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

es.

Mandibular Advancement

College of Oral and Maxillofacial Surgery Volume 6, Number 2, 2020 - ISSN 2358-2782

Acompanhe de perto o tratamento ClearCorrect de seus pacientes, e agende consultas somente quando necessário.

Mandibular Advancement

Journal of the Brazilian

Maxillary Advancement with Mandibular

Total Arch Restoration (Implant Supported fixed bridge)

Implant (Anterior Socket Grafting) CONSULTAS EFICIENTES

Volume 6, Number 2, 2020

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J Braz Coll Oral Maxillofac Surg. 2020 May-August;6(2):1-84

ISSN 2358-2782

Journal of the Brazilian

College of Oral and Maxillofacial Surgery JBCOMS

Since 2016

International Cataloging Data on Publication (CIP) _______________________________________________________________________ Journal of the Brazilian College of Oral and Maxillofacial Surgery v. 1, n. 1 (jan./abr. 2015). – Maringá: Dental Press International, 2015.

DIRECTOR: Bruno D’Aurea Furquim - EDITORIAL DIRECTOR: Bruno D’Aurea Furquim - Rachel Furquim Marson - EDITORIAL PRODUCER: Júnior Bianco - DESKTOP PUBLISHING: Gildásio Oliveira Reis Júnior - ARTICLES SUBMISSION: Stéfani Rigamonte - Caio dos Santos - Ana Carolina Fernandes - REVIEW/COPYDESK: Ronis Furquim Siqueira - COMMERCIAL DEPARTMENT: Roseneide Martins Garcia - LIBRARY/NORMALIZATION: Simone Lima Lopes Rafael - DISPATCH: Rui Jorge Esteves da Silva - FINANCIAL DEPARTMENT: Mônica Ecks Rabecini HR: Rosana Araki. O Journal of the Brazilian College of Oral and Maxillofacial Surgery (ISSN 2358-2782) Is a journal

Quarterly ISSN 2358-2782

published three times a year of Dental Press Ensino e Pesquisa Ltda. – Av. Dr. Luiz Teixeira Mendes, 2.712 – Zona 05 – ZIP code: 87.015-001 – Maringá/PR – Brazil. All published articles are the exclusive responsibility of the authors. The opinions expressed do not necessarily correspond to the opinions of the Journal. Advertising services are the responsibility of advertisers. Subscription: dental@dentalpress.com.br or Tel./Fax: +55 44 3033-9818.

1. Cirurgia Bucomaxilofacial. I. Dental Press International.

CDD 21 ed. 617.605005 _______________________________________________________________________

Journal of the Brazilian College of Oral and Maxillofacial Surgery - Qualis/CAPES: B4 - Dentistry

EDITOR-IN-CHIEF Sylvio Luiz Costa de Moraes

ASSOCIATE EDITOR-IN-CHIEF Jonathan Ribeiro

SECTION EDITORS

Oral Surgery Alejandro Martinez 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 Federal Fluminense - Niterói/RJ / Centro Universitário São José - São José/RJ - Brazil UNIFESO / UNISJ - São José/RJ - Brazil

Private practice - Mexico 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

Rodrigo dos Santos Pereira

Waldemar Daudt Polido

Trauma

Aira Bonfim Santos

Florian Thieringer

Leandro Eduardo Kluppel

Liogi Iwaki Filho

Márcio Moraes

Nicolas Homsi

Otacílio Luiz Chagas Júnior Ricardo José de Holanda Vasconcellos

Universidade Federal de Santa Catarina - UFSC - Florianópolis/SC - Brazil University Hospital Basel - Switzerland 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 Federal de Pelotas - UFPEL - Pelotas/RS - 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

Paul Maurette

Rafael Alcalde

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 Centro Médico Docente La Trinidad - Venezuela South Miami Hospital - USA 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 - India

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 Centro Universitário Serra dos Órgãos - UNIFESO - Teresópolis/RJ - Brazil Private practice - 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 - USA

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 - Brazil Universidade Federal do Maranhão - UFMA - São Luís/MA - Brazil Universidade Federal do Maranhão - UFMA - São Luís/MA - Brazil Hospital Federal de Bonsucesso - Rio de Janeiro/RJ - Brazil

table of contents

4

Case Reports and Ethics Committees Sylvio Luiz Costa de Moraes

6

CBCTBMF supports the Brazilian Consensus for Multisectoral Ethical Collaboration in healthcare sectors José Rodrigues Laureano Filho

13

Interview Fernanda Boos Lima

16

Covid-19 pandemic caused 92.5% drop in elective oral maxillofacial surgeries, reveals unprecedented survey Belmiro Cavalcanti do Egito Vasconcelos, José Rodrigues Laureano Filho

Articles

17

Anatomical and clinical implications of third molars displacement into deep fascial spaces: two cases report

27

Recurrent luxation of TMJ treated with hemotherapy and intermaxillary fixation

32

Desmoplastic ameloblastoma in mandible: case report

39

Treatment of mandibular angle fracture with grid plate: case report

44

Immunocompromised and descending necrotizing mediastinitis: case report

50

Alloplastic reconstruction of temporomandibular joint: indications and contraindications

56

A critical view of medical hegemony in relation to dentistry, in urgency and emergency care

60

Evaluation of nasal permeability after treatment of fractures

68

Evaluation of postoperative infection after third molars extraction

74

Incidence of facial trauma in a hospital at Bauru city

80

Information for authors

Rafael Correia, Isabela P. Bergamaschi, Marina Fanderuff, Nelson Luis B. Rebellato, Delson J. Costa, Leandro E. Kluppel, Rafaela Scariot

Saulo Chateaubriand Nascimento, Marcelo Vinicius de Oliveira, Gustavo Cavalcanti Albuquerque, Valber Barbosa Martins, Joel Motta Júnior

Maylson Nogueira Barros, Vitor Bruno Teslenco, Diogo Henrique Marques, Herbert de Abreu Cavalcanti, Guilherme Nucci Reis, Everton Floriano Pancini

Felippe Almeida Costa, Rogério Almeida da Silva, Fábio Ricardo Loureiro Sato, Lucas Martins de Castro e Silva

Anna Carolina Jaccottet Oliveira, Natasha Magro Ernica, Ricardo Augusto Conci, Geraldo Luiz Griza, Eleonor Álvaro Garbin Júnior

Leandro E. Kluppel, Caio Augusto Munuera Ueti

Beatriz Sobrinho Sangalette, Thayna da Silva Emídio, Marcos Mauricio Capelari, Cláudio Maldonado Pastori, Rafaella Ferrari Pavoni, Gustavo Lopes Toledo

Márcio Menezes Novaes, Adriano Rocha Germano, Leandro Barbosa Ribeiro, José Sandro Pereira da-Silva

Bruna de Lima Rigo, Eleonor Álvaro Garbin Júnior, Luiza Roberta Bin, Mauro Carlos Agner Busato, Ricardo Augusto Conci, Mateus Diego Pavelski

Angie Patricia Castro-Merán, Bruno Gomes Duarte, Eduardo Stedile Fiamoncini, Patricia Frare Campos, Osny Ferreira Júnior, Eduardo Sanches Gonçales

Editorial

Case Reports and Ethics Committees

Some collaborators have questioned the need to submit “Case Report” publications to Institutional Review Boards.

We should remember some important points about this type of publication.

It is a type of study in the health area with a descriptive design, without control group, of narrative and reflective nature, whose data come from daily practice or professional activity. Obviously, it is understood that, at the time of preparation of the case report, the reported events will be finished, thus no experiments are planned as study objectives.

They are ethically acceptable, as long as the precepts related to the privacy of participants, confidentiality of data and human dignity are respected.

However, they are not exempt from risks and they may break the confidentiality, resulting in material and moral damage to the participant and third parties.

When using the images of the participant, authorization to use the images must be obtained by an Informed Consent Form (ICF) or a separate document.

How to cite: Moraes SLC. Case Reports and Ethics Committees. J Braz Coll Oral Maxillofac Surg.

2020 May-Aug;6(2):4-5. DOI: https://doi.org/10.14436/2358-2782.6.2.004-005.edt

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Editorial

In order to clarify the subject, the National Committee of Research Ethics (CONEP) – according to the Resolutions of the National Health Council (CNS) n. 466, of 2012, and n. 510, of April 07th, 2016 – guided the Institutional Review Boards (IRB) and researchers, by the Letter 166/2018-CONEP/SECNS/MS of June 12th 2018, on the procedures for submission to the IRB, via Plataforma Brasil, in relation to both Case Reports and Case Report Projects.

Considering the aforementioned aspects, the editors advise that all “Case Report” should fully meet the recommendations of CONEP, so that they can be published.

We rely on the collaboration of all for the progress of our important journal.

Prof. Sylvio Luiz Costa de Moraes Editor-in-Chief of JBCOMS Journal of Brazilian College of Oral and Maxillofacial Surgery

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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J Braz Coll Oral Maxillofac Surg. 2020 May-Aug;6(2):4-5

Letter from the President

CBCTBMF supports the Brazilian Consensus for Multisectoral Ethical Collaboration in healthcare sectors

How to cite: Laureano Filho JR. CBCTBMF supports the Brazilian Consensus for Multisectoral Ethical Collaboration in healthcare sectors. J Braz Coll Oral Maxillofac Surg.

2020 May-Aug;6(2):6-7.

DOI: https://doi.org/10.14436/2358-2782.6.2.006-007.crt

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

The first semester of 2020 was marked by great changes in the lives of everyone, and it was not different for the College. We had the great challenge of reprogramming the Brazilian Congress of Oral and Maxillofacial Surgery and Traumatology (COBRAC 2020) for November 4th to 7th 2020 in Belém/PA, and we continue the work to make this event the largest meeting of the specialty in Latin America.

Also, the current board remains strongly involved in aspects related to professional defense.

In February, the Federal Medical Council (CFM) revoked the CFM Resolution N. 1950/2010 and published another (CFM N. 2272 of February 14th 2020). Thus, the Brazilian College of Oral and Maxillofacial Surgery and Traumatology (CBCTBMF) suggested a document to the Federal Dental Council (CFO) with important points for a possible new resolution to be issued by this Council, to provide clarity and legal security to oral and maxillofacial surgeons in relationships inherent to the clinical practice. The text recognizes that the CFO must decide on dental law, as well as determine the fields of work of Dentistry; the text considers several topics of the activity and suggests some articles.

We have always advocated that surgical procedures for facial harmonization should only be performed by dental professionals specialized in Oral and Maxillofacial Surgery, and that it is necessary to create a favorable environment for that purpose, such as thoroughly including the subject in congresses and implementing training and update courses in the country and abroad, with clear rules to assure a good formation and update. Therefore, we are already taking all necessary steps so that CFM Resolution N. 2,272, of February 14th 2020, does not harm us, even though we know that the effects of the MEDICAL ATT do not “affect” us and that our field of work is protected by LAW 5081 and CFO resolutions.

But we also look at our own problems and the CBCTBMF emphasized, in one of its Communications, the Dental Code of Ethics, which regulates the activities of dentists and legal entities that perform activities in the field of Dentistry in the public and/or private sectors. Due to the constant complaints about the performance of surgeons who work with audit, the

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J Braz Coll Oral Maxillofac Surg. 2020 May-Aug;6(2):6-7

Carta do Presidente

CBCTBMF released its Dental Code of Ethics and warned that we should be attentive to possible misconduct. We also advised the oral and maxillofacial surgeons to report directly to the regional councils in which that person is registered, as well as to defend those oral and maxillofacial surgeons who work with audit and act in a coherent and impartial manner, following the protocol of rational use of special materials of the CBCTBMF. We held a meeting, by videoconference, with presidents of several Regional Dental Councils (CROs). The goal was to discuss the future of the specialty in Brazil and to continue to work relentlessly, so that our specialty remains recognized and valued.

Considering the current pandemic and aiming at always providing the best conduct to patients and professionals, with all possible safety, CBCTBMF has published in the website www.bucomaxilo.org.br a Guide to Practices in Oral and Maxillofacial Surgery and Traumatology, based on the most recent available information, experiences and expert guidance.

We further emphasize that the Guide contains only recommendations, and that the decision in the treatment of patients is still up to the professional, individually.

Also considering the reality imposed by the new coronavirus and the real need to regulate the dental teleconsultations, aimed at screening urgent cases, postoperative evaluations, elucidation of doubts and treatment plans, based on all legal information, we requested the Federal Dental Council to regulate the Teledentistry, so that dental professionals may be legally supported to provide remote assistance to the countless patients who are and will still be unassisted for some time. In this sense, we are following the Law Project 1253/20, which is being discussed in the Deputy Chamber, proposed by Deputy Patricia Ferraz (PODE/AP) and which regulates the distance dental treatment on a temporary basis. According to the text, Teledentistry, when possible, may include pre-clinical care, assistance support, consultation, monitoring and diagnosis, by information and communication technology, both in the Public Unified Health System (SUS) and in private health. The attendance should occur directly between dentist and patient, ensuring the confidentiality of information.

Last, but not least: this year, the CBCTBMF celebrates its 50th anniversary, always fighting for its specialty, especially in difficult times. Great surgeons and professors of this renowned entity were responsible for historical achievements in the specialty and obviously in Dentistry. For this reason, we continue to reinforce the need for thorough and strict training as an essential requirement, so that we can follow the evolution of surgical techniques and gain space with respect in the job market.

We continue to defend our specialty!

Hugs to everyone!!!

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

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

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J Braz Coll Oral Maxillofac Surg. 2020 May-Aug;6(2):6-7

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Interview

Interview with Fernanda Boos Lima

» Residency in Oral and Maxillofacial Surgery and Traumatology at Londrina State University (UEL). » MSc in Oral and Maxillofacial Surgery and Traumatology by São Paulo State University (FOA Unesp – Araçatuba). » PhD in Oral and Maxillofacial Surgery and Traumatology by São Paulo State University (FOAR Unesp – Araraquara). » Adjunct Professor of Oral and Maxillofacial Surgery and Traumatology at the Federal University of Minas Gerais (UFMG). » Effective member of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology.

How to cite: Lima FB, Ribeiro J. Interview with Fernanda Boos Lima. J Braz Coll Oral Maxillofac Surg.

2020 May-Aug;6(2):13-5.

DOI: https://doi.org/10.14436/2358-2782.6.2.013-015.oar Submitted: July 06, 2020 - Revised and accepted: July 16, 2020

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Interview

How is the specialty of Oral and Maxillofacial Surgery and Traumatology defined by the Consolidation of Norms for Procedures in Dental Councils, approved by the resolution of the Federal Dental Council CFO-63/2005? And what are the specialty's assignments?

According to the Consolidation of Norms for Procedures in Dental Councils, Oral and Maxillofacial Surgery and Traumatology is the specialty that aims at the diagnosis and surgical and supporting treatment of diseases, traumas, injuries and anomalies, both congenital and acquired, of the masticatory system and associated craniofacial structures.

The fields of work for the specialist in Oral and Maxillofacial Surgery and Traumatology include: a) implants, grafts, transplants and replantations; b) biopsies; c) surgery for prosthetic purposes; d) surgery for orthodontic purposes; e) orthognathic surgery; and f) diagnosis and surgical treatment of cysts, root and periradicular diseases, salivary gland diseases, temporomandibular joint (TMJ) diseases, injuries of traumatic origin in the maxillofacial area, congenital or acquired malformations of the maxilla and mandible, benign tumors of the oral cavity, malignant tumors of the oral cavity (in which case the specialist should work as part of an oncology team) and neurological disorder with maxillofacial manifestation, in collaboration with a neurologist or neurosurgeon.

It is exclusive competence of medical doctors to treat malignant neoplasms, neoplasms of major salivary glands (parotid, sublingual, submandibular), access to the infrahyoid cervical region, as well as the practice of esthetic surgery, except for esthetic-functional surgeries of the stomatognathic system, which are competence of the dental doctor.

The Brazilian College of Oral and Maxillofacial Surgery and Traumatology interviews, in this issue, Dr. Fernanda Brasil Daura Jorge Boos Lima, Effective Member of the CBCTBMF and Adjunct Professor of Oral and Maxillofacial Surgery and Traumatology, Department of Clinics, Pathology and Dental Surgery at the School of Dentistry at the Federal University of Minas Gerais (UFMG), about the Job Market Analysis work for Oral and Maxillofacial Surgeons in Brazil.

What encouraged you to develop this work?

The idea first came to understand the job market and the degree of insertion of oral and maxillofacial surgeons in Brazilian hospitals. Only with a reliable database, we could think of devising political strategies to expand the presence of the specialty. In my understanding, every action should be based on deep knowledge on the topic, strategic planning and serious management.

When did you start the work?

In 2015, I talked to Dr. Sylvio Luiz Costa de Moraes about the idea of the project. He took the presidency of the College on January 1st 2016 and has supported me a lot since then. The personal support of him and the College directly reflected on the expressive number of responses from hospitals: 1,428 hospitals replied to us, 82% of the total number.

How was the Commission established?

Dr. Sylvio gave me complete freedom of choice. I chose Dr. AntĂ´nio Albuquerque de Brito to compose the commission because he is a great friend and we live in the same city, which facilitates our contact. In addition, I was helped by two students I supervised at UFMG, ThainĂĄ Mendes and Ianca Batista, who collaborated a lot in the database survey.

How many surgeons specializing in Oral and Maxillofacial Surgery and Traumatology, in the average, are actually present in emergency services or responding to alerts in Brazilian hospitals?

The survey evaluated all Brazilian hospitals in cities with more than 100,000 inhabitants. The numbers are alarming. Only 8.83% of hospitals have an oral and maxillofacial surgeon in the emergency room to treat patients who are victims of facial trauma. In less than half of the hospitals there is an oral and maxillofacial surgeon on call (47.4%).

What is the percentage of specialists in Oral and Maxillofacial Surgery and Traumatology in relation to the total number of Brazilian dental professionals (CD)?

Currently, 349,648 dental professionals are registered with the Federal Dental Council; among these, only 4,903 are specialists in Oral and Maxillofacial Surgery and Traumatology, i.e. only 1.4% of all Brazilian dentists.

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Lima FB, Ribeiro J

How is the “trauma disease”, treated by the Oral and Maxillofacial Surgeon, epidemiologically distributed?

In the Northern region, 25% of hospitals present the specialty for emergency care; in the Northeast, 12.69%; in the Central West region, 10.71%; in the Southeast, 6.10%; and finally, in the South region, only 4.95% of hospitals have the specialty for emergency care. In other words, the worst rates of professional presence in the emergency room are in the South and Southeast regions, exactly the two regions that have the highest human development index. The data make it clear that, in these regions, the specialty loses space for medical specialties.

on call, which indicates that there is still little space for the maxillofacial surgeon in the first care of traumatized patients, even in regions with more access to health systems.

What is the proposal of this working group for the CBCTBMF? This information demonstrates that there is a great need to inform and clarify political authorities, health managers and hospital administrations regarding the importance of including the maxillofacial surgeon as part of the clinical staff in the emergency room. The lack of appropriate specialist professional for the case can compromise the treatment and the patient’s evolution, resulting in lower quality of the service provided, either public or private. Therefore, investing in an Oral and Maxillofacial Surgery and Traumatology service, both for emergency care and for elective procedures, in all general hospitals in the country, will represent an improvement in the job market and value both the profession and the specialty. Also, such investment will add greater efficiency and safety for the patient in the emergency care services, thus placing health services in Brazil at a higher level of care quality.

Considering the Brazilian regions, what is the percentage of specialists in Oral and Maxillofacial Surgery and Traumatology on an alert basis for facial trauma care?

In the Central West region, 30.35% of hospitals have a maxillofacial surgeon on call; in the North, 41%; in the Northeast, 42.06%; in the Southeast, 49.60%; and in the South, 57.02% of hospitals have a maxillofacial surgeon on call. In regions with less presence of professionals in the emergency room, there is an increase in the number of professionals

The work has just begun.

Prof. Dr. Jonathan Ribeiro » Associate editor-in-chief JBCOMS Journal of the Brazilian College of Oral and Maxillofacial Surgery.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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CBCTBMF

Covid-19 pandemic caused 92.5% drop in elective oral maxillofacial surgeries, reveals unprecedented survey The national survey of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology also found that only emergency surgeries are being performed and in a very isolated manner. “The work should be resumed faster”, according to the entity president treatment”, predicts Laureano Filho. The president believes that the work should be resumed faster, with safety for professionals and patients. “Otherwise, there will be an increase in morbidity for resection surgeries, in cases of tumors, due to the lesion evolution, with need for new exams for the procedures, besides increase in cases of sequelae”, concludes the President of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology.

The Brazilian College of Oral and Maxillofacial Surgery and Traumatology promoted a national survey with associates to know the impact of the new coronavirus health crisis on elective and emergency surgeries in the specialty. According to the survey, elective surgeries, i.e. those scheduled in advance, had a reduction of 92.5% in the average. There was interruption in nearly the entire country between March 16th and May 22nd, during which only trauma surgeries were performed, involving serious accidents or violence, abscess drainage (which are caused by bacterial infections) and few cases of cancer whose treatments were allowed in the period.

For the president of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology, José Rodrigues Laureano Filho, it has been a very long time without elective procedures, which are still slowly resumed. “The survey found that, in a few states, elective surgeries were resumed in late May; however, only for diseases that cannot be postponed, such as procedures related to benign pathologies, cases of maxillary deformities with important impact on masticatory, respiratory, swallowing and speech functions, and dysfunctions in mandibular joints”, he explains. In most states, it is expected to resume the activities still postponing to July and August. “Normal flow, only after September and according to the guidance of each State Department of Secretariat”, complements the president of the College.

According to the specialist, there will be a restrain in the second semester and a huge volume of surgeries to be performed, besides worsening of many cases. “We have a health system that was already working at the limit before the pandemics. With the reduction of surgeries, we will see overcrowded operating theaters, with many patients giving up the

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Belmiro Cavalcanti do Egito Vasconcelos - Doctor in Dentistry, Universitat de Barcelona, Facultad de Odontología (Barcelona, Spain).

- University of Pernambuco, School of Dentistry, Discipline of Oral and Maxillofacial Surgery and Traumatology (Camaragibe/ PE, Brazil).

- Scientific Director of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology.

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

How to cite: Vasconcelos BCE, Laureano Filho JR. Covid-19 pandemic caused 92.5% drop in elective oral maxillofacial surgeries, reveals unprecedented survey. J Braz Coll Oral Maxillofac Surg.

2020 May-Aug;6(2):16. DOI: https://doi.org/10.14436/2358-2782.6.2.016.cbc Submitted: February 26, 2020 - Revised and accepted: February 28, 2020

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CaseReport

Anatomical and clinical implications of third molars displacement into deep fascial spaces:

two cases report

RAFAEL CORREIA1 | ISABELA P. BERGAMASCHI1 | MARINA FANDERUFF1 | NELSON LUIS B. REBELLATO1 | DELSON J. COSTA1 | LEANDRO E. KLUPPEL1 | RAFAELA SCARIOT1,2

ABSTRACT Introduction: Accidental cases of third molars displacement into deep fascial spaces may occur due to different etiologies, from anatomical limitations to iatrogenic situations. Adjacent anatomical spaces such as lateral pharyngeal space, infratemporal fossa, pterygomandibular and buccal space have been reported in literature.

