Revista JBCOMS - Vol. 6, Number 3, 2021

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Maxillary Advancement with Mandibular

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Implant (Anterior Socket Grafting)

Journal of the Brazilian

College of Oral and Maxillofacial Surgery

Maxillary Advancement with Mandibular

Total Arch Restoration (Implant Supported fixed bridge)

Implant (Anterior Socket Grafting)

Volume 6, Número 3, 2020

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

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J Braz Coll Oral Maxillofac Surg. 2020 September-December;6(3):1-68

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 - 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 published three times a year of Dental Press Ensino

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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 Sumário

4

Norms for publication: an important rout Sylvio Luiz Costa de Moraes

6

CBCTBMF completed 50 years with many activities and actions for members José Rodrigues Laureano Filho

11

CBCTBMF decides, in a meeting with the General Council, to postpone COBRAC to 2021 José Rodrigues Laureano Filho

12

Interview José Thiers Carneiro Júnior

Articles

15

Assessment of hilotherapy compared to ice pack therapy in pain and edema control after orthognathic surgery: a pilot study Alessandro Oliveira de Jesus, Guilherme Lacerda de Toledo, Gustavo Marques de Oliveira Chiavaioli, Belini Freire Maia, Marcio Bruno Figueiredo Amaral

21

Analysis of linear transverse measurements after SARPE

30

The role of anxiety in blood pressure variation before dental care

37

Mandibular reconstruction of comminuted fracture by gunshot

42

Psoriatic arthritis with temporomandibular joint involvement: case report

Marcelo Minharro Ceccheti, Wladimir Gushiken de Campos, Tatiane Ferrari, Camilla Vieira Esteves, Maria da Graça Naclério-Homem, Celso Augusto Lemos

Thayara Lima de Morais, Girleide de Sousa Silva, Eder Alberto Sigua-Rodriguez, Douglas Rangel Goulart

Jair Queiroz de Oliveira Neto, Edson Luiz Cetira Filho, Pedro Henrique da Hora Sales, Manoel de Jesus Rodrigues Mello

Killian Evandro Cristoff, José Stechman Neto, Bianca Lopes Cavalcante-Leão, Rodolfo Jorge Kubiak, Marina Pereira Silva, Alice Helena de Lima Santos Cardoso

47

Tooth autotransplantation as an option for impacted tooth treatment in pediatric patient

52

Reconstruction of mandibular fracture using Locking® system: Case report

57

Hemophiliac patient with extensive complex odontoma in mandible

Lucas Costa Nogueira, Pablo Cornélius Comelli Leite, Liogi Iwaki Filho

Igor Almeida Mascarenhas Soares, João Pedro Lisboa Damasceno Pereira, Ricardo José de Holanda Vasconcelos, Marcelo Marotta Araujo, José Ricardo Mikami, Marcus Antônio Brêda Junior

Ariany Cristina Freitas Ribeiro, Paulo Matheus Honda Tavares, Gustavo Cavalcanti de Albuquerque, Marcelo Vinicius de Oliveira, Dirceu Virgolino de Oliveira, Valber Barbosa Martins

64

Information for authors

Editorial

Norms for publication: an important rout

The submission of scientific papers is the result of the initiative of professionals focused on the production of knowledge, which is usually enriching and very welcome for any journal selected for this purpose.

During manuscript preparation, it is important to adapt the content to the scope, format and overall editorial conditions.

Therefore, it is necessary to follow, step by step, the publication guidelines required by the journal, according to the type of work to be submitted.

An academically well-written article, from title to conclusion, and properly structured, according to the instructions presented in the publication guidelines, will have unequivocal conditions for the quick referral to the peer review stage.

However, if the submission does not meet the instructions, it may not be accepted or, if deemed of scientific interest, it may need repair, often complex, restrictive, suppressive or additive, which often significantly delay the referral to reviewers.

How to cite: Moraes SLC. Norms for publication: an important rout. J Braz Coll Oral Maxillofac Surg.

2020 Sept-Dec;6(3):4-5. DOI: https://doi.org/10.14436/2358-2782.6.3.004-005.edt

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Editorial

Therefore, to the new collaborators, who are also always highly appreciated, we emphasize that the guidelines of a journal are an important path to be strictly followed for the work conception.

Let’s continue together for the continuous growth of our strong journal!

Prof. Sylvio Luiz Costa de Moraes Editor-in-Chief of 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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J Braz Coll Oral Maxillofac Surg. 2020 Sept-Dec;6(3):4-5

Letter from the President

CBCTBMF completed 50 years with many activities and actions for members Dear members of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology, the CBCTBMF celebrated 50 years during a period of pandemic, with enormous challenges, not only in the daily routine, adaptations imposed to the work of maxillofacial surgeons, but also from structural and organizational standpoints.

In addition to all activities that this board has been developing during the 2018/2020 period, we were present in all communication channels, promoting weekly lives and publishing testimonies of former presidents, among other homages in social media.

We have been working to keep our specialty recognized and valued by organizations as the Ministry of Health and the National Supplementary Health Agency (ANS), for example, with an increase in the authorization of oral and maxillofacial surgery procedures by health insurance companies.

The College has also developed important actions with organizations as the Federal Dental Council (CFO) and the Ministry of Education (MEC), besides the Federal Senate and the Deputies Chamber, presenting the problems of the specialty and trying to solve them at the national, state and municipal levels with their directors and Chapter members.

Great advances were made in the training of maxillofacial surgeons, with many specialization courses in residency format, reaching 8,640 hours as determined by resolution N. 1 of April 2018, published by MEC. Currently, we have accompanied a uniformization in training and care throughout the country, with well-structured and high-quality services.

We perform many actions, together with our Legal Department, which aim to assure the legal exercise of the profession to our members.

How to cite: Laureano Filho JR. CBCTBMF completed 50 years with many activities and actions for members. J Braz Coll Oral Maxillofac Surg. 2020 Sept-Dec;6(3):6-7. DOI: https://doi.org/10.14436/2358-2782.6.3.006-007.crt

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Carta do Presidente

The CBCTBMF has been working strongly in the professional defense and continuing education of its members. The work to regulate the training of maxillofacial surgeons has been an essential requirement, so that we can follow the evolution of surgical techniques and gain space with respect in the job market, besides being present with professionals still in training.

It has been 50 years, for which we have a lot to celebrate, but still a lot to fight for!

Hugs for all!

José Rodrigues Laureano Filho President 2018/2020 Brazilian College of Oral and Maxillofacial Surgery and Traumatology

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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C

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CM

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CMY

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DIAGNÓSTICO E PLANEJAMENTO PARA CIRURGIA BUCO-MAXILO-FACIAL

SCAN

ME

GUIAS CIRÚRGICAS A cirurgia ortognática é planejada virtualmente, por meio da combinação entre modelos digitais, tomografia computadorizada e fotografias, gerando as guias SurgeGuide, que orientam a posição óssea planejada.

Todas as guias são confeccionadas em material biocompatível esterilizável.

BIOMODELOS Os SurgeModels são réplicas dos ossos da face, produzidos por impressoras 3D, a partir da tomografia computadorizada do paciente. Os biomodelos são utilizados, principalmente, para simulações cirúrgicas, fortalecendo o diagnóstico e potencializando o resultado.

0800 671 7277 contato@compass3d.com.br compass3d.com.br

/compasscomvoce /orthoaligner @compasscomvoce @orthoaligner

20 a 22 de Maio de 2021 . Maringá . PR . Brasil

Palestrantes

Presidente do Congresso - Gustavo Giordani

Florin Cofar

Eric Van Dooren

Carlos Alexandre Câmara

Daniel Machado

Fabiano Marson

Felipe Villa Verde

Marcelo Giordani

Marcelo Kyrillos

Marcelo Moreira

Marcos Pitta

Ronaldo Hirata

Sidney Kina

Thiago Ottoboni

Confira a programação!

44.99843.0099

Luis Calicchio

Paulo Vinicius Soares

Victor Clavijo

CBCTBMF

CBCTBMF decides, in a meeting with the General Council, to postpone COBRAC to 2021 Considering all data collected by the research, but also the exceptional situation imposed by the pandemic, the heterogeneity of the disease – which affects the entire country – and the uncertainty of permission to agglomerate in an event as large as COBRAC, the General Council unanimously decided to postpone COBRAC to June 12 to 15 2021 in the same place – Hangar Convenções & Feiras da Amazônia, at Belém/PA. The CBCTBMF, as a health organization, could not put its members and partners at risk.

Certain that we are making the best decision, always thinking about the safety and well-being of participants, speakers and partners, we rely on the understanding by everyone.

The Brazilian College of Oral and Maxillofacial Surgery and Traumatology decided, in a virtual meeting with the General Council of CBCTBMF, on August 18, to postpone COBRAC to June 2021.

The event, which would be held on June 2020, was postponed to November of the same year due to COVID-19. However, as the pandemic and many uncertainties persisted, the decision for a new postponement was made based on several considerations and also with the support of a survey conducted with the participants registered for the event.

According to the survey, the majority (67.5%) stated that they would not participate or that they would not be able to decide if they would participate in the event if it was held in November 2020, as foreseen.

For 72% of respondents, if the event were postponed to the first semester of 2021, the presence would be confirmed, and only 21% would still not be able to define their participation at that time.

The survey was also concerned with the sponsoring companies: 62% prefer to participate in 2021 and 38% are indifferent to the postponement.

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

How to cite: Laureano Filho JR. CBCTBMF decides, in a meeting with the General Council, to postpone COBRAC to 2021. J Braz Coll Oral Maxillofac Surg. 2020 Sept-Dec;6(3):11.

DOI: https://doi.org/10.14436/2358-2782.6.3.011-011.cbc Submitted: August 26, 2020 - Revised and accepted: September 14, 2020

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Interview

Interview with José Thiers Carneiro Júnior

» Counselor and Full Member of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology. » Professor of the Post-Graduation Program in Dentistry at the Federal University of Pará (UFPA). » Coordinator of the Residency Program in Oral and Maxillofacial Surgery and Traumatology at Hospital Ophir Loyola. » Professor of the Specialization Course in Oral and Maxillofacial Surgery and Traumatology at the Brazilian Dental Association – Pará Section. » Fellow of the International Association of Oral & Maxillofacial Surgery. » PhD in Neuroscience and Cell Biology by UFPA. » MSc in Morphofunctional Sciences by the University of São Paulo. » Specialist in Oral and Maxillofacial Surgery and Traumatology (SCM/SP - CBCTBMF). » Oral & Maxillofacial Surgery Fellowship - Dalhousie University, Canada.

How to cite: Carneiro Júnior JT, Ribeiro J. Interview with José Thiers Carneiro Júnior. J Braz Coll Oral Maxillofac Surg. 2020 Sept-Dec;6(3):12-4.

DOI: https://doi.org/10.14436/2358-2782.6.3.012-014.ent Submitted: August 27, 2019 - Revised and accepted: September 11, 2019

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Carneiro Júnior JT, Ribeiro J

Are the national speakers confirmed? How many will there be?

Alike the international speakers, the new date was also well received by the national speakers, who confirmed their presence. So far, we have 174 confirmed.

The Brazilian College of Oral and Maxillofacial Surgery and Traumatology interviews, in this issue of the journal, the president of the XXV Brazilian Congress of Oral and Maxillofacial Surgery and Traumatology (XXV COBRAC), Dr. José Thiers Carneiro Júnior, full member of the CBCTBMF, with Residency in Oral and Maxillofacial Surgery and Traumatology at Santa Casa de Misericórdia at São Paulo, MSc in Anatomy by the University of São Paulo (USP), PhD in Neuroscience and Cell Biology by the Federal University of Pará (UFPA) and Fellowship in Oral and Maxillofacial Surgery at the University of Dalhousie (Canada).

Were the free oral presentations and posters changed, due to the new date change?

With the postponement of the Congress, we decided to extend the deadline for abstract submission and, with that, we reached about 800 approved abstracts.

Will abstract submissions be reopened?

At the moment, we do not consider necessary to the submissions, since we have a significant number of accepted abstracts.

The SARS-CoV-2 (COVID-19) pandemic caused many changes in our technical-professional daily lives, such as the need to re-arrange scientific events of different sizes. What happened to the XXV COBRAC? Virtually all events, not only in Brazil but worldwide had to be canceled or rescheduled for a future date. It was not different for COBRAC and, at first, we had postponed it to November this year. However, due to the uncertainties related to the pandemic, the organization of COBRAC, together with the College Board, decided to reschedule our congress for June 2021.

The new date positions the event starting on Saturday (June 12, 2021) and ending on Tuesday (June 15, 2021). Was the date chosen for some special reason or was it due to the availability of the convention center agenda?

We believe that June would be ideal for the event, because we believe that the issues related to COVID-19 will already be well controlled and, in this period, the Convention Center was available only on those dates.

Is the event confirmed? Will the planned venue be maintained?

Yes, COBRAC is confirmed to take place from June 12 to 15, 2021, at Hangar Centro de Convenções, in Belém do Pará, and it will be a great event, as it deserves to be.

Did the change of dates result in additional charges for the event?

There was no charge for the event.

With regard to the XXV COBRAC commercial exhibition, how does the Organizing Committee interpret the results of fundraising so far?

The organizing committee is very satisfied with the participation of our commercial partners, who combined to the participants, managed to reach the previously established goal so far.

Did the scientific program need to be rearranged? If so, how was this rearrangement planned?

The scientific program of COBRAC remains the same, as well as the parallel events addressing the entire spectrum of our specialty. The new date pleased speakers, exhibitors and most participants.

Is there still space available in the commercial exhibition for interested sponsors?

The commercial space was nearly entirely commercialized, yet due to the great demand we have made a resizing and expanded the exhibition area for exhibitors who still want to show their products.

Are the international speakers confirmed?

How many will there be?

We have 26 international speakers confirmed for the event.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Entrevista

We expect to have a great event in Belém next year. What is the message left for our readers by the president of XXV COBRAC in this interview?

The organizing committee has been working for 4 years so that we may have a great COBRAC and, for that, we have organized a very attractive scientific grid, covering the entire spectrum of our specialty, with national and international professors recognized worldwide for their work in their countries of origin. I also emphasize that COBRAC will be fully adapted to this new post-pandemic scenario, aiming at the safety for all. It will be an important time to meet, and we are struggling to offer moments of friendship and exchange of experiences between colleagues. We remind that we will be in the middle of the Amazonian summer and the participants may wish to extend their stay and explore our culture and cuisine.

How does the Organizing Committee interpret the number of registrations to the event so far?

We are satisfied with the registrations so far, because many participants registered even in the most critical period of the pandemic.

From the standpoint of the Municipal Health Department, how is the SARS-Cov-2 (COVID-19) pandemic evolving in the city of Belém?

Belém was one of the first Brazilian capitals to reach the peak contamination by COVID-19, even under a lockdown regime, but it was also one of the first to drop the number of cases and, for some months, we have lived a period of stability, with return to commercial and school activities.

Interviewer: Prof. Dr. Jonathan Ribeiro - Associate Editor-in-Chief of 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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Original article

Assessment of hilotherapy compared to ice pack therapy in pain and edema control after orthognathic surgery: a pilot study

ALESSANDRO OLIVEIRA DE JESUS1 | GUILHERME LACERDA DE TOLEDO2 | GUSTAVO MARQUES DE OLIVEIRA CHIAVAIOLI2 | BELINI FREIRE MAIA2 | MARCIO BRUNO FIGUEIREDO AMARAL1,2

ABSTRACT Introduction: Orthognathic surgeries are indicated for correction of facial deformities, but they have side effects: swelling, pain, neural dysfunction and trismus are the patients’ main complaints. The cold therapies are well established and elucidated in the literature for these patients’ complaints regarding the reduction of postoperative edema and pain. Objective: The aim of this study was to compare conventional therapy with ice packs and hilotherapy, by evaluating and measuring soft tissue edema, pain, and surgical time. Methods: A prospective study after bimaxillary orthognathic surgery comparing both therapies with clinical measurements was performed in 17 patients divided into two groups: Group 1) hilotherapy (n = 10); Group 2) conventional therapy with ice packs (n = 7). Results: The results were in agreement with the results presented in the scientific literature, indicating that hilotherapy reduced the swelling more effectively than ice packs, even though they did not occur in the same pain analysis. Conclusion: This pilot study demonstrates that hilotherapy in the postoperative of orthognathic surgery seems to provide satisfaction to the patient with significant decrease of edema and equal pain report by both groups.

