decs.bvs.br/) and MeSH (www.nlm.nih.gov/mesh).

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

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Information for authors

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

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

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

Figures • The digital images should be sent in JPG or TIFF format, with at least 7cm width and 300dpi resolution. • They should be submitted as separate files. • If a figure has been previously published, its legend should mention the original source. • All figures should be cited in the text.

Institutional review board If applicable, the manuscripts should mention the Institutional Review Board approval. Copyright transfer Assigning the manuscript copyright to Dental Press, in case the manuscript is published.

Graphs and cephalometric tracings • These should be cited in the text as figures. • The authors should send the files containing the original versions of graphs and tracings, in the softwares used for their preparation. • The submission of images in bitmap format (not editable) is not recommended. • The submitted drawings may be enhanced or redesigned by the journal production, as indicated by the Editorial Board.

Conflict of interest If there is any interest of the authors concerning the study objective, it should be explicitly mentioned. Human rights and animal protection If applicable, the authors should mention the compliance with international institutions for protection and the Helsinki declaration, following the ethical guidelines of the human/animal institutional review board. In case of studies on humans, the authors should mention the approval by the Institutional Review Board, according to Resolution 466/2012 CNS-CONEP.

Tables • The tables should be self-explanatory and should complement, but not duplicate the text. • Tables should be numbered in Arabic numbers, in order of appearance in the text. • Each table should have a short title. • If a table has been previously published, a footnote should be included mentioning the original source. • The tables should be submitted as text files (e.g. Word or Excel), and not as graphs (non-editable image).

Permission to use copyrighted images Illustrations or tables, either original or modified, from copyrighted material should be accompanied by permission of utilization granted by the copyright owners and the original author (and the legend should properly refer the source). Informed consent The patients have right to privacy, which should not be violated without an informed consent. Identifiable photographs of individuals should be accompanied by a consent form signed by the person or the parents or caretakers, in case of underage individuals. These authorizations should be kept indefinitely by the manuscript author. A cover letter should be submitted stating that all patients’ consents were obtained and are stored by the corresponding author.

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

J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):64-8

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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Revista JBCOMS - Volume 5, Number 3, 2020

Articles inside

Information for authors

Tissue expansion as an option for reconstruction of craniofacial defects and alopecia area: Report of two cases

Prevalence of mandibular fractures of a tertiary hospital, reference in trauma of São Paulo

Indication for extraction of impacted third molars: Cross-sectional study

Conservative treatment of ameloblastoma in mandible: case report

Removal of sialolite in Wharton’s duct by electrosurgery: case report

Evaluation of prevalence for B and C hepatitis virus on dentist

Interview

Benign myoepithelioma of salivary gland in palate: case report

A cycle that ends