Objective: The main purpose of this report is to describe two cases of third molars displacement and highlight the anatomical implications of it. Cases report: The first case reports a displacement of the right maxillary third molar into the buccal space. Tooth was assessed intraorally through a submucosal incision under the parotid papilla, and removed using a periosteal elevator, due to the fact that the crown of the tooth was in the line of the incision. In the second case, the right mandibular third molar was displaced into the submandibular space. It was assessed through an extraoral approach due to its proximity to the mandibular base. Discussion and Considerations: Knowing the anatomical features of the maxillofacial region is important to the oral surgeon for a correct diagnosis and treatment of third molars displacement. When the tooth movement in an unfavorable direction, it is suggested that open surgical procedures should be conducted instead of using elevators or excessive force.

Keywords: Oral surgical procedures. Molar, third. Fascia.

Universidade Federal do Paraná, Departamento de Cirurgia Bucomaxilofacial (Curitiba/PR, Brazil).

Universidade Positivo, Departamento de Cirurgia Bucomaxilofacial (Curitiba/PR, Brazil).

1

How to cite: Correia R, Bergamaschi IP, Fanderuff M, Rebellato NLB, Costa DJ, Kluppel LE, Scariot R. Anatomical and clinical implications of third molars displacement into deep fascial spaces: two cases report. J Braz Coll Oral Maxillofac Surg. 2020 May-Aug;6(2):17-26.

DOI: https://doi.org/10.14436/2358-2782.6.2.017-026.oar

2

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

Submitted: May 28, 2018 - Revised and accepted: April 21, 2019

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

Contact address: Rafaela Scariot E-mail: rafaela_scariot@yahoo.com.br

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Anatomical and clinical implications of third molars displacement into deep fascial spaces: two cases report

INTRODUCTION The extraction of third molars is one of the most common procedures in oral surgery. 1 Complications as pain, dry alveolus, edema, paresthesia of the lingual and inferior alveolar nerves, bleeding and infection are frequent in the daily routine of surgeons, in the trans- and postoperative periods of this surgical procedure. Conversely, dental displacement to adjacent anatomical regions is a rare complication, occurring in approximately 1% of third molar surgeries. 1,2,3 Thus, this type of surgery requires not only technical knowledge, but also adequate clinical and radiographic evaluation to provide a safe surgery for patient and surgeon.

According to the literature, tooth displacement to adjacent anatomical spaces, such as the maxillary sinus, infratemporal fossa, pterygomandibular space, lateral pharyngeal space and buccal space, has been rarely reported. Due to this low incidence, there are few cases reported in the literature and limited information on the treatment in general. The most common space for displacement of third molars is the maxillary sinus.4 However, analyzing the tooth displacement into deep fascial spaces, the incidence of this complication is even lower. Fascial spaces are virtual spaces, limited by fasciae, filled with poorly vascularized fat and loose connective tissue, whose relevant characteristic is the easy spread of infections, which usually require complex treatment.5 Except for cases in which the atypical anatomical characteristics should be better evaluated, such as distolingual dental inclination or thin lingual cortical plate, the displacement can usually be associated with application of excessive force during the surgical procedure, excessive manipulation, inadequate surgical planning or inadequate clinical and/or radiographic evaluation.4 Thus, the main objective of this paper is to report two clinical cases of displacement of third molars to the buccal and submandibular fascial spaces, respectively, besides providing specific information about the anatomical characteristics of each space. Â CASE REPORT A 48-year-old male patient was referred to the Oral and Maxillofacial Surgery and Traumatology Service of a Hospital Emergency Department in Curitiba/PR for emergency care, with the chief com-

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plaints of pain, edema and limited mouth opening on the right side in the zygomatic region. Clinical examination revealed asymmetry and redness in the right malar region. The patient presented previous medical history of unsuccessful attempt to remove an impacted upper right third molar, under local anesthesia, seven days earlier (Fig 1).

After careful evaluation of the alveolus, and observing absence of alveolar repair, a panoramic radiograph was requested to better understand the etiology of this alteration. It was observed that the upper right third molar was anatomically anterior to the mandibular ramus, at the level of crowns of second molars. Computed tomography revealed that the displaced tooth had moved into the buccal space and was interposed between the masseter and buccinator muscles. The 3D reconstruction of the computed tomography showed that the tooth was positioned anteriorly and medially to the anterior border of the ramus, with its crown mesial to the second molar and its long axis extending in mesiodistal direction (Fig 2). Before tooth removal, the signs and symptoms of infection were controlled by antibiotic therapy with clindamycin hydrochloride 600 mg at every eight hours, analgesics and thermotherapy. After two days of hospitalization with intravenous medication, edema and pain decreased and the patient presented less complaint during mouth opening, though still limited. The tooth was easily palpated in the buccal area during intraoral examination.

Under general anesthesia, an incision was performed under the parotid papilla and, by plane divulsion, access was obtained to the tooth. The crown was in the line of submucosal incision; separation between the periodontal surface and fat tissues was then performed, showing formation of fibrous tissue between the structures. With the aid of a periosteum elevator, the tooth was removed from the buccal space. A Penrose drain was placed (Fig 3).

After 24 hours of postoperative hospitalization, adding up to three days of hospitalization, the patient was discharged with maintenance of analgesia and oral antibiotic therapy, maintaining clindamycin hydrochloride 300mg at every eight hours, for another seven days. After six months of postoperative follow-up, the patient was in good general condition, asymptomatic and with complete resolution of the infection.

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Correia R, Bergamaschi IP, Fanderuff M, Rebellato NLB, Costa DJ, Kluppel LE, Scariot R

A

B

C

Figure 1: A) Frontal image of the patient, with the third molar displaced into the buccal space. An increase in volume can be seen in the right malar region; B and C) the increase in volume was followed by redness in the region, pain and infection.

A

B

Figure 2: A) Computed tomography confirming the presence of non-sectioned third molar interposed between the masseter and buccinator muscles. B) 3D tomographic reconstruction showing the upper third molar positioned anteriorly and laterally to the anterior border of the ramus, with its crown mesial to the second molar and its long axis extending in mesiodistal direction.

A

B

C

Figure 3: A) Submucosal incision was performed below the parotid papilla. B) Penrose drain in place. C) Tooth removed from the buccal space.

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Anatomical and clinical implications of third molars displacement into deep fascial spaces: two cases report

CASE 2 A 17-year-old female patient was referred to the Oral and Maxillofacial Surgery and Traumatology Service of a private hospital in Curitiba/PR, presenting as chief complaints edema and pain in the right submandibular region, associated with limited mouth opening and redness in the region for seven days. Examination revealed facial asymmetry and pain on palpation, resulting from edema in the mandibular angle region. The previous clinical history revealed that, two months before the present appointment, she had undergone an unsuccessful surgical procedure to remove an impacted right lower third molar, performed under local anesthesia by a general dentist (Fig 4).

After careful evaluation of the alveolus, a panoramic radiograph was requested, which revealed the presence of a radiopaque mass similar to a third molar in the mandibular angle region. For a detailed imaging evaluation, a CT scan was requested and a hyperdense area located in the right submandibular region was found, demonstrating the position of the displaced tooth (Fig 5).

Intravenous antibiotics (ceftriaxone 1g at every 24h and clindamycin 600mg at every 8h), analgesics and antipyretics were prescribed, as well as routine hematological exams. After three days of hospitalization, the fever, edema and pain were solved, although the patient persisted with pain complaints during mouth opening. Drainage and removal of the tooth from the

A

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submandibular space was then planned and performed by extraoral approach, under general anesthesia.

Under general anesthesia, a 20-mm incision was performed below the mandibular base to access the non-sectioned lower third molar. The surgical site was carefully exposed by plane dissection. After skin incision, retraction of the margins exposed the platysma muscle, and its dissection allowed access to the superficial layer of the deep cervical fascia and the pterygomasseteric sling. The pterygomasseteric sling was divided and, by divulsion, the mylohyoid muscle was reached and divided, allowing entry into the submandibular space to access the displaced lower third molar.

The tooth was removed with the aid of a periosteum elevator and all fascial spaces involved were drained.

A Penrose drain was placed on the surgical wound (Fig 6). Suture was performed in planes with Vicryl 3.0 up to the skin, in which an intradermal suture with 5-0 nylon was performed. The patient remained hospitalized for another five days, under IV antibiotic therapy and monitoring. In the postoperative period the patient evolved without complications, showing improvement in her infectious condition after a total period of hospitalization of nine days. Besides maintaining the oral painkillers, the patient was maintained on clindamycin 300 mg at every eight hours until the end of a fourteen-day cycle of antibiotic therapy. The patient was asymptomatic at the one-year follow-up.

Figure 4: A) Frontal image of the patient, with the third molar displaced into the submandibular space. It is possible to observe the volume increase in the right submandibular region. B) Swelling was followed by redness in the area, pain and infection.

B

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Correia R, Bergamaschi IP, Fanderuff M, Rebellato NLB, Costa DJ, Kluppel LE, Scariot R

A

B

Figure 5: A) Panoramic radiograph showing the displaced tooth adjacent to the mandibular base. B) CT confirming the presence of a non-sectioned mandibular third molar in the submandibular space.

A

B

C

D

Figure 6: A, B) 20-mm incision below the mandibular base, performed to access the non-sectioned lower third molar. C) Surgical site carefully exposed, showing the displaced third molar. D) Tooth removed.

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Anatomical and clinical implications of third molars displacement into deep fascial spaces: two cases report

DISCUSSION The displacement of third molars to the fascial spaces is an uncommon complication, becoming even more rare when the tooth is displaced into the buccal or submandibular spaces. The buccal space is a deep fascial space adjacent to the maxillary alveolar crest and delimited by the muscles buccinator, masseter, zygomaticus major and minor, superficial layer of the deep cervical fascia (SLDCF) and the anterior mandibular region.6 The buccal tissue space extends along the lateral surface of the buccinator and the posterior portion, which is occupied by the buccal fat pad.6,7 The buccal fat pad rests primarily between the buccinator and masseter or the mandible ramus, and also behind the parotid duct.7 The buccinator originates on the external surface of the maxillary alveolar ridge and is inserted inferiorly in the mandibular alveolar ridge, and posteriorly on the anterior border of the pterygomandibular ligament.6 The submandibular and submental spaces are located just below the sublingual space, separated by the mylohyoid muscle. These spaces communicate behind the posterior border of the mylohyoid muscle and also through spaces in this muscle, crossed by vessels and nerves.5 Between the submandibular and submental spaces, infections are known to spread easily through the anterior belly of the digastric muscle. The submandibular space is located in the submandibular triangle, with its upper limit delimited by the SLDCF, which continues from the roof of the submental space after joining the anterior belly of the digastric muscle. In the posterior portion of the space, the SLDCF divides to form an intrafascial space containing only the submandibular gland. The anterior portion of the space is associated with lymph nodes, vessels and nerves surrounded by fibroadipose tissue. The space roof is formed by the mylohyoid muscle, covered by a thin layer of connective tissue, apparently continuous with the submental space floor.5,8 There is no fascial barrier separating the sublingual and submandibular spaces from the lower lateral pharyngeal space. Therefore, there is free communication between these regions and the tooth can easily move into more distant spaces and lead to serious complications.

The most common displacement into fascial spaces is in the infratemporal space. During extraction, the instrument can force the tooth posteriorly, through the periosteum, into the infratemporal fossa. The

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tooth is almost always lateral to the lateral pterygoid lamina and inferior to the lateral pterygoid muscle.

The surgeon may carefully attempt to recover the tooth with a hemostatic forceps; however, the tooth is usually no longer visible, and a blind examination results in more distant displacement. If the tooth is not recovered after a simple attempt, the surgery must be closed, and the patient must be informed.9 Regarding extremely rare displacements into the buccal space, the use of elevators can lead to fracture of the buccal wall, which consists mainly of trabecular bone with a thin cortical layer, and then the tooth can be easily pushed into the buccal space if there is no other anatomical barrier10. The risk of pushing it into the buccal space is even greater when the tooth is impacted and deep in relation to the maxillary bone crest.

Tooth displacement into the fascial spaces has great potential for the occurrence of complications, depending on the associated risk factors. Patient’s age, tooth positioning, presence of lingual cortical fracture, thin thickness of the lingual cortical plate, excessive or uncontrolled strength, lack of professional experience and inadequate radiographic and clinical evaluation before surgery suggest a greater risk.1,3,11,12 Excessive force in the use of elevators and inadequate surgical technique are cited as the most common causes of iatrogenic displacement of lower third molars.13 To investigate the incidence of this complication, a review of previously published data is presented in relation to the displacement of upper third molars to different anatomical spaces, most of which were treated under local anesthesia with intraoral approach (Table 1). Evaluation of Table 1 reveals that there is only one report of tooth displacement to the buccal space.10 The accidental displacement of fragments of third molars – mostly of root apices – to the sublingual, submandibular or pterygomandibular spaces is reported as a rare complication.1,3,14 Table 2 analyzes previously published data regarding the displacement of non-sectioned lower third molars.

Considering these data, to reduce the risk of displacement, it is suggested to remove these teeth in young individuals, before the roots are fully formed.4 Also, impacted teeth should receive special attention, especially when the tooth presents distolingual inclination and/or a thin lingual cortical plate. The application of finger pressure on the lingual bone plate or placement of retractors in the region can prevent

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Table 1: Displacement of upper third molars. Three keywords were used: “third molar displacement�, in three different databases (Pubmed, Medline and Science Direct). A total of 127 articles were found, considering only the displacements of upper third molars. Thus, the total number of articles chosen for this table was 14, from 1986 to 2017. Most articles describe the displacement of upper third molars into the infratemporal fossa, followed by the maxillary sinus, buccal space, pterygopalatine fossa and lateral pharyngeal space.

Authors

Maxillary sinus

Infratemporal fossa

Polo et al.25 (2017)

1

Sencimen et al.26 (2017)

1

Roshanghias et al. (2016)

1

27

Buccal space

Pterygopalatine fossa

Lee et al.28 (2013)

1

Bertossi et al.29 (2013)

1

Ozer et al.30 (2013)

1

Iwai et al.31 (2012)

1

Huang et al.32 (2011)

1

Selvi et al.33 (2011)

1

Kocaelli et al.34 (2011)

1

Dimitrakopoulos et al.35 (2007) Sverzut et al.36 (2005)

1 1

Patel et al. (1994)

1

37

Oberman et al.38 (1986)

2

1

ment was associated with infection. The timing for removal is not established in the literature; however, it is well described that signs and symptoms of infection must be controlled before surgery. Different authors suggest different moments for removal: from immediate removal in one day,4 suggesting that the patient would not have enough time to develop infection, or even in one month.16 Huang et al.12 suggested that removal after more than 24 hours may result in inflammatory response, which can lead to severe pain, edema, trismus, migration of tooth or root apices into deep spaces, producing a foreign body reaction. Some patients are asymptomatic, while others experience pain, edema and trismus in the immediate postoperative period. Conversely, some authors suggest postponing surgery for a few weeks, to allow the occurrence of fibrosis and to stabilize the tooth in a firm position.4

their displacement into adjacent anatomical areas. In addition, open surgical techniques involving ostectomy and tooth sectioning help to minimize these complications.

Computed tomography is considered the most appropriate technique to locate displaced third molars or apices of third molars within the fascial spaces, since it provides important information about the size and exact location of the displaced tooth.12,13,15 Cone beam computed tomography, if available, can provide the advantage of low radiation exposure and three-dimensional image. If tomography is not available, the combination of panoramic and occlusal radiographs is a good option.13,15 The symptoms of a tooth displaced into the deep fascial spaces depend on its size (> 5 mm),4 location and whether or not there is associated infection3,4,6.

In both case reports presented in this paper, displace-

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Lateral pharyngeal space

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Anatomical and clinical implications of third molars displacement into deep fascial spaces: two cases report

Table 2: Displacement of lower third molars. Three keywords were used: “third molar displacement”, in three different databases (Pubmed, Medline and Science Direct). A total of 127 articles were found, considering only the displacements of lower third molars. Articles describing displacement of root apices of third molars were not included in this table. Thus, the total number of articles selected was 13, from 1978 to 2016. Most articles described the displacement of lower third molars into the lateral pharyngeal space, followed by the pterygomandibular, sublingual, submandibular and infratemporal spaces.

Submandibular space

Authors

Lateral pharyngeal space

Pterygomandi- Sublingual bular space space

Varvara et al.39 (2016)

1

Silveira et al.40 (2014)

1

Kose et al. (2014) 41

2

Suer et al.42 (2014)

1

Lee et al.43 (2013)

1

Shahakbari et al. (2011)

1

44

Medeiros et al.45 (2008)

1

Ertas et al. (2002)

1

Esen et al.47 (2000)

1

Gay-Escoda et al.48 (1993)

1

46

Papadogeorgakis et al. (1990)

1

Hernandez50 (1978)

1

49

Hoew (1958)

1

51

an extraoral approach or a combination of intra-oral and extra-oral accesses may be indicated.17,18 In Case 1, an intraoral approach was chosen because, topographically, the upper third molar was easily palpable in the buccal area during intraoral examination. General anesthesia was indicated in this treatment due to the limited mouth opening and presence of infection. In addition, management of the patient in Case 1 was extremely difficult when it was explained that the etiological factor was the upper third molar. The previous dentist had not explained about the failure of tooth extraction and the possible displacement of this tooth. In Case 2, an extraoral approach was chosen because the lower third molar was located deep in the submandibular space. When the patient sought emergency care, she had difficulty opening her mouth because infection was already in place, and pain and edema were also limiting factors. We opted to perform the procedure under general anesthesia, given the limitations of mouth opening and pain.

In Case 2, the patient had no pain and infection associated with tooth displacement to the submandibular space for seven weeks. For an unknown reason, in the eighth week, after the failed attempt to extract the right lower third molar, the patient developed pain, infection, trismus and facial asymmetry, leading her to seek for emergency care. Conversely, in case 1, the patient sought hospital emergency care because, one week after the alleged extraction of the upper third molar, signs and symptoms as pain, infection and facial asymmetry, as well as redness in the malar region, were still present.

Different approaches for removal of third molars, root apices and displaced dental implants have been described in the literature, ranging from intraoral approaches17,18 and submandibular access19 to endonasal access.20 The intraoral approach under local anesthesia is the simplest and less invasive technique for removing displaced root apices. However, this approach may not provide adequate visibility and access.

When a tooth or fragment is moved into deep spaces,

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Infratemporal space

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Correia R, Bergamaschi IP, Fanderuff M, Rebellato NLB, Costa DJ, Kluppel LE, Scariot R

can be infected by tooth displacement, resulting in exacerbation of inflammation.10

FINAL CONSIDERATIONS Adequate clinical and radiographic evaluation are mandatory before removal of lower or upper third molars.3,4,10,24 Although reports of dental displacement are rare in the literature, their repercussions can be catastrophic for the patient. When a possible tooth movement in unfavorable direction is identified, open surgical procedures should be performed, rather than using elevators or excessive force. In the extraction of third molars, the anatomical characteristics of both the lingual cortex (thickness, presence of fractures and perforations) and the maxillary tuberosity (which presents a trabecular pattern more vulnerable to fractures and non-pathological perforations) must be evaluated, and the patient should be properly informed about the risks.

Adequate preoperative planning, accurate imaging evaluation of the impacted tooth, good selection of the surgical method and correct use of instruments are recommended to obtain good surgical results.

Many complications, including paresthesia and hemorrhage, can occur after attempts to remove root apices or third molars from the submandibular space, due to their close proximity to the lingual nerve, lower alveolar nerve and blood vessels.3,4,11 The submandibular space is closely related to important structures, such as the lingual and inferior alveolar nerves.21,22 For this reason, in surgery for removal, it is recommended to provide favorable access to avoid nerve damage, such as temporary or permanent paresthesia, as well as vascular injuries. The buccal division of the facial nerve and the buccal branch of the mandibular nerve are the main contents of the buccal space.

10,23 Although no injuries have been reported, tooth displacement also has potential for nerve damage.

The branches of the buccal nerve cross the buccinator muscle and spread across the mucous membranes of the cheek; thus, if damaged by a displaced tooth, sensory disturbances can occur6,10. If the motor branches are injured, the muscle can become stiff in the cheek area. The facial and buccal arteries that pass through the buccal space are also susceptible to injury. Likewise, the minor salivary glands present in the space

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Anatomical and clinical implications of third molars displacement into deep fascial spaces: two cases report

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1. Susarla SM, Blaeser BF, Magalnick D. Third molar surgery and associated complications. Oral Maxillofac Surg Clin North Am. 2003 May;15(2):177-86.

2. Borgonovo A, Bianchi A, Marchetti A, Censi R, Maiorana C. An uncommon clinical feature of IAN injury after third molar removal: a delayed paresthesia case series and literature review. Quintessence Int. 2012 May;43(5):353-9.

3. Tumuluri V, Punnia-Moorthy A. Displacement of a mandibular third molar root fragment into the pterygomandibular space. Aust Dent J. 2002 Mar;47(1):68-71.

4. Aznar-Arasa L, Figueiredo R, Gay-Escoda C. Iatrogenic displacement of lower third molar roots into the sublingual space: report of 6 cases. J Oral Maxillofac Surg.

2012 Feb;70(2):e107-15.

5. Grodinsky M, Holyoke, EA. The fasciae and fascial spaces of the head, neck and adjacent regions. Am J Anat. 1938 Nov: 63(3):367-408.

6. Tu AS, Geyer CA, Mancall AC, Baker RA. The buccal space: a doorway for percutaneous CT-guided biopsy of the parapharyngeal region. AJNR Am J Neuroradiol.

1998 Apr;19(4):728-31.

7. Standring S. Gray’s anatomy: the anatomical basis of clinical practice. 41th ed. Philadelphia: Churchill Livingstone Elsevier; 2008.

8. Anatomy for surgeons Vol. I: The Head and Neck.

Postgrad Med J. 1954 Nov;30(349):610.

9. Hupp JR, Ellis III E, Tucker MR. Cirurgia oral e maxilofacial contemporânea, 5ª ed. Rio de Janeiro: Elsevier; 2009.

10. Kocaelli H, Balcioglu HA, Erdem TL. Displacement of a maxillary third molar into the buccal space: anatomical implications apropos of a case. Int J Oral Maxillofac Surg. 2011 June;40(6):650-3.

11. Ertas U, Yaruz MS, Tozoglu S. Accidental third molar displacement into the lateral pharyngeal space. J Oral Maxillofac Surg. 2002 Oct;60(10):1217.

12. Huang IY, Wu CW, Worthington P. The displaced lower third molar: a literature review and suggestions for management. J Oral Maxillofac Surg. 2007 June;65(6):1186-90.

13. Sverzut CE, Trivellato AE, Sverzut AT, de Matos FP, Kato RB. Removal of a maxillary third molar accidentally displaced into the infratemporal fossa via intraoral approach under local anesthesia: report of a case. J Oral Maxillofac Surg. 2009 June;67(6):1316-20.

14. Kamburoglu K, Kursun S, Oztas B. Submandibular displacement of a mandibular third molar root during extraction: a case report. Cases J. 2010 Jan 6;3:8.

15. Grandini SA, Barros VM, Salata LA, Rosa AL, Soares UN. Complications in exodontia--accidental dislodgment to adjacent anatomical areas. Braz Dent J. 1993;3(2):103-12.

16. Jolly SS, Rattan V, Rai SK. Intraoral management of displaced root into submandibular space under local anaesthesia: A case report and review of literature.

Saudi Dent J. 2014 Oct;26(4):181-4.

17. Ozalp B, Kuvat SV, Emekli U. Conservative treatment of displacement mandibular third molar. J Craniofac Surg.

2010 July;21(4):1314-5.

18. Yeh CJ. A simple retrieval technique for accidentally displaced mandibular third molars. J Oral Maxillofac Surg. 2002 July;60(7):836-7.