Keywords: Edema. Pain. Orthognathic surgery.

How to cite: Jesus AO, Toledo GL, Chiavaioli GMO, Maia BF, Amaral MBF. Assessment of hilotherapy compared to ice pack therapy in pain and edema control after orthognathic surgery: a pilot study.

J Braz Coll Oral Maxillofac Surg. 2020 Sept-Dec;6(3):15-20.

DOI: https://doi.org/10.14436/2358-2782.6.3.015-020.oar

Hospital João XXIII, Residency Program in Oral and Maxillofacial Surgery and Traumatology (Belo Horizonte/MG, Brazil).

Hospital da Baleia - CENTRARE, Service of Oral and Maxillofacial Surgery (Belo Horizonte/ MG, Brazil).

1

2

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

Submitted: January 01, 2019 - Revised and accepted: December 13, 2019 Contact address: Marcio Bruno Figueiredo Amaral Av. Professor Alfredo Balena, 400 CEP: 30.130-100 – Santa Efigênia, Belo Horizonte

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

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Assessment of hilotherapy compared to ice pack therapy in pain and edema control after orthognathic surgery: a pilot study

INTRODUCTION Orthognathic surgery is a surgical procedure to correct facial deformities and asymmetries when there are discrepancies in the jaws in relation to the skull base, providing a functionally stable occlusion and facial harmony. For that purpose, movements of the maxilla, mandible or both are used.1 The postoperative period can cause great discomfort to the patient, often reporting pain, edema and functional limitations of the stomatognathic system. Pain and edema are the main complaints of patients, who wish for any mechanism to control and benefit against this discomfort.2 There are several ways to reduce the postoperative discomfort of orthognathic surgeries, including cryotherapy (cold therapy). Cryotherapy is described in the literature as topical application of ice over the surgical site and has been used by medicine for many years. Cryotherapy provides vasoconstriction of arterioles and reduced tissue temperature, which consequently provides analgesia, as well as reduced metabolic reactions and edema.3-5 The physiological mechanisms involved in cryotherapy are the decrease in tissue perfusion and the reduction of inflammatory reactions, as well as reduction of the inflammatory process. Cooling plays an important role in the postoperative period for the management of pain and edema after orthognathic surgeries.5 Hilotherapy (Hilothem GmbH, Argenbühl-Eisenharz, Germany) consists of a cooling system by propulsion and circulation of water using a standardized facial mask system with an anatomical shape of the face, adapting over the entire surface, which circulates chilled water at a constant temperature of 15ºC, also reducing thermal injuries caused by ice, discomfort and some postoperative complications, since the temperature is above the water freezing point.6-8 Thus, the objective of the present study was to evaluate, in a pilot study, which of the postoperative treatments, ice packs or hilotherapy, is more effective in reducing discomfort, pain and edema in patients undergoing orthognathic surgery.

Standards of Reporting Trials)9, after approval by the Institutional Review Board of Hospital da Baleia/ CENTRARE, Belo Horizonte, under protocol number 53476816.9.0000.5149. The sample size and the definition of type I and II errors were based on the scientific literature.4,10,11,12,13 Patients with skeletal dentofacial deformities with indication for bimaxillary orthognathic surgery were included in the study. Patients with indication for single jaw surgery and/or surgically assisted maxillary expansion or in continuous use of anti-inflammatory and/or analgesics were excluded from the study.

Patients with indication for surgery after relapse were also excluded from the study. A randomized list of numbers was generated using software (Microsoft Office Excel, 2010) to allocate patients to the intervention and control groups. The patients read and signed the informed consent form before being included in the study.

Surgical procedure The patients underwent bimaxillary orthognathic surgery using bilateral sagittal osteotomy, Le Fort I osteotomy and/or mentoplasty techniques, with movements performed based on facial analysis and virtual planning using specific software (Dolphin Imaging 3D, version 11.95). All procedures were performed under balanced general anesthesia and hypotension. Local infiltrative anesthesia with 2% lidocaine with adrenaline (1:100,000) was used (DFL Indústria e Comércio SA, Rio de Janeiro, Brazil). The total surgical time (incision to suture) was measured using a digital chronometer (Vollo VL 1809). Osteotomies were conventionally performed with reciprocating saw and drills. After adequate osteotomy fixation, continuous suturing of incisions was performed using resorbable 4.0 suture (Ethicon, Johnson & Johnson, USA).

Postoperative evaluation The Control Group (G1, n=7) included patients who used ice packs on the face for cooling, and in Intervention Group (G2, n=10) was composed of patients who used standardized cooling masks on the face after surgery (hilotherapy) (Fig 1). An evaluator blinded to the applied therapy performed the postoperative evaluations of the parameters. Postoperative pain was assessed using a visual analog scale (VAS)

METHODS Patients and study design The study was a prospective comparative study, conducted in a single institution, following the CONSORT systematization (checklist of Consolidated

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used were the Shapiro-Wilk test, using the Wilcoxon post-test for non-parametric samples and the Student t test for parametric samples. The significance level considered was p<0.05 in all evaluations, and descriptive analysis of the sample’s variables was performed jointly: age, sex, type of surgery performed and surgical time.

measuring pain on a scale of 0 to 10, in which 0 represents the absence of pain and 10 the greatest pain ever felt by the patient. Subsequent to this, the score assigned by the patient when assessing pain was categorized into: 1 to 3 = mild pain; 4 to 6 = moderate pain; and 7 to 9 = severe pain. Edema was assessed by postoperative measurements using the modified technique described by Ustun et al,14 measuring seven fixed reference points: tragus, lateral corner of the eye, subnasal point, lip commissure, pogonion, mandible angle, intersection of lines drawn between the pupil and the nasal ala10 (Fig 2). Measurements were performed at the following times: preoperative (T0), 1, 7, 14, 21 and 28 postoperative days (T1, T2, T3, T4 and T5, respectively). For comparative analysis of edema measurements, the values ​​found at the preestablished points were added to completely characterize the edema, not only in a specific region of the face.

RESULTS When comparing age between groups, no statistical difference was found by analyzing the minimum-maximum interval and the mean±standard error: G1) 25-31; 28.43±0.812 years; G2) 16-47; 27.70±3.004 years. The duration of surgery, measured in minutes, showed no statistically significant difference: G1) 145.00±70.371; G2) 160.00±18.562 (median±standard deviation). The Wilcoxon test showed that, in the assessment of postoperative pain, both groups presented similarly over the first 4 days (Table 1). In average, the edema present in group G2 (hilotherapy) was smaller, regressing more quickly than the group using ice packs (G1) for relief of postoperative pain (Table 2 and 3).

Statistical analysis Statistical analysis was performed using the SPSS software (Statistical Package for the Social Sciences v.

22, IBM Inc., New Armonk, NJ, USA). The parameters

Figure 1: Patient wearing a mask for hilotherapy.

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Figure 2: Reference points on the face for measurement of postoperative edema.

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Assessment of hilotherapy compared to ice pack therapy in pain and edema control after orthognathic surgery: a pilot study

Table 1: Evaluation of postoperative pain in the control (G1) and hilotherapy groups =(G2).

Postoperative days

T1 T2 T3 T4

G1 (n=7)

G2 (n=10)

0 – 8 2 ± 3.047 0 – 5 3 ± 1.496 0 – 5 3 ± 1.718 0 – 2 0 ± 0.787

0 – 5 1 ± 1.912 0 – 5 1 ± 1.780 0 – 4 1 ± 1.650 0 – 2 0 ± 0.675

Interval: minimum-maximum; median ± standard deviation. * Wilcoxon test (p<0.05).

Table 2: Evaluation of postoperative edema in the control (G1) and hilotherapy groups (G2).

Postoperative days

G1 (n=7)

G2 (n=10)

T0

1184.00 ± 9.444

1138.50 ± 16.162

T1

1273.86 ± 15.532

1210.60 ± 23.151

T2

1221.00 ± 5.477

1186.50 ± 12.361*

T3

1208.43 ± 4.508

1186.40 ± 11.545

T4

1213.57 ± 9.579

1168.70 ± 14.255*

T5

1213.86 ± 6.798

1171.30 ± 14.488*

Mean ± standard error. * Student t test (p<0.05).

Table 3: Progression of reduction of postoperative edema in the control (G1) and hilotherapy groups (G2).

Postoperative days

G1 (n=7)

G2 (n=10)

T1

89.86

72.10

T2

37.00

48.00*

T3

24.43

47.90

T4

29.57

30.20*

T5

28.86

30.20*

Mean. * Student t test (p<0.05).

DISCUSSION Cryotherapy is a traditional and common way to reduce pain, edema and discomfort after facial trauma or surgery; however, the quality of evidence is poor.5 Against this background, some studies show an impairment in the blood flow of microvascularization and lymphatic drainage, frostbite and even nerve damage. Cold therapies limit pain and edema by mul-

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

tiple ways, including reduction of cellular metabolism, vascular constriction and impairment of conduction of neural impulses.4-7,15 The mechanisms of action of cryotherapy has a direct effect on vascular constriction, reducing vascular permeability, preventing the outflow of plasma into the extracellular space and consequently reducing edema. Hilotherapy is a cooler system that allows the

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Jesus AO, Toledo GL, Chiavaioli GMO, Maia BF, Amaral MBF

Similarly, Yontar and Tatar7 analyzed gel mask cooling compared to the cost-benefit of ice packs, finding improvements in the postoperative period. In the work

by Tahim et al,19 it was concluded that there is great reduction in the hospitalization time after orthognathic surgery, which generates a great saving for the health system. However, in the present study, there was no difference in the hospital stay length in the sample evaluated, and all patients, regardless of the group, control or intervention, were discharged within 24 hours of hospitalization.

In general, different authors6,10,11,12 clearly demonstrate the postoperative advantages of using hilotherapy in significantly reducing edema in 72 hours and pain in 48 hours. In this pilot study, postoperative pain did not show statistical difference between groups; however, concerning postoperative edema, there was significant reduction, corroborating the findings in the literature.

Hilotherapy allows the temperature to be adjusted and kept fixed between 15 and 22° C. El-Karmi et al.21 report that at 18°C the patient reports greater comfort. The study by Gerold et al13 shows that at 15°C there is complete analgesia. The homogeneous distribution of local cold therapy promoted by the mask favors the rapid beneficial effect for the patient5.

Meta-analysis studies have shown that the use of hilotherapy reduces postoperative pain and edema after orthognathic surgery, also including better satisfaction and confidence than patients using ice packs or compresses.5 Also, when assessing comfort, patients have better acceptance and adherence to treatment with hilotherapy, due to its convenience and ease.18,21 Therefore, there is a great need to continue this study, covering a larger number of participants, to better elucidate the conclusions, solidifying the outcomes found in this pilot study.

face to cool to inhibit edema and postoperative pain.

It consists of anatomically pre-molded polyurethane masks and, by this system, deionized water circulates at a temperature between 12.8 and 15.6°C, the most effective temperatures for reducing edema.5,8,16,17 Hilotherapy has the potential to reduce the formation of hematoma, as well as to block the alpha adrenergic innervation, associated with the analgesic effect, due to the reduced speed of conduction of nerve impulses in C fibers, inhibiting nociceptors of the thalamic neural pathway.9,10 Another possible mechanism for reducing the effectiveness of conventional therapies is that, at 0°C, the temperature of water solidification, nerve conduction is completely inhibited and vasoconstriction reverses to vasodilation. Such low temperatures decrease the drainage of lymph nodes and the cellular metabolism, consequently increasing the edema.15,18,19 In the present study, it was observed that, statistically, there was no difference in the surgical time, nor in the age of patients, which could be a great bias, since the surgical time is directly proportional to the resulting edema, as well as the pain, due to the time and force for tissue removal.

The study by Glass et al.10 initially analyzed edema and pain and secondarily tolerance, hematoma and ecchymosis. In three of the four clinical trials, edema was performed using three-dimensional morphometric and volumetric image analysis software.10 In the present study, the analysis was performed by measuring the distance between craniometric points, modified from those previously described by Ustun et al.14 Due to previously validated techniques, correlations and applicability in this study of similar methodologies and perspectives can be established.

Bates et al,4 in their systematic review and meta-analysis on the effectiveness of hilotherapy, conclude that hilotherapy significantly reduces edema, pain and trismus, up to 48 hours after surgery. This is complemented by the result of Chadha et al,20 who carried out an economic analysis of the cost-effectiveness of hilotherapy, resulting in a 90% reduction in hospitalization, also reducing the need for analgesics.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

CONCLUSION This pilot study demonstrates that hilotherapy after orthognathic surgery seems to lead the patient to satisfaction, with a significant reduction in edema and with a similar report of pain by both groups.

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Assessment of hilotherapy compared to ice pack therapy in pain and edema control after orthognathic surgery: a pilot study

References:

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

2. Proffit W, White R. Who needs surgical-orthodontic treatment? Int J Adult Orthod Orthognath Surg. 1990; 5(2):81-9.

3. Sortino F, Cicciù M. Strategies used to inhibit postoperative swelling following removal of impacted lower third molar. Dent Res J. 2011;8(4):162-71.

4. Bates AS, Knepil GJ. Systematic review and metaanalysis of the efficacy of hilotherapy following oral and maxillofacial surgery. Int J Oral Maxillofac Surg.

2016 Jan; 45(1):110-17.

5. Greenstein G. Therapeutic efficacy of cold therapy after intraoral surgical procedures: a literature review.

J Periodontol. 2007;78(5):790-800.

6. Collier J, Knepil GJ. Facial cooling following orthognathic surgery - pilot data and recommendations for a multi-centre study. Br J Oral Maxillofac Surg.

2012;50(Suppl. 1):S38.

7. Yontar Y, Tartar S. Cooling gel eye mask: low-cost and efficacious alternative for postoperative comfort of the rhinoplasty patients. J Exp Clin Med. 2016;33(4):259-60.

8. Hilotherm GmbH. [Access: Jul 04, 2018]. Available from: www.hilotherm.com.

9. Schultz KF, Altman DG, Moher D. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomized trials. BMC Med. 2010 Mar; 8:18.

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10. Glass GE, Waterhouse N, Shakib K. Hilotherapy for the management of preoperative pain and swelling in facial surgery: a systematic review and meta-analysis. Br J Oral Maxillofac Surg. 2016 Oct; 54(8):851-56.

11. Barca I, Colangeli W, Cristofaro MG, Giudice A, Giofrè E, Varano A, et al. Effects of cold therapy in the treatment of mandibular angle fractures: hilotherm system vs ice bag. Ann Ital Chir. 2016 Jan;87:411-6.

12. Ernst E, Fialka V. Ice freezes pain? A review of the clinical effectiveness of analgesic cold therapy.

J Pain Symptom Manage. 1994 Jan; 9(1):56-9.

13. Gerold KHE, Haers PE, Sailer HF. Adjuvante kryotherapie nach maxillofacial en operationen. Acta Med Dent Helv. 1998; 3(5):93-9.

14. Ustun Y, Erdogan Ö, Esen E, Karsli ED. Comparison of the effects of 2 doses of methylprednisolone on pain, swelling and truisms after third molar surgery.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod.

2003;96(5):535-9.

15. Belli E, Rendine G, Mazzone N. Cold therapy in maxillofacial surgery. J Craniofac Surg.

2009;20(3):878-80.

16. Moro A, Gasparini G, Marianetti TM, Boniello R, Cervelli D, Di Nardo F, et al. Hilotherm efficacy in controlling postoperative facial edema in patients treated for maxillomandibular malformations. J Craniofac Surg. 2011;22(6):2114-7.

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17. Laureano Filho JR, Silva EDO, Camargo IB, Gouveia FMV. The influence of cryotherapy on reduction of swelling, pain and trismus after third-molar extraction: a preliminary study. J Am Dent Assoc.

2005;136(6):774-8.

18. Beech AN, Haworth S, Knepil GJ. Effect of a domiciliary facial cooling system on generic quality of life after removal of mandibular third molars. Br J Oral Maxillofac Surg. 2018 May;56(4):315-21.

19. Tahim A, Rumani S, Igra A, Ali N. The use of a cooling facemask to reduce hospital stay after orthognathic surgery. Br J Oral Maxillofac Surg. 2016 Dec; 54(10):e136.

20. Chadha A, Cronin N, Fan K. Economic analysis of hilotherapy use in patients undergoing orthognathic surgery in the NHS setting. Br J Oral Maxillofac Surg.

2015 Dec;53(10):e120.

21. El-Karmi A, Hassfeld S, Bonitz L. Development of swelling following orthognathic surgery at various cooling temperatures by means of hilotherapy - a clinical, prospective, mono centric, singleblinded, randomized study. J Craniofac Surg. 2018 Sep;46(9);1401-07.

J Braz Coll Oral Maxillofac Surg. 2020 Sept-Dec;6(3):15-20

Original article

Analysis of linear transverse measurements after SARPE MARCELO MINHARRO CECCHETTI1 | WLADIMIR GUSHIKEN DE CAMPOS2 | TATIANE FERRARI3 | CAMILLA VIEIRA ESTEVES4 | MARIA DA GRAÇA NACLÉRIO-HOMEM5 | CELSO AUGUSTO LEMOS6

ABSTRACT Objective: To analyze the effectiveness of surgically assisted rapid palatal expansion (SARPE) in gaining horizontal maxillary distance. Methods: Eleven patients with transverse maxillary deficiency submitted to SARPE participated in the study. Study models were obtained before and after surgery. The transverse measurements of the maxillary models were performed between the canine cusps, palatal cusps of the first premolars, and buccal cusps of the first upper molars. These measurements were performed before and after SARPE. Results: Regarding the total number of turns applied to Hyrax and the average gain in maxillary transverse distance, there was a statistically significant correlation (p = 0.006) between the total number of turns of the device and the average gain in the region. Regarding the canine region (p = 0.45) and molar region (p = 0.925), there was no statistically significant correlation between the number of turns in the device and the obtained distance. Conclusion: The average gain in maxillary transverse distance was statistically significant for the canine, premolar and molar regions and arch perimeter. There was a statistically significant correlation between the total number of device activations and the distance gained in the premolar region.

Keywords: Palatal expansion technique. Orthodontics. Orthodontics, corrective. Orthodontics, interceptive.

How to cite: Cecchetti MM, Campos WG, Ferrari T, Esteves CV, Naclério-Homem MG, Lemos CA. Analysis of linear transverse measurements after SARPE. J Braz Coll Oral Maxillofac Surg. 2020 Sept-Dec;6(3):21-9.

DOI: https://doi.org/10.14436/2358-2782.6.3.021-029.oar

Postdoc, Dental Division, Service of Oral and Maxillofacial Surgery and Traumatology, Clinics Hospital of the Medical School of University of São Paulo (São Paulo/SP, Brazil).

1

MSc, Department of Stomatology at the School of Dentistry of University of São Paulo (São Paulo/ SP, Brazil).

2

Submitted: December 09, 2019 - Revised and accepted: February 11, 2020

Specialist in Oral and Maxillofacial Surgery of the Dental Department of Clinics Hospital of Ribeirão Preto, Universidade de São Paulo (São Paulo/SP, Brazil).

3

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

PhD, Department of Stomatology at the School of Dentistry of University of São Paulo (São Paulo/ SP, Brazil).

4

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

Full Professor of the Department of Oral and Maxillofacial Surgery, Prosthodontics and Traumatology, School of Dentistry of University of São Paulo (São Paulo/SP, Brazil).

5

Contact address: Wladimir Gushiken de Campos Faculdade de Odontologia (Departamento de Estomatologia) da Universidade de São Paulo Av. Professor Lineu Prestes, 2227, São Paulo/SP, Brasil E-mail: wgushiken@hotmail.com

Associate Professor of the Department of Stomatology at the School of Dentistry of University of São Paulo (São Paulo/SP, Brazil).

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Analysis of linear transverse measurements after SARPE

INTRODUCTION Maxillary hypoplasia is the volumetric discrepancy between the maxilla and mandible, of multifactorial etiology, including congenital, developmental, traumatic and iatrogenic factors. To correct the transverse maxillary deficiency, orthopedic and orthodontic-surgical therapies can be used, depending on the patient’s bone growth potential and the magnitude of the desired correction.1 Historically, the difficulty in opening the midpalatal suture in adults has been assigned to fusion of the sutures and can be avoided by associated surgical therapy, releasing bone structures that resist to orthodontic expansion forces.2 Thus, surgically assisted rapid maxillary expansion (SARME) consists of decreasing the bone resistance to palatal expansion,3 by osteotomies on the maxillary walls and sutures and placement of orthopedic appliances, such as Hyrax. There are several recommendations for osteotomies and corticotomies for maxillary separation, but there are few studies on cross-sectional measurements after SARME or even the number of activations required in the appliance in the postoperative period.4

MATERIAL AND METHODS Eleven patients with severe maxillary hypoplasia submitted to SARME participated in the study. The patients had mean age 26.45 years (minimum 19 and maximum 36). The patients included in the study underwent previous orthodontic evaluation and received indication for surgery. The Hyrax appliance was fixed to the first premolars and first molars bilaterally (Fig 1). This retrospective study was approved by the Institutional Review Board of Clinics Hospital, Medical School, University of São Paulo (CAAE 56228776.7.3001.0168).

After release of the palatal suture and Le Fort I osteotomy, without releasing the pterygomaxillary suture, activation of eight quarters of turn was performed on the appliance, i.e., 2 mm (each quarter of turn corresponding to 0.25 mm).

The hospitalization period was 48 hours. The activation of the Hyrax appliance was initiated after 5 to 7 days; 4 patients activated two quarter of turn per day (1/4 in the morning and 1/4 at night) and seven patients activated a full turn per day (2/4 in the morning and 2/4 at night).

Figure 1: Hyrax appliance fixed on the first premolars and first molars, bilaterally.

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Cecchetti MM, Campos WG, Ferrari T, Esteves CV, Naclério-Homem MG, Lemos CA

ing with acrylic resin). However, in 3 of the 11 patients studied, the postoperative casts were evaluated only after the onset of orthodontic movement, since they did not attend the clinic within the specified period. Transverse measurements of the dental casts were obtained between the canine cusps, palatal cusps of the first premolars and buccal cusps of the first maxillary molars (Fig 2). The arch length was measured in anteroposterior direction (Fig 3) and the arch perimeter was measured from the most distal point of the central incisors, mesial surface of first premolars and mesial surface of first molars (Fig 4). These measurements were obtained before and after SARME, with a ruler and caliper.

The measurements were statistically analyzed by the Wilcoxon test, adopting a significance level of 5%.

The software used to obtain the results was SPSS v.

13.0 (Statistical Package for the Social Sciences). For correlation of the obtained data, Spearman’s correlation was used.

The total number of activations varied from patient to patient, with a minimum of 16 activations and maximum of 52. The total number of activations varied according to the gain required in the transverse maxillary dimension of each patient. When the required distance was reached, the device was fixed with acrylic resin.

During the postoperative period, the patients were evaluated weekly, using periapical and occlusal radiographs, to observe the separation of the palatal suture and its ossification. Clinically, the gain was measured by the distance between the upper central incisors, using a caliper. The appliance was maintained for about 4 to 6 months, i.e., until bone consolidation of the palatal suture. When ossification of the suture was observed, the appliance was removed, and orthodontic treatment was performed.

Dental casts were obtained before and after surgery (after stopping the appliance activation and fix-

Figure 2: Transverse measurements of the maxilla between the canine cusps (C-C), palatal cusps of the first premolars (PM-PM) and buccal cusps of the first maxillary molars (M-M).

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Analysis of linear transverse measurements after SARPE

Figure 3: Measurement of arch length in anteroposterior (CO) direction.

Figure 4: Measurement of arch perimeter (PE).

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Cecchetti MM, Campos WG, Ferrari T, Esteves CV, Naclério-Homem MG, Lemos CA

RESULTS The pre- and postoperative casts were measured before and after SARME, obtaining the transverse distances from cusp to cusp between canines (CC), first premolars (PM-PM) and first molars (MM), in addition to arch length (CO) and perimeter (PE) of all patients

who participated in the study (Table 1). In seven of the eleven cases studied, an increase in upper arch perimeter was obtained. Two cases maintained the same perimeter measurements as before SARME, and in other two, there was a decrease in arch perimeter after surgery. The two cases in which the perimeter remained the

Table 1: Preoperative (M1) and postoperative measurements (M2) (in mm).

Patient

Age

Sex

1 2 3 4 5 6 7 8 9 10 11

30 22 21 19 21 31 29 32 22 36 28

F F M F F F M F M F F

31 32 39 33 32 40 28 25 36 30 30

PM-PM

M1 M-M

CO

PE

C-C

22 30 36 35 25 31 25 28 30 27 27

44 53 54 49 43 53 39 53 57 50 40

29 26 25 25 27 26 30 23 31 28 21

77 71 72 64 65 67 76 70 77 71 72

35 42 40 36 35 39 36 32 39 39 34

PM-PM

M2 M-M

CO

PE

30 40 40 39 32 38 32 35 34 37 31

51 63 56 52 50 55 49 61 61 61 52

29 27 23 27 27 20 32 24 29 29 27

80 78 70 69 65 65 79 73 77 81 73

AT

40 52 28 25 38 40 34 30 22 32 16

Legend: C-C = canine to canine, PM-PM = premolar to premolar, M-M = molar to molar, CO = upper arch length, PE = upper arch perimeter, AT = total number of activations.

Table 2: Preoperative measurements (M1) (in mm).

Canines Premolars Molars Length Perimeter

Mean

M1 Standard deviation

Minimum

Maximum

32.36 28.73 48.64 26.45 71.09

4.5 4.24 6.15 2.98 4.48

25 22 39 21 64

40 36 57 31 77

Mean

M2 Standard deviation

Minimum

Maximum

37 35.27 55.55 26.73 73.64

3 3.72 5.15 3.33 5.82

32 30 49 20 65

42 40 63 32 81

Table 3: Postoperative measurements (M2) (in mm).

Canines Premolars Molars Length Perimeter

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Analysis of linear transverse measurements after SARPE

of premolars (22.76%) in relation to canines (14.34%) and molars (14.21%), and the mean gain in intercanine and intermolar regions was similar. However, this mean gain is not the real bone gain, since the inclination of teeth that served as support for the appliance must be considered.

Regarding the total number of turns applied to the Hyrax and the mean gain in the transverse distance of the maxilla, there was statistically significant correlation (p = 0.006) between the total number of turns of the appliance and the mean gain in the region – i.e., the correlation coefficient is positive (the greater the number of turns, the greater the mean gain). Regarding the canine region (p = 0.45) and the molar region (p = 0.925), there was no statistically significant correlation between the number of turns on the appliance and the distance obtained, and the correlation coefficient was positive for canines and negative for molars (Table 5).

same were because orthodontic movement was already started, which masked a probable gain in arch perimeter after SARME. In the other two cases in which there was decrease in arch perimeter, one occurred due to alveolar fracture and no release of the palatal suture, and in the other case the first premolars were extracted after SARME (Table 1).

Preoperative (M1) (Table 2) and postoperative (M2) (Table 3) measurements were performed with α = 0.05.

The values ​​obtained show that there was a mean gain in the transverse distance between teeth (M2 - M1) of 4.64 mm, 6.54 mm, 6.91 mm, 0.28 mm and 2.55 mm for canines, premolars, molars, arch length and perimeter, respectively. This gain was statistically significant (p <0.05) for canines (p = 0.005), premolars (p = 0.003), molars (p = 0.003) and arch perimeter (p = 0.719). Table 4 shows the results obtained in this study.

There was greater gain (percentage) in the region

Table 4: Mean transverse increase in the maxilla after SARME (in mm).

M2-M1

Canines Premolars Molars Length Perimeter

Mean

(p)

4.64 6.54 6.91 0.28 2.55

0.005 0.003 0.003 0.719 0.037

M2-M1 = mean transverse increase in the maxilla.

Table 5: Correlation between number of activations performed in the Hyrax appliance and mean transverse increase in the maxilla.

Canines Premolars Molars

Correlation coefficient +/-

(p)

0.255 0.769 -0.032

0.45 0.006 0.925

Table 6: Correlation between mean increase in upper arch perimeter and mean increase in the canines, premolars and molars regions.

Canines Premolars Molars

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Correlation coefficient +/-

(p)

0.623 0.594 0.297

0.041 0.054 0.375

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Cecchetti MM, Campos WG, Ferrari T, Esteves CV, Naclério-Homem MG, Lemos CA

significant in all regions, except for the gain in arch length, which was not statistically significant. A gain in the horizontal maxillary distance was expected after SARME, regardless of the technique used.

There was a percentage gain of 22.76% in the premolar region, 14.34% in the canine region and 14.21% in the molar region. The greatest gain in the horizontal maxillary distance occurred in the region of premolars, followed by the canine region and then the molars region. For Betts et al. 12 and Bailey et al,13 in SARME, the greatest gain occurs in the canine region and the smallest in the molar region.

This gain in the posterior region obtained by the present study reinforces the idea that the greatest area of resistance ​​ to palatal expansion is the zygomatic pillar and, if released, posterior expansion occurs without the need to release the pterygomaxillary suture. Kennedy et al 14 concluded that the largest area of ​​palatal resistance is the zygomatic-maxillary pillar. Moss15 and Lehman and Haas4 also observed that the zygomatic pillar is the main area of​​ resistance to lateral movements of the maxilla when performing SARME. The mean gain in the transverse maxillary distance (4.64 mm, 6.54 mm, 6.91 mm, 0.28 mm and 2.55 mm, respectively, for canines, premolars, molars, arch length and perimeter) does not correspond to the real bone gain, since there is dental inclination in buccal and palatal direction of the first premolars and first maxillary molars. This inclination is due to forces generated in these teeth during Hyrax activation, since they act as support for the appliance.

Chung and Goldman 16 had already concluded in their studies that, during SARME, there is buccal inclination of first premolars and first upper molars, which act as anchorage for the appliance.

Thus, the gain observed in this study, in the region of premolars and molars, involves bone gain of the maxilla plus inclination of the aforementioned teeth. In the canine region and in the arch perimeter, however, the gain can be considered real, since there is no anchorage of appliance in the canines, which probably will not cause tooth inclination and, in case of the arch perimeter, since this is a mesiodistal measurement, there is also no involvement of tooth inclination.

The percentage gain of 22.76% in the premolar region, 14.34% in the canine region and 14.21% in

The mean gain in arch perimeter had statistically significant correlation with the gain in the canine region (p = 0.041), with a positive coefficient, and this coefficient, though positive for premolars and molars, was not statistically significant (p = 0.054 for premolars and p = 0.375 for molars) (Table 6).

There were two surgical complications. In one of them, the Hyrax appliance loosened during transoperative activation. In this case, the patient was referred to the orthodontist for appliance fixation and its expansion occurred without major problems. In the other case, there was lateral displacement of the upper central incisors during separation of the midpalatal suture. In this patient, it was decided to interrupt the treatment for about six months, until dental relapse and fracture repair, to perform a new surgery.

Postoperatively, the patients were also asked about pain, discomfort and satisfaction with surgery. Most patients complained of discomfort when activating the appliance and the diastema created by expansion between the upper central incisors. After removal of Hyrax and onset of orthodontic movement, the patients showed high satisfaction.

DISCUSSION The number of turns applied to the device was, in the average, 8/4 turns transoperatively and 4/4 turns per day in the postoperative period, unlike several authors 1,4-11 who state that the total number of activations during surgery should correspond to 1 mm and that the number of activations per day should be 2/4 of turn. The 4/4 turn performed postoperatively generates a real expansion smaller than expected (1 mm), i.e., 1/4 turn in the expander does not correspond to a bone expansion of 0.25 mm.

A period of 5 to 7 days was allowed after surgery to start the expansion, as suggested by Ilizarov,7 who recommends waiting a period of five days to start the activation (2/4 per day). This time is necessary, according to the author, for the repair of intraosseous capillaries, and restoration of the blood supply favors the complete ossification of the area.