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19. Araújo RZ, Pinto Júnior AAC, Lehman LFC, Campos FEB, Castro WH. Deslocamento de implante dentário para o espaço submandibular. J Braz Coll Oral Maxillofacial Surg. 2015 May-Aug;1(2):68-73.

20. Assis GM, Osório Júnior HA, Rego GC, Dantas WRM, Gondim ALMF. Remoção de implante dentário por via endonasal. J Braz Coll Oral Maxillofac Surg. 2016 Sept-Dec;2(3):58-61.

21. Pippi R, Perfetti G. Lingual displacement of an entire lower third molar. Report of a case with suggestions for prevention and management. Minerva Stomatol. 2002 June;51(6):263-8.

22. Hutchinson D. An unusual case of lingual displacement of a mandibular third molar root apex. Oral Surg Oral Med Oral Pathol. 1975 June;39(6):858-61.

23. Oberman M, Horowitz I, Ramon Y. Accidental displacement of impacted maxillary third molars. Int J Oral Maxillofac Surg. 1986 Dec;15(6):756-8.

24. Goldberg MH, Nemarich AN, Marco WP 2nd. Complications after mandibular third molar surgery: a statistical analysis of 500 consecutive procedures in private practice. J Am Dent Assoc. 1985 Aug;111(2):277-9.

25. Polo TOB, Momesso GAC, de Lima VN, Faverani LP, Souza F, Garcia-Junior IR. Inappropriate management after accidental displacement of upper third molar to the Infratemporal fossa may disrupt its subsequent removal.

J Craniofac Surg. 2017;28(3):e298-e9.

26. Sencimen M, Gülses A, Secer S, Zerener T, Özarslantürk S. Delayed retrieval of a displaced maxillary third molar from infratemporal space via trans-sinusoidal approach: a case report and the review of the literature.

Oral Maxillofac Surg. 2017 Mar;21(1):1-6.

27. Roshanghias K, Peisker A, Zieron JO. Maxillary tooth displacement in the infratemporal fossa. Dent Res J (Isfahan). 2016 July-Aug;13(4):373-5.

28. Lee D, Ishii S, Yakushiji N. Displacement of maxillary third molar into the lateral pharyngeal space. J Oral Maxillofac Surg. 2013 Oct;71(10):1653-7.

29. Bertossi D, Procacci P, Aquilini SE, Bollero R, De Santis D, Nocini PF. An unusual case of third molar displaced into the infratemporal fossa. Minerva Stomatol. 2013 Apr; 62(4 Suppl 1):63-7.

30. Ozer N, Uçem F, Saruhanoğlu A, Yilmaz S, Tanyeri H. Removal of a maxillary third molar displaced into pterygopalatine fossa via intraoral approach. Case Rep Dent.

2013;2013:392148.

31. Iwai T, Matsui Y, Hirota M, Tohnai I. Endoscopic removal of a maxillary third molar displaced into the maxillary sinus via the socket. J Craniofac Surg. 2012 July;23(4):e295-6.

32. Huang IY, Chen CM, Chuang FH. Caldwell-Luc procedure for retrieval of displaced root in the maxillary sinus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011 Dec;112(6):e59-63.

33. Selvi F, Cakarer S, Keskin C, Ozyuvaci H. Delayed removal of a maxillary third molar accidentally displaced into the infratemporal fossa. J Craniofac Surg. 2011 July;22(4):1391-3.

34. Kocaelli H, Balcioglu HA, Erdem TL. Displacement of a maxillary third molar into the buccal space: anatomical implications apropos of a case. Int J Oral Maxillofac Surg. 2011 June;40(6):650-3.

35. Dimitrakopoulos I, Papadaki M. Displacement of a maxillary third molar into the infratemporal fossa: case report. Quintessence Int. 2007 July-Aug;38(7):607-10.

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36. Sverzut CE, Trivellato AE, Lopes LM, Ferraz EP, Sverzut AT. Accidental displacement of impacted maxillary third molar: a case report. Braz Dent J. 2005;16(2):167-70.

37. Patel M, Down K. Accidental displacement of impacted maxillary third molars. Br Dent J. 1994 July;177(2):57-9.

38. Oberman M, Horowitz I, Ramon Y. Accidental displacement of impacted maxillary third molars. Int J Oral Maxillofac Surg. 1986 Dec;15(6):756-8.

39. Varvara G, Murmura G, Cardelli P, De Angelis D, Caputi S, Sinjari B, et al. Mandibular third molar displaced in the sublingual space: clinical management and medicolegal considerations. J Biol Regul Homeost Agents. 2016 Apr-June;30(2):609-13.

40. Silveira RJ, Garcia RR, Botelho TL, Franco A, Silva RF. Accidental displacement of third molar into the sublingual space: a case report. J Oral Maxillofac Res. 2014 Oct;5(3):e5.

41. Kose I, Koparal M, Güneş N, Atalay Y, Yaman F, Atilgan S, et al. Displaced lower third molar tooth into the submandibular space: Two case reports. J Nat Sci Biol Med. 2014 July;5(2):482-4.

42. Suer BT, Kocyigit ID, Ortakoglu K. Iatrogenic displacement of impacted mandibular third molar into the pterygomandibular space: a case report. Oral Health Dent Manag. 2014 June;13(2):179-82.

43. Lee D, Ishii S, Yakushiji N. Displacement of maxillary third molar into the lateral pharyngeal space. J Oral Maxillofac Surg. 2013 Oct;71(10):1653-7.

44. Shahakbari R, Mortazavi H, Eshghpour M. First report of accidental displacement of mandibular third molar into infratemporal space. J Oral Maxillofac Surg. 2011 May;69(5):1301-3.

45. Medeiros N, Gaffrée G. Accidental displacement of inferior third molar into the lateral pharyngeal space: case report. J Oral Maxillofac Surg. 2008 Mar;66(3):578-80.

46. Ertas U, Yaruz MS, Tozoğlu S. Accidental third molar displacement into the lateral pharyngeal space. J Oral Maxillofac Surg. 2002 Oct;60(10):1217.

47. Esen E, Aydoğan LB, Akçali MC. Accidental displacement of an impacted mandibular third molar into the lateral pharyngeal space. J Oral Maxillofac Surg. 2000 Jan;58(1):96-7.

48. Gay-Escoda C, Berini-Aytés L, Piñera-Penalva M. Accidental displacement of a lower third molar. Report of a case in the lateral cervical position. Oral Surg Oral Med Oral Pathol. 1993 Aug;76(2):159-60.

49. Papadogeorgakis N, Pigadas N. [Surgical removal of a lower semimpacted wisdom tooth displaced in the pterygomandibular space]. Hell Period Stomat Gnathopathoprosopike Cheir. 1990 Sept;5(3):125-9.

50. Hernandez AL. Unusual displacement of mandibular third molar into the superior ramus -complications and treatment. Fla Dent J. 1978 Spring;49(1):12-3.

51. Howe GL. Tooth removed from the lingual pouch.

Br Dent J. 1958;104:283-4.

J Braz Coll Oral Maxillofac Surg. 2020 May-Aug;6(2):17-26

CaseReport

Recurrent luxation of TMJ treated with hemotherapy and

intermaxillary fixation

SAULO CHATEAUBRIAND NASCIMENTO1| MARCELO VINICIUS DE OLIVEIRA1 | GUSTAVO CAVALCANTI ALBUQUERQUE1 | VALBER BARBOSA MARTINS1 | JOEL MOTTA JÚNIOR1

ABSTRACT Introduction: Dislocation of TMJ occurs when the condyle moves out of the glenoid fossa, previously locking the joint eminence. This condition is called recurrent when episodes become frequent. Objective: The aim of this work is to report a case of a patient with recurrent TMJ treated conservatively, through intra-articular autologous blood injection (ISA) and pericapsular tissue, associated with intermaxillary fixation (FIM) for three weeks. Case report: A 31-year-old female patient with main complaint of frequent episodes of mandibular “fall”, initiated after trauma two years before the consultation. Click and crackling were observed in the opening and closing movements of the mouth, bilateral TMJ dislocation, local pain, dysphonia, dysphagia, and dysarthria. It was verified, by means of a caliper, that the degree of opening that caused dislocation was from 30 mm. Conclusion: The patient responded satisfactorily to the treatment, without recurrent episodes of dislocation. The ISA associated with FIM has been shown to be a safe, simple and economical method for the treatment of recurrent TMJ dislocation, being a conservative approach with high success rates.

Keywords: Temporomandibular joint. Joint dislocations. Temporomandibular joint disorders.

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

1

How to cite: Nascimento SC, Oliveira MV, Albuquerque GC, Martins VB, Motta Júnior J. Recurrent luxation of TMJ treated with hemotherapy and intermaxillary fixation. J Braz Coll Oral Maxillofac Surg.

2020 May-Aug;6(2):27-31.

DOI: https://doi.org/10.14436/2358-2782.6.2.027-031.oar

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

Submitted: July 02, 2018 - Revised and accepted: September 22, 2018

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

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Contact address: Saulo Chateaubriand Nascimento Av. Codajás, 198, Cachoeirinha – Manaus/AM – CEP: 69.065-130 E-mail: saulo.chateaubriand@hotmail.com

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Recurrent luxation of TMJ treated with hemotherapy and intermaxillary fixation

INTRODUCTION The temporomandibular joint (TMJ) is formed by the mandibular fossa of the temporal bone, mandibular condyle, articular disc, besides ligaments and muscles.

Of peculiar complexity, this joint is classified as ginglymoarthrodial, due to its hinge and sliding movements.

Under normal conditions, there is a relatively smooth movement of the condyle when moved downward and beyond the articular eminence, aided by posterior rotation of the disc over the condyle during translation.1 In TMJ dislocation, the condyle moves out of the mandibular fossa, with locking anterior to the articular eminence, maintained by the spasm of masticatory muscles. It is called habitual, relapsing or recurrent when it becomes frequent and progressively more severe, being associated with hypermobility of the mandible and inclination of the articular eminence, in most cases. This type of dislocation is reported between 3 and 7% of the general population.2 Regarding the pathogenesis, factors such as laxity of the TMJ ligaments, derangements in the joint capsule, articular eminence with abnormal size or projection, hyperactivity or muscle spasm, neurological and psychiatric disorders have been reported.3 Episodes of chronic recurrent dislocation usually happen as a result of common activities, such as yawning and laughing, or during prolonged mouth opening, becoming a condition of considerable negative impact on the patient’s routine.4 The diagnosis is achieved by analyzing the excessive range of mobility, identifying the impossibility of mandibular closure, due to ligament laxity, besides the presence of pain during and after the episode. Unlike subluxation, in chronic recurrent dislocation, the patient is unable to reduce the condyle back to its normal position without professional help. Imaging exams, such as PT scans and panoramic radiographs, are used to assess the bone structures and identify lesions.5 Many surgical and non-surgical treatments are described in cases of chronic recurrent dislocation. The surgical approaches involve capsular ligaments or bone structure, including eminectomy, scarification of the temporal muscle tendon, increasing the articular eminence by the use of alloplastic graft, plication of the joint capsule and use of miniplates in the articular eminence.

Non-surgical techniques include injection of sclerosing agents in the TMJ (such as autologous blood and 3% sodium tetradecyl sulfate), maxillomandibular block and muscle exercises.2,6

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

The autologous blood injection (ABI) corresponds to blood injected into the pericapsular tissues (PT) and the upper articular space (UAS), forming intercompartmental adhesions by fibrous tissue. It is a safe approach, with minimal complications, and can be used repeatedly.

However, attention should be paid to the development of fibrous or bone ankylosis and degeneration of the articular cartilage. Considering that the treatment success requires restriction of mandibular movement, it has been shown that combining intermaxillary fixation (IMF) with autologous blood injection provides a considerably more efficient result, aiding the development of fibrosis within the joint capsule.7 Thus, the purpose of the present work is to describe the therapeutic approach used in a case of recurrent TMJ dislocation, with an association of autologous blood injection and intermaxillary fixation.

CASE REPORT A 31-year-old female patient, who signed an Informed Consent Form (ICF), presented a report of frequent episodes of “fall” of the mandible as main complaint, starting after trauma suffered two years before the consultation. She declared that she started using a chin cup by professional advice nine months earlier, since the episodes were frequent and occurred after a certain degree of mouth opening and even if the patient spoke for a longer period.

The examination revealed clicks and crepitus in mouth opening and closing movements, bilateral TMJ dislocation, local pain, dysphonia, dysphagia and dysarthria. It was verified, by measuring with a caliper, that the limit of opening that caused dislocation was from 30 mm.

The nuclear magnetic resonance imaging showed reduction in the joint spaces, degenerative changes in the TMJs with anterolateral displacements of the articular discs and their rupture, besides bilateral reduced condylar excursion. The bone structure was analyzed by cone beam computed tomography (CBCT), with panoramic reconstruction, observing the mandibular condyle positioned in front of the articular eminence of the temporal bone (Fig 1).

The therapeutic approach chosen was the association of autologous blood injection and maxillomandibular block (MMB), to favor the development of fibrous tissue in an environment with restricted movement.

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Nascimento SC, Oliveira MV, Albuquerque GC, Martins VB, Motta JĂşnior J

moved and then 5 ml of blood was collected from the cubital fossa, of which 4 ml were injected into the upper joint space and 1 ml into the pericapsular tissue of both joints (Fig 2), followed by intermaxillary fixation using IMF screws with heavy orthodontic elastics (Fig 3).

The block was removed on the postoperative consultation after three weeks, and the patient returned after one, three, six, nine and sixteen months, showing unrestricted mandibular movements, with 35-mm mouth opening, without painful symptoms and without episodes of TMJ dislocation, and the digital panoramic radiographs showed normal structures.

The arthrocentesis surgical procedure was performed under general anesthesia. A tragus reference line was delimited at the eye corner, marking a point 10 mm anterior to the tragus and 2 mm below the reference line, in which a sterile 40/12 disposable needle was inserted. The second point was marked at 20 mm from the tragus and 10 mm below the reference line, in which the second needle was inserted. Mandibular manipulation confirmed the correct location of the needles in the joint space.

Initially, using the first needle, 20 ml of 0.9% saline was used to wash the TMJ. The second needle was re-

Figure 1: Panoramic reconstruction of CBCT.

Figure 2: Injection of autologous blood in the upper joint space and pericapsular tissues.

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

Figure 3: IMF screws for maxillomandibular block.

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Recurrent luxation of TMJ treated with hemotherapy and intermaxillary fixation

DISCUSSION In a systematic literature review, it was observed that the main etiology of TMJ dislocations is trauma, accounting for about 60% of cases, and may also be due to excessive mouth opening due to yawning, laughter, singing, prolonged mouth opening due to oral and otorhinolaryngological procedures, and vigorous mouth opening due to anesthetic and endoscopic procedures.8 The dislocation is considered to be recurrent when the episodes become frequent, progressively worsening. Regarding the prevalence, it is reported that about 3 to 7% of the population have this type of dislocation.2,5 In this work, the treatment of a patient with frequent episodes of condylar dislocation for about two years was presented, which occurred with the least effort and after a certain degree of mouth opening, diagnosed with chronic recurrent TMJ dislocation.

The choice of treatment depends on the analysis of predisposing factors and the TMJ morphology, as well as the risks and benefits between techniques, classified as surgical and non-surgical. Surgically, internal fixation materials or grafts are used to create a mechanical barrier that prevents condyle excursion anterior to the articular eminence. Another measure is to eliminate the factor that causes locking, such as cases of inferiorly extended articular eminence.

However, surgical techniques require hospitalization, general anesthesia and tissue dissection to access the TMJ. Therefore, they involve risks of complications and postoperative occurrences, such as facial nerve paresthesia, edema, pain and infection.3 Chronic recurrent dislocations respond better to conservative approaches when they are related to oromandibular dystonia. Surgical methods do not necessarily offer the best treatment results. Before that, more conservative techniques should be chosen, which should be conducted after detailed evaluation and treatment planning.8 Based on the diagnosis, a treatment plan was developed based on data from the literature that encourage conservative techniques in the first approaches, opting for the injection of autologous blood and intermaxillary fixation.

The autologous blood injection to treat recurrent condylar dislocation was first reported by Schulz in 1973. It is a conservative technique that can be performed both under local anesthesia and local anesthesia combined with sedation or general anesthesia.6,7

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The pathophysiological mechanism is similar to that of other joints when bleeding. First, the joint capsule and periarticular tissues are distended by the injection of blood, which promotes an inflammatory reaction with release of mediators by the platelets and dead or injured cells, altering the local microcirculation, with plasma exudation by vasodilation, causing edema, thus impairing joint movement. Subsequently, there is formation of a blood clot that, associated with forms of loose fibrous tissue, maintains the joint stiffness. When this tissue matures, there is permanent limitation of joint movement.4 In a study conducted on 30 patients, randomly divided into two groups, in which one received autologous blood injection only in the upper joint space and the other received both in the UAS and in the periarticular tissues (PT), digital radiography of patients of the second group showed the presence of condylar head posterior to the articular eminence, in an open position, instead of anteriorly before the injection. This finding was absent in the first group, which received autologous blood injection only in the UAS.9 Carneiro Jr et al.10 reported a case in which, with the aid of an arthroscope, they performed application of autologous blood in the UAS and PT; in this case, follow-up after two years demonstrated resolution of recurrent TMJ dislocation. The technique performed in the present study used injection of 4 ml of blood in the UAS and 1 ml in the PT in both joints of the patient.

Intermaxillary fixation used as an isolated treatment is recommended for a period of three to six weeks and can be used as a complement to other treatment methods, such as the use of sclerosing agents.

The disadvantages of this technique include the need of patient compliance and its impossibility in edentulous patients.7 Using IMF screws and heavy orthodontic elastics, intermaxillary fixation was maintained for a period of three weeks.

In a prospective, randomized and controlled clinical trial conducted in 2013, the effectiveness of treatment of chronic recurrent dislocation with isolated autologous blood injection, isolated IMF and the combination of ABI and IMF was evaluated. The results showed that the use of IMF alone achieved better results than ABI alone. The combined technique did not present recurrence of displacement in any case studied. There was significant difference in results between the combined group and the isolated

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Nascimento SC, Oliveira MV, Albuquerque GC, Martins VB, Motta Júnior J

FINAL CONSIDERATIONS Chronic recurrent dislocation managed with an association of autologous blood injection and intermaxillary fixation presents consistent results as conservative treatment. Despite the lack of direct visualization of the TMJ structures, it is a simple technique when carefully planned, with low rate of complications and postoperative recovery with low morbidity, when compared to open surgery.

techniques; however, there was no considerable difference between the individualized ABI and IMF groups, even though the latter technique was considered better compared to the first.7 Corroborating these data, an effective result was obtained using the techniques in association, achieving the advantages of formation of intercompartmental fibrous adhesions created by blood injection in the TMJ, favored by the immobilization offered by intermaxillary fixation.

References:

1. Okeson JP. Tratamento das desordens temporomandibulares. 6ª ed. Rio de Janeiro: Elsevier; 2008.

2. Vasconcelos BC, Campello RI, Oliveira DM, Nogueira RV, Mendes Júnior OR. Luxação da articulação temporomandibular: revisão de literatura.

Rev Cir Traumatol Buco-Maxilo-Fac. 2004 Oct-Dec;4(4):218-22.

3. Goulart DR, Silva BN, Moraes M. Tratamento conservador de luxação recidivante de ATM. J Braz Coll Oral Maxillofac Surg. 2015 Jan-Apr;1(1):60-4.

4. Machon V, Abramowicz S, Paska J, Dolwick MF. Autologous blood injection for the treatment of chronic recurrent temporomandibular joint dislocation. J Oral Maxillofac Surg. 2009 Jan;67(1):114-9.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

5. Carrasco MT, Cordero RT, Bohórquez DO, Caiza NJ. Luxación recidivante de la articulación témporo-mandibular, reporte de caso. Rev Med FCM-UCSG. 2014;18(3):195-9.

6. Hasson O, Nahlieli O. Autologous blood injection for treatment of recurrent temporomandibular joint dislocation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001 Oct;92(4):390-3.

7. Hegab AF. Treatment of chronic recurrent dislocation of the temporomandibular joint with injection of autologous blood alone, intermaxillary fixation alone, or both together: a prospective, randomised, controlled clinical trial. Br J Oral Maxillofac Surg.

2013 Dec;51(8):813-7.

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8. Akinbami BO. Evaluation of the mechanism and principles of management of temporomandibular joint dislocation. Systematic review of literature and a proposed new classification of temporomandibular joint dislocation. Head Face Med. 2011 June 15;7:10.

9. Daif ET. Autologous blood injection as a new treatment modality for chronic recurrent temporomandibular joint dislocation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 Jan;109(1):31-6.

10. Carneiro Jr JT, Tabosa AKS, Falcão ASC, Real RPV. Manejo de luxação da ATM com injeção de sangue autólogo. J Braz Coll Oral Maxillofac Surg. 2015 Sept-Dec;1(3):47-9.

J Braz Coll Oral Maxillofac Surg. 2020 May-Aug;6(2):27-31

CaseReport

Desmoplastic ameloblastoma in mandible:

case report

MAYLSON NOGUEIRA BARROS1 | VITOR BRUNO TESLENCO1 | DIOGO HENRIQUE MARQUES1 | HERBERT DE ABREU CAVALCANTI1 | GUILHERME NUCCI REIS1 | EVERTON FLORIANO PANCINI1

ABSTRACT Introduction: Ameloblastomas are classified as benign tumors of odontogenic epithelium origin. They are subdivided into three different classifications, presenting different clinical and radiographic aspects, separated due to different therapeutic, in: conventional, unicystic and peripheral (extraosseous). Its appearance comes from the remains of the dental blade of the enamel, remains of Malassez, remains of Serres and cystic coatings. Desmoplastic ameloblastoma is one of the rare histopathological subtypes of ameloblastoma, and may present different radiographic characteristics of the other ameloblastomas. Objective: to report to the academic community the conservative treatment of an odontogenic tumor. Case report: 36-years-old patient, leucoderma, complaining of right mandibular volume increase, spontaneous pain and paresthesia in the lower lip region, with diagnosis of desmoplastic ameloblastoma. Treatment involved two enucleations and curettage associated with peripheral osteotomy. During clinical and radiographic follow-up, bone neoformation was observed after the approaches. Conclusion: It was observed that conservative treatment proposed avoided a more invasive/radical approach, avoiding mutilations and sequels. It was found successful until now due to the absence of clinical and radiographic signs of recurrence, during a follow-up period of six years.

Keywords: Ameloblastoma. Surgery, oral. Pathology, oral.

Associação Beneficente Santa Casa de Campo Grande, Serviço de Cirurgia e Traumatologia Bucomaxilofacial (Campo Grande/MS, Brazil).