An increase in the horizontal maxillary length after SARME was observed in this study. The mean gain in the transverse maxillary distance was 4.64 mm, 6.54 mm, 6.91 mm, 0.28 mm and 2.55 mm, respectively, for canines, premolars, molars, arch length and perimeter. These gains were statistically

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Analysis of linear transverse measurements after SARPE

In the present study, although the greatest horizontal gain occurred in the region of premolars, followed by the canine region, the arch perimeter is statistically correlated only with the canines, since real transverse maxillary gain was obtained in this region.

the molar region shown above can be explained by the anchorage of teeth. The greater gain in the region of premolars in relation to the region of molars is probably due to the greater bone anchorage of molars, i.e., it is a tooth with three roots, while the first premolar may have one or two roots. Thus, dental inclination of the premolar will be greater than that of the molar, generating a greater apparent gain in the premolar region.

The gain in the canine region does not correspond to the number of activations, i.e., with a mean of 32 activations, approximately, a gain of 8 mm would be expected, and not 4.64 mm, as observed.

Thus, for each activation, there is clinical evidence of a real mean gain of 0.145 mm in the canine region.

The mean gain in arch perimeter is statistically correlated with the mean gain in the transverse maxillary distance in the canine region, confirming the study by Pinto et al,17 who concluded that the gain in arch perimeter is correlated with the gain in horizontal distance of the maxilla in the canine and premolar regions. It can be stated that there is a ratio between the mean transverse gain in the canine region in relation to the mean gain in arch perimeter of 1.8: 1.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

CONCLUSION There was increase in the transverse maxillary distance in patients with mean age 26.45 years, regardless of the release of the pterygomaxillary suture. The mean gain in the transverse maxillary distance was statistically significant for the canine, premolar and molar regions and arch perimeter. There is statistically significant correlation between the total number of activations of the appliance and the distance gained in the premolar region, although this distance is apparent. In the canine region, although not statistically significant, the bone gain is real, that is, with every 1/4 turn in the device, there is a mean gain of 0.145 mm in the transverse dimension in the canine region. The mean maxillary transverse gain in the canine region is statistically correlated with the mean gain in upper arch perimeter in the proportion of 1.8:1.

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Cecchetti MM, Campos WG, Ferrari T, Esteves CV, Naclério-Homem MG, Lemos CA

References:

1. Reyneke JP, Conley RS. Surgical/orthodontic correction of transverse maxillary discrepancies. Oral Maxillofac Surg Clin North Am. 2020;32(1):53-69.

2. Silverstein K, Quinn PD. Surgically-assisted rapid palatal expansion for management of transverse maxillary deficiency. J Oral Maxillofac Surg. 1997;55(7):725-7.

3. Ferreira BB, Duarte BG, Fiamoncini ES, Ferreira Júnior O, Gonçales ES. Avaliação da movimentação dos dentes maxilares e mandibulares causada pela expansão rápida de maxila assistida cirurgicamente.

J Braz Coll Oral Maxillofac Surg. 2018: 2358-782.

4. Lehman JA, Haas AJ. Surgical-orthodontic correction of transverse maxillary deficiency. Dent Clin North Am. 1990;34(2):385-95.

5. Glassman AS, Nahigian SJ, Medway JM, Aronowitz HI. Conservative surgical orthodontic adult rapid palatal expansion: Sixteen cases. Am J Orthod.

1984;86(3):207-13.

6. Pogrel MA, Kaban LB, Vargervik K, Baumrind S. Surgically assisted rapid maxillary expansion in adults. Int J Adult Orthodon Orthognath Surg. 1992;7(1):37-41.

7. Ilizarov GA. Clinical application of the tension-stress effect for limb lengthening. Clin Orthop Relat Res. 1990;250:8-26.

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8. Schimming R, Feller KU, Herzmann K, Eckelt U. Surgical and orthodontic rapid palatal expansion in adults using Glassman’s technique: retrospective study. Br J Oral Maxillofac Surg. 2000;38(1):66-9.

9. Chung CH, Woo A, Zagarinsky J, Vanarsdall RL, Fonseca RJ. Maxillary sagittal and vertical displacement induced by surgically assisted rapid palatal expansion.

Am J Orthod Dentofacial Orthop. 2001;120(2):144-8.

10. Lanigan DT, Mintz SM. Complications of surgically assisted rapid palatal expansion: Review of the literature and report of a case. J Oral Maxillofac Surg.

2002;60(1):104-10.

11. Chamberland S. Long-term dental and skeletal changes following surgically assisted rapid palatal expansion. Oral Surg Oral Med Oral Pathol Oral Radiol.

2013;116(1):120-1.

12. Betts NJ, Vanarsdall RL, Barber HD, Higgins-Barber K, Fonseca RJ. Diagnosis and treatment of transverse maxillary deficiency. Int J Adult Orthodon Orthognath Surg. 1995;10(2):75-96.

13. Bailey LJ, White RP, Proffit WR, Turvey TA. Segmental Le Fort I osteotomy for management of transverse maxillary deficiency. J Oral Maxillofac Surg.

1997;55(7):728-31.

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14. Kennedy JW, Bell WH, Kimbrough OL, James WB. Osteotomy as an adjunct to rapid maxillary expansion.

Am J Orthod. 1976;70(2):123-37.

15. Moss JP. Rapid expansion of the maxillary arch. II. Indications for rapid expansion. JPO J Pract Orthod.

1968 May;2(5):215-23 concl.

16. Chung CH, Goldman AM. Dental tipping and rotation immediately after surgically assisted rapid palatal expansion. Eur J Orthod. 2003;25(4):353-8.

17. Pinto PX, Mommaerts MY, Wreakes G, Jacobs WV. Immediate postexpansion changes following the use of a transpalatal distractor. J Oral Maxillofac Surg.

2001;59(9):994-1000.

J Braz Coll Oral Maxillofac Surg. 2020 Sept-Dec;6(3):21-9

Original article

The role of anxiety in blood pressure variation before dental care THAYARA LIMA DE MORAIS1 | GIRLEIDE DE SOUSA SILVA1 | EDER ALBERTO SIGUA-RODRIGUEZ2 | DOUGLAS RANGEL GOULART1,3

ABSTRACT Introduction: Fear and anxiety are common in patients requiring dental treatment.

Objective: The aim of this study was to evaluate the relationship between blood pressure and heart rate measurements and the degree of anxiety of patients awaiting dental care. Methods: A cross-sectional study was conducted with 68 randomly selected patients, aged between 18 and 65 years. Each patient answered a questionnaire consisting of questions involving sociodemographic data. To evaluate anxiety, the modified Corah Dental Anxiety Scale was used. The patients underwent two consecutive blood pressure and heart rate assessments using the device model 7113 Omron. Results: Sixty-eight patients were evaluated, with female prevalence and mean age of 40.49 years. It was found that patients who reported being hypertensive had higher blood pressure measurements. Men presented higher pressure measurement, with statistically significant difference (p<0.01). There were no statistically significant differences regarding the procedure to be performed and the degree of anxiety.

Conclusion: The degree of anxiety does not seem to influence blood pressure and heart rate measurements; patients who are hypertensive seem to be more likely to variation of these measures in the face of stress situations.

Keywords: Anxiety. Dental anxiety. Tooth extraction. Anesthesia. Dentistry.

How to cite: Morais TL, Silva GS, Sigua-Rodriguez EA, Goulart DR. The role of anxiety in blood pressure variation before dental care. J Braz Coll Oral Maxillofac Surg. 2020 Sept-Dec;6(3):30-6.

DOI: https://doi.org/10.14436/2358-2782.6.3.030-036.oar

Euro-Americano University Center, School of Dentistry (Brasília/DF, Brazil).

1

Institución Universitaria Colegios de Colombia, Centro de Investigaciones del Colegio Odontológico (CICO) (Bogotá/Distrito Capital, Colombia).

2

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

Federal University of Goiás, School of Dentistry (Goiânia/GO, Brazil).

3

Submitted: December 18, 2019 - Revised and accepted: March 17, 2020 Contact address: Douglas Rangel Goulart E-mail: douglasrgoulart@gmail.com

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Morais TL, Silva GS, Sigua-Rodriguez EA, Goulart DR

INTRODUCTION For some decades, diseases of the circulatory system have been among the main causes of death and hospital admissions in the Brazilian population and usually are not known to the individual, since they frequently present asymptomatic clinical aspects.1 High blood pressure (hypertension) is usually an asymptomatic condition, in which the abnormal increase of pressure in the arteries increases the risk of disturbances in several systems. It is defined by the mean systolic pressure at rest of 140 mmHg or more and/or by mean diastolic pressure at rest of 90 mmHg or more. In cases of arterial hypertension, both systolic and diastolic pressure are common.1 The maximum pressure is also called systolic, and the minimum diastolic. Systolic pressure (SP) can be altered under physiological conditions, such as physical exercise, mental condition, sleep or meals. Diastolic pressure (DP) assesses the peripheral resistance posed by the vascular system and depends mainly on the tone of arterioles. DP is less subject to temporary variations compared to SP. In addition, many factors can lead to mistaken BP reading: elements such as tobacco, caffeine, alcohol and cocaine can temporarily increase the value found. 1 Fear and anxiety are common feelings for patients who need dental treatment.2 Fear can be defined as a fear of something external and presents as a real danger, which threatens the person’s physical or psychological integrity. Anxiety is characterized as a fear; however, in this fear, there is no real object. 2 The patient with signs of anxiety and fear can be identified by the behavior and by evaluation or recognition of some signs and manifestations, such as verbal complaint, restlessness, agitation, mydriasis, pallor, excessive sweating, tingling sensation in the extremities, hyperventilation and increase in blood pressure and heart rate.2 Most dental professionals consider anxiety as an extremely relevant component of psychological dimension in their practice, as well as an impediment to full satisfaction by the patients. 3 Negative experiences can arise as a consequence of recent traumatic experiences, negative attitudes of family members, fear of pain, apprehension of failure of previous treatment and painful treatment, reported as the etiological factors of fear reactions.3,4

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The relationship between anxiety and variation in vital signs can interfere with the increased risk of medical emergencies in the dental office, especially when the patient will be submitted to invasive procedures. The risk assessment, obtaining a good patient history, by knowledge of the current disease history, history of family diseases and harmful habits, is the first step in preventing such situations. 5 Thus, the objective of the present research was to relate the blood pressure and heart rate measurements with the degree of anxiety of patients who were waiting for dental appointment at the Euro-Americano University Center (UNIEURO) and correlate them according to the procedure to which the patients would be submitted.

METHODS A cross-sectional study was conducted on randomly selected patients, without sex restriction, aged 18 to 65 years, from March to August 2019, in the waiting room of the Dental Clinic at UNIEURO. Patients who were waiting in the waiting room, who knew which procedure they would undergo, and who had an educational level that allowed them to complete the proposed questionnaire were included.

Each patient answered a questionnaire including questions on identification, gender, age, procedure they would undergo, presence of pain before the dental appointment, if they take any medication, if they drank coffee or did physical activity before the procedure, if they were smokers and hypertensive. The questionnaire was applied before dental care, to explore the main characteristics of situations related to anxiety before treatment. To assess the presence of anxiety prior to dental treatment, the modified Corah Dental Anxiety Scale (MDAS)6 was applied, which contains five questions that can be scored from 1 to 5 points. Thus, the sum of responses is limited to 5 to 25 points and is categorized as follows: less than 9 points – mild or nonexistent anxiety when visiting the dentist; between 9 and 12 points – moderate anxiety when visiting the dentist; between 13 and 14 points – high anxiety when visiting the dentist; and from 15 points – extremely anxious or phobia when visiting the dentist.

Before filling in the questionnaire and applying the Corah Scale, blood pressure and heart rate were

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The role of anxiety in blood pressure variation before dental care

19 patients used (27.9%) and 49 did not (71.1%).

Thirteen patients reported smoking (19.1%). Among the descriptive data of the sample, the minimum age was 18 years and the maximum 65 years, with a mean of 40.49 ± 12.26 years. Concerning the measurement of systolic blood pressure (SBP), the minimum was 102 and the maximum 167, with a mean of 130.56 ± 15.85 mmHg. Measurement of diastolic blood pressure (DBP) revealed a minimum of 62 and maximum 123, with a mean of 86.96 ± 13.39 mmHg. Regarding the measurement of heart rate (HR), the minimum among patients was 48 and the maximum 118, with a mean of 77.01 ± 13.41 beats per minute.

According to information collected in the questionnaire, 17.6% of the sample population (n=12) reported having hypertension. Table 1 presents data on blood pressure and heart rate, comparing hypertensive patients to non-hypertensive patients. Hypertensive patients had higher SBP, with statistically significant difference (p = 0.01).

The blood pressure and heart rate data and the sum of points on the Corah anxiety scale were compared for sex. Systolic blood pressure was higher in men, with statistically significant difference (p = 0.01). However, the heart rate and the sum of points on the Corah scale were higher in women, with statistically significant difference (p = 0.01 and p <0.01). Table 2 presents the data for comparison of variables between sexes.

There were no statistically significant differences in the measurements of systolic and diastolic blood pressure and heart rate according to the procedure to be performed. Table 3 presents data on blood pressure and heart rate according to the treatments performed.

On the modified Corah Dental Anxiety Scale (MDAS), 38 patients were classified as having mild or nonexistent anxiety; 17 with moderate anxiety; 6 with high anxiety and 7 with severe anxiety or phobia. Table 4 presents data on blood pressure and heart rate regarding the patients’ degree of anxiety.

measured using an Omron 7113 digital device, and measurements were made according to the manufacturer’s instructions twice with consecutive five-minute intervals. For comparison, the mean of these two assessments was used.

Statistical analysis The collected data were recorded in Microsoft Excel spreadsheets (Office 2016 package) and transferred to the SSPS® 18.0 program (IBM, Statistical Package for the Social Sciences for Windows). In this software, descriptive and comparative statistical analyses were performed; categorical variables were expressed in absolute numbers and as percentage. The comparative analysis between means was performed using the Student’s t test. The results were considered statistically significant for values ​​of p<0.05.

IRB approval This study was inserted in the Brazil Platform and was approved by the Institutional Review Board of the Euro-Americano University Center under number 3.308.549.

RESULTS A total of 68 volunteer patients were evaluated, being 39.7% (n=27) males and 60.3% (n=41) females.

In the questionnaire, it was asked which procedure the patient would undergo before dental treatment.

The patients reported the following specialties: Dentistry, 24 patients (35.3%); Endodontics, 16 patients (23.5%); Surgery, 14 patients (20.6%); Prosthodontics, 12 patients (17.6%) and Periodontics, 2 patients (2.9%).

It was asked if the patient had pain before the procedure. Four patients reported feeling pain (5.9%) and 64 did not (94.1%). As for coffee intake and physical activity prior to the service, 48 patients responded yes to both questions (70.6%) and 20 denied it (29.4%). Concerning the use of medication,

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Morais TL, Silva GS, Sigua-Rodriguez EA, Goulart DR

Table 1: Comparison of blood pressure measurements and heart rate between hypertensive and non-hypertensive patients.

SBP DBP HR

Hypertensive

Number of patients

Mean

Standard deviation

Yes No Yes No Yes No

12 56 12 56 12 56

144.42 127.59 96.00 85.02 73.17 77.84

16.13 14.25 15.94 12.08 11.56 13.72

p*

0.01 0.09 0.277

* t test. SBP = systolic blood pressure. DBP = diastolic blood pressure. HR = heart rate.

Table 2: Comparison of variables of blood pressure, heart rate and sum of points of the modified Corah scale between men and women.

SBP DBP HR Points on the Corah scale

Sex

Number of patients

Mean

Standard deviation

Male Female Male Female Male Female

27 41 27 41 27 41

136.22 126.83 90.00 84.95 71.93 80.37

16.52 14.40 15.39 11.67 15.49 10.77

Male

27

7.07

2.26

Female

41

10.59

4.61

p*

0.01 0.129 0.01

<0.01

* t test. SBP = systolic blood pressure. DBP = diastolic blood pressure. HR = heart rate.

Table 3: Distribution of blood pressure and heart rate measurements according to the procedure performed.

Procedure

Surgery

Restorative Dentistry

Endodontics

Periodontics

Prosthodontics

Number of patients

Minimum

Maximum

Mean

Standard deviation

14 14 14 24 24 24 16 16 16 2 2 2 12 12 12

112 68 53 102 62 48 103 63 50 117 78 57 107 73 67

167 123 102 165 115 99 152 107 118 124 87 70 145 98 92

133.36 88.21 75.43 135.83 91.46 77.04 126.00 82.81 77.37 120.50 82.50 63.50 124.50 82.75 80.58

17.574 16.619 13.043 16.002 14.090 12.966 14.656 12.079 17.385 4.950 6.364 9.192 13.256 7.399 8.522

SBP DBP HR SBP DBP HR SBP DBP HR SBP DBP HR SBP DBP HR

SBP = systolic blood pressure. DBP = diastolic blood pressure. HR = heart rate.

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The role of anxiety in blood pressure variation before dental care

Table 4: Distribution of blood pressure and heart rate according to evaluation of the modified Corah scale.

Evaluation

Mild/absent anxiety Moderate anxiety High anxiety Severe anxiety/phobia

Number of patients

Minimum

Maximum

Mean

Standard deviation

38 38 38 17 17 17 6 6 6 7 7 7

102 62 48 107 73 50 103 80 61 105 67 65

167 120 118 167 123 99 159 115 95 138 94 92

130.08 85.08 75.42 134.35 91.24 80.12 133.00 93.67 79.17 121.86 81.00 76.29

15.578 13.547 15.047 16.348 13.349 10.994 19.809 12.972 12.671 11.553 9.798 10.372

SBP DBP HR SBP DBP HR SBP DBP HR SBP DBP HR

SBP = systolic blood pressure. DBP = diastolic blood pressure. HR = heart rate.

DISCUSSION Due to fear and anxiety, many people avoid dental treatment. Only when problems worsen, these patients undergo treatment, which usually becomes more complex and painful. 7 Changes in heart rate and in SBP and DBP are observed in patients before dental treatment, and these changes are often justified by fear and anxiety. In this study, it can be noted that, despite being extremely anxious, patients did not change these vital signs, which was only evident in patients who already had high blood pressure. This suggests that, in the presence of change in blood pressure, the dentist should refer this patient to the cardiologist, for prior evaluation for dental care.

Regarding the study variables and gender, men showed higher SBP compared to women, which may be related to women seeking more frequent medical care. Thus, many of the male patients assessed could have hypertension that had not yet been diagnosed.

Thus, BP measurements must be performed by the dentist in all new patients and in all return visits.8,9 There were no major changes in anxiety measurements related to the procedures the patients would undergo, which may be puzzling to several dental professionals, who expect anxiety to be pres-

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

ent in invasive procedures. However, the patient’s fear and anxiety are often found in specific procedures of the dentist, such as anesthesia or even the expectation of pain in the face of any procedure to be performed. The dental office itself can be considered a potentially anxiogenic place, in which an individual in pain and in a vulnerable state requires care by a professional who, preferably, should know how to deal with anxiety disorders and behaviors resulting from the treatment to be performed.4 In a large part of the population, fear and pain can be linked to the image of the dentist, either by the instruments or by the intervention performed.

The evaluation of dental anxiety inducing factors, especially preoperative, is extremely relevant, especially in the detection of anxiety symptoms, besides presenting a clinical differential for the updated professional. 10 In addition, the influence of the use of sympathomimetic vasoconstrictors, present in local anesthetics, should be considered according to the BP, a theme that is common in the world literature. The use of epinephrine in uncontrolled hypertensive patients was associated with a small increase in sys-

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Morais TL, Silva GS, Sigua-Rodriguez EA, Goulart DR

that, in the control group, there was significant increase in SBP and DBP in relation to the onset and completion of surgery, and this was not observed in the group that received sedation. They concluded that the use of Diazepam as a preoperative anxiolytic has a cardiovascular protective effect during extraction surgeries.

Evaluation of the comparison of anxiety with high blood pressure revealed no difference between groups. The correlation between values ​​obtained for anxiety and the values of ​​ blood pressure and heart rate proved to be weak for the sample studied, as also found by other authors. 12 However, this study had limitations regarding the sample size. Thus, it is possible to increase the sample and also to measure it at different treatment stages, which may clarify more points on this issue.

tolic and diastolic BP. However, the combination of stress and local anesthesia with vasoconstrictor can produce a significant change in the cardiovascular system in compromised patients.8 Psychosomatic changes in the pre- and transoperative periods of dental treatments promote variations in several vital functions, expressing as tachycardia, peripheral vasoconstriction, sweating, agitation, elevated blood pressure and generalized increase in body metabolism, determining a typical situation of stress. The increase of this stress increases the risk of medical emergencies. Considering those occurring in a dental office, 55% are due to psychogenic stress, determining a typical stress condition. 5,8 It is perceived that anxiety control is fundamental for a safe and comfortable dental care for patients, thus pharmacological or non-pharmacological control measures can be used. Daróz et al.11 conducted a study to assess the capillary glycemia and blood pressure in patients undergoing extraction with and without the use of oral sedation. A total of 68 healthy patients, aged 18 to 40 years, were divided into a control group and a group that received 5 mg of preoperative Diazepam. The authors reported

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

CONCLUSION Women were more anxious about dental care.

However, the degree of anxiety does not seem to influence blood pressure and heart rate measurements; patients who are hypertensive seem to be more subject to variation in these measurements in the face of stressful situations, such as dental care.

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The role of anxiety in blood pressure variation before dental care

References: 1. Rodrigues CS, Silveira JCF, Castro SHD, Silva SFC. Avaliação da variação da pressão arterial em pacientes submetidos a tratamento odontológico. Rev Odontol.

2013;25(3):196-202.

2. Medeiros LDA, Ramiro FMS, Lima CAA, Souza LMDA, Fortes TMV, Groppo FC. Avaliação do grau de ansiedade dos pacientes antes de cirurgias orais menores.

Rev Odontol UNESP. 2013;42(5):357-63.

3. Ferreira MA, Manso MC, Gavinha S. Ansiedade e fobia dentária - avaliação psicométrica num estudo transversal. Rev Port Estomatol Med Dent Cir Maxilofac.

2008;49(2):77-86.

4. Possobon RF, Carrascoza KC, Moraes AB, Costa A. O tratamento odontológico como gerador de ansiedade. Psicol Estud. 2007;12(3):609-16.

5. Tolentino AB, Silva DR, Lopes PF, Ferreira GT, Strini PJSA, Strini PJSA, et al. Pressão arterial antes, durante e após atendimento em serviço de urgência odontológica. Robrac. 2014;23(65):108-12.

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6. Humphris GM, Morrison T, Lindsay SJ. The modified dental anxiety scale: validation and United Kingdom norms. Community Dent Health. 1995;12(3):143-50.

7. Oliveira PC, Zanetta-Barbosa D, Souza HJ, Batista JD, Ranali J, Costa MDMA, et al. Avaliação do nível de ansiedade e dor de pacientes em urgências endodônticas e sua influência sobre parâmetros cardiovasculares. Braz Dent Sci. 2007;10(4):70-5.

8. Ferraz EG, Carvalho CM, Jesuíno AA, Provedel L, Sarmento VA. Avaliação da variação da pressão arterial durante o procedimento cirúrgico odontológico. Rev Odontol UNESP. 2007;36(3):223-9.

9. Gealh WC, Franco WPG. Atendimento odontológico ao paciente hipertenso protocolo baseado no VII JNC. J Bras Clin Odontol Int. 2006:01-9.

10. Souza AB, Nicolau RA, Ribeiro NR. Avaliação da ansiedade pré-operatória em âmbito odontológico.

V Encontro Latino Americano de Pós-graduação – Universidade do Vale do Paraíba; 2003. p.1716-8.

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11. Daróz NQ, Guimarães FTM, Cabral ADM, Alvares MCNL, Silva DN, Bertollo RM, et al. Sedação oral em cirurgia odontológica: análises da glicemia capilar e das variações pressóricas. J Braz Coll Oral Maxillofac Surg. 2018;4(1):22-7.

12. Fonseca FCA, Coelho RZ, Nicolato R, Malloy-Diniz LF, Filho HCS. A influência de fatores emocionais sobre a hipertensão arterial. J Bras Psiquiatr. 2008;58(2):128-34.

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Case report

Mandibular reconstruction of comminuted fracture by gunshot JAIR QUEIROZ DE OLIVEIRA NETO1 | EDSON LUIZ CETIRA FILHO1 | PEDRO HENRIQUE DA HORA SALES1 | MANOEL DE JESUS RODRIGUES MELLO1

ABSTRACT Introduction: Injuries caused by firearms involving the face are a real challenge for surgeons concerning treatment of these patients, due to its complexity, associated with energy dissipated by the projectile, degree of bone comminution, tissue loss, among other factors. Objective: This study aims to report a clinical case of a patient with mandibular defect caused by firearm, treated using reconstruction plate. Results and Discussion: Combination between projectile structure, kinetic energy and interaction with tissues will define the aspects of maxillofacial trauma. As far as we concern, lesions with great bone comminution treated with early open fixation may cause loss of nutrition and vascularization of the affected bone tissue, with subsequent infection and tissue necrosis. The patient is in postoperative follow-up of six months, reestablishing the mandibular anatomy, occlusion, and without pain and functional complaints. Conclusion: Thus, traumas by firearms are a real challenge for surgeons, due to its complexity and patient expectation to restore esthetics and maxillofacial function. A proper ballistic evaluation of the trauma, and characteristics of the lesion associated to clinical and imaging examinations become essential for the success of treatment.

Keywords: Mandible. Mandibular fractures. Wounds, gunshot.

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How to cite: Oliveira Neto JQ, Cetira Filho EL, Sales PHH, Mello MJR. Mandibular reconstruction of comminuted fracture by gunshot. J Braz Coll Oral Maxillofac Surg. 2020 Sept-Dec;6(3):37-41.

DOI: https://doi.org/10.14436/2358-2782.6.3.037-041.oar

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

Submitted: January 24, 2018 - Revised and accepted: October 15, 2018

Institute Doutor José Frota, Service of Oral and Maxillofacial Surgery and Traumatology (Fortaleza/CE, Brazil).

Contact address: Jair Queiroz de Oliveira Neto E-mail: jairqueiroz_neto@hotmail.com

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

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Mandibular reconstruction of comminuted fracture by gunshot

INTRODUCTION Facial injuries caused by a firearm projectile (FAP) involving the mandibular bone and soft tissues represent a major challenge for surgeons, regarding the reconstruction and rehabilitation of the patient, due to the complex anatomical geometry, action of muscles that act in several directions, position of condyles in the glenoid fossa and occlusion, besides the functional deficits that may be present.

The complexity of these defects can cause a serious imbalance in facial harmony, related to functional and esthetic factors. 1,2 Bone defects in the maxillofacial region are caused by tumors, trauma, bone infections and related aspects. The four basic principles of successful reconstruction are: 1) establishing a satisfactory occlusal relationship; 2) evaluation of bone for intimate contact with a possible graft/flap; 3) stable bone fixation; and 4) adequate vascularization of soft tissues. Although these surgical principles have not changed over the years, technology has changed the way in which surgical results can be obtained. 2 Usually, in FAP fractures, bone comminution occurs. Comminuted fracture is defined as the presence of multiple fractures, resulting in small bone portions within the same area of the ​​ mandible.3 This can also occur in multiple areas.4 These fractures result from a significant impact on a localized area of ​​the mandible, caused by a high-speed collision or a high-speed projectile.5 Due to its hardness, the bone cannot absorb the impact energy of the projectile, leading to fracture and accumulation of hydraulic pressure, resulting in pulverization of the bone structure.6,7

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Thus, the objective of this paper is to report a clinical case of a patient with a mandibular bone defect caused by firearm perforation, treated using a reconstruction plate.

CASE REPORT A 28-year-old male patient was referred to an oral and maxillofacial surgery service, reference in traumatology, four days after being victim of perforation by firearm in the face. After initial clinical evaluation, extensive edema was observed in the right submandibular region with an entry orifice in the region of the right upper lip (Fig 1A), with no visible exit orifice; besides dental malocclusion and blunt wound on the oral mucosa, already sutured in the initial care. A computed tomography was requested, which revealed comminuted fracture of the mandibular ramus and body (Fig 1B and C).

After clinical and radiographic examination, a late approach to open reduction surgery was chosen using rigid internal fixation with a 2.4mm reconstruction plate. The patient was operated three months after the accident, with physical compensation. Wide extraoral access was performed in the right submandibular region, for direct visualization of fragments (Fig 1D), which were reduced and initially fixed with 2.0mm plates and screws (MDT®) to simplify the definitive fixation (Fig 2A). A 2.4mm reconstruction plate (MDT®) was modeled and then placed juxtaposed to the bone, to support masticatory loads in the postoperative period; after this process, the 2.0mm plates and screws were removed (Fig 2B). Six months after surgery, the patient was stable, with good dental occlusion and without esthetic or functional complaints (Fig 2C and D).

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A

B

C

D

Figure 1: A) Preoperative clinical image. B) Preoperative computed tomography image (3D reconstruction), showing extensive bone comminution. C) Preoperative computed tomography image (axial view). D) Transoperative clinical aspect.

DISCUSSION The etiology of mandibular fractures is broad, which includes traffic accidents, physical aggressions, sports activities, falls and firearms. To restore the esthetic contour and physiological balance with masticatory, respiratory, speech and swallowing functions of the mandible, a bone reconstruction

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

protocol is necessary with maintenance of good force dissipation mechanics. 2,3 Firearm injuries are real challenges for surgeons, due to their complexity and difficult rehabilitation. A combination of projectile structure, kinetic energy and interaction with the tissue define the aspects of maxil-

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Mandibular reconstruction of comminuted fracture by gunshot

A

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Figure 2: A) Reduction and initial fixation of fractures with a 2.0 mm plate and screw system. B) Fixation of load bearing type with 2.4 mm system. C) Tomographic aspect six months after surgery. D) Clinical aspect six months after surgery.

high-speed projectiles (> 600 m/s) raise a discussion between early or late reconstruction, due to the possibility of evolution to tissue necrosis.8,10 In the present case, there was a perforating injury of low energy and absence of avulsed tissue, resulting in a comminuted fracture of the right mandibular body and ramus region.

lofacial trauma.9 Penetrating and piercing wounds, coming from low-intensity projectiles (250-370 m/s), are approached by closed or open reduction with internal fixation and minimal debridement with primary closure.

In general, they cause smaller entry orifices and comminuted fracture. However, avulsion wounds caused by

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amination, it was possible to observe the presence of larger bone fragments, which could support the application of the plate and screw system. In our understanding, lesions with large bone comminutions treated with early open fixation can cause loss of nutrition and vascularization of the affected bone tissue, with subsequent infection and tissue loss.

The literature still disagrees on two key points in the treatment: the best time for surgical approach and the conduct to reduce fractures. Supporters of a late reconstruction report that the prolonged period reduces the incidence of infection, necrotic debris and allows better assessment of the lesion extent.

Conversely, others advocate an early approach, stating to cause less occurrences of wound contracture, better tissue coverage and functional and esthetic result of the deformity. 9 It was decided, in this case report, to approach at a late moment, in which satisfactory result was obtained. Infection can be reduced by careful patient selection, effective debridement, use of antibiotics and the surgeon’s skill and experience.10 When planning the presented case, we opted for open late reduction with internal fixation of the 2.4mm system reconstruction, since by image ex-

FINAL CONSIDERATIONS Firearm trauma is a real challenge for surgeons, not only because of its complexity but also due to the patient’s expectation to have esthetics and maxillofacial function restored. A good assessment of the trauma ballistics and characteristics of the injury associated with imaging exams is essential to choose the approach. Decreased infection rate and maintenance of bone support are two key points for successful treatment with good case follow-up.

References:

1. Williams CN, Cohen M, Schultz RC. Immediate and long-term management of gunshot wounds to the lower face. Plast Reconstr Surg. 1988;82(3):433-9.

2. Cohen A, Laviv A, Berman P, Nashef R, Abu-Tair J, Israel J. Mandibular reconstruction using stereolithographic 3-dimensional printing modeling technology.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod.