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How to cite: Barros MN, Teslenco VB, Marques DH, Cavalcanti HA, Reis GN, Pancini EF. Desmoplastic ameloblastoma in mandible: case report J Braz Coll Oral Maxillofac Surg. 2020 MayAug;6(2):32-8. DOI: https://doi.org/10.14436/2358-2782.6.2.032-038.oar

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

Submitted: February 13, 2019 - Revised and accepted: August 09, 2019 Contact address: Maylson Nogueira Barros Rua Rui Barbosa, 4744, apto 71, Centro – Campo Grande/MS E-mail: maylson.bucomaxilofacial@gmail.com

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

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Barros MN, Teslenco VB, Marques DH, Cavalcanti HA, Reis GN, Pancini EF

CASE REPORT Female patient, Caucasoid, aged 36 years, was referred to the outpatient clinic of the Oral and Maxillofacial Surgery and Traumatology service due to complaints of volume increase on the right mandible, spontaneous pain and numbness in the lower lip region. On anamnesis, the patient denied previous allergies or comorbidities. Extraoral clinical examination revealed facial asymmetry and volume increase involving the right mandibular region. Intraoral examination evidenced bulging of cortical bone and slight mobility of tooth 46. Tomographic examination showed a hypodense, expansive image, located in the mandibular ramus surrounding tooth 46, with an insufflation aspect, with rupture of medial cortical plate (Figures 1 and 2). An incisional intraoral biopsy was performed under local anesthesia, which revealed histopathological confirmation of desmoplastic ameloblastoma. A conservative approach was proposed, through which enucleation with curettage was performed, associated with peripheral osteotomy under general anesthesia.

An incision was made using a monopolar electric scalpel in the right retromandibular region, extending from the ascending ramus to the mandibular body, measuring approximately 8 cm, and mucoperiosteal detachment with exposure of cortical bone, accessing the lesion with a round bur. Then, enucleation and curettage of the lesion were performed, associated with extraction of tooth 46 (Fig 2). Peripheral osteotomy was performed with a round carbide bur and abundant irrigation with 0.9% saline. The mucosa was sutured with continuous stitches without anchoring with resorbable suture, and application of 4-0 polyglycolic acid.

After one-year follow-up the lesion relapsed. Following the line of the first treatment, it was decided to perform retreatment similar to the previous surgery.

The patient remains under clinical and tomographic follow-up until now (Fig 3).

INTRODUCTION Ameloblastomas are benign tumors originating from odontogenic epithelium. They arise from the remnants of the enamel organ, rests of Malassez, rests of Serres and cystic coatings; however, the mechanism of neoplastic transformation is unknown. They occur in three different situations, with different clinical and radiographic aspects, which are separated due to different histological, therapeutic and prognostic considerations: conventional, unicystic and peripheral (extraosseous).1,2 Conventional ameloblastoma has some microscopic subtypes in which follicular and plexiform types are the most commonly found. Others, less common, are those of basal cells, desmoplastic, acanthomatous and of granular cells.1,2,3 It presents slow growth and local tissue invasion, due to the overexpression of TNF-a, anti-apoptotic proteins (Bcl2 and Bclx), interface proteins (fibroblast growth factor – FGF) and matrix metalloproteinases (MMPs),1,2,4 spreading across the medullary spaces. When located in the posterior regions of the maxilla, they can cause obliteration of the maxillary sinus. They are often asymptomatic but can present as painless swelling. However, recurrences and root resorption are common.1,2 Desmoplastic ameloblastoma contains small islands and cords of odontogenic epithelium in a densely collagenized stroma.1,3,5 The differential diagnosis includes odontogenic cysts, myxomas and bone pathologies.1,3,4 Treatment for ameloblastoma is variable and includes marsupialization; enucleation associated with curettage, with the aid of peripheral osteotomy; cryotherapy or application of Carnoy solution; and resection, with a margin of 1.5 to 2 cm.1,5,6 Thus, the present study aims to present a case report of treatment of desmoplastic ameloblastoma in the mandible.

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Desmoplastic ameloblastoma in mandible: case report

Figure 1: Initial photographs of the patient (frontal, profile and intraoral) and initial panoramic radiography.

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Barros MN, Teslenco VB, Marques DH, Cavalcanti HA, Reis GN, Pancini EF

Figure 2: Initial tomography of the face (3D reconstruction, coronal and axial sections) and transoperative image of the lesion site.

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Desmoplastic ameloblastoma in mandible: case report

Figure 3: Tomography of the face (axial sections and 3D reconstructions), panoramic radiography on the six-year follow-up and current photographs (frontal and profile).

Figure 4: Histological sections: islands and cords of ameloblastic odontogenic epithelium and fibrous connective tissue stroma.

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Barros MN, Teslenco VB, Marques DH, Cavalcanti HA, Reis GN, Pancini EF

DISCUSSION Desmoplastic ameloblastoma has a relevant predilection for affecting the anterior regions of jaw bones, especially in the mandible, with different radiographic characteristics from conventional ameloblastoma. 1,3 However, the present case involved the right posterior region of the mandible, presenting on the radiographic examination as a multilocular lesion, with soap-bubble pattern, differing from the pattern of mixed lesions with radiolucent and radiopaque images.

For the treatment of these lesions, several factors should be considered to choose the type of approach, including the anatomical regions involved in the lesion, age, clinical behavior, size, structures involved and severe systemic diseases limiting the patient.5,6,7,9 It is fundamental that the selected approach has sufficient indication and coverage for cost-benefit balance, obtaining the final result of lesion removal, being as conservative as possible, considering the recurrences and malignant transformations of the lesion.1,3,6,8 In their study, Hammarfjord et al.9 observed a high rate of recurrence in patients treated conservatively, requiring new conservative approaches. In general, recurrence can take many years to become clinically evident, and the five-year disease-free periods do not indicate a cure.1,3-7 Tumor removal by enucleation associated with curettage can leave small islands of tumor cells, which can significantly increase the recurrence rate by up to 90%.1,4,5,9 However, the literature demonstrates that the association of adjuvant surgical techniques, such

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

as peripheral osteotomy and the application of solutions, decreases the conditions of recurrence.4,5,6 Resection has lower relapse rates; however, mutilations, deformations and esthetic changes are complications expected from this approach. Radical treatment is indicated for tumors with destructive behavior, rapid growth, multiple relapses after conservative treatment and lesions close to vital structures.1,6-9 Radiotherapy is controversial, being reserved for patients who may not undergo surgery, impossibility to define the lesion margins and excessively fast growth.1,6,7,8,10 The choice of a more conservative approach, in this case, was proposed because she is a young patient, with an extensive lesion involving noble structures, and the main factor considered is the possibility to avoid postoperative sequelae, even considering the high relapse rates and possibilities for new surgeries. After lesion relapse, enucleation and curettage, associated with peripheral osteotomy, was again proposed to avoid radical treatment, considering the same factors previously exposed.

FINAL CONSIDERATIONS The conservative treatment avoided a more invasive, radical or radiotherapy approach, as well as mutilations and sequelae. During a six-year follow-up period only one relapse was observed, which was treated again by a conservative approach, successful until now. Despite the apparent success of treatment, and even if the patient is asymptomatic, further studies are needed to obtain greater predictability in treatment planning and follow-up for long years, since relapses are possible.

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Desmoplastic ameloblastoma in mandible: case report

References:

1. Neville BW, Damm DD. Patologia oral e maxilofacial.

4ª ed. Rio de Janeiro: Guanabara Koogan; 2016. p. 654-63.

2. Barnes L, Eveson JA, Reichart P, Sindrasky D. Genética e patologia dos tumores de cabeça e pescoço.

São Paulo: Santos; 2009. p. 296- 305.

3. Bachmann AM, Linfesty RL. Ameloblastoma, solid/multicystic type. Head Neck Pathol. 2009 Dec;3(4):307-9.

4. Majumdar S, Uppala D, Kotina S, Veera SK, Boddepalli R. Desmoplastic ameloblastoma. Int J Appl Basic Med Res. 2014 Sept;4(Suppl 1):S53-5.

5. Kim SW, Jee YJ, Lee DW, Kim HK. Conservative surgical treatment for ameloblastoma: a report of three cases. J Korean Assoc Oral Maxillofac Surg. 2018 Oct;44(5):242-7.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

6. Sharma Lamichhane N, Liu Q, Sun H, Zhang W. A case report on desmoplastic ameloblastoma of anterior mandible. BMC Res Notes. 2016 Mar 16;9:171.

7. Wakoh M, Harada T, Inoue T. Follicular/desmoplastic hybrid ameloblastoma with radiographic features of concomitant fibro-osseous and solitary cystic lesions.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod.

2002 Dec;94(6):774-80.

8. Rais R, El-Mofty SK. Malignant transformation of a desmoplastic ameloblastoma to squamous cell carcinoma: A case report. Head Neck Pathol. 2019 Dec;13(4):705-10.

9. Hammarfjord O, Roslund J, Abrahamsson P, Nilsson P, Thor A, Magnusson M, et al. Surgical treatment of recurring ameloblastoma, are there options? Br J OralMaxillofac Surg. 2013 Dec;51(8):762-6.

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10. Abtahi MA, Zandi A, Razmjoo H, Ghaffari S, Abtahi SM, Jahanbani-Ardakani H, et al. Orbital invasion of ameloblastoma: A systematic review apropos of a rare entity.

J Curr Ophthalmol. 2017 Nov 6;30(1):23-34.

J Braz Coll Oral Maxillofac Surg. 2020 May-Aug;6(2):32-8

CaseReport

Treatment of mandibular angle fracture with grid plate:

case report

FELIPPE ALMEIDA COSTA1 | ROGÉRIO ALMEIDA DA SILVA1 | FÁBIO RICARDO LOUREIRO SATO1 | LUCAS MARTINS DE CASTRO E SILVA1

ABSTRACT Introduction: The mandibular angle fractures have a higher rate of complications when compared to other types of mandibular fractures. The reasons for the high rate of complications are: anatomy of the region, location and difficulty to fixation of this type of fracture. There are several modalities for the treatment of this type of fracture. Objective: The objective of this study is to report a case of mandibular angle fracture treated with grid plate and to discuss the advantages of this type of fixation for the treatment of this fracture. Case report: Patient came to the emergency complaining of physical aggression on face. He related occlusal alteration and was diagnosed with bilateral mandibular fracture. It was proposed the reduction and fixation of the fracture by intraoral access, under general anesthesia. Results and Conclusion: The patient was in postoperative follow-up for three years, without complications. The grid plate showed to be an effective alternative for the treatment of mandibular angle fractures without displacement, presenting as main advantages of this treatment: easy manipulation and adaptation of the plate, less morbidity, shorter surgical time and lowest complication rate.

Keywords: Bone plates. Fracture fixation. Mandibular fractures.

Hospital Geral “Dr. José Pagela” de Vila Penteado, Serviço de Cirurgia e Traumatologia Bucomaxilofacial (São Paulo/SP, Brazil).

1

How to cite: Costa FA, Silva RA, Sato FRL, Castro e Silva LM. Treatment of mandibular angle fracture with grid plate: case report. J Braz Coll Oral Maxillofac Surg. 2020 May-Aug;6(2):39-43.

DOI: https://doi.org/10.14436/2358-2782.6.2.039-043.oar Submitted: February 18, 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: Felippe Almeida Costa Av. Min. Petrônio Portela, 1800, Jardim Iracema – São Paulo/SP – CEP: 02.802-120 E-mail: felippealmeida@usp.br

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

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Treatment of mandibular angle fracture with grid plate: case report

CASE REPORT A 20-year-old male patient was assisted in the emergency service of a public hospital in the north region of São Paulo by the Oral and Maxillofacial Surgery and Traumatology team, after facial trauma. The patient reported physical aggression and presented a 20-mm mouth opening limitation, malocclusion, pain (VAS: 7) and mobility of bone sections during manipulation in the left parasymphysis region and right mandibular angle. Imaging examination revealed a gap in the left parasymphysis region and the right mandibular angle (Fig 1). The diagnosis was left parasymphysis fracture with displacement and fracture of the right mandibular angle without displacement. For surgical planning, surgical reduction by intraoral access of both fractures was proposed, with the use of a 2.0 mm system plate in the tension zone, a 2.3 mm system plate in the compression zone of the parasymphysis fracture and a grid plate system 2.0 in the mandibular angle fracture.

The procedure was performed in the hospital under general anesthesia. Infiltration was performed with 2% lidocaine with epinephrine 1:200,000 in the region of fractures to promote adequate hemostasis during surgery, and analgesia in the immediate postoperative period. Erich bar and maxillomandibular block with stainless steel wire n. 1 were used transoperatively. After intraoral approach of both fractures, the parasymphysis fracture was reduced and fixed using a 2.0 mm system plate with monocortical screws in the tension zone, and a 2.3 mm plate with bicortical screws in the compression zone (Stryker® Michigan, USA). The mandibular angle fracture was reduced and fixed with a 2.0 mm grid plate with monocortical screws (Stryker® Michigan, USA). This plate was placed in the neutral area of ​​the mandible, which facilitates fracture reduction and stability (Fig 2). To avoid transoral access for screws placement, this plate used drilling and a 90º insertion wrench (Stryker® Michigan, USA), which avoids extraoral incisions and allows adequate and perpendicular screw placement in the plate. After fracture fixation and immediate postoperative tomography (Fig 3), the Erich bar was removed. The patient has been under three-year outpatient follow-up, during which no complications were observed with the use of fixation with the grid plate (Figures 4 and 5).

INTRODUCTION In the last decades, several methods for the treatment of mandibular fractures have been proposed.

The open treatment of these fractures by reduction and stable internal fixation can be performed with a wide variety of plate systems, both by extra- and intraoral access. Most simple fractures, without displacement or with minimal displacement, can be adequately treated using one or two plates.1 Among mandibular fractures, the angle fracture is the most common, accounting for approximately 30% of cases. Due to their location and biomechanics, mandibular angle fracture often becomes a challenging treatment and has a higher rate of complications compared to other types of mandibular fracture.

This also occurs because these fractures have less bone contact in the fracture line, consequently with vascularization problems in the region. 1,2 A large number of fixation methods have been reported in the literature for the treatment of mandibular angle fractures. This reflects the fact that there are several possibilities regarding the ideal fixation method. Some methods described include a single 2.0 system plate on the upper edge, a single 2.4 system plate, two plates, one on the top and one on the bottom, grid plates and lag screw. 2 Among the options for the treatment of mandibular angle fractures, there is the grid plate, which is formed by joining two plates connected by bars, being used both in facial fractures and orthognathic surgery. The advantages of this plate are bone stability, easy adaptation, both in the upper and lower portions, malleability, shorter surgical time and low rate of complications. 2,4,5 According to Gear et al. 3, only 6% of American and European AO/ASIF instructors used grid plates for the treatment of mandibular angle fractures.

This reflects the lack of knowledge about the use of the grid plate to treat this type of fracture.

Thus, the present paper reports a case of mandibular angle fracture treated using the grid plate and discusses the advantages of this type of fixation in the treatment of these fractures.

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Costa FA, Silva RA, Sato FRL, Castro e Silva LM

Figure 1: Preoperative radiographic examination (posteroanterior of the mandible), showing fractures.

Figure 2: Grid plate fixed in the neutral area of the mandible.

Figure 3: 3D reconstruction of the tomographic examination in the immediate postoperative period.

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Treatment of mandibular angle fracture with grid plate: case report

Figure 4: Computed tomography in coronal section, after three-year follow-up.

Figure 5: Computed tomography in sagittal section, after three-year follow-up.

DISCUSSION With the emergence of stable internal fixation, the period of maxillomandibular block was greatly reduced, facilitating the return to function6. The main objective of the treatment of mandibular fractures recommended by AO/ASIF is to restore the function, allowing fast, active and pain-free mobilization during the period of fracture repair.7 Guimond et al.8 evaluated the occurrence of complications after treatment of 37 mandibular angle fractures using a grid plate and conventional systems. This resulted in a lower rate of complications (5.4%) using the grid plate, when compared to traditional systems (7.5%).

Hochuli-Vieira et al.4 evaluated the percentage of infection of mandibular angle fractures treated with different fixation systems. Trapezoidal plates had a rate of 4.4%, while patients treated with conventional systems presented a rate of 32%. Locking fixation systems had an infection rate similar to observed with trapezoidal plates (3.6%).

The factors that justify the lower rate of complications includes the structural design of the grid plate. Using two plates joined by vertical bars, greater structural rigidity is promoted, reducing the occurrence of gaps on the lower edge of the mandible and bone mobility, when compared to single fixation of the 2.0 system on the external oblique line or on the superolateral edge. Another important factor is the smaller mucoperiosteal detachment required to fix the plate, increasing the vascularization in the area, thus decreasing the chance of complications.4,8 A study by Hoffer et al.5 compared the stable internal fixation in sixty patients with mandibular angle fractures, being thirty patients treated with a plate on the external oblique line of the 2.0 mm system and thirty treated with a grid plate. The authors concluded that the mean time of surgery, from intubation to extubation, was 81.07 minutes in patients treated with a grid plate, while patients treated with the plate in the external oblique line had a mean time of 89.3 minutes.

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chanical load, a value much higher than masticatory forces during the healing process after a mandibular angle fracture, which varies between 25N and 66N. Thus, more studies are necessary to evaluate this type of stable internal fixation.

The shorter surgical time is justified by the need to place a single plate in a neutral zone, with minimal need for adaptation and additional curvature.9 Biomechanical studies involving grid plate for the treatment of mandibular fractures have been published, showing results similar to those found with the use of miniplates and monocortical screws arranged according to the guidelines of Champy and AO/ASIF.10 It is also observed that grid plates have adequate resistance to support masticatory loads, as suggested by the biomechanical studies conducted

by Wittenberg et al.10 and Zix et al.1, who presented plate deformation with 230N when subjected to me-

FINAL CONSIDERATIONS It can be concluded that, for mandibular angle fractures without displacement, treatment with the grid plate proved to be an effective option, presenting as main advantages the easy adaptation in the region, less morbidity to the patient, shorter surgical time and lower rate of complications.

References:

1. Zix J, Lieger O, Iizuka T. Use of straight and curved 3-dimensional titanium miniplates for fracture fixation at the mandibular angle. J Oral Maxillofac Surg. 2007 Sept;65(9):1758-63.

2. Al Moraissi EA, Ellis E. What method for management of unilateral mandibular angle fractures has lowest rate of postoperative complications? A systematic review and meta-analysis. J Oral Maxillofac Surg. 2014 Nov;72(11):2197-211.

3. Gear AJL, Apasova E, Schmitz JP, Schubert W. Treatment modalities for mandibular angle fractures. J Oral Maxillofac Surg. 2005 May;63(5):655-63.

4. Hochuli-Vieira E, Ha TKL, Pereira-Filho VAL, Landes CA. Use of rectangular grid miniplates for fracture fixation at the mandibular angle. J Oral Maxillofac Surg.

2011 May;69(5):1436-41.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

5. Höfer SH, Ha L, Ballon A, Sader R, Landes C. Treatment of mandibular angle fractures - Linea obliqua plate versus grid plate. J Craniomaxillofac Surg. 2012 Dec;40(8):807-11.

6. Ellis E, Carlson DS. The effects of mandibular immobilization on the masticatory system: A review.

In: Bell WH. Modern practice in orthognathic and reconstructive surgery. Philadelphia: WB Saunders; 1992. p. 1624-51.

7. Prein J. Manual of internal fixation in the cranio-facial skeleton. Berlin: Springer-Verlag; 1998. p. 227.

8. Guimond C, Johnson JV, Marchena JM. Fixation of mandibular angle fractures with a 2.0-mm 3-dimensional curved angle strut plate. J Oral Maxillofac Surg. 2005 Feb;63(2):209-14.

9. Bui P, Demian N, Beetar P. Infection rate in man-

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dibular angle fracture treated with a 2.0-mm 8-hole curved strut plate. J Oral Maxillofac Surg. 2009 Apr;67(4):804-8.

10. Wittenberg JM, Mukherjee DP, Smith BR, Kruse RN. Biomechanical evaluation of new fixation devices for mandibular angle fractures. Int J Oral Maxillofac Surg.

1997 Feb;26(1):68-73.

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CaseReport

Immunocompromised and descending necrotizing mediastinitis:

case report

ANNA CAROLINA JACCOTTET OLIVEIRA1 | NATASHA MAGRO ERNICA1 | RICARDO AUGUSTO CONCI1 | GERALDO LUIZ GRIZA1 | ELEONOR ÁLVARO GARBIN JÚNIOR1

ABSTRACT Introduction: The descending necrotizing mediastinitis (DNM) is caused by an odontogenic infection that invades facial and cervical spaces and reaches the mediastinum. Sometimes the signals and primary symptoms can be discrete, however, it cannot be underestimated. Objective: The present work aims to relate a clinical case of DNM originated from a dental abscess of the tooth #37. Case report: The patient affected by the infection is a 43-year-old, male, diabetic, hypertensive, alcoholist and smoker. He was admitted in the hospital with invasive odontogenic infection with several facial and cervical spaces. Clinically, he showed extraoral necrosis and active fistulisation in certain regions. After physical and imagiologic exams, through computed tomography scan, the DNM was diagnosed. In view of such diagnosis, the antibiotic therapy was started along with the drainage and debridement of the affected regions. This procedure was realized with the General Surgery team. The patient remained in the Intensive Care Unit after the surgery being under antibiotic therapy and systemic conditions control. Results and Conclusion: Due to the aggressive surgical treatment associated to the antibiotic therapy and the systemic conditions control, it was possible to achieve success on the treatment.

Keywords: Mediastinitis. Infection. Drainage. Diabetes mellitus. Alcoholism.

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

1

How to cite: Oliveira ACJ, Ernica NM, Conci RA, Griza GL, Garbin Júnior EA. Immunocompromised and descending necrotizing mediastinitis: case report. J Braz Coll Oral Maxillofac Surg. 2020 MayAug;6(2):44-9.

DOI: https://doi.org/10.14436/2358-2782.6.2.044-049.oar

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

Submitted: February 25, 2019 - Revised and accepted: July 17, 2019 Contact address: Anna Carolina Jaccottet Oliveira Rua Duque de Caxias, 544, apto. 91, Centro – Cascavel/PR CEP: 85.801-100 – E-mail: annacarolinajo@hotmail.com

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

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Oliveira ACJ, Ernica NM, Conci RA, Griza GL, Garbin Júnior EA

INTRODUCTION Oral and maxillofacial infections are characteristically polymicrobial infections caused by aerobic, anaerobic, endogenous and opportunistic bacteria.¹ Most infections originate from extensive carious processes, after unsuccessful endodontic treatment, pericoronaritis and after tooth extractions.¹ Also, immunocompromised patients are often more affected.² Patients with type 1 and 2 diabetes are more prone to developing infections, because they have a lower immune response compared to healthy individuals, thus being, hospitalized and developing severe infections more frequently. These infections are fatal eight times more frequently.³ Diabetes alone increases the chances of infection and does not require related pathologies. However, heart problems further increase the lethality of these infections.³ Infections of dental origin, if not solved early, can evolve into a series of complications such as cervical infections, which are manifested by clinical signs of pain in the cervical region, dysphagia, anorexia, dyspnea, tachypnea, fever, odynophagia , hoarseness, erythema, edema and crepitus.4 Thus, the present paper reports a case of descending necrotizing mediastinitis in an immunologically compromised patient, as well as its evolution and proposed treatment until the condition was solved.

At the onset of pain in tooth 37 he went to the local basic health unit, where he was medicated with Amoxicillin 500mg every 8 hours and Dipyrone 500mg every 6 hours. With the persistence and intensification of pain and edema, the patient attended the emergency service in the city of Cascavel, state of Paraná, where, after three days of hospitalization, he presented areas of deep tissue necrosis, with fistula in the left submandibular angle and cervical region and active and spontaneous drainage in the area. He presented generalized edema of great volume, hyperemia and flushing in the bilateral submandibular region, with greater volume on the left side, extending to the cervical region to the chest in the mediastinal region, presenting regions of deep necrosis with fistula discharging purulent and extremely fetid secretion.