2009;108(5):661-6.

3. Finn RA. Treatment of comminuted mandibular fractures by closed reduction. J Oral Maxillofac Surg.

1996;54(3):320-7.

4. Li Z, Li ZB. Clinical characteristics and treatment of multiple site comminuted mandible fractures. J Craniomaxillofac Surg. 2011;39(4):296-9.

5. Alpert B, Tiwana PS, Kushner GM. Management of comminuted fractures of the mandible. Oral Maxillofac Surg Clin North Am. 2009;21(1):185-92.

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6. Stefanopoulos PK, Soupiou OT, Pazarakiotis VC, Filippakis K. Wound ballistics of firearm related injuries-part 2: mechanisms of skeletal injury and characteristics of maxillofacial ballistic trauma. Int J Oral Maxillofac Surg. 2015;44(1):67-78.

7. Bede SYH, Ismael WK, Al-Assaf D. Characteristics of mandibular injuries caused by bullets and improvised explosive devices: a comparative study. Int J Oral Maxillofac Surg. 2017;46(10):1271-5.

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

9. Kaufman Y, Cole P, Hollier L. Contemporary issues in facial gunshot wound management. J Craniofacial Surg. 2008;19(2):421-7.

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10. Bukhari SGA, Khan I, Pasha B, Ahmad W. Management oh facial gunshot wounds. J Coll Physicians Surg Pak. 2010;20(6):382-5.

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Case report

Psoriatic arthritis with temporomandibular joint involvement: case report KILLIAN EVANDRO CRISTOFF1,2 | JOSÉ STECHMAN NETO1,3 | BIANCA LOPES CAVALCANTE-LEÃO1,3 | RODOLFO JORGE KUBIAK1 | MARINA PEREIRA SILVA1 | ALICE HELENA DE LIMA SANTOS CARDOSO1

ABSTRACT Introduction: Psoriatic arthritis (PA) is a chronic reactive inflammatory disease of the joints and skin. Severity can range from mild, non-destructive disease to severe, progressive and erosive arthropathy. The etiology of this disease is unknown, although studies report a strong genetic predisposition. The clinical manifestations of the PA rarely affect the temporomandibular joint (TMJ), these patients can suffer great joint degeneration, altering the movement of the joint, causing pain, reduced opening, articular noises. Case report: Female patient, 39 years old, who was referred to the ATM diagnosis and treatment center (CDATM), presenting severe facial pain, cracking, limited mouth opening. There was already a diagnosis of PA, involving the hip and elbow. The diagnosis of PA in ATM was given from the clinical exams, magnetic resonance imaging (MRI) and a cytopathological evaluation. The treatment of choice was conservative treatment. Conclusion: Follow-up showed an improvement in relation to orofacial pain and mandibular movements. It should be emphasized that this condition is relatively uncommon in the TMJ, and the clinician must make a correct diagnosis to make an appropriate treatment, thus returning an improvement in the functions of the stomatognathic system with a favorable prognosis.

Keywords: Arthritis, psoriatic. Temporomandibular joint disorders. Arthritis.

University Tuiuti Do Paraná, Center for Diagnosis and Treatment of Temporomandibular Dysfunctions (Curitiba/PR, Brazil).

Hospital Nossa Senhora do Pilar, Service of Oral and Maxillofacial Surgery and Traumatology (Curitiba/PR, Brazil).

3 University Tuiuti do Paraná, MSc and PhD Program in Communication Disorders (Curitiba/PR, Brazil).

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How to cite: Cristoff KE, Stechman Neto J, Cavalcante-Leão BL, Kubiak RJ, Silva MP, Cardoso AHLS. Psoriatic arthritis with temporomandibular joint involvement: case report. J Braz Coll Oral Maxillofac Surg. 2020 Sept-Dec;6(3):42-6.

DOI: https://doi.org/10.14436/2358-2782.6.3.042-046.oar

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Submitted: August 28, 2018 - Revised and accepted: October 15/10/2018 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. » Patients displayed in this article previously approved the use of their facial and intraoral photographs.

Contact address: Killian Evandro Cristoff E-mail: killian.cristoff@utp.br, drkillian@hotmail.com

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Cristoff KE, Stechman Neto J, Cavalcante-Leão BL, Kubiak RJ, Silva MP, Cardoso AHLS

CASE REPORT The female patient, aged 39 years old, was referred to the TMJ Diagnosis and Treatment Center (CDATM), presenting severe pain in the face, clicking in the temporomandibular joint and limited mouth opening. The diagnostic hypothesis of psoriatic arthritis was raised based on clinical examinations, imaging tests and cytopathological evaluation.

On clinical examination, the patient had maximum mouth opening without pain of 21 mm and maximum opening with pain of 31 mm – pain score 7, according to the visual analog pain scale (VAS). Clicking was always present in both TMJs. The presence of parafunctional habits was reported by the patient.

The physical examination was positive for joint pain.

Myofascial pain was present, with trigger points in the masseter and sternocleidomastoid muscles. She showed no signs of skin lesions. The patient was followed by the rheumatology service, which introduced fluoxetine hydrochloride therapy. The rheumatologist was asked to replace this medication, due to the adverse effects in cases of TMD, which was replaced by Vortioxetine.

There were painful symptoms in the elbow and hip. The panoramic radiography exam showed bilateral condylar degeneration (Fig 1), and magnetic resonance imaging (MRI) showed degenerative signs, with deformities in both condyles. Formation of osteophytes, narrowing of the joint space, flattening of the mandible head and subchondral sclerosis were observed (Fig 2). The articular discs were displaced with the mouth closed, with degenerative signs in the left articular disc. Cytopathological evaluation by puncture and aspiration revealed acellular granular material, with inflammatory content and presence of interleukins. The treatment of choice was the use of intraoral device (IOD), dry needling in the masseter and bilateral sternocleidomastoid muscles. Intra-articular corticosteroid application was performed: intra-articular infiltration was performed with 2mL triamcinolone hexacetonide in each TMJ, following the infiltration technique described by Nitzan.9 At three-year follow-up, the patient reported being asymptomatic in relation to orofacial pain – pain score

INTRODUCTION Psoriatic arthritis (PA) is a chronic and inflammatory systemic disease that affects the body joints, usually preceded by psoriasis. 1 The etiology of this disease is unknown, although studies report a strong genetic predisposition. 2 There are also risk factors, such as trauma, and environmental factors, which are still being studied. Both factors are related to genetic susceptibility appropriate to psoriatic disease.3 PA belongs to a group of inflammatory arthritis called seronegative spondyloarthropathy and shares some clinical and laboratory characteristics with other diseases within the same group, making the differential diagnosis more challenging. This disease has potential to be extremely severe and results in significant functional impairment.4 The clinical manifestations of PA rarely affect the temporomandibular joint (TMJ) and, when they affect the TMJ, patients can suffer great joint degeneration. 5 It alters the physiological dynamics of the joint, causing joint and/or muscle pain, joint noise and difficulties in mandibular kinematics.1,2,5,6 These are the predominant symptoms and can be debilitating if left untreated.

The manifestations in imaging exams are the formation of osteophytes, narrowing of the joint space, flattening of the condyle and subchondral sclerosis.5,6,7 PA not only presents clinical manifestations, but is also characterized by structural and immunological changes.8 The clinical course of PA is highly variable. Some patients have a mild, non-destructive clinical phenotype, but others develop progressive joint damage that, if left untreated, can cause functional impairment and disability. 3 The initial treatment in the management of TMJ with PA aims to relieve painful symptoms, control disease activity, improve physical function and quality of life and prevent structural damage to the joints 2,8. The use of occlusal appliances, physiotherapy and intra-articular infiltration is described as efficient in controlling painful symptoms.4 Surgical treatments are an option when less invasive treatments have failed to provide adequate symptomatic control.

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Psoriatic arthritis with temporomandibular joint involvement: case report

the IOD, which improves the stability of occlusion.

The patient continued to be followed and the current MRI showed lesion stabilization lesion and preserved cortical (Fig 3).

0, according to the VAS scale. There was also improvement in bordering movements, with maximum mouth opening reaching 40 mm. Due to the presence of an asymptomatic click, the patient continued using

Figure 1: Initial panoramic radiograph, in which degeneration is observed in both condyles.

Figure 2: Initial nuclear magnetic resonance imaging of the right and left sides, in sagittal section.

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Cristoff KE, Stechman Neto J, Cavalcante-Leão BL, Kubiak RJ, Silva MP, Cardoso AHLS

Figure 3: Magnetic resonance imaging of the right and left sides, with 3-year follow-up.

DISCUSSION According to some studies, the diagnosis of PA is difficult, due to the non-specificity of symptoms, imaging tests and laboratory markers, since it shares some of these clinical and laboratory characteristics with other diseases within the same group, such as: ankylosing spondylitis, undifferentiated spondyloarthropathies, reactive arthritis (Reiter’s syndrome), enteropathic arthropathies, rheumatoid arthritis and systemic lupus erythematosus arthritis. This makes the differential diagnosis more challenging.4,6 In addition, psoriatic skin lesions may not be present or identifiable.6 Inflammatory TMJ arthritis is uncommon, yet it is debilitating when severe functional restriction occurs, such as ankylosis.5 Early diagnosis and correct treatment can help to slow the progression of this condition.5 Conservative therapy is established at the first moment, with the purpose of relieving pain. It is done by the intraoral device, drug therapies, physiotherapy, cognitive behavioral therapy or intraarticular infiltrations – which, in this report, was performed with triamcinolone hexacetonide, for anti-inflammatory action, since it modulates the inflammatory response.

In this case, dry needling was also performed, due to the presence of myofascial pain. Invasive procedures are indicated when conservative therapies fail to elim-

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inate joint pain and restore functional movements of the TMJ.4 In this case, the rheumatologist was asked to replace fluoxetine, since some studies suggest that selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, could stimulate or potentiate movement disorders, including bruxism, by increase in serotonin concentration and interactions with the dopaminergic system.10 Insomnia is also a frequent side effect in patients undergoing therapy with these drugs.10 The application of intraarticular corticosteroids is controversial.5 However, for cases of degenerative diseases, it shows significant regression of the process and, in some cases, even formation of cortical bone.10 In this case, considerable improvement was observed with intraarticular application. It is believed that, in the present case, not only the use of corticosteroids was the cause of exponential improvement in pain and functional improvement, but also the use of an interocclusal device – whose main function was to decrease the intraarticular pressure, thus enabling a better movement condition.4 It must be emphasized that this condition is relatively uncommon in TMJ, and the clinician must make a correct diagnosis, besides an appropriate treatment, thus restoring the functions of the stomatognathic system with favorable prognosis, by minimally invasive treatments.

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Psoriatic arthritis with temporomandibular joint involvement: case report

FINAL CONSIDERATIONS It is concluded that there is a need for a better understanding of comorbidities caused by degenerative disorders. It is understood that minimally invasive practices for these cases can be positive if there is constant monitoring of this patient. Corticosteroids had a desirable effect for the reported case and are widely proposed in degenerative cases.

References:

1. Crincoli V, Di Comite M, Di Bisceglie MB, Fatone L, Favia, G. Temporomandibular disorders in psoriasis patients with and without psoriatic arthritis: an observational study. Int J Med Sci. 2015;12(4):341-8.

2. Lamazza L, Guerra F, Pezza M, Messina A, Galluccio A, Spink M, et al. The use of etanercept as a non-surgical treatment for temporomandibular joint psoriatric arthritis: a case report. Aust Dent J. 2009;54(2):161-5.

3. De Vlam K, Gottlieb AB, Mease PJ. Current concepts in psoriatic arthritis: pathogenesis and management.

Acta Derm Venereol. 2014; 94(6): 627-4.

4. Puricelli E, Corsetti A, Tavares JG, Luchi GHM. Clinical-surgical treatment of temporomandibular joint disorder in a psoriatic arthritis patient. Head Face Med. 2013;9:11.

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5. O’Connor RC, Fawthrop F, Salha R, Sidebottom AJ. Management of the temporomandibular joint in inflammatory arthritis: involvement of surgical procedures.

Eur J Rheumatol. 2017;4(2):151-6.

6. Sidebottom AJ, Salha R. Management of the temporomandibular joint in rheumatoid disorders. Br J Oral Maxillofac Surg, 2013;51(3):191-8.

7. Kulkarni AU, Gadre PK, Kulkarni PA, Gadre KS. Diagnosing psoriatic arthritis of the temporomandibular joint: a study in radiographic images. BMJ Case Rep. 2013; 2013:bcr2013010301.

8. Coates LC, Conaghan PG, D’Agostino MA, De Wit M, FitzGerald O, Kvien TK, et al. Remission in psoriatic arthritis-where are we now? Rheumatology.

2017;57(8):1321-31.

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9. Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular joint arthrocentesis: a simplified treatment for severe, limited mouth opening. J Oral Maxillofac Surg.

1991;49(11):1163-70.

10. Gerber PE, Lynd LD. Selective serotonin-reuptake inhibitor-induced movement disorders. Ann Pharmacother. 1998;32(6): 692-8.

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Case report

Tooth autotransplantation as an option for impacted tooth treatment in pediatric patient LUCAS COSTA NOGUEIRA1 | PABLO CORNÉLIUS COMELLI LEITE1 | LIOGI IWAKI FILHO1

ABSTRACT Introduction: Tooth autotransplantation may be indicated in certain situations, such as in dentoalveolar traumas, replacement of teeth with poor prognosis, developmental abnormalities, ectopic eruption and impacted teeth. Objective: The objective of this study is to report a case in which a 8-year-old patient was diagnosed with impaction of tooth #35 in horizontal position, so that orthodontic traction would not be possible, and autotransplantation was chosen to resolve the case. Conclusion: At seven years’ follow-up, the transplanted tooth was in position and maintaining occlusion with the maxillary arch. From proper indication and correct use of the technique, the dental autotransplantation presented as a good alternative for the resolution of the case.

Keywords: Transplantation. Autologous. Dental implantation. Transplants.

Maringá State University, Health Sciences Center, Department of Dentistry (Maringá/PR, Brazil).

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How to cite: Nogueira LC, Leite PCC, Iwaki Filho L. Tooth autotransplantation as an option for impacted tooth treatment in pediatric patient. J Braz Coll Oral Maxillofac Surg. 2020 SeptDec;6(3):47-51.