During intraoral examination, large coronary destruction by tooth decay of teeth 37 and 47 was diagnosed, the first being pointed out as a possible focus of infection. Also, he presented normal excursion of the mandibular condyles and trismus with an interincisal distance of 12mm.

In the tomographic evaluation, it was observed that the infection involved the buccal, submandibular, sublingual, masseteric, infraorbital, retropharyngeal and lateral pharyngeal spaces, extending bilaterally to the mediastinal zone (Fig 2).

The laboratory examination, at the time of admission, revealed that the patient had 15,300 leukocytes per mm³, band neutrophils in 24% and segmented neutrophils in 9,362 per mm³.

Upon hospitalization, intravenous antibiotic therapy with Meropenem 2 g was prescribed at every eight hours, since this is a broad-spectrum antibiotic used for polymicrobial infections.

The patient was taken to the operating room for drainage of spaces affected by the infection, debridement of necrotic tissues and removal of the infectious focus.

The surgical procedure was performed in the operating room, under general anesthesia. During orotracheal intubation there were complications, precluding its accomplishment due to extensive edema and the distorted anatomy of the abscess in the region.

Thus, it was necessary to perform an emergency tracheostomy. During tracheostomy incision, there was purulent drainage and a deviation caused by infection in the trachea was observed, causing displacement to

CASE REPORT Male patient, aged 43 years old, Caucasoid, was admitted to the hospital service by the Oral and Maxillofacial Surgery and Traumatology team with odontogenic infection extending to the cervical and mediastinal spaces with areas of submandibular and thorax necrosis.

During anamnesis, the patient reported being a chronic alcoholic for 20 years, hypertensive, under daily use of medication to control the condition, smoker and without drug allergies. On physical examination, he presented patent airway, normal motor skills and visual acuity, feverish, with body temperature at 38 degrees Celsius, respiratory rate increased by 22 mpm and heart rate at 90 bpm, reporting dysphagia for solid foods and dyspnea during small efforts. He also reported pain in tooth 37 and the cervical region for 10 days (Fig 1).

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Immunocompromised and descending necrotizing mediastinitis: case report

A

B

A

B

Figure 1: A) Initial aspect of the patient, with massive swelling of the entire middle and lower facial thirds, besides redness in the area and in the cervical region. B) Areas of necrosis in the thorax and left submandibular region, with active drainage.

C

D

E

Figure 2: A) Periapical lesion in tooth 37. B) Gas accumulation in tissues, product of infection, on the same side as the focal tooth. C) Coronal section showing formation of gas in a descending manner from the lesion site to the mediastinal region. D) Airway deformation, with narrowing and gas formation on the opposite side of the infection focus. E) Section of the thorax region, showing generalized invasion of infection in these areas.

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Oliveira ACJ, Ernica NM, Conci RA, Griza GL, Garbin Júnior EA

in healthy tissue. In addition, at that time, tooth 37 was extracted because it was the focus of infection, as well as tooth 47, for prophylactic purposes.

After the surgical procedure, the patient remained under medical care in the Intensive Care Unit, in a serious but stable condition. During the period, there were frequent changes of dressings, which presented a large amount of secretion, performing daily irrigation of rigid drains with saline, to assist drainage and perform the mechanical removal of debris resulting from infection.

On the 12th day of hospitalization, there was a reduction in drainage of secretion through the drains, clinical improvement of the condition and also improvement of the infectious condition in the cell count.

There was a decrease in cell count of leukocytes, being 10,500 mm³, band neutrophils at 420 mm² and segmented neutrophils at 5,510 mm³. With these results, the intra- and extraoral drains were removed. However, the patient remained hospitalized, monitored by the maxillofacial surgery and traumatology team and the medical team, receiving antibiotic therapy and treatment to control systemic health conditions, such as hypertension and diabetes. Healing of the thoracic region was also monitored, which remained with a large area of exposure due to debridement.

After 27 days of hospitalization, the patient was afebrile, with fascial spaces with clinical and tomographic aspects within normal standards. Despite the several systemic impairments of the patient, which contributed to the onset of a severe condition, the case progressed satisfactorily, resulting in patient discharge from the hospital (Fig 3).

the right side. During this procedure, the patient suffered cardiopulmonary arrest due to hypoxia, requiring cardiopulmonary resuscitation, which was successfully performed. After tracheostomy, the patient returned to normal saturation during the procedure.

Thoracic and mediastinal surgery was performed by the general surgery medical team, which performed drainage of cervical and mediastinal spaces, debridement of necrotic tissues of the chest, which were quite extensive, and abundant irrigation with saline during the procedure. At the end of this step, the large amount of necrotic tissue was removed, leaving an extensive thoracic area without skin coverage at the end of the procedure.

Drainage in the oral and facial areas was performed by the Oral and Maxillofacial Surgery and Traumatology team. The extraoral procedure was performed with incisions in the submandibular region, bilaterally, dividing the tissues with the use of hemostatic forceps, inside the infected facial spaces, aiming at disrupting the infectious sites, thus performing an aggressive exploration of the fascial space and its emptying. Submental incisions were also performed on both sides, with the aforementioned type of drainage, communicating with the submandibular incision by a throughand-through drainage, which allowed placement of rigid and perforated drains in these regions.

In the intraoral drainage procedure, incisions were made in areas of the buccal sulcus of the tooth first affected by infection, allowing active drainage of the region and subsequent divulsion with hemostatic forceps. After draining the secretion, Penrose drains n. 1 and 3 were inserted and held in place by suturing

Figure 3: Aspect of the patient after treatment, without areas or signs of infection.

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Immunocompromised and descending necrotizing mediastinitis: case report

DISCUSSION The evolution of oral diseases as caries and periodontal diseases can lead to occupation of primary and secondary fascial spaces, due to infection. It can also present a more dangerous evolution to the deep cervical spaces, causing airway distortion and even obstruction.5 From this evolution, there are potential ways for the infection to reach the mediastinal space. Among the three main pathways, the deep cervical fascia plays an important role in determining the location and course of pathology propagation within the soft tissues of the neck,2 namely the pre-tracheal pathways for the anterior mediastinum, lateral pharyngeal route for the medium mediastinum, and retropharyngeal/retrovisceral route to the posterior mediastinum7. Among them, the most common route through which cervical infections communicate with the mediastinum is through the retrovisceral space.7 In some cases, when the infection descends towards the cervical tissues, these tissues may undergo a process of necrosis that clinically begins with painful and localized erythema, which has a progressive increase, associated with edema, known as descending necrotizing mediastinitis.2 Determination of this invasion is possible by analysis of computed tomography,2 which must be achieved early, evidencing tissues infiltrated by the infection, loss of the tissue planes, purulent and gas collections, besides continuous infectious process from the cervical region to the mediastinum.6 Dental infections, even if seemingly simple, especially in diabetic or immunocompromised patients and chronic alcoholics, cannot be underestimated in their capacity of invasion and progression to cases of mediastinitis.2 In addition, patients with diabetes commonly have necrosis and tissue gangrene. Some reasons that corroborate the greater predisposition of these patients are vascular insufficiency and tissue hypoxia caused by diabetic microangiopathy, creating appropriate conditions for the development and evolution of mixed aerobic-anaerobic infections.7 The lethality rate of infections also increases when patients are immunocompromised or when there is a delay in performing surgical drainage, and when the mediastinal space is invaded.8

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The complication called descending necrotizing fasciitis has a high rate of mortality and severity.

In this disorder, the cervical tissues involved in the infectious process undergo necrosis, starting with erythema and painful and localized edema, which progressively increases in hours or days, evolving to formation of bubbles with a dark yellowish or reddish content and extensive necrosis of subcutaneous tissues, fascia and, in more severe cases, even muscles.2 An aspect of concern in the treatment of these infections is the maintenance of the airway, which can be difficult to perform, as in the present case. Tracheostomy is considered the preferred technique in cases of difficult airway. Selection of the airway maintenance technique should be based on the patient’s status and the proper conditions to perform it.9 Diagnosis at the time of care and careful treatment with surgical drainage and adjuvant antibiotic therapy are necessary to control the infection and prevent progression to the fascial spaces, which contiguous and easy to communicate. Due to the proximity to the central nervous system and the airway, control and treatment as early and effective as possible is critical.6,10 Surgical treatment is extremely important and is performed by extra- and intraoral incisions for access and drainage of spaces filled by secretion, performing drainage of purulent secretion and also the extensive debridement and removal of necrotic tissues, such as subcutaneous tissue, fascia, muscles and skin at the affected site.10 FINAL CONSIDERATIONS Odontogenic infections are common in the routine of maxillofacial surgeons. Cases in immunocompromised patients should never be underestimated, due to the low capacity of these patients to resolve the infectious condition and the greater chance of progression of the infection, worsening rapidly and leading to patient’s death. Treatment with intravenous antibiotic therapy and immediate aggressive surgical treatment in cases of descending necrotizing mediastinitis is essential. Also, the involvement of different health areas and specialties contributes to the effective treatment and satisfactory resolution of cases.

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References:

1. Veronez B, De Matos FP, Monnazzi MS, Sverzut AT, Sverzut CE, Trivellato AE. Maxillofacial infection. A retrospective evaluation of eight years. Braz J Oral Sci. 2014 Apr-June;13(2):98-103.

2. Pinto A, Scaglione M, Scuderi MG, Tortora G, Daniele S, Romano L. Infections of the neck leading to descending necrotizing mediastinitis: Role of multi-detector row computed tomography. Eur J Radiol. 2008 Mar;65(3):389-94.

3. Bertoni AG, Saydah S, Brancati FL. Diabetes and the risk of infection-related mortality in the U.S. Diabetes Care. 2001 June:24(6):1044-9.

4. Sumi Y. Descending necrotizing mediastinitis: 5 years of published data in Japan. Acute Med Surg. 2014 June;2(1):1-12.

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5. Han J, Liau I, Bayetto K, Cheng A, Sambrook P, Goss A. The financial burden of acute deep-space odontogenic infections. Int J Oral Maxillofac Surg. 2015 Oct;44(Suppl 1):e223-4.

6. Roccia F, Pecorari GC, Oliaro A, Passet E, Rossi P, Nadalin J, et al. Ten years of descending necrotizing mediastinitis: Management of 23 cases. J Oral Maxillofac Surg. 2007 Sept;65(9):1716-24.

7. Wheat LJ. Infection and diabetes mellitus. Diabetes Care. 1980 Jan-Feb;3(1):187-97.

8. Guzmán-Letelier M, Crisosto-Jara C, Diaz-Ricouz C, Peñarrocha-Diago M, Peñarrocha-Oltra D. Severe odontogenic infection: An emergency. Case report.

J Clin Exp Dent. 2017 Feb;9(2):e319-24.

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9. Potter JK, Herford AS, Ellis E. Tracheotomy versus endotracheal intubation for airway management in deep neck space infections. J Oral Maxillofac Surg 2002 Apr;60(4):349-54.

10. Costa IMC, Cabral ALSV, de Pontes SS, de Amorim JF. Necrotizing fasciitis: new insights with a focus on dermatological aspects. An Bras Dermatol.

2004;79(2):211-24.

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CaseReport

Alloplastic reconstruction of temporomandibular joint:

indications and contraindications LEANDRO E. KLUPPEL1 | CAIO AUGUSTO MUNUERA UETI1

ABSTRACT Introduction: The alloplastic reconstruction has been one of the successful applications for the treatment of degenerative diseases of the temporomandibular joint.

The aim of the present study is to present a clinical case of alloplastic reconstruction of the temporomandibular joint and to carry out a review of the literature on this treatment modality, with emphasis on indications, contraindications, advantages and disadvantages. Methods: A search was performed in the following electronic databases: Pubmed/Medline and SciELO. Ten relevant articles were selected, which demonstrate that the alloplastic reconstruction of the temporomandibular joint is indicated for the treatment of TMJ severely compromised by pathologies such as: ankylosis, inflammatory arthritis, reabsorptive pathologies, tumors, successive failures of autogenous reconstruction, failures of alloplastic reconstruction itself, and congenital deformities such as microsomia. The alloplastic reconstruction shouldn’t be used in patients with systemic conditions favoring infections, local joint infection, allergy to materials, and poor bone quality and quantity for fixation of prosthetic components. Case report: A 62-year-old patient diagnosed with advanced osteoarthritis (Wilkes V) who underwent condilectomy and alloplastic reconstruction of both temporomandibular joints. Conclusion: The patient is now five years follow-up, presenting a good mouth opening, occlusion preserved and without pain.

Keywords: Mandibular condyle. Temporomandibular joint disorders. Osteoarthritis.

Universidade Federal do Paraná, Departamento de Cirurgia e Traumatologia Bucomaxilofacial (Curitiba/PR, Brazil).

1

How to cite: Kluppel LE, Ueti CAM. Alloplastic reconstruction of temporomandibular joint: indications and contraindications. J Braz Coll Oral Maxillofac Surg. 2020 May-Aug;6(2):50-5.

DOI: https://doi.org/10.14436/2358-2782.6.2.050-055.oar

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

Submitted: May 24, 2019 - Revised and accepted: August 09, 2019

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

Contact address: Leandro E. Kluppel E-mail: lekluppel@hotmail.com

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Kluppel LE, Ueti CAM

INTRODUCTION Currently, alloplastic reconstruction of the TMJ has been one of the most successful applications for the treatment of irreversibly damaged temporomandibular joint tissue. The number of implanted prostheses is growing at a significant rate, due to the success of surgical procedure, greater population longevity and the search for a better quality of life.1 Alloplastic joint reconstruction aims to replace, morphologically and functionally, the original temporomandibular joint.2 There are two types of total TMJ prostheses: stock prostheses and customized prostheses. The stock prosthesis is found in predefined sizes and shapes. It has two components: the mandibular fossa, made of polyethylene of ultra-high molecular weight; and the mandibular component, made of cobalt-chromium with a superficial layer of titanium, which comes into contact with the bone structure. The two components are found in three different sizes; however, the mandible head and the concavity of the prosthetic fossa have similar sizes.3 Custom prostheses are manufactured according to a stereolithographic model, which is produced by computed tomography. That is, it is a personalized prosthetic system, built by tomographic examinations of the patient’s face. The components of the customized alloplastic prosthesis are a fossa consisting of a pure titanium base, attached to the skull base, connected to an articular surface of polyethylene of ultra-high molecular weight. It also has a mandibular component, which is made of titanium, and a mandible head, made of chromium, cobalt and molybdenum.3 The fixation of components of both types of prosthesis to the bone structure is performed using titanium screws. The fossa is fixed to the zygomatic arch or skull base with 2.0 mm screws, and the mandibular component is fixed to the side of the mandibular ramus with 2.0 mm screws.3 The stock prosthesis is a solution with lower cost compared to customized prosthesis; however, there is

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

risk of bone resorption, due to the micro movements of prosthetic components.4 The host’s mandibular fossa and ramus must be modified during surgery to accommodate a stock TMJ prosthesis. It is also possible to interpose bone or alloplastic cement between the prosthetic components and the bone bed, for better adaptation to the host. Modification maneuvers can cause overload and micro movement of the alloplastic prosthesis. Micromovement promotes the formation of dense fibrous connective tissue between the host bone and the prosthesis, which results in loosening of components and treatment failure. Customized TMJ prostheses do not require any significant bone modification of the host to acquire stability, since their components adapt precisely to the bone. The fixation screws attenuate the micro movement and maximize the osseointegration of the prosthetic device.5 CASE REPORT Female patient, aged 62 years old, diagnosed with degenerative disease of both temporomandibular joints, Wilkes V classification. The patient had upper and lower protocol dentures. She reported severe pain in the temporomandibular joints bilaterally.

There was limited mouth opening and altered occlusion. In computed tomography, the condyle showed resorption and erosion of the bone surface (Fig 1).

The proposed treatment plan was condylectomy and alloplastic reconstruction of both temporomandibular joints.

The patient underwent full bilateral reconstruction with prostheses from the Biomet system (Biomet 3i do Brasil Ltda., São Paulo/SP, Brazil). Bilateral pre-auricular and retromandibular accesses, condylectomy and finally placement of stock prostheses were performed. The sequence of prosthesis placement consisted of the fossa component and then the mandibular component (Fig 2). The patient has been followed for five years, with good mouth opening and preserved occlusion and without pain (Fig 3).

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Alloplastic reconstruction of temporomandibular joint: indications and contraindications

A

B

C

D

Figure 1: A) Frontal view of the patient at rest.

B) Lateral view of the patient at rest. C) Upper and lower protocol dentures. D) Reduced maximum mouth opening, 27 mm. E) Right lateral view on computed tomography, showing resorption of the mandibular condyle. F) Left side view on computed tomography, showing resorption of the mandibular condyle.

E

F

A

B

C

D

E

F

Figure 2: A) Right preauricular access. B) Left pre-auricular access. C) Right mandibular component placed on the lateral aspect of the mandibular ramus through the retromandibular access. D) Right fossa component placed at the skull base through the preauricular access. E) Left mandibular component placed on the lateral aspect of the mandibular ramus through the retromandibular access. F) Left fossa component placed at the skull base through the preauricular access.

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A

B

C

D

Figure 3: A) Postoperative frontal view of the patient at rest. B) Postoperative lateral view of the patient at rest. C) Preserved postoperative occlusion. D) Maximum postoperative opening of 30 mm. E) Postoperative panoramic radiography.

E

DISCUSSION Until the 1990s, alloplastic reconstruction of the temporomandibular joint was applicable to a small number of patients with pathologies as ankylosis, severe condylar losses due to comminuted fractures and developmental abnormalities. Currently, it became an excellent method for the treatment of severely compromised temporomandibular joints, with failures of other alloplastic prostheses and autogenous grafts.3

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According to Souza,6 the following are indications for alloplastic reconstruction of the temporomandibular joint: arthritic conditions, such as osteoarthritis, traumatic arthritis and rheumatoid arthritis; ankylosis, with excessive heterotopic bone formation; avascular necrosis; joints submitted to various surgeries without success; and degenerated or resorbed joints with severe anatomical discrepancies.

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Alloplastic reconstruction of temporomandibular joint: indications and contraindications

mation of fibrosis and heterotopic bone around the prosthesis.7,8 Osteoarthritis, sometimes called degenerative joint disease, is a pathology in which excessive loads on the temporomandibular joint exceed its ability to adapt. In this disease, there is degeneration of the hard and soft joint tissues. Osteoarthritis causes pain, reduced mouth opening and bone resorption of the mandible head.9 According to Mehra,10 alloplastic reconstruction combined to orthognathic surgery is the treatment of choice for adult patients with intense forms of condylar resorption, using orthognathic surgery when necessary to correct the impairment of the patient’s facial harmony. Mandibular advancement, open bite closure and a substantial increase in height of the posterior facial third are esthetically and functionally beneficial for patients with condylar resorption.

For Throckmorton,8 they indications include when two or more TMJ surgeries were unsuccessful; inflammatory or resorptive pathologies; autoimmune pathologies; fibrous or bone ankylosis; absence of joint structures due to pathology, trauma or congenital deformity, such as hemifacial microsomia; and tumors involving areas of the condyle and mandibular ramus.

For Quinn,7 indications for TMJ alloplastic reconstruction include temporomandibular joints submitted to multiple surgeries and reconstruction with alloplastic implants of materials such as Silastic and Proplast-teflon, without success; inflammatory and resorptive pathologies, such as osteoarthritis; autoimmune diseases as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, systemic lupus erythematosus, Sjogren’s syndrome and scleroderma; ankylosis; and reconstructions after resection of benign or malignant tumors.

Advantages for alloplastic reconstruction of the temporomandibular joint are the reduction in surgical time, since it does not require a donor area; shorter hospital stay; and the possibility of immediate function.8 According to Mercuri,2 the contraindications for alloplastic TMJ reconstructions involve patients with excessive expectations regarding functional gains and pain resolution; systemic diseases, such as uncontrolled diabetes mellitus; active infections in the joint; and allergy to some prosthetic material. It also has restricted use in growing patients.

The adverse effects caused by the placement of alloplastic prostheses of the temporomandibular joint include loosening and displacement of the prosthesis, systemic or superficial infection, allergic reaction or foreign body reaction, facial edema, wear of the mandibular fossa, injuries to the facial nerve, ear problems and formation of neuromas.6 The disadvantage of alloplastic prostheses are their high cost, restricted use in growing patients and loss of translation movement. With the inability of translational movement, mandibular laterality and protrusion are impossible. This occurs because disinsertion of the lateral pterygoid muscle is necessary during condylectomy. In condylectomy, the lateral pterygoid muscle is detached, and later there is for-

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

FINAL CONSIDERATIONS Considering this literature review with a case report, and respecting the objectives of this paper, it is possible to conclude that: 1) Alloplastic reconstruction of the temporomandibular joint aims to restore severe anatomical and functional changes in the TMJ; however, it does not equivalently replace the original tissue. The patient who receives this type of rehabilitation becomes unable to perform mandibular laterality and protrusion movements.

2) Alloplastic reconstruction of the temporomandibular joint is indicated for the treatment of TMJ severely compromised by pathologies as ankylosis, inflammatory arthritis, resorptive pathologies, tumors, successive failures of autogenous reconstruction, failures of alloplastic reconstruction and congenital deformities, such as microsomia.

3) In the treatment of traumatic injuries, it should not be considered as the first treatment option, being restricted to cases with loss of substance or total destruction of the joint, besides cases of sequelae.

4) Alloplastic reconstruction should not be used in patients with systemic conditions that favor infections, local joint infection, allergy to prosthetic materials and insufficient bone quality and quantity for fixation of prosthetic components.

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References:

1. Wolford LM, Mercuri LG, Schneiderman ED, Movahed R, Allen W. Twenty-year follow-up study on a patient-fitted temporomandibular joint prosthesis: The techmedica/TMJ concepts device. J Oral Maxillofac Surg. 2015 May;73(5):952-60.

2. Mercuri LG. The use of alloplastic prostheses for temporomandibular joint reconstruction. J Oral Maxillofac Surg. 2000 Jan;58(1):70-5.

3. Mercuri LG, Edibam NR, Giobbie-Hurder A. Fourteenyear follow-up of a patient-fitted total temporomandibular joint reconstruction system. J Oral Maxillofac Surg.

2007 June;65(6):1140-8.

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4. Westermark A. Total reconstruction of the temporomandibular joint. Up to 8 years of follow-up of patients treated with Biomet® total joint prostheses. Int J Oral Maxillofac Surg. 2010 Oct;39(10):951-5.

5. Mercuri LG. Patient-fitted (“custom”) alloplastic temporomandibular joint replacement technique.

Atlas Oral Maxillofac Surg Clin North Am. 2011 Sept;19(2):233-42.

6. Souza DPE. Avaliação clínico-funcional de pacientes submetidos a tratamento com prótese total de ATM. [dissertação]. São Paulo: Universidade de São Paulo; 2009.

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7. Quinn PD. Alloplastic reconstruction of the temporomandibular joint. Oral Maxillofac Surg. 2000; 7(5):3-23.

8. Throckmorton GS. Temporomandibular joint biomechanics. Oral Maxillofac Surg Clin North Am. 2000;12(1):27-42.

9. Tanaka E, Detamore MS, Mercuri LG. Degenerative disorders of the temporomandibular joint: etiology, diagnosis, and treatment. J Dent Res. 2008 Apr;87(4):296-307.

10. Mehra, P, Henry CH, Giglou KR. Temporomandibular joint reconstruction in patients with autoimmune/connective tissue disease. J Oral Maxillofac Surg. 2018 Aug;76(8):1660-4.