DOI: https://doi.org/10.14436/2358-2782.6.3.047-051.oar

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

Submitted: April 30, 2018 - Revised and accepted: November 13, 2018

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

Contact address: Lucas Costa Nogueira E-mail: lcn_2003@hotmail.com

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Tooth autotransplantation as an option for impacted tooth treatment in pediatric patient

INTRODUCTION Tooth autotransplantation is defined as translocation of a tooth from one site to another, in the same person. It may involve the transfer of an impacted or erupted tooth to an extraction site or to a surgically prepared site. It can be indicated in certain situations, such as: dentoalveolar trauma, replacement of teeth with poor prognosis, developmental abnormalities, ectopic eruption and impacted teeth.1-4 This technique has some advantages over other rehabilitation options, such as maintaining a viable periodontal ligament, the possibility of performing orthodontic treatment, better cost/benefit, the tooth has mobility and physiological movement, allowing it to accommodate system functions stomatognathic,5 and ensures bone maintenance of the alveolar ridge, facilitating the future placement of implants after growth completion or in case of ankylosis and root resorption1,3. However, it has some disadvantages, such as risk of ankylosis or inflammatory root resorption, the need for a patient’s own donor tooth, and that tooth will be susceptible to all natural diseases of the mouth, such as caries and periodontal disease.5 To be successful in using this technique and achieve a satisfactory result, some factors are extremely important and must be considered in planning and surgery, as well as in the postoperative period. The best time for transplantation is ideally before completion of root growth, between 2/3 and 3/4 of root growth. The more advanced the root formation, the greater the chances of pulp resorption and changes,2 thus, when immature and presenting an open apex, there are greater chances of revascularization.3 The periodontal ligament cells remaining at the root of the donor tooth suffer deterioration, due to mechanical damage and exposure to the environment, thus transplantation should be performed as soon as possible after careful tooth extraction – the recipient bed must be prepared and adjusted prior to extraction.2,3 Splinting or dental retention, flexible or semi-rigid, is essential for the good prognosis of the case, allowing for adequate regeneration of the periodontal ligament.6 The prescription of systemic antibiotics can reduce the risk of infectious root resorption. Monitoring of pulp vitality should be performed, especially in cases of transplantation of mature teeth, in which endodontic treatment can be performed extraorally, intraoperatively, or started between 7-14 days after

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

surgery.6 Different success and survival rates can be found in the literature. In a systematic review and meta-analysis, Chung et al.6 obtained, for teeth with formed root, a survival rate of 98% with 1-year follow-up and 90.5% over 5 years. In another review, in immature teeth, Cross et al.3 presented success rates varying between studies, from 81% to 100% and survival rate from 56.6% to 100%. The criteria for considering success in transplanted teeth are: absence of progressive root resorption, normal bone and gingival tissue around the tooth, and crown/root ratio smaller than 1.3 Dental impaction is a common condition, affecting 0.8 to 3.6% of the general population. The most affected teeth are, in decreasing order of prevalence: third molars, upper canines, lower premolars and upper central incisors. It has a multifactorial etiology, involving systemic, genetic and local factors. The local factors include failure in deciduous tooth exfoliation, early loss of the deciduous tooth, alteration of the eruption path, presence of supernumerary teeth, space loss, pathologies associated with the tooth, dental trauma, positioning abnormalities and root lacerations.7 CASE REPORT Female patient, 8 years old, was assisted in a private clinic, referred by the orthodontist, due to changes in the radiographic examination for orthodontic purposes. The patient was asymptomatic, with no previous history of trauma in the region. On tomographic examination, it was possible to notice the presence of deciduous teeth 75 and 85 in place, without signs of exfoliation, and presence of the respective permanent teeth (35 and 45). However, the lower left second premolar was impacted in a horizontal position, so that it would not allow the natural eruption of the tooth, making orthodontic traction difficult or impossible (Fig 1). The possibilities of treatment were studied, and we decided to use the tooth autotransplantation technique – a surgical procedure performed in an outpatient setting, under local anesthesia. An intrasulcular canine incision was made distal to the first molar, with the aid of two relaxing incisions, and the mucoperiosteal flap was folded. Tooth sectioning was performed on tooth 75, to facilitate extraction and avoid further trauma to the permanent tooth. After extraction, ostectomy was performed to

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2). Amoxicillin with Clavulanate was the antibiotic of choice, prescribed for 7 days after surgery. Periodic follow-ups were performed, and the patient is currently in 7-year postoperative period, without complaints in the region, with the transplanted tooth responding positively to the pulp vitality test, in occlusion with the upper arch. Tomographically, closure of the apex, presence of a hard lamina and no evidence of ankylosis or active root resorption was observed (Fig 3).

create a buccal bone window, also with the objective of assisting permanent extraction and minimizing damage to the periodontal ligament. The tooth to be transplanted was tested in the recipient bed, with good adaptation. Sutures with 4-0 silk thread were used to reposition the flap. With the transplanted tooth in infraocclusion, a 4-0 “X” silk suture over the occlusal surface served as semi-rigid splinting method for the case, which was maintained for 14 days (Fig

Figure 1: Tomographic examination showing impaction of tooth 35 and positioning in horizontal direction.

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Figure 2: A) Intraoral view of tooth 75. B) Tooth sectioning of tooth 75. C) Ostectomy of the buccal plate, to facilitate removal of tooth 35. D) Donor tooth in infraocclusal position and maintained by suture.

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A

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Figure 3: A) 7-year tomographic control, absence of ankylosis or root resorption. B) Clinical view in occlusion. C) Lateral clinical view.

DISCUSSION The following treatment options would be possible to solve the case, each presenting advantages and disadvantages, when compared to each other: keeping the deciduous tooth in position and only extracting the impacted tooth; extraction of 75 and 35 and conventional prostheses; tooth extraction followed by endosseous implant, for implant-supported prosthesis; extraction of the deciduous tooth, with orthodontic traction of the impacted tooth; or extraction of tooth 75 and autotransplantation of tooth 35.

Maintaining the primary tooth can be a good treatment option for certain cases of permanent agenesis; however, it presents a high risk of root resorption, ankylosis and positioning in infraocclusion.8 Fixed prostheses to supply missing teeth may be contraindicated in certain cases, since they do not allow normal growth of the alveolar process and facial bones.9 They also have a lower survival rate compared to implant prostheses.8 Despite the great increase in the use of implants for dental rehabilitation and its advantages, this option can be contraindicated in infant patients, since their facial growth is not complete.2,4 Implants placed in infant patients do not accompany skeletal growth and behave similarly to ankylosed teeth, resulting in functional and esthetic changes, unpredictable displacement of implants, infraocclusion of the implant, interference with growth and possible interference with the eruption and positioning of adjacent tooth buds.2,3,10 Endosseous implants do not seem to influence bone growth when placed in the mandibular symphysis region, since to the median suture of the mandible

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

closes in the first year of life,2 being the region with the best prognosis for the placement of implant-supported prostheses in growing patients.10 Patients with multiple hypodontia or congenital syndromes, such as ectodermal dysplasia, have reduced growth and atrophy of alveolar processes, which are greatly benefited from treatment with dental implants, also contributing as part of psychosocial treatment.10 The infant patient has a poor prognosis (72.4%) regarding the placement of implants, compared to adolescents and adults (93% and 97.4% respectively).8 It is recommended to wait for completion of craniofacial growth, with the exception of extreme cases, such as syndromic patients.10 In infant and adolescent patients with dental agenesis, maintaining the deciduous tooth or autotransplanting from another area are the ideal treatment options, compared to implants.8 Impacted teeth are commonly treated with orthodontic traction to their usual position. Teeth presenting unfavorable conditions, such as excessive angulation of the tooth long axis, require greater application of forces and anchorage for traction, increasing the treatment time and discomfort for the patient. In some more severe cases, autotransplantation provides a quick and simplified treatment.1-3 The tooth autotransplantation is a technique that has been used for a long time, with different success rates, presenting factors that are decisive and must be followed for success, such as choice of the surgical moment, preservation of the remaining vital periodontal ligament in the root, protocol used for splinting and its duration, and endodontic monitoring.

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Nogueira LC, Leite PCC, Iwaki Filho L

kylosis.1,6,9 The occurrence of root ankylosis is three times higher with the use of rigid splinting than with suture retention.6 Transplantation of a tooth with incomplete root formation has a pulp revascularization rate of 96%, while the expected regeneration rate in a tooth with complete root formation is only 15%.9 The diameter of the apex is also decisive for revascularization: apices with a diameter smaller than 1 mm do not have a favorable prognosis for revascularization, unlike apices larger than 1 mm in diameter, making endodontic treatment an important factor for success in cases of tooth transplants with completed root formation.6 Like other treatment methods that involve the permanence or maintenance of natural teeth, autotransplantation presents risks for the occurrence of ankylosis, root resorption and endodontic changes.

When the autotransplantation technique is chosen, the extraction of the donor tooth must be performed so as to generate less mechanical damage to the root, in order to preserve the remaining periodontal ligament cells – which can also be traumatized by extraoral biochemical factors, such as the variation of pH, osmotic pressure and dehydration. Regeneration of the periodontal ligament is a critical factor for success, usually taking eight weeks to fully occur; its success can be seen by the appearance of the hard lamina, continuous space around the tooth, and absence of root resorption.1 The autotransplanted tooth in young patients continues to erupt together with the dentition, enabling an adequate dentofacial development, maintaining the volume of alveolar bone and the alveolar ridge shape1,3,4. Even if the transplanted tooth is lost in the future, this technique is still advantageous, since the alveolar process is preserved, facilitating subsequent rehabilitation.4 Splinting helps to stabilize the transplanted tooth in its position; however, rigid splinting or a prolonged period, longer than four weeks, may increase the risk of complications such as root resorption and ankylosis.1,9 Semi-rigid retention, using flexible wires or stabilization by sutures, allows a physiological load on the tooth, leading to better regeneration of the periodontal ligament and minimizes the risk of an-

FINAL CONSIDERATIONS Tooth autotransplantation, by correct indication and proper use of the technique, presented as a good option in the rehabilitation and treatment of infant patient in the skeletal development phase, since it allowed natural growth, maintenance of a viable periodontal ligament, pulp revascularization and maintenance of the alveolar process, providing a stable occlusion and assuring the possibility of future orthodontic treatments.

References:

1. Thomas S, Turner SR, Sandy JR. Autotransplantation of teeth: is there a role? Br J Orthod.

1998;25(4):275-82.

2. Meechan JG, Carter NE, Gillgrass TJ, Hobson RS, Jepson NJ, Nohl FS, et al. Interdisciplinary management of hypodontia: oral surgery. Br Dent J. 2003;194(8):423-7.

3. Cross D, El-Angbawi A, McLaughlin P, Keightley A, Brocklebank L, Whitters J, et al. Developments in autotransplantation of teeth. Surgeon. 2013;11(1):49-55.

4. Tunc SK, Kayasan MS, Ozeroglu E, Eroglu CN. Malpositioned canine treatment with autotransplantation and laser. Eur J Dent. 2017;11(4):395-7.

5. Tsukiboshi M. Autogenous tooth transplantation: a reevaluation. Int J Periodontics Restorative Dent.

1993;13(2):120-49.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

6. Chung WC, Tu YK, Lin YH, Lu HK. Outcomes of autotransplanted teeth with complete root formation: A systematic review and meta-analysis. J Clin Periodontol. 2014;41(4):412-23.

7. Kaczor-Urbanowicz K, Zadurska M, Czochrowska E. Impacted teeth: an interdisciplinary perspective.

Adv Clin Exp Med. 2016;25(3):575-85.

8. Terheyden H, Wüsthoff F. Occlusal rehabilitation in patients with congenitally missing teeth-dental implants, conventional prosthetics, tooth autotransplants, and preservation of deciduous teeth: a systematic review. Int J Implant Dent. 2015;1(1):30.

9. Cohen AS, Shen TC, Pogrel MA. Transplanting teeth successfully: autografts and allografts that work. J Am Dent Assoc. 1995;126(4):481-5.

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10. Mankani N, Chowdhary R, Patil BA, Nagaraj E, Madalli P. Osseointegrated dental implants in growing children: a literature review. J Oral Implantol.

2014;40(5):627-31.

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Case report

Reconstruction of mandibular fracture using Locking® system: Case report IGOR ALMEIDA MASCARENHAS SOARES1 | JOÃO PEDRO LISBOA DAMASCENO PEREIRA1 | RICARDO JOSÉ DE HOLANDA VASCONCELOS2 | MARCELO MAROTTA ARAUJO3 | JOSÉ RICARDO MIKAMI4 | MARCUS ANTÔNIO BRÊDA JUNIOR5

ABSTRACT Introduction: The atrophic edentulous mandible is more predisposed to fractures, and in high impact traumas —such as perforations by firearms, which causes comminuted fractures —, require surgical treatment with a supported load reconstruction plate, for a more stable osteosynthesis, obtaining better treatment results and recovering the shape and function of the mandible. Objective: The objective of this study is to report a clinical case of a patient victim of firearm accident in a partially edentulous mandible with mild atrophy, corrected with supported load reconstruction plate.

At 40-day postoperative follow-up, the patient presented preserved occlusion, with plaque and screws in position —as seen in radiographic examination—, moderate edema, without pain complaint, absence of motor nerve damage, but with sensitive nerve damage. Conclusion: The treatment with open reduction and rigid internal fixation with 2.3mm Locking® system of supported load demonstrates good result, with adequate functional restoration in comminuted fracture due to firearm lesion in atrophic mandible.

Keywords: Mandibular reconstruction. Fracture fixation. Mandible.

University Center Tiradentes (UNIT), Graduation in Dentistry (Maceió/AL, Brazil).

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How to cite: Soares IAM, Pereira JPLD, Vasconcelos RJH, Araújo MM, Mikami JR, Brêda Junior MA. Reconstruction of mandibular fracture using Locking® system: Case report. J Braz Coll Oral Maxillofac Surg. 2020 Sept-Dec;6(3):52-6.

DOI: https://doi.org/10.14436/2358-2782.6.3.052-056.oar

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

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São Paulo State University, Institute of Science and Technology, Department of Diagnosis and Surgery (São José dos Campos/SP, Brazil).

Submitted: July 17, 2018 - Revised and accepted: December 11, 2018

General Hospital of the State of Alagoas, Section of Oral and Maxillofacial Surgery and Traumatology (Maceió/AL, Brazil).

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

University Center Tiradentes (UNIT), Graduation in Dentistry, Disciplines of Semiology, Minor Oral Surgery, Stomatology and Integrated Clinics II (Maceió/AL, Brazil).

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

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Contact address: João Pedro Lisboa Damasceno Pereira E-mail: joao-pedro-lisboa@hotmail.com

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Soares IAM, Pereira JPLD, Vasconcelos RJH, Araújo MM, Mikami JR, Brêda Junior MA

INTRODUCTION Mandibular fractures can be caused by high or low intensity trauma, with low intensity trauma fractures being more common in atrophic mandibles.1 Fractures caused by high-impact trauma, such as injuries by firearms, represent a complex challenge for the maxillofacial surgeon. Wounds can cause loss of both soft tissue and bone tissue. In most cases, firearm injuries are more complex and are associated with an increased risk of infection, ischemia and tissue necrosis. 2 Mandibular bone atrophy is commonly caused by tooth loss followed by resorption of alveolar bone. Due to the progression of mandibular atrophy, the mandibular diameter is reduced. 1 It is defined as atrophic, according to the classification of Luhr et al,3 if there is height smaller than 20 mm, with subclassification into class I (16 to 20 mm), class II (11 to 15 mm) and class III (< 10 mm). The signs and symptoms found in patients with atrophic mandibular fractures can be: pain, mandibular mobility and extra and intraoral ecchymosis in the lingual and buccal floor region. 4 Edema, facial asymmetry, bone crepitation and paresthesia can also be observed. To aid in the diagnosis, complementary imaging tests should be used, including: panoramic radiographs, posteroanterior mandibular, oblique lateral of the mandible (on the right and/or left side), facial profile and computed tomography in section for bone tissue and 3D reconstruction. 5 The treatment of atrophic mandible fracture consists of stabilization with rigid internal fixation with more resistant plates – in this case, load-bearing plates have better results. The Locking® plate has a threaded hole, and the screw head also has threads.

This type of osteosynthesis material obtains locking and stability by plate and screw connection. Thus, Locking® does not require a precise adaptation with bone tissue, different from conventional systems, thus reducing the blood compromise of the bone underlying the fractured area. The forces are transmitted from the bone to the screw and then to the plate. The purpose is to provide rigidity and stability of segments with the lowest load on the screws. 4,5 The advantages of this locking system are: better screw stability, minimized risk of infection, easier handling, less compression and blood damage to the fractured area. As a disadvantage, it can cause defor-

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

mation of the plate orifice at the moment of folding, when the inset screws are not used. Locking of the screw to the plate must be perpendicular, since it allows little angulation, thus impairing to redirect the screw to avoid reaching important structures. Also, a drilling guide is needed to avoid tilting the screw.4 The present study reports a clinical case of a patient victim of a firearm projectile, showing a comminuted fracture of the atrophic mandible, treated with the 2.3mm Locking® reconstruction system.

CASE REPORT A 40-year-old Caucasoid patient, victim of a firearm wound to the face, was admitted to a hospital in São Paulo. During anamnesis, he reported pain and dysphagia. He was lucid, oriented and normal.

On physical examination, he presented edema in the region of the right mandibular body and the entry orifice in the body region of the ipsilateral zygoma.

On intraoral examination, presence of teeth 34, 43 and 44, laceration in the mandibular alveolar mucosa and mobility and bone crepitation in the mandibular body on the right side were observed (Fig 1A and 1B). PA radiography of the mandible and oblique lateral view of the right mandible were requested (Fig 1C and 1D).