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OriginalArticle

A critical view of medical hegemony in relation to dentistry, in urgency and

emergency care

BEATRIZ SOBRINHO SANGALETTE1 | THAYNA DA SILVA EMÍDIO1 | MARCOS MAURICIO CAPELARI2 | CLÁUDIO MALDONADO PASTORI3 | RAFAELLA FERRARI PAVONI4 | GUSTAVO LOPES TOLEDO4

ABSTRACT Introduction: Dentistry has a wide field of practice, conducted in outpatient care or hospital environments. Therefore, its working limits merge with the medical area, leading to inquiries about the responsibilities that already have legal provisions for each of the professional cases. This type of situation is common and occurs mainly in urgent and emergency circumstances, be it in clinics or hospitals. Method: In order to clarify what each professional is responsible for in an emergency care, focusing on the hospital environment, this study carried out a cross-sectional retrospective research of the national and international literature, between 2000 and 2017, in research bases such as PubMed, Bireme, SciELO and Lilacs. Results: From the evaluation of 6 articles, 5 books, 2 laws and 4 resolutions, it was possible to verify that 10 of these indicated that the limits are defined from the aspects of complexities, and 7 stated that the performance refer to the specific qualification of each area. Conclusion: Multidisciplinary decentralized work of the presumed hegemonic medical figure is the mechanism to fill these gaps and to carry out responsible medical-dental care, safeguarding the most precious asset that is the patient’s life.

Keywords: Emergency medicine. Emergency relief. First aid.

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

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

3 Centro Universitário de Adamantina, Departamento de Cirurgia e Traumatologia Bucomaxilofacial (Adamantina/SP, Brazil).

4 Universidade Estadual do Norte do Paraná, Acadêmica de Odontologia (Jacarezinho/PR, Brazil).

1

How to cite: Sangalette BS, Emídio TS, Capelari MM, Pastori CM, Pavoni RF, Toledo GL. A critical view of medical hegemony in relation to dentistry, in urgency and emergency care. J Braz Coll Oral Maxillofac Surg. 2020 May-Aug;6(2):56-9.

DOI: https://doi.org/10.14436/2358-2782.6.2.056-059.oar

2

Submitted: April 16, 2019 - Revised and accepted: February 25, 2020 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article.

Contact address: Beatriz Sobrinho Sangalette E-mail: drabeatrizsangalette@gmail.com

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Sangalette BS, Emídio TS, Capelari MM, Pastori CM, Pavoni RF, Toledo GL

METHODS A retrospective cross-sectional study of national and international literature was conducted in the bibliographic databases Bireme, PubMed, Scielo and Lilacs between the years 1966 and 2018. The chosen descriptors were obtained from the DeCS/MeSH Platform, including “emergency medicine”, “urgent care” and “first aid”, used separately during the search. In addition, laws relevant to the topic were used, provided that they met the following inclusion and exclusion criteria: » Inclusion Criteria: all articles that cited the common activities between medical doctor, maxillofacial surgeon and their duties. » Exclusion Criterion: articles that did not deal with this topic or presented adverse discussions that did not contribute to this issue.

INTRODUCTION The terms urgency and emergency, though treated in an equivalent manner by dictionaries, have different meanings in the medical field. Paim1 defines emergency as a process with imminent risk of life, diagnosed and treated in the first hours after its discovery,1 i.e. he emphasizes that care must be immediate, and the patient’s consent to provide first aid is unnecessary. The author also elucidates urgency as an acute clinical or surgical process, without imminent risk of life, showing distinction between both terminologies.2 Regarding the legal aspects involved in an urgency or emergency situation, it is emphasized that the professional is legally responsible for the patient, which assumes autonomy to manage situations that expose to imminent risks.3 Malamed3 reinforces that the victim must be kept alive by treating until recovery or until another more qualified individual takes responsibility for the treatment.

In a hospital environment, the entire team is responsible for care. However, the so-called hegemonic medical figure centralizes this action, placing the rest of the staff in a position of defensive and occasionally submissive position, including the maxillofacial surgeon, a specialist in the dental field, who works in both outpatient and hospital settings, which shows biases present in relation to what is up to each professional.

It should be noted that, when entering the emergency environment, inherent priorities will be established to safeguard the life of patients, who are evaluated by an emergency medical doctor, who will provide first aid and, once clinically stabilized, will be assisted by other indispensable specialties in global service. It is important to say that the emergency service may occasionally require assistance from specialties that are momentarily not priority to the initial care to help, e.g. to stop bleeding or even to facilitate access, allowing intubation.

Aiming to elucidate the circumstances under responsibility of the maxillofacial surgeon, this study carried out a retrospective cross-sectional literature review, using the predetermined time period from 1966 to 2018.

There is a need to incorporate national and international laws and regulations to reduce errors during emergency situations, clarifying the fine line that separates the performance of the maxillofacial surgeon and the emergency medical doctor – when in the area of ​​the facial/ stomatognathic complex. Thus, it is expected to decrease the number of iatrogenic, or even negligent, situations that lead the patient to severe later problems or death.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

RESULTS From the evaluation of six articles, it was possible to notice that aspects of complexity were the guiding factors of performance, since these define the hierarchy in care. Among these eight, two also reported lack of information regarding the performance of the maxillofacial surgeon, as well as their time to act in urgency and emergency situations, both for the lay public and for the medical profession itself. The five selected books address the professional’s ethical and legal obligations in situations where the patient’s life is at imminent risk. The two laws and the four resolutions provided that action is based on the specific training of each area, as well as on the general clinical condition of the victim.

DISCUSSION The separation between schools Medicine and Dentistry – which were united in the past – was established by decree n. 9311, of October 25th 1884, known as Savoy Reform. This reform officially instituted the course of Dentistry at the School of Medicine of Rio de Janeiro.6 At this point, the two areas began to have their assignments partially determined by laws and decrees of the time, increasing the number of dentists among the population and, consequently, performing a greater degree of activity.6 Even though Dentistry involves working in outpatient and hospital environments, in the latter it is observed that Medicine assumes a leadership position, making the multidis-

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A critical view of medical hegemony in relation to dentistry, in urgency and emergency care

gree in Medicine, not only because of the bias found in Brazilian legislation, showing that there is “an immaturity of health in understanding itself as an area of​​ independent activity”,7 which leads to losses in medical and dental care, since the maxillofacial surgeon has knowledge in medical fields related to the oral and maxillofacial region, making it an extremely important resource, especially during emergency care.10 At this point, it is emphasized that Law 5081/66, in a comprehensive manner, determines in Article 6, Item I, that “It is responsibility of the dentist to practice all acts pertinent to Dentistry, resulting from knowledge acquired in a regular course or in postgraduate courses”, 5 i.e. this health professional should provide emergency care to patients who need their assistance. However, the law is still flaw on the extent of such assistance. 11 Additionally, Law 12842/2013, which regulates the practice of Medicine, states in Art. 30 that “The doctor who is part of the health team that assists the individual or the community will act in mutual collaboration with other health professionals who compose it”, indicating the clear need for multidisciplinary care.12 The Dental Code of Ethics, regulated by Resolution CFO 118/2012, in Art. 5, allows the dentist the right to “diagnose, plan and perform treatments, with freedom of conviction, within the limits of his attributions, observing the current state of science and its professional dignity”. 13 Accordingly, Art. 6, item VIII of Law 5081/66 regulates the practice of Dentistry and states that the surgeon should “prescribe and apply emergency medication in the case of serious accidents that compromise the patient’s life and health”. 5 However, it does not elucidate, for example, the way such medication should be administered to the victim, leaving the administration route open, such as application of intravenous drugs, as obvious as this premise may seem, in view of the pharmacodynamic and pharmacokinetic knowledge on drugs.

In addition, resolution CFO-63/2005 infers that “the areas of competence for the work of specialists in Oral and Maxillofacial Surgery and Traumatology include. Single paragraph. In the event of surgical accidents, which endanger the patient’s life, the dentist may use all possible means to save him”. 8 In contrast, Resolution N. 2217/2018 of the Federal Medical Council infers, in Art. 4, that: “In situations involving procedures in polytraumatized patients, it is the duty

ciplinary integration in the hospital team increasingly tiring, because of the management expressed by Medicine, placing the rest of the team in a position of defensive performance.7 This fact disagrees from the regulatory norm, since Art. 49 of Resolution n.

63 of April 8 th 2005 infers that: “In procedures in polytraumatized patients, the dental professionals who is a member of the emergency care team must obey a protocol for the priority of patient care, and their performance must be defined according to the priority of the patient’s injuries”.8 Also, according to Art. 50 of the same resolution, “In lesions in sites common to Dentistry and Medicine, and when the team is composed of dental and medical doctors, the treatment must be performed jointly, and the team leader shall be the professional responsible for treating the most serious and/or complex lesion”.8 Therefore, the dentist who is a specialist in Oral and Maxillofacial Surgery must assume the supporting responsibility when requested by the emergency medical doctor and, if necessary, integrate a decision-making position when the action requires technical support that exceeds the knowledge acquired by the medical professional.

This situation is reminiscent of what was known as the Flexner Report, written in 1910 by Abraham Flexner, which aimed to reorganize and regulate the curriculum of medical schools. However, it brought losses that persist until today in the health area, by inferring as its main basis the idea that “good medical education determines both the quality of medical practice and distribution of the workforce, the performance of health services, and eventually the health status of people”. 9 In other words, he attributes the medical doctor as the central figure in the service; thus, when introducing a learning system based on the disease and the hospital, the activity of other professionals who might have more knowledge to solve certain cases is relegated to a secondary role, disregarding important aspects that, according to Pagliossa et al, 9 generated a “reductionist vision that reserves little space, if any, for the social, psychological and economic dimensions of health and for the inclusion of the broad spectrum of health, which goes far beyond Medicine and its doctors”.

For this reason, we observe that the professional exercise between medical doctors and maxillofacial surgeons is discrepant, due to the posture they assume in the work environment, especially those with a de-

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Sangalette BS, Emídio TS, Capelari MM, Pastori CM, Pavoni RF, Toledo GL

CONCLUSION In lesions in areas common to Dentistry and Medicine, and when the team is composed of maxillofacial surgeon and medical surgeon, it can be concluded that, according to the current regulations on this theme, in verbis, in procedures in polytraumatized patients, dental professionals member of the emergency care team must follow a priority protocol for patient care, and their work must be defined by the priority of patient’s lesions, as well as lesions in areas common to Dentistry and Medicine. When the team consists of both dental and medical doctors, the treatment must be conducted jointly, led by the professional responsible for the treatment of the most serious and/ or complex lesion, since related and “sister” areas of distinct responsibilities are observed for both. Multidisciplinary work, decentralized from the supposed hegemonic medical figure, is the mechanism to fill these gaps and provide responsible medical and dental care, safeguarding the most precious asset: the patient’s life.

of the emergency medical doctor, after providing care, to define which specialized area will have priority following treatment”14. Then, the professional who first took the case should provide care and define the relevant therapy, thus resulting in responsibility for the integral health and reduction of sequelae caused by trauma, as inferred in Art. 4 of CFO Resolution 100/2010, in full: “In procedures for polytraumatized patients, dental professional who is member of emergency care teams must follow a protocol for the priority of patient care, and their action must be defined by the priority of patient’s injuries”. 15 Thus, all these factors, when associated, cause damages and losses both with regard to training and work of the hospital team – mainly medical doctor and maxillofacial surgeon, who work together with different services for the patient’s well-being – as well as the individual who seeks care, since, in case of disagreement as to the timing of each of these professionals, multidisciplinary work can, and consequently, will be impaired. 16,17

References: 1. Paim JS. Organização da atenção à saúde para a urgência/emergência [monografia]. Salvador: Centro Editorial e Didático da Universidade Federal da Bahia; 1994.

2. Giglio-Jacquemot A. Urgências e emergências em saúde: perspectivas de profissionais e usuários. 20ª ed.

Rio de Janeiro: Fioocruz; 2005.

3. Malamed SF. Emergências médicas em Odontologia.

7ª ed. Rio de Janeiro: Elsevier; 2016.

4. Queiroga TB, Gomes RC, Novaes MM, Marques JLS, Santos KSA, Grempel RG. Situações de emergências médicas em consultório odontológico. Avaliação das tomadas de decisões. Rev Cir Traumatol Buco-Maxilo-Fac. 2012 Jan-Mar; 12(1):1-7.

5. Brasil. Lei n.0 5.081, de 24 de agosto de 1966. Regula o exercício da Odontologia. Diário Oficial da União.

Brasília (DF); [1966 ago 26]; Seção 1:1.

6. Silva RHA. Orientação legal para o cirurgião-dentista: ética e legislação. Ribeirão Preto: Santos; 2010.

7. Godoi APT, Francesco AR, Duarte A, Kemp APT, Silva-Lovato CH. Odontologia hospitalar no Brasil. Uma visão geral. Rev Odontol UNESP. 2009;38(2):105-9.

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

9. Pagliosa FL, Da Ros MA. O relatório Flexner: para o bem e para o mal. Rev Bras Educ Med.2008 Oct-Dec; 32(4):492-9.

10. Hupp JR, Ellis III E, Tucker MR. Cirurgia oral e maxilofacial. 5ª ed. Rio de Janeiro: Elsevier; 2009.

11. Sobrinho Sangalette B, Vieira LV, Nascimento JA, Capelari VI, Shinohara AL, Marzola C, et al. Bichectomia: uma visão crítica. J Braz Coll Oral Maxillofac Surg.

2018 Sept-Dec; 4(3):22-7.

12. Brasil. Lei 12.842, de 10 de julho de 2013. Dispõe sobre o exercício da Medicina. Diário Oficial da União.

Atos do Poder Legislativo. Brasília (DF); [2013 jul 10]; Sec. 1:1 13. Brasil. Resolução CFO 118/2012, de 11 de maio de 2012. Revoga o Código de Ética Odontológica aprovado pela Resolução CFO-42/2003 e aprova outro em substituição. Diário Oficial da União. Atos do Poder Legislativo. Brasília (DF); [2012 jun 14]; Sec. 1:118-121.

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14. Brasil. Resolução CFM 2.217/2018, de 27 de setembro de 2018. Aprova o código de ética Médica. Rio de Janeiro; [2018 nov 01].

15. Brasil. Resolução CFO 1950/2010, de 07 de julho de 2010. O Conselho Federal de Medicina e o Conselho Federal de Odontologia estabelecem, conjuntamente, critérios para a realização de cirurgias das áreas de bucomaxilofacial e crânio-maxilo-facial. Entidades de Fiscalização do Exercício das Profissões Liberais.

Diário Oficial da República Federativa do Brasil. 2010 Jul 7; Sec 1:132 16. Zanetti LSS, Uceli CM, Marano RR, Coser RC, Rangel JA, Beccalli I. Análise do grau de conhecimento de Médicos e Dentistas sobre a especialidade de CTBMF na Grande Vitória/ ES. Rev Bras Cir Buco-Maxilo-Fac. 2010;10(1):13-22.

17. Pita Neto IC, Soares ECS, Esses DFS, Costa FWG, Bezerra TP. Avaliação do conhecimento do público leigo e de profissionais da saúde sobre a cirurgia e traumatologia buco-maxilo-facial em Fortaleza- CE. Rev Cir Traumatol Buco-Maxilo-Fac. 2011 Apr-June;11(2):63-74.

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OriginalArticle

Evaluation of nasal permeability after

treatment of fractures MÁRCIO MENEZES NOVAES1 | ADRIANO ROCHA GERMANO2 | LEANDRO BARBOSA RIBEIRO3 | JOSÉ SANDRO PEREIRA DA-SILVA4

ABSTRACT Objective: The present study analyzes nasal permeability in patients suffering from nasal fractures. Methods: Prospective observational cohort study to evaluate the signs and symptoms of nasal obstruction in patients with fracture in this region, correlating the clinical findings of the nasal air escape area in the Altmann mirror (rhino-hygrometry) and the symptoms observed on the nasal obstruction symptom scale (NOSE) by Stewart et al. (2004). Results: Twenty-eight patients were enrolled, and nasal obstruction symptoms decreased by 25% to 10% on the NOSE scale (p < 0.05).

Rhino-hygrometry showed an increase in air leakage area, but without statistical significance (p > 0.05) and no correlation between statistical and objective variables.

The surgeries performed in the first two weeks after trauma showed better results regarding the reduction of nasal obstruction symptoms and increased nasal escape area. Conclusion: Surgery to reduce nasal fractures improves symptoms of nasal obstruction and when performed in the first two weeks, present the best results.

Keywords: Nasal bone fracture. Airway. Nasal obstruction.

Universidade Federal do Rio Grande do Norte, Especialista em Cirurgia e Traumatologia Bucomaxilofaciais pelo programa de residência multiprofissional (UFRN, Natal/RN, Brazil).

1

How to cite: Novaes MM, Germano AR, Ribeiro LB, da-Silva JSP. Evaluation of nasal permeability after treatment of fractures. J Braz Coll Oral Maxillofac Surg. 2020 May-Aug;6(2):60-7.

DOI: https://doi.org/10.14436/2358-2782.6.2.060-067.oar

Universidade Estadual de Campinas, Doutorado na Área de Cirurgia e Traumatologia Bucomaxilofaciais (UNICAMP, Campinas/SP, Brazil).

2

Submitted: June 26, 2019 - Revised and accepted: January 14, 2020

Faculdade de Tecnologia e Ciência, Graduação em Odontologia (FTC, Juazeiro/BA, Brazil).

3

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

Universidade de São Paulo, Doutorado em Ciências Médicas (USP, São Paulo/SP, Brazil).

4

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

Contact address: Márcio Menezes Novaes E-mail: marcionovaes89@gmail.com

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Novaes MM, Germano AR, Ribeiro LB, da-Silva JSP

Inclusion criteria All patients with fractures of the nasal complex who underwent treatment and whose data could be fully collected were included.

Instrument for data evaluation and collection The tests were applied before treatment (T0), one month (T1) and three months (T2) posttreatment, using the instruments described below, to collect information on respiratory function/nasal permeability: 1) Scale of subjective evaluation of nasal obstruction symptoms (NOSE) proposed and validated

by Stewart et al.5, in 2004. On this scale, the patient answers questions about sensations of nasal obstruction and breathing difficulties. At the end, a score is assigned for the degree of obstruction in percentages from 0 (without obstruction) to 100% (total obstruction) or classified as mild (1 to 25%), moderate (26 to 50%) or severe (51 to 100%). The patient was considered satisfied with the surgical procedure, in relation to breathing, when he reported a sensation of totally unobstructed nostril or a slight degree of obstruction, not wishing for a new treatment (Table 1).

2) In an objective manner, nasal permeability was assessed by rhino-hygrometry, placing the recess of the Altman mirror below the nasal columella, with the patient sitting in a chair with back support, being asked to close the eyes, not explaining to the patient the reason to avoid influence on respiratory movements. After the tenth expiration, the mean area of ​respiratory fog formed in the mirror was outlined simultaneously with a pilot pencil, and the drawing was transferred to a transparent millimeter paper (Fig 1). All patients underwent pre- and postoperative evaluations after 30 and 90 days.

To perform the test with the mirror, the individuals remained seated in an air-conditioned room for a period of 30 minutes, with the head positioned vertically and centralized, with the eyes and mouth closed, so that they did not see the mirror. Exhalation was natural and the patient did not know the purpose of the plate under the nose (Fig 1A and 1B).

A total of 10 expirations were waited, and the most repeated fog was contoured with pilot pencil for boards. Then, the drawing was transferred to a millimeter paper and the area was measured in square centimeters in the AutoCAD-2014 (AutoDesk) software.

Exclusion criteria All patients with history of nasal surgery or previous nasal pathologies were excluded, as well as those with allergic processes that affect the respiratory function.

Fracture pattern Fractures were categorized arbitrarily into pure fractures of nasal bones (NB) (type I) and associated with septum fracture (type II), excluding NOE (naso-orbito-ethmoidal) fractures.

INTRODUCTION The nasal complex is the site most affected by fractures in the facial region, due to its prominent position. If not properly treated, they cause important esthetic and functional changes.1 In Brazil, they account for 14 to 22% of all facial fractures, caused mainly by physical aggressions, traffic accidents and falls from own height. 2 The treatment often consists of early surgical approaches, specific to the nasal septum and secondary repairs.3 It was observed, by dynamic study of the air flow, the need for respiratory effort six times greater in the nostril whose fracture is displaced. 4 During diagnostic assessments of nasal fractures, most surgeons rely only on the symptoms, without objective analysis. Therefore, this study aimed to assess, in an objective and subjective manner, the nasal permeability in patients with fractures in this region.

METHODS Ethical aspects This study was approved by the Institutional Review Board registered in Plataforma Brasil under n. 732.420, and free informed consent forms (ICF) were signed by the patients.

Study design Observational, cohort, prospective study conducted in patients suffering from nasal trauma treated at Hospital Universitário Onofre Lopes (HUOL/ UFRN) in Natal/RN in Northeast Brazil, over a period of one year.

Sample The sample was intentional (not probabilistic), based on the demand of patients assisted.

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A

B

C

D

Figure 1: A) Altmann millimeter mirror positioned in the subnasal region. B) Contour of the respiratory fog formed on the mirror, to be transferred to the transparent millimeter paper. C) Outline of the respiratory fog transferred to transparent millimeter paper, showing a decrease in the area of respiratory fog on the left side, in the preoperative period. D) Outline of the respiratory fog transferred to the transparent millimeter paper, showing an increase in the area on the left side, in the postoperative period.

Table 1: NOSE (Nasal Obstruction Symptom Evaluation).

Variable

None

Mild

Moderate

Very bad

Severe

Nasal obstruction Breathing difficulty Breathing difficulty during sleep

0 0 0

1 1 1

2 2 2

3 3 3

4 4 4

Impossibility of air passage through the nose

0

1

2

3

4

Difficult air passage through the nose during exercises

0

1

2

3

4

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Novaes MM, Germano AR, Ribeiro LB, da-Silva JSP

Statistical analyses Data obtained were statistically analyzed using SPSS version 15.0, using the Shapiro-Wilk test to verify the sample normality, which resulted in a non-parametric sample. Then, Wilcoxon’s nonparametric test was applied.

fractures showed statistically significant improvement after treatment. Conversely, type II fractures improved in general, but without statistical significance (Fig 3A and 3B).

Type II fractures were more related to more severe complaints, of which 62.5% caused functional and esthetic problems. While 45% of patients with Type I fractures sought the service only for esthetic complaints, 40% reported breathing and esthetic difficulties and 15% had only functional complaints, showing that the association with septal dislocation leads to more severe problems.

When assessing the influence of the fracture pattern on the ANAE before surgery, it was observed that the area in nasal fractures associated with the septum was smaller than the nasal fracture without septum involvement, respectively with means of 22.1 cm 2 and 27.2 cm2.

The area of ​​nasal air escape in the Altman mirror increased in both patterns, yet without statistical difference. Specifically analyzing Type II fractures (8 cases), 2 patients presented synechia formation in the postoperative period, which led to an increase in the sensation of nasal obstruction from 10% to 75% in the first case and from 35% to 45% in the second case.

Surgeries performed over 15 days had no statistically significant improvement (p = 0.104), while those performed up to 15 days showed the best results (p = 0.05).

Though not statistically significant, the area of nasal air escape in the Altman mirror increased in both fracture patterns, and the mean interval from trauma to treatment was 19.8 days after trauma, ranging from 7 to 32 days . Fractures treated within the first 15 days achieved an increase in the area of​​ air escape by 22.1%, while in fractures treated late a mean gain of 6.6% was observed.

There were no statistically significant correlations between the increase in the area of nasal air escape in the Altman mirror and the symptoms of NOSE obstruction, but it was noted that, as the air escape area increased, there was a decrease in the sensation of nasal obstruction (Fig 4A and 4B).

Of all operated cases, 21.5% reported a feeling of moderate to severe nasal obstruction, wishing for a new surgical approach, which were associated with 5 cases of obstruction due to formation of nasal synechia and a deviated septum.

RESULTS The sample consisted of 28 patients, among which 23 (82.1%) were males and 5 (17.9%) were females, with a mean age of 29 years, ranging from 19 to 59 years.

In 24 (85.7%) cases, closed surgical treatments were performed using Ascher and Walshan forceps, and in 4 (14.3%) patients an open technique was performed. Two cases had type II fracture sequelae, with septoplasty; and two cases were associated with fracture of frontal bone, in which OPN reduction and fixation to the frontal bone was performed by coronal access.

Concerning the etiology of trauma, most fractures were due to traffic accidents (32%), physical aggression (21.4%) and sports accidents (21.4%), followed by work accidents (14.3%) and fall from own height (10.7%). In 14%, there were only functional complaints, 39% esthetic complaints and 47% both complaints.

When assessing the gain in the area of nasal ​​ air escape in the mirror, it was observed that, in general, there was an increase in the area around 0.4% in the first month and 5.3% in the third month, without statistical significance (Fig 2A).

The mean symptoms of nasal obstruction before surgery in the 28 patients was 25% in NOSE (Nasal Obstruction Symptom Evaluation). After the surgical procedure, the feeling of nasal obstruction decreased to 10% in the first month, with a slight increase of 5% in the third month compared to the first, with a general improvement in relation to the preoperative, statistically significant at T1 (p = 0.0037) and T2 (p = 0.0494) (Fig 2B).

In 78.5% of cases, the patients were satisfied with their breathing, not wishing for a new surgical approach or treatment after three months. Among these, 68.5% did not have obstruction symptoms (0% NOSE) and 10% had a mild sensation (1 to 25%).

Evaluating the influence of the fracture pattern on the perception of symptoms of nasal function obstruction by NOSE, it was observed that type I

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Nasal area

Score on the NOSE scale

Evaluation of nasal permeability after treatment of fractures

A

B

Figure 2: A) Area of nasal air escape after surgeries (T1, p = 0.697) (T2, p = 0.2694), two-tailed Wilcoxon paired test (n = 28). B) Symptoms of nasal obstruction after surgical procedures (T1, p = 0.0037) (T2, p = 0.0494), two-tailed Wilcoxon paired test (n = 28).

Score on the NOSE scale

Fracture with septum

Score on the NOSE scale

Fracture without septum

A

B

Figure 3: A) Symptoms of nasal obstruction after surgical procedures (T1, p = 0.0181) (T2, p = 0.0907), two-tailed Wilcoxon paired test (n = 20). B) Symptoms of nasal obstruction after surgical procedures (T1, p = 0.2351) (T2, p = 0.2932), compared to their values before therapy, two-tailed Wilcoxon paired test (n = 8).

NOSE x Nasal area (3 months-pre)

NOSE x Nasal area (1 month-pre)

NOSE

NOSE

Nasal area Nasal area

A

B

Figure 4: Correlation between the sensation of nasal obstruction and the area of nasal air escape in the Altman mirror.

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DISCUSSION Despite the high incidence of nasal fractures, these lesions are usually neglected and considered minor trauma, which promotes functional and esthetic problems because they are not properly treated.3 Most studies aimed to evaluate the esthetic and functional results, comparing surgeries performed under local or general anesthesia, and did not use uniform methodologies to evaluate these variables.

In this article, all patients underwent surgery under general anesthesia and 78.5% were satisfied with their breathing, while 21.5% reported moderate to severe nasal obstruction, wanting a new surgical approach. The high rate of symptoms of nasal obstruction after surgery was attributed to the 5 cases of nasal synechia after surgery, and the permanence of deviated septum in one case, who were referred to the Otorhinolaryngology sector for treatment.

There was increase in the area of nasal air escape (ANAE) in the Altman mirror in the two evaluation periods after surgery; however, without statistically significant difference. This can be assigned to the reduced sample size and cases of postoperative complications (formation of synechia) in 17.8% of the sample. In general, there was gain of 0.4% in the first month and 5.3% in 3 months after surgery in the area of nasal â&#x20AC;&#x2039;â&#x20AC;&#x2039; air escape.

Similar results to this study revealed, by a visual analog scale (VAS), that 83.3% of patients reported good or satisfactory nasal permeability and 16.6% reported symptoms of obstruction. 6 Rajapakse et al,7 in a retrospective study on 197 patients, evaluated the results of the treatment of nasal fractures and observed that 79.1% of patients were satisfied with the nasal function; among these, 20.8% said their breathing worsened, but it was acceptable, while 20.8% reported total functional dissatisfaction. Of the total number of operated patients, 12% progressed to a second intervention (septoplasty, rhinoplasty or septorhinoplasty).

Gertner, Podoshin and Fradis,8 in a research with Glatzel mirror, observed in 93 patients with deviated septum that the major axis of drawing formed by the air in the mirror was 4 cm and, after surgery, it increased to 7 cm, showing that the surgical procedure promoted an increase in the area of nasal air escape. They stated that the mirror is a tool that can

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be used for clinical follow-up after treating patients with nasal obstruction, capable of quantitatively portraying changes in the nasal area.

Chun et al,9 by measuring the cross-sectional area, measured by acoustic rhinomanometry, detected reduction of 15% to 36% after nasal fractures, compared to healthy individuals. Bilateral fractures caused more obstruction than unilateral, with septal dislocation associated with more severe obstructions. In general, airway obstruction improved immediately after reduction, with a 21% increase in the cross-sectional area, decreasing 4% one year after surgery. 9 Analyzing the influence of the fracture pattern on the nasal function individually, this study corroborates the data by Chun et al, 9 since the perception of nasal obstruction symptoms by NOSE demonstrated that type I fractures showed statistically significant improvement after treatment. Conversely, type II fractures improved in general, but without statistical significance, showing the severity of this fracture pattern, which may receive greater attention in relation to the surgical technique to be chosen.

Open surgery was performed in four cases in this study, of which two were due to sequelae, causing esthetic and functional deformity, with nasal obstruction of 75% and 100% according to NOSE, with open septoplasty, which evolved respectively to 0% and 25% of obstructed sensation. In the other two cases, nasal fractures were associated with frontal bone fracture and were exposed by bicoronal access.

In these cases, function was preserved in the preoperative period and was maintained in the postoperative period.

Ridder et al.10 stated that, in addition to the fracture pattern, the variables that influence the prognosis of treatment of nasal fractures are the interval between trauma and reduction; type of anesthesia (local or general); and surgical technique (open or closed). Except for septal hematoma drainage, which must be immediate, fractures must be treated within 10 days to 14 days after trauma.

Although the statistical test did not reveal significance in changing the area of nasal air escape, using the Altman mirror, patients treated in the first 15 days had an increase in the area of nasal air escape by 22.1%, while the mean gain for patients treated after this period was only 6.6%. In general,

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stometry and acoustic rhinometry, with the validated NOSE scale for assessing nasal permeability. The results showed weak to moderate correlation between the values ​​of objective tests and the NOSE scale; however, they concluded that, in the assessment of nasal permeability, it seems advisable to use both tests, since they do not appear to be completely redundant variables, besides serving as legal documentation.

Catunda et al 13 used the Glatzel mirror method to verify changes in the nasal airway in patients undergoing rapid maxillary expansion. The research revealed an increase in the area of ​​respiratory fog in 80% of cases (p <0.05), compatible with the expected for the surgical procedure. However, there was no correlation with the subjective variables verified in NOSE, which was attributed to the small sample of 10 patients.

it can be seen that the functional prognosis is better when the treatment period is in the first two weeks after trauma.

Applying NOSE and crossing the results with the time elapsed from trauma to the surgical procedure, it was noted that patients decreased the symptoms of nasal obstruction. However, in 20 patients operated after 15 days, there were no statistically significant results (p = 0.104), while the 8 patients operated on the first two weeks showed statistically significant improvement (p = 0.05). Despite having been a smaller sample, it clearly demonstrates the importance of operating in the first 15 days.

There was an increase in the area of ​​respiratory fog in the Altman mirror after treatment and a decrease in symptoms of nasal obstruction on the NOSE scale. However, the samples were non-parametric and the statistical tests showed no correlation between the objective tests on the Altman mirror and the symptoms of nasal obstruction on the NOSE scale, maybe due to the small sample size and some cases of postoperative complications, which may suggest the need to continue the work and check the correlation of methods.

André et al, 11 in a meta-analysis, concluded that the correlation between objective and subjective variables by rhinomanometry and acoustic rhinometry tests remains unclear. The main problem with all past studies is that subjective symptoms were determined only by visual analog scales and non-validated questionnaires.

Braun, Rich and Kramer,12 in a sectional study, aimed to correlate the values obtained ​​ with rhinoresi-

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

CONCLUSION In general, surgery to reduce nasal fractures improves the symptoms of obstruction, and the best functional results are achieved when performed in the first two weeks.

Type I fractures have better prognosis; it is noted that fractures with septum involvement require greater attention, since the functional gain was not statistically significant.

The objective assessment of nasal permeability is recommended, in association with the NOSE scale, which is the only specifically validated for symptoms of nasal obstruction. Although there was no correlation between them, future studies should assess this correlation.

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References:

1. Al-Moraissi EA, Ellis E. Local versus general anesthesia for the management of nasal bone fractures: A systematic review and meta-analysis. J Oral Maxillofac Surg. 2015 Apr;73(4):606-15.

2. 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.

3. Kelley BP, Downey CR, Stal S. Evaluation and reduction of nasal trauma. Semin Plast Surg. 2010 Nov;24(4):339-47.

4. Chen XB, Lee HP, Chong VFH, Wang DY. Assessments of nasal bone fracture effects on nasal airflow: A computational fluid dynamics study. Am J Rhinol Allergy. 2011;25(1):e39-e44.

5. Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and validation of the nasal obstruction symptom evaluation (NOSE) scale. Otolaryngol Head Neck Surg. 2004 Feb;130(2):157-63.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

6. Jones TM, Nandapalan V. Manipulation of the fractured nose: A comparison of local infiltration anaesthesia and topical local anaesthesia. Clin Otolaryngol Allied Sci. 1999 Sept;24(5):443-6.

7. Rajapakse Y, Courtney M, Bialostocki A, Duncan G, Morrissey G. Nasal fractures: A study comparing local and general anaesthesia techniques. ANZ J Surg.

2003 June;73(6):396-9.

8. Gertner R, Podoshin L, Fradis M. A simple method of measuring the nasal airway in clinical work. J Laryngol Otol. 1984 Apr;98(4):351-5.

9. Chun K-W, Han S-K, Kim S-B, Kim W-K. Influence of nasal bone fracture and its reduction on the airway.

Ann Plast Surg. 2009 July;63(1):63-6.

10. Ridder GJ, Boedeker CC, Fradis M, Schipper J. Technique and timing for closed reduction of isolated nasal fractures: a retrospective study. Ear Nose Throat J. 2002 Jan;81(1):49-54.

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11. André RF, Vuyk HD, Ahmed A, Graamans K, Nolst Trenité GJ. Correlation between subjective and objective evaluation of the nasal airway. A systematic review of the highest level of evidence. Clin Otolaryngol.

2009 Dec;34(6):518-25.

12. Braun T, Rich M, Kramer MF. Correlation of three variables describing nasal patency (HD, MCA, NOSE score) in healthy subjects. Braz J Otorhinolaryngol.

2013 May-June;79(3):354-8.

13. Catunda IS, Vasconcelos BCDE, Caubi AF, do Amaral MF, Moreno EFC, Melo AR. Evaluation of changes in nasal airway in patients having undergone surgically assisted maxillary expansion. J Craniofac Surg. 2013 July;24(4):1336-40.

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OriginalArticle

Evaluation of postoperative infection after third

molars extraction

BRUNA DE LIMA RIGO1 | ELEONOR ÁLVARO GARBIN JÚNIOR2 | LUIZA ROBERTA BIN2 | MAURO CARLOS AGNER BUSATO1 | RICARDO AUGUSTO CONCI2 | MATEUS DIEGO PAVELSKI2

ABSTRACT Introduction: The extraction of third molars is a frequent procedure in dental practice. To minimize postoperative infectious complications, the use of antibiotics has been routinely employed. However, there are reports in the literature of different ways to use this prescription drug, seeking to reduce the bacterial resistance index.

Objective: The objective of this study was to evaluate the incidence of postoperative infection in three groups, by analyzing each prescription for third molar extractions patients. Methods: The 30 subjects were randomized into three groups of 10 patients each. The first practice consisted in using the systemic antibiotic only in the preoperative period (Amoxicillin 2g, 1 hour before the procedure). In the second, the systemic antibiotics were administered only postoperatively (Amoxicillin 500mg every 8 hours for 7 days). In the third group, there was no systemic antibiotic prescription. Results: regarding the occurrence of infections, in this study, there was no statistically significant difference between the protocols. However, concerning the occurrence of pain, there was a difference between the protocols used. In group 3, more individuals reported pain, compared to G1 and G2 patients. Conclusion: It was observed that systemic antibiotic administration does not interfere with postoperative infectious events in third molar extraction. Keywords: Molar, third. Antibiotic prophylaxis. Surgical wound infection.

Keywords: Molar, third. Antibiotic prophylaxis. Surgical wound infection.

Universidade Estadual do Oeste do Paraná, Odontologia (Cascavel/PR, Brazil).

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

1

How to cite: Rigo BL, Garbin Júnior EA, Bin LR, Busato MCA, Conci RA, Pavelski MD. Evaluation of postoperative infection after third molars extraction. J Braz Coll Oral Maxillofac Surg. 2020 MayAug;6(2):68-73. DOI: https://doi.org/10.14436/2358-2782.6.2.068-073.oar

2

Submitted: September 02, 2019 - Revised and accepted: April 24, 2020 Contact address: Bruna de Lima Rigo E-mail: bnrigo@hotmail.com

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

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Rigo BL, Garbin Júnior EA, Bin LR, Busato MCA, Conci RA, Pavelski MD

INTRODUCTION The extraction of third molars is the procedure most performed by dental professionals in the field of oral surgery.1 The indications for extraction include third molars with previous pericoronaritis, dental caries, associated cysts or associated; those that are not functioning (erupted or impacted), for planning orthognathic surgery and for orthodontic or prosthetic purposes.2 The implications that can lead to extraction of third molars include pain, swelling, trismus, alveolitis and infection of the surgical site. 3 Complication rates associated with removal of third molars are generally low; when present, they are associated with unerupted/impacted teeth, being the most common postoperative infections at the surgical site.4 Antibiotic prophylaxis involves the prescription of antibiotics for patients who do not show signs of infection, as a preventive measure for microbial colonization and postoperative complications, preventing infections ranging from very serious, such as infective endocarditis 5 and brain abscess, 15 to usual conditions as localized infections. 5 In the literature, there is no consensus about the prophylactic indication for the use of antibiotics in third molar surgeries, with different prescription protocols, including from single doses6 to prolonged use in the postoperative period.7 Thus, the aim of the present study was to verify the real importance of using antibiotics in these types of surgeries, to prevent postoperative infection and simultaneously to avoid unnecessary or incorrect use.

ized blind, considering that the operator was unaware of the group in which the patient was included.

Thirty healthy patients were selected, without any acute infectious process and who required third molar extraction. Panoramic radiography was requested for all patients.

The patients were randomly divided into three groups of 10 individuals each. All groups received prescription of 4 mg of Dexamethasone before the procedure and anti-inflammatory (Nimesulide 100mg, every 12 hours, for 3 days), analgesic (Dipyrone Sodium 500 mg/ml, 30 drops at every 6 hours, for 2 days) and mouthwash (0.12% Chlorhexidine Digluconate, at every 12 hours, for 7 days) in the postoperative period. Group 1 received antibiotic prophylaxis (Amoxicillin 2 g) 1 hour before the procedure.

Group 2 received antibiotic therapy with Amoxicillin 500 mg at every 8 hours for 7 days, starting shortly after surgery. Finally, group 3 did not receive any prophylactic or therapeutic administration.

The research consisted of postoperative evaluation of patients undergoing extraction of third molars at the dental clinic of Unioeste. In lower third molars, distal wedge incisions were performed over the region of the retained molar and a releasing incision was performed from the bottom of the buccal sulcus to the mesiobuccal aspect of the second molar 8. In impacted upper molars, an anteroposterior incision was performed over the dental arch and a releasing incision between the mesiobuccal angle and the papilla of the upper second molar to the bottom of the sulcus. 8 The extraction technique was recommended using elevators (Apical, Seldin 2, Seldin 1L and Seldin 1R), performing osteotomy and/or tooth sectioning.

According to the need, a high speed or straight handpiece was used, with a cylindrical carbide surgical drill 702.

Preoperative data were tabulated according to tooth positioning (upper, subdivided into position; or lower, subdivided into position and class), according to the classification by Pell and Gregory 16 (1933).

Concerning intraoperative complications, root fracture was evaluated without fragment removal or hemorrhage. In the seven-day postoperative period, infection, alveolitis, edema, trismus, pain and hemorrhage were evaluated. These data were distributed according to the preestablished groups (1, 2 and 3).

METHODS Aiming to meet the ethical standards, the project was reviewed by the Institutional Review Board of the Centro de Ciências Biológicas e da Saúde of Universidade Estadual do Oeste do Paraná (UNIOESTE). After approval by the IRB (report n. 2,787,771), data collection was started based on the postoperative evaluation of patients. All surgeries were performed by two calibrated operators (recommending the same technique and operative sequence). The calibration involved a theoretical lecture for the two operators, followed by a practical class and subsequent accomplishment of 10 surgeries by each, and these patients were not included in the research sample. The study was characterized as random-

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of pain, and in patients in group 3, without the use of antibiotics, more individuals reported pain compared to patients in G1, with preoperative administration of antibiotics, and G2, with postoperative administration of antibiotics (Table 4).

Analyzing the position of upper teeth concerning to their position in relation to postoperative data, patients with upper molars in position C had statistically more pain and more trismus (Table 5).

Patients with lower molars in position C had statistically more pain and more trismus than positions A and B, which were similar to each other (Table 6).

Patients with lower molars in Class II had statistically more edema than patients with molars in Class I. There were no molars in Class III (Table 7).

According to inferential statistics, qualitative variables alveolitis, pain, edema, trismus, infection and hemorrhage were evaluated, according to their presence or not, by the Fisher Test, at a significance level of 5%.

RESULTS The 30 patients included 11 males and 19 females, with mean age 21.9 years. Overall, 120 third molars were extracted, being 60 upper and 60 lower.

The position of each extracted tooth is detailed in Tables 1, 2 and 3. Osteotomy and tooth sectioning were necessary in 32 and 28 patients, respectively.

There was statistically significant difference between protocols only in relation to the occurrence

Table 1: Positioning of upper teeth according to the classification of Pell and Gregory16 (1933).

Upper position Group

Position A

Position B

Position C

G1 G2 G3

13 15 12

4 1 4

3 4 4

Table 2: Positioning of lower teeth according to the classification of Pell and Gregory16 (1933).

Lower position Group

Position A

Position B

Position C

G1 G2 G3

9 8 9

4 8 6

7 4 5

Table 3: Classification of lower teeth according to the mandibular ramus (Pell and Gregory,16 1933).

Lower classification GROUP

I

II

III

G1 G2 G3

9 9 11

11 11 9

0 0 0

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Table 4: Analysis of presence of signs in each group, with respective p-values, considering statistically significant results if p < 0.05.

Infection Alveolitis Edema Trismus Pain Hemorrhage

G1

G2

G3

p-valor

0 0 2 0 0 0

0 0 0 0 0 0

0 0 2 1 3 0

1.000 1.000 0.3154 0.3554 0.0357 1.000

Table 5: Absolute frequency of occurrence of pain, edema and trismus in the different groups, according to the position of upper molars and result of the chi-square test for comparison of groups.

PAIN/POSITION

A*

B*

C#

YES NO Chi-square

2 38 0.0050

0 9

4 7

EDEMA/POSITION

A*

B*

C*

YES NO Chi-square

3 35 0.1891

2 7

3 8

TRISMUS/POSITION

A*

B*

C#

YES NO Chi-square

0 40 0,01

0 9

2 9

Similar symbols indicate statistical similarity between groups. Different symbols indicate statistically significant difference between groups (p < 0.05).

Table 6: Absolute frequency of occurrence of pain, edema and trismus in the different groups, according to the position of lower molars (A, B, C) and result of the chi-square test for comparison of groups.

PAIN/POSITION

A*

B*

C#

YES NO Chi-square

1 25 0.0038

0 18

5 11

EDEMA/POSITION

A*

B*

C*

YES NO Chi-square

1 25 0,1602

4 14

3 13

TRISMUS/POSITION

A*

B*

C#

YES NO Chi-square

0 26 0.0581

0 18

2 14

Similar symbols indicate statistical similarity between groups. Different symbols indicate statistically significant difference between groups (p < 0.05).

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Evaluation of postoperative infection after third molars extraction

Table 7: Absolute frequency of pain, edema and trismus in the different groups, according to the position of lower molars (classes) and result of the chi-square test for comparison of groups.

PAIN/POSITION

I*

II*

YES NO Chi-square

0 40 0.1018

0 9

EDEMA/POSITION

I*

II#

YES NO Chi-square

1 28 0.029

7 24

TRISMUS/POSITION

I*

II*

YES NO Chi-square

0 29 0.1642

2 29

Similar symbols indicate statistical similarity between groups. Different symbols indicate statistically significant difference between groups (p < 0.05).

DISCUSSION This research comprised a randomized clinical trial, which consists of a type of experimental study conducted in human beings that aims at knowing the effect of health interventions, and is one of the most important tools for the achievement of studies aiming at the clinical practice9.

In the literature, there are basically three ways of conducting antibiotic therapy in the extraction of third molars, namely in a single preoperative dose, multiple doses in the postoperative period or using both forms simultaneously. 10 In the present study, patients were divided into three groups with the following antibiotic administrations: only in the preoperative period (Amoxicillin 2 g, 1 hour before the procedure), only in the postoperative period (Amoxicillin 500 mg, every 8 hours, for 7 days) and the third group received no antibiotic prescription as prophylaxis and therapy. The same results were obtained in both prescriptions regarding postoperative infection, without incidence in any group (Table 4).

According to Lopez-CĂŠdrum et al. 11, in their research, the efficacy was greater when Amoxicillin was administered postoperatively, compared to the group receiving a prophylactic preoperative dose. For Milani et al.6, the administration of antibiotics in a single preoperative dose proved to be more effec-

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tive than in multiple postoperative doses. According to Siddiqi et al.12, there was no statistically significant difference between groups with preoperative and pre- and post-concomitant prophylaxis. Xue et al. 13 reported, in a double-blind split-mouth clinical trial on 192 patients, that there was no difference between groups in the incidence of inflammatory complications, and that prophylactic amoxicillin was not effective in preventing or reducing postoperative inflammatory complications.

For Siddiqi et al.12, the use of prophylactic antibiotics did not have statistically significant effect on postoperative infections in third molar surgeries, and they should not be routinely administered when patients are not immunocompromised. Bezerra et al. 14 reported that the use of prophylactic antibiotics before surgery to remove third molars did not reduce the presence of associated inflammatory or infectious events.

Considering that this therapeutic strategy does not seem to impose additional benefits on the young and healthy adult population, it is concluded that there is no indication to use this drug in healthy patients.

It must be considered that the use of antibiotics is not a totally effective measure for preventing infections. It is also important to note that 6 to 7% of

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type I diabetes, immunosuppression, previous local irradiation, prolonged surgery and/or in an infected area, among other factors. 8

treated patients experience some type of adverse reaction.8 Non-drug approaches, such as efficient sterilization of instruments, antisepsis, dressing, skill in the surgical technique and postoperative hygiene care, reduce the risks of postoperative infection by 75%.8 Thus, the risk-benefit ratio should greatly favor prevention, considering cost, resistance and toxicity 8. Factors associated with increased risk of postoperative infection should be considered, such as malnutrition, obesity, underlying diseases, such as

CONCLUSION It can be concluded that the administration of amoxicillin in a single preoperative dose and in multiple postoperative doses is not more effective than the non-administration of antibiotics for infection prevention.

References:

1. Friedman JW. The prophylactic extraction of third molars: A public health hazard. Am J Public Health.

2007 Setp;97(9):1555-9.

2. Steed MB. The indications for third-molar extractions.

J Am Dent Assoc. 2014 June;145(6):570-3.

3. Chuang SK, Perrott DH, Susarla SM, Dodson TB. Risk factors for inflammatory complications following third molar surgery in adults. J Oral Maxillofac Surg. 2008 Nov;66(11):2213-8.

4. Susarla SM, Sharaf B, Dodson TB. Do antibiotics reduce the frequency of surgical site infections after impacted mandibular third molar surgery? Oral Maxillofac Surg Clin North Am. 2011 Nov;23(4):541-6.

5. Pallasch JT, Slots J. Antibiotic prophylaxis and the medically compromised patient. Periodontol 2000.

1996 Feb;10:107-38.

6. Milani BA, Jorge WA, Peixoto IF, Horlana ACRT, Bauer HC. Avaliação clínica da eficácia da amoxicilina ministrada em múltiplas doses no pós-operatório de exodontias de terceiros molares inferiores. RPG Rev Pós Grad. 2012;19(2):69-75.

7. Braimah RO, Ndukwe KC, Owotade JF, Aregbesola SB. Impact of oral antibiotics on health-related quality of life after mandibular third molar surgery: An observational study. Niger J Clin Pract. 2017 Sept;20(9):1189-94.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

8. Hupp JR, Ellis III E, Tucker MR. Cirurgia oral e maxilofacial contemporânea. 6ª ed. Rio de Janeiro: Elsevier; 2015.

9. Souza RF. O que é um estudo clínico randomizado?

Medicina (Ribeirão Preto). 2009;42(1):3-8.

10. Pedrosa MS, Ferro FED, Pompeu JGF, Borba MSC. Administração profilática de amoxicilina em cirurgias de terceiros molares retidos em pacientes saudáveis: revisão de literatura. Rev Bahiana Odontol. 2016 Mar;7(1):41-8.

11. López-Cedrún J, Pijoan J, Fernández S, Santamaria J, Hernandez G. Efficacy of amoxicillin treatment in preventing postoperative complications in patients undergoing third molar surgery: A prospective, randomized, double-blind controlled study. J Oral Maxillofac Surg.

2011 June;69(6):e5-14.

12. Siddiqi A, Morkel JA, Zafar S. Antibiotic prophylaxis in third molar surgery: A randomized double-blind placebo-controlled clinical trial using split-mouth technique.

Int J Oral Maxillofac Surg. 2010 Feb;39(2):107-14.

13. Xue P, Wang J, Wu B, Ma Y, Wu F, Hou R. Efficacy of antibiotic prophylaxis on postoperative inflammatory complications in Chinese patients having impacted mandibular third molars removed: a split-mouth, double-blind, self-controlled, clinical trial. Br J Oral Maxillofac Surg. 2015 May;53(5):416-20.

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14. Bezerra TP, Studart-Soares EC, Scaparo HC, PitaNeto IC, Batista SHB, Fonteles CSR. Prophylaxis versus placebo treatment for infective and inflammatory complications of surgical third molar removal: A split-mouth, double-blind, controlled, clinical trial with amoxicillin (500 mg). J Oral Maxillofac Surg. 2011 Nov;69(11):e333-9.

15. Auler IP, Lavarezze L, Leal AL, Gavassoni R, Antunes V, Salim MAA. Brain abscess due to infection after tooth extraction. J Braz Coll Oral Maxilofac Surg. 2018 SeptDec;4(3):53-9.

16. Pell GJ, Gregory GT. Impacted mandibular third molars: classifications and modified technique for removal. Dent Digest 1933.

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OriginalArticle

Incidence of facial trauma in a hospital at

Bauru city

ANGIE PATRICIA CASTRO-MERÁN1 | BRUNO GOMES DUARTE1 | EDUARDO STEDILE FIAMONCINI1 | PATRICIA FRARE CAMPOS2 | OSNY FERREIRA JÚNIOR1 | EDUARDO SANCHES GONÇALES1

ABSTRACT Introduction: Facial fractures can cause aesthetic and functional changes, as well as other complications. Objective: To verify the incidence of facial trauma of individuals treated from January 2015 to July 2017, in a public hospital in Bauru/SP (Brazil). Methods: A total of 509 facial fractures of 441 individuals were analyzed by collecting data from hospital electronic records. The data collected were sex, age, trauma etiology, anatomical location of the fractures and type of treatment chosen for each case. Results: The male sex was the most affected (79.36%) with a mean age of 32 years. The most common cause was physical aggression (32.87%), followed by traffic accidents (24.04%). The type of treatment of choice was open reduction with stable internal fixation. Conclusion: Nasal fractures were prevalent in the group of individuals studied, affecting mainly men, victims of physical aggression.

Keywords: Traumatology. Facial bones. Epidemiology. Etiology.

Faculdade de Odontologia de Bauru da Universidade de São Paulo (FOB-USP), Departamento de Cirurgia, Estomatologia, Patologia e Radiologia (Bauru/SP, Brazil).

Hospital de Base, Serviço de Cirurgia e Traumatologia Bucomaxilofacial (Bauru/SP, Brazil).

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How to cite: Castro-Merán AP, Duarte BG, Fiamoncini ES, Campos PF, Ferreira Júnior O, Gonçales ES. Incidence of facial trauma in a hospital at Bauru city. J Braz Coll Oral Maxillofac Surg. 2020 MayAug;6(2):74-9. DOI: https://doi.org/10.14436/2358-2782.6.2.074-079.oar

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Submitted: August 13, 2019 - Revised and accepted: October 13, 2019 Contact address: Eduardo Sanches Gonçales E-mail: eduardogoncales@usp.br

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

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Castro-Merán AP, Duarte BG, Fiamoncini ES, Campos PF, Ferreira Júnior O, Gonçales ES

INTRODUCTION The word trauma can be defined as a sudden injury, wound or contusion to an organism, resulting from an extremely violent aggression, caused by an external agent. The result of this action is called trauma, which can be local or general.1 Individuals assessed after trauma often have facial fractures, due to greater exposure of facial bones, which may also occur in isolation not affecting other bones of the appendicular or axial skeleton.2 Facial trauma is an important public health problem, 3 since it causes expenses for health services, besides causing damage to the health of victims, such as functional loss, facial deformity and emotional disorders. 4,5 The prevalence of facial trauma in young male adults, regardless of their etiology, varies between countries and regions, according to sociocultural factors or time of the year.4,6-9 The literature indicates traffic accidents, violence, sports accidents and fall from own height as the main causes of facial fractures,3,4,8 with a relationship between trauma and the use of legal and/or illegal drugs.10 The facial fractures most commonly reported in the literature are located in the mandible,3,7,9-13 body,14 angle12 and condyle4,15 regions, followed by zygomatic bone fractures.3,4,5,8,9,11-13 The most common management is surgical treatment,14 specifically open reduction with stable internal fixation.3,5 Brazilian epidemiological studies have shown that traffic accidents and physical aggression were more frequent,5,9,12,13 with the nose and mandible being the most affected regions.2 Epidemiological studies help to understand trauma and its consequences for the individual and society, besides improving conditions to minimize facial trauma.

This study conducted a retrospective epidemiological observational survey of individuals affected by facial trauma and treated at a public hospital in Bauru/SP.

Data were obtained by analysis of medical records from the hospital’s electronic system, and data from patients hospitalized in the specialties of Head and Neck Surgery and Maxillofacial Surgery in the aforementioned period were analyzed. The study collected information on age, sex, etiology, location of facial fractures and treatment type. Only cases of facial fractures were included.

The etiology of facial fractures was divided into: 1) physical aggression; 2) traffic accidents (running over, motorcycle accidents and car accidents); 3) fall from bicycle; 4) accidents at work; 5) sports accidents; 6) fall from own height; 7) fall from higher level; and 8) others (accidents with animals, fractures by firearms [FGA], domestic accidents and unreported).

The anatomical location of facial fractures was divided into 1) mandible, subdivided into symphysis, parasymphysis, body, angle, ramus and condyle; and 2) fixed face segment, subdivided into frontal, orbit, nasal bones, zygomatic bone, zygomatic arch, zygomatic-orbital complex, naso-orbito-ethmoidal complex and maxilla.

The treatment types were: 1) conservative (without any type of intervention); 2) closed reduction; 3) maxillomandibular block; and 4) open reduction associated with stable internal fixation.

The etiology of fractures was correlated to the sex of affected patients, considering their mean age.

The incidence of fractures was also assessed according to their anatomical location and correlated with the type of treatment.

RESULTS The study consisted of evaluating the medical records of 441 individuals with facial trauma who had 509 fractures, with the midface being the most affected, with 337 fractures (66.20%), and the mandible with 172 fractures (33.80%).

The male sex was the most affected (81.40%), with a mean age of 35.25 years. When considering the etiology, the most common cause was physical aggression (32.87%), followed by traffic accidents (24.04%), fall from own height (13.83%), others (12.25%), sports accidents (6.81%), work accidents (4.08%), fall from bicycle (3.63%), and fall from a higher level (2.49%). The relationship between sex, age and etiology of the is detailed in Table 1.

METHODS This study was approved by the Institutional Review Board under n. 2.020.697. The study was conducted by a retrospective epidemiological observational survey of individuals assisted by the Oral and Maxillofacial Surgery and Traumatology team at Hospital de Base in Bauru (Bauru/SP), from January 1, 2015 to July 31, 2017.

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Incidence of facial trauma in a hospital at Bauru city

Table 1: Etiology of facial trauma according to sex and age range.

Etiology

Males (n)

Females (n)

Total

%

Mean age (total)

Physical aggression Traffic accidents Fall from own height Others Sports accidents Work accidents Fall from bicycle Fall from higher level TOTAL

114 85 38 42 30 15 15 11 350

31 21 23 12 0 3 1 0 91

145 106 61 54 30 18 16 11 441

32.87% 24.04% 13.83% 12.25% 6.81% 4.08% 3.63% 2.49% 100.00

30 32 65 35.5 25 32 25.5 47 35.25

Table 2: Types of treatment performed.

Type of treatment

Mandible (n)

Midface(n)

Total

%

Conservative Closed reduction Open reduction + stable internal fixation Maxillomandibular block

5 7

75 157

80 164

14.54% 29.81%

151

108

259

47.09%

45

2

47

8.54%

Closed reduction was more used in the midface, in naso-orbito-ethmoidal fractures (75%), nasal bones (70.73%), zygomatic arch (53.33%), maxilla (28.57%), zygomatic bone (18.75%), orbit (9.67%) and frontal (5%). It was less frequently used in the mandible, ramus (14.28%), condyle (8.57%), symphysis (2.63%), body (2.56%) and angle (2%).

Conservative treatment in the midface was most used for isolated fractures of the orbit (45.16%), frontal (30%), nasal bones (29.27%), zygomatic bone (23.52%) and zygomatic arch (6.12%). In the mandible, it was used only for condyle (14.28%) and angle (6.12%) fractures.

Maxillomandibular block was most used in fractures of symphysis (52.63%), ramus (14.28%), maxilla (14.28%), mandible body (10.25%), condyle (8.57%) , angle (4.81%) and zygomatic-orbital complex (1.56%).

Among 337 fractures in the midface, the nasal bones were the most affected (48.66%), followed by the zygomatic bone (24.03%), isolated orbit (9.19%), zygomatic arch (8.90%), frontal (5.93%), maxilla (2.07%) and naso-orbito-ethmoidal fracture (1.18%) (Fig 1).

Of 172 mandible fractures, the angle region was the most affected (27.32%), followed by the body (23.83%), symphysis (22.09%), condyle (20.34%), ramus (3.48%) and parasymphysis (2.90%) (Fig 2).

Among the four treatment types, the most used was open reduction with stable internal fixation (47.09%), followed by closed reduction (29.81%), conservative treatment (14.54%) and maxillomandibular block (8.54 %) (Table 2).

Open reduction with stable internal fixation was most used in the mandible for parasymphysis, mandibular angle and body fractures. In the midface, it was more used in fractures of zygomatic bone and maxilla (Fig 3).

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Nasal bones

Zygomatic bone

Isolated of the orbit

Zygomatic arch

Frontal

Maxilla Figure 1: Distribution of anatomical location of midface fractures.

Naso-orbito-ethmoidal

Angle

Body

Symphysis Condyle

Ramus

Parasymphysis

Figure 2: Distribution of mandibular fractures.

Naso-orbito-ethmoidal Isolated of the orbit Zygomatic arch Front Maxilla Zygomatic bone Condyle Ramus Body Angle Parasymphysis Symphysis Figure 3: Location of open reductions with stable internal fixation.

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Incidence of facial trauma in a hospital at Bauru city

DISCUSSION In this study, it was observed that most individuals were men (n=350), with mean age 32 years. Likewise, the literature points out the prevalence of facial trauma for males,4,6-9,12,13 although there are studies in which most victims were women, victims of physical aggression and traffic accidents16,17,18. In the present study, although most causes of facial fractures were interpersonal violence, this was greater for men. Male individuals in the third decade of life represent a portion of the population possibly in professional activity, which cautions to the economic impact of facial fractures, since the affected individual is away from activities for a variable period of time, bringing costs to the government, losses to society, family and themselves.

Concerning the etiology, in this study, physical aggression prevailed (n=145), with traffic accidents in second place (n=106). This is compatible with studies in which physical aggression was the main cause of maxillofacial trauma,4,8,9,10,12,13,14,16,17 although other studies have indicated traffic accidents as the main cause of facial fractures.3,5,7,11,15,18,19 It is believed that the reduction in facial trauma resulting from traffic accidents was due to the adoption of stricter laws, associated with the mandatory use of seat belts and helmets, and the reduction in the number of individuals who drive under the influence of drinks, mandatory in Brazil according to the Brazilian Traffic Code - Law 9503/97 | Law N. 9503 of September 23, 1997.20 Thus, it is important to caution the State and the population about the high rate of interpersonal violence, which is a public health and national security problem, and these cases may be related to the use of illicit drugs and/or alcohol.

The higher incidence of facial trauma resulting from physical aggression observed in this study indicates an increase in violence in the city of Bauru and in cities of the region, since the institution where the study was conducted is the reference service for trauma to Bauru and region.

There was lack of data regarding the type of aggression and their motivation. However, this does not make the study unfeasible; it only limits it to generic and unspecific information. It is emphasized that such information, within a context of public health and safety, would be relevant.

In this study, fall from own height represented the third most common cause of facial trauma (13.83%)

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in the elderly, who had a mean age of 65 years. However, this does not corroborate other studies in which the most common cause in elderly individuals was physical aggression17 and traffic accidents.18 In the present study, most fractures affected the nasal bones (n=164), which is the opposite result, therefore, to a large number of studies that identified the mandible3,4,7,10-15 and zygomatic bone5,8,9 as the most affected regions.

In the mandibular fractures found in the present study, most were in the angle region (n=47). This coincides with a study in which mandibular fractures occurred mainly in the angle,12 unlike the referenced literature, in which the most affected sites, in the mandible, were the condyle,4,15 body and parasymphysis.14 In this study, open reduction associated with stable internal fixation was the most used treatment (n=259), similar to other studies in which open reduction and stable internal fixation were also the most used.3,5,14 Conservative treatment was the third most used treatment (n=80), representing 14.54% of cases, mainly in cases of isolated orbit fracture, probably used in cases of non-displaced fractures without functional deficit. Similarly, this study revealed that 75% of naso-orbito-ethmoidal fractures were treated conservatively, since only 4 of these fractures were verified in the medical records, and 3 were treated as mentioned. It is noteworthy that, in studies like this, retrospective and involving medical records, there is possibility of data bias resulting from inaccurate and/or incomplete notes, impairing data collection.

In the mandible, 5 cases were treated conservatively; all 5 cases were condyle fractures, although there was dissonance between these data and those found in a study in which conservative treatment was indicated for 26.8% of cases of mandible fractures.14 Understanding trauma represents a valuable tool for the study of a given population. In the present study, it was possible to determine the etiology and incidence of facial trauma, as well as its treatment.

CONCLUSION It was possible to conclude that nasal fractures were the most prevalent facial fractures in the group of individuals studied, mainly affecting men who were victims of physical aggression.

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6. Martinez AY, Como JJ, Vacca M, Nowak MJ, Thomas CL, Claridge JA. Trends in maxillofacial trauma: a comparison of two cohorts of patients at a single institution 20 years apart. J Oral Maxillofac Surg. 2014 Apr;72(4):750-4.

7. Pradhan L, Jaisani MR, Dulal S, Dongol A, Sagtani A. A study on the pattern of maxillofacial injury in patients reporting to a tertiary care hospital in eastern Nepal.

J Oral Maxillofac Surg Med Pathol. 2015 Sept; 27(5): 656-1.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

8. Schneider D, Kämmerer PW, Schön G, Dinu C, Radloff S, Bschorer R. Etiology and injury patterns of maxillofacial fractures from the years 2010 to 2013 in Mecklenburg-Western Pomerania, Germany: A retrospective study of 409 patients. J Craniomaxillofac Surg. 2015 Dec;43(10):1948-51.

9. Zamboni RA, Wagner JCB, Volkweis MR, Gerhardt EL, Buchmann EM, Bavaresco CS. Epidemiological study of facial fractures at the oral and maxillofacial surgery service, Santa Casa de Misericórdia Hospital Complex, Porto Alegre - RS Brazil. Rev Col Bras Cir. 2017 Sept-Oct;44(5):491-7.

10. Goulart DR, Durante L, de Moraes M, Aspirno L. Characteristics of maxillofacial trauma among alcohol an drug users. J Craniofac Surg. 2015 Nov;26(8):e783-6.

11. Bonavolontà P, Dell’aversana Orabona G, Abbate V, Vaira LA, Lo Faro C, Petrocelli M, et al. The epidemiological analysis of maxillofacial fractures in Italy: The experience of a single tertiary center with 1720 patients.

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12. Roquejani CL, Martins MS, Gil JN. Pilot study of maxillofacial traumas in a reference hospital, Florianópolis/SC. J Braz Coll Oral Maxillofac Sur. 2019 May-Aug;5(2):17-23.

13. Pedroso Junior JL, Vasques MAB, Moraes RB, Arruda Júnior CA, Freitas DL, Sacchetti R. Epidemiological study of facial injuries in Cocoal/RO, Brazil. J Braz Coll Oral Maxillofac Surg. 2019 May-Aug;5(2):30-5.

14. González-Sánchez D, Pérez-Guillen DP, Acuña-Pérez JL, Barreras-Campos A. Caracterización de las fracturas mandibulares traumáticas en pacientes atendidos en el hospital provincial de Las Tunas. Revista Electrónica Dr. Zoilo E. Marinello Vidaurreta. 2018; 43(6). Available from: http://www. revzoilomarinello.sld.cu/index.php/zmv/article/view/1498.

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16. Garcez RHM, Thomaz EBAF, Marques RC, de Azevedo JAP, Lopes FF. Caracterização de lesões bucomaxilofaciais decorrentes de agressão física: diferenças entre gênero. Ciênc Saúde Coletiva. 2019 Jan-Mar;24(3):1143-52.

17. Carvalho Filho MAM, Saintrain MV L, dos Anjos RES, Pinheiro SS, Cardoso LCP, Moizan JAH, et al.

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PLoS One. 2015 Aug 19;10(8):e0135813.

18. Possebon APDR, Granke G, Faot F, Pinto LR, Leite FRM, Torriani MA. Etiology, diagnosis, and demographic analysis of maxillofacial trauma in elderly persons: A 10-year investigation. J Craniomaxillofac Surg. 2017 Dec;45(12):1921-6.

19. Alves LS, Aragão I, Sousa MJC, Gomes E. Pattern of maxillofacial fractures in severe multiple trauma patients: A 7-year prospective study. Braz Dent J. 2014 Nov-Dec;25(6):561-4.

20. Brasil. Código de Trânsito Brasileiro - Lei 9503/97 / Lei nº 9.503, de 23 de setembro de 1997 [Access 2019 july 11]. Available from: http://www.planalto.gov.br/ ccivil_03/leis/l9503.htm.

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Information for authors

Information for authors

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

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

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

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

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

• The manuscripts should be submitted in Portuguese.

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

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

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

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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

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

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

• The figures should be submitted as separate files.

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

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

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

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

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

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

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

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Information for authors

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

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

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

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

• They should be submitted as separate files.

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

• All figures should be cited in the text.

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

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

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

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

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

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

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

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

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

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

• Each table should have a short title.

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

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

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

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

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

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

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Information for authors

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

- All references should be cited in the text.

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

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

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

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

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

- Use the examples below:

Book chapter Baker SB. Orthognathic surgery. In: Grabb and Smith’s Plastic Surgery. 6th ed. Baltimore: Lippincott Williams & Wilkins. 2007. Chap. 27, p. 256-67.

Book chapter with editor Breedlove GK, Schorfheide AM. Adolescent pregnancy. 2nd ed. Wieczorek RR, editor. White Plains (NY): March of Dimes Education Services; 2001.

Dissertation, thesis and monograph Ryckman MS. Three-dimensional assessment of soft tissue changes following maxillomandibular advancement surgery using cone beam computed tomography [Thesis]. Saint Louis: Saint Louis University; 2008.

Electronic publication Sant´Ana E. Ortodontia e Cirurgia Ortognática – do planejamento à finalização. Rev Dental Press Ortod Ortop Facial. 2003 maio-jun;8(3):119-29 [Acesso 12 ago 2003]. Disponível em: http://www.dentalpress.com.br/ artigos/pdf/36.pdf.

Paper with up to six authors Espinar-Escalona E, Ruiz-Navarro MB, Barrera-Mora JM, Llamas-Carreras JM, Puigdollers-Pérez A, Ayala-Puente. True vertical validation in facial orthognathic surgery planning. Clin Exp Dent. 2013 Dec 1;5(5):e2318.

Paper with more than six authors Pagnoni M, Amodeo G, Fadda MT, Brauner E, Guarino G, Virciglio P, et al. Juvenile idiopathic/rheumatoid arthritis and orthognatic surgery without mandibular osteotomies in the remittent phase. J Craniofac Surg.

2013 Nov;24(6):1940-5.

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Notice to Authors and Consultants Registration of Clinical Trials

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)Â 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.

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

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.

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 Regis-

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Comunicado aos Autores e Consultores - Registro de Ensaios Clínicos

try), 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.

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.

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 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.

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

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

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Yours sincerely,

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