Computed tomography exam with axial window cut for bone tissue and 3D reconstruction were performed, which revealed a comminuted fracture in the region of the right mandibular body (Fig 2A and 2B). Surgery was performed under general anesthesia and nasotracheal intubation. The dental prosthesis was used for the maxillomandibular block and fixed with a screw in the arches, maintained in stable occlusion to reduce and fix the fracture, reestablishing the occlusion and vertical dimension of the face. Extended submandibular access was performed, obtaining exposure of the fractured segment (Fig 2C and 2D).

Then, the bone segments were fixed with Locking® reconstruction plate (Stryker Craniomaxillofacial, Kalamazoo, MI, USA), 2.3mm low profile system and bicortical screws. Combined to stabilization of fractured segments, an intermediate fragment was fixed to the plate to minimize bone discontinuity, followed by continuous suture and insertion of a suction drain to minimize hematoma formation (Fig 3A and 3B).

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Reconstruction of mandibular fracture using Locking® system: Case report

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Figure 1: A) Preoperative, frontal view. B) Preoperative, intraoral view. C) Right side oblique radiograph of the mandible. D) PA radiography of the mandible.

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Figure 2: A) Computed tomography in 3D reconstruction. B) Computed tomography in axial section. C) Occlusion by prosthesis, during surgery. D) Exposure of the fracture.

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Soares IAM, Pereira JPLD, Vasconcelos RJH, Araújo MM, Mikami JR, Brêda Junior MA

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Figure 3: A) Locking® reconstruction plate. B) Suture and suction drain. C) Motor deficit assessment. D) Postoperative radiography: mandibular profile.

RESULTS Patient under 40-day postoperative follow-up, without pain complaints, preserved occlusion, moderate edema, absence of motor nerve damage; however, he presented sensitive nerve damage. In the postoperative imaging examination, plate and screws are observed in place (Fig 3C and 3D).

better bone alignment compared to intraoral access.

Another advantage is the reduced contamination index, considering that there is no contact with the oral cavity.8 In the present case, the surgical approach used was extended submandibular surgical approach, since it is an extensive comminuted fracture, in which a wide view of the operative field was necessary to adapt the 2.3mm Locking® reconstruction plate.

The utilization of steel wires in the past to treat this type of fracture had a higher complications rate, such as infection and pseudoarthrosis. It is recommended to use load-bearing fixation with reconstruction plate.4 These load-bearing plates are more suitable for absorbing biomechanical forces, allowing for better recovery.9 The 2.3mm Locking® reconstruction plate was used in this case to allow less force transmission to the fragments, presenting a satisfactory result, corroborating with the literature.

Some postoperative complications include pseudoarthrosis, inaccurate reduction, infections, absence of contact between fragments, and even sensitive and/ or motor nerve injuries.4 In more severe cases, in which

DISCUSSION Mandibular fractures have a diverse etiology, having as main causes physical aggressions, car, motorcycle and bicycle accidents, pedestrian accidents and falls.6 Fractures in atrophic mandibles mostly affect older patients.7 However, in the reported case, the patient was not elderly and had a mild degree of mandibular atrophy. The fracture was caused by a high impact trauma caused by perforation with a firearm projectile, causing a comminuted fracture of the mandible body.

Submandibular surgical access is indicated for fracture of the mandibular body and angle and provides a wide view of the fractured region, allowing

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Reconstruction of mandibular fracture using Locking® system: Case report

FINAL CONSIDERATIONS The treatment with open reduction and rigid internal fixation with a 2.3mm load-bearing Locking® system demonstrated, in this case, a satisfactory result in comminuted fracture due to firearm injury in an atrophic mandible, with adequate functional restoration.

Monitoring the patient for a longer period is necessary to rule out late complications from this procedure and confirm the patient’s complete recovery.

the degree of mandibular atrophy is less than 10 mm, there is a higher rate of complications in the postoperative period, such as plate loss, osteomyelitis and non-union of fractured fragments.10 In the postoperative period of the present clinical case, no major complications were observed related to the fixation system or infectious conditions. However, probably due to the fracture pattern, the patient has a sensitive deficit of the inferior alveolar nerve.

References:

1. Pereira RS, Bornadi JP, Silva JR, Mourão CFAB, Barbosa Junior PR, Magacho LF. Tratamento cirúrgico da fratura de mandíbula atrófica pela técnica AO: relato de caso. Arch Health Invest. 2017;6(3):145-9.

2. Vatsyayan A, Kumar AA, Chandra SD, Malik K. Reconstruction and rehabilitation of short-range gunshot injury to lower part of face: a systematic approach of three cases. Chin J Traumatol.

2016;19(4):239-43.

3. Luhr HG, Reidick T, Merten HA. Results of treatment of fractures of the atrophic edentulous mandible by compression P/a ting: a retrospective evaluation of 84 consecutive cases. J Oral MaxillofacSurg. 1996; 54(3); 250-4.

4. Ehrenfeld M, Manson PN, Pnein J. Principles of internal fixation of the craniomaxillofacial skeleton trauma and orthognathic surgery. Manual AOCMF. 2012; 2(4):169-78.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

5. Camino RJ. Estudo prospectivo da utilização do sistema de placas e parafusos 2.0-mm locking® comparado com sistemas convencionais no tratamento de fraturas mandibulares [tese]. São Paulo: Universidade de São Paulo; 2016.

6. Munante Cardenas JL, Nunes PHF, Passeri LA. Etiology, treatment, and complications of mandibular fractures. J Craniofac Surg. 2015; 26(3):611-15.

7. Lima LB, Oliveira MTF, Batista JD, Rocha FS, Silva MCP, Silva CJ. Tratamento cirúrgico de fratura em mandíbula atrófica. Robrac. 2014;23(67).

8. Mendonça JCG, Jardim ECG, Manrique GR, Lopes HB, Freitas GP. Acesso cirúrgico para tratamento de fraturas mandibulares: revisão de literatura.

Arch Health Invest. 2013;2(2):19-23.

9. Feudis F, Benedittis M, Antonicelli V, Vittore P, Cortelazzi R. Decision-making algorithm in treatment of the atrophic mandible fractures. G Chir. 2014; 35(3/4): 94-100.

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10. Flores-Hidalgo A, Altay MA, Atencio IC, Manlove AE, Schneider KM, Baur DA, et al. Management of fractures of the atrophic mandible: a case series.

Oral Surg Oral Med Oral Pathol Oral Radiol.

2015;119(6):619-27.

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Case report

Hemophiliac patient with extensive complex odontoma in mandible ARIANY CRISTINA FREITAS RIBEIRO1 | PAULO MATHEUS HONDA TAVARES1 | GUSTAVO CAVALCANTI DE ALBUQUERQUE1 | MARCELO VINICIUS DE OLIVEIRA1 | DIRCEU VIRGOLINO DE OLIVEIRA1 | VALBER BARBOSA MARTINS1

ABSTRACT Introduction: Odontomas are the most common type of odontogenic tumors.

They are classified as mixed odontogenic tumors, being divided into compound and complex types, usually asymptomatic and diagnosed on radiographic examinations.

Treatment consist of simple local excision. Hemophilia A is a genetic disorder characterized by prolonged bleeding caused by the decrease or absence of the coagulation factors (factor VIII) required for blood clot formation. Case report: Patient complaining of “jaw pain and bad taste in the mouth,” reporting to have hemophilia A. He presented a blotting and traumatic ulcer in the left mandibular ramus; CT scan showed a hyperdense lesion with hypodense halo, well defined and with well-defined borders. The diagnostic hypothesis was complex odontoma. Thirty minutes before surgery, coagulation factor VIII was restored. Intraoral access was performed, followed by mucoperiosteal detachment, section of the lesion with drill 702 in smaller portions, to facilitate removal, and copious suture. Conclusion: The surgical removal was satisfactory and conservative, using the principles for extraction of included teeth, there were no complications due to coagulopathy. The theoretical basis and a detailed surgical planning were fundamental for the conduction and favorable prognosis of this clinical case.

Keywords: Odontogenic tumors. Odontoma. Mandible.

How to cite: Ribeiro ACF, Tavares PMH, Albuquerque GC, Oliveira MV, Oliveira DV, Martins VB. Hemophiliac patient with extensive complex odontoma in mandible . J Braz Coll Oral Maxillofac Surg. 2020 Sept-Dec;6(3):57-63.

DOI: https://doi.org/10.14436/2358-2782.6.3.057-063.oar

University of the State of Amazonas, Residency in Oral and Maxillofacial Surgery and Traumatology (Manaus/AM, Brazil).

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

Submitted: September 30, 2018 - Revised and accepted: December 11, 2018

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

Contact address: Ariany Cristina Freitas Ribeiro E-mail: arianyribeiro__@hotmail.com

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Hemophiliac patient with extensive complex odontoma in mandible

INTRODUCTION Odontogenic tumors are relatively common lesions that affect the maxillofacial region and should always be considered when there is expansion of the jaws. The odontoma is the most common type of odontogenic tumor, with prevalence around 22%, exceeding all other odontogenic tumors in combination.1 Odontomas are classified as mixed odontogenic tumors, since they are composed of tissue of epithelial and mesenchymal origin. They are considered by the World Health Organization (WHO) as developmental anomalies (hamartoma), rather than true neoplasms.

The tissues are formed in disordered patterns, consisting of enamel, dentin, and occasionally cementum.

Its etiology is still unknown. Factors as local trauma, infections or genetic mutations may be involved in its development.2 Clinically, odontomas are usually asymptomatic, being discovered during routine radiographic examinations or to investigate a change in the tooth eruption process. They may be associated with retention of deciduous teeth, dental agenesis, expansion of bone cortical, dental pain or displacement and, when extensive, they may cause facial asymmetries.1 Odontomas are classified into two types: compound odontoma and complex odontoma, since they present clinical, imaging and histopathological differences. The compound odontoma is caused by proliferation of the dental lamina, in which the tissues follow an ordered pattern, forming multiple small structures similar to denticles, while in the complex odontoma there is invagination of epithelium into the developing bud, in which there is formation of a mass of enamel and dentin without resemblance with the dental anatomy.3 Radiographically, odontomas are manifested as a well-defined radiopacity, similar to the dental structure, with higher density than the adjacent bone tissue.

In the compound odontoma, the lesion appears as malformed teeth of variable sizes and shapes, surrounded by a thin radiolucent zone. The complex odontoma manifests as a disorganized radiopaque mass also delimited by a radiolucent margin.4 Histologically, the composite odontoma consists of multiple structures represented by mature enamel contained in a loose fibrous matrix. Pulp tissue can be found in the root and coronal portion of tooth-like structures. The complex odontoma consists of mature

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tubular dentin. Small islands of eosinophilic epithelial ghost cells are present in 20% of complex odontomas and may represent remnants of odontogenic epithelium that underwent keratinization and cell death due to local anoxia1.

Treatment is surgical and includes simple local excision following the principles for extraction of impacted teeth. They are easily enucleated, since they are separated from the surrounding bone by a thin layer of connective tissue; the prognosis is excellent.5 Additionally, patients with hereditary coagulopathies are at high risk of bleeding, especially after trauma or surgical procedures. Hereditary coagulopathies are hemorrhagic diseases resulting from deficiency of one or more plasma proteins (factors) of blood clotting, due to mutations in the genes that encode them, the most common being hemophilia and von Willebrand disease. Hemophilia is a genetic disorder characterized by prolonged bleeding caused by decrease or absence of one of the clotting factors required to form a blood clot.

It affects approximately one in ten thousand people and the two most frequent types are hemophilia A or classic hemophilia, characterized by a decrease in factor VIII; and hemophilia B, defined by deficiency of factor IX. Hemophilia A is a disorder linked to X chromosome genes. Women characteristically carry the trait, but the disease manifests mainly in men. Its classification varies according to the level of clotting activity of factor VIII, the normal level being defined as 1 IU/ml of F VIII: C (100%). Thus, patients are classified as: a) severe, those who have F VIII:C lower than 1% of normal or <0.01 IU/ml; b) moderate, those with F VIII:C between 1% and 5% of normal or 0.01 to 0.05 IU/ml; and c) mild, those with F VIII:C> 5% and <40% of normal or> 0.05 and <0.40 IU/ml.6 Since hemophilia is the result of deficiency or absence of some clotting factors, the treatment consists of providing the absent factor by intravenous administration. Locally, fibrin sealant is also used, which mimics the final clotting route, suture or other supporting hemostatic substances. Therefore, patients with coagulopathies need additional care when submitted to dental surgery. This paper reports a clinical case of removal of a large odontoma, involving the mandibular ramus and angle region, in a patient with hemophilia A, addressing clinical and imaging aspects, as well as the type of surgical treatment performed.

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Ribeiro ACF, Tavares PMH, Albuquerque GC, Oliveira MV, Oliveira DV, Martins VB

CASE REPORT A 53-year-old male patient attended the residency service in Oral and Maxillofacial Surgery and Traumatology with the chief complaint of “pain in the mandible and bad taste in the mouth”. During anamnesis, the patient reported having been aware of a tumor in the mandible for approximately 10 years during routine dental care: however, at the time he did not give attention to the case and did not seek for treatment. Also, he reported having hemophilia A and visual impairment.

On extraoral clinical examination, a slight increase in volume was observed in the left mandibular angle. On intraoral clinical examination, there was an increase in volume in the left retromolar region and the presence of a traumatic ulcer in the left mandibular ramus, causing exposure of the lesion in the oral cavity, which was the chief complaint of the patient and the reason to seek for care.

Radiographic examination revealed an extensive and well-defined radiopaque image, delimited

by a radiolucent area, covering the left mandibular angle and ramus. A cone beam computed tomography was requested, which evidenced the presence of a hyperdense conglomerate lesion, well-defined with a hypodense halo, measuring 34.3 mm, 23.8 mm and 17.8 mm in the greatest superoinferior, mesiodistal and buccolingual dimensions, respectively, in the left retromolar region, involving the mandibular angle and ramus (Fig 1).

Due to the clinical and radiographic findings, the diagnostic hypothesis was complex odontoma. The proposed treatment was surgical removal of the tumor in a hospital environment, under general anesthesia, because, besides providing greater comfort to the patient, it would enable immediate treatment of a possible fracture due to mandibular fragility during lesion enucleation, besides facilitating the replacement and control of clotting factors. The patient was informed about the procedure, and informed consent was obtained.

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Figure 1: Preoperative aspect. A) Intraoral photograph, showing an area of ulceration and lesion exposure. B) CBCT coronal reconstruction, showing the large proportion of the lesion. C) Panoramic reconstruction of CBCT.

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Hemophiliac patient with extensive complex odontoma in mandible

portions to facilitate its removal, besides avoiding a possible mandibular fracture due to application of excessive force. The smaller fragments were easily detached from the adjacent bone tissue. The absence of lingual bone cortex and the presence of a fibrous capsule covering the hard tissue mass facilitated the removal of fragments without the need for osteotomies, which could weaken the remaining bone (Fig 2).

The surgical site was curetted, irrigated and sutured with absorbable Vycril 4.0. The surgery evolved satisfactorily, without excessive bleeding due to coagulopathy.

The factor replacement was maintained during three postoperative days, as instructed by the hematologist; there were no complications related to coagulopathy. Af-

Thirty minutes before surgery, the preoperative protocol for patients with hemophilia A was performed, with replacement of clotting factor VIII, under guidance of the hematologist responsible for the patient. The therapeutic regimen indicated for the patient was: preoperative with Factor VIII recomb 1,500 IU (30 minutes before surgery) and postoperative with Factor VIII recomb 1,500 IU at every 24 hours, from the first to the third postoperative day. The surgical approach was initiated by local infiltration of vasoconstrictor, followed by intraoral access with mandibular buccal incision, following the ulcer formed by lesion exposure. Detachment of full mucoperiosteal flap continued until total lesion exposure, which was sectioned with using bur n. 702 into smaller

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Figure 2: Lesion excision. A) Buccal access directly over the lesion. B) Surgical excision following principles of extraction of impacted teeth. C) Posterior region of the mandible after lesion removal. D) Lesion fragments after excision.

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Ribeiro ACF, Tavares PMH, Albuquerque GC, Oliveira MV, Oliveira DV, Martins VB

ond intention. The patient was evaluated weekly in the first two months, biweekly in the second two months and then monthly until completing one-year follow-up, when the local tissue closure was clinically observed, and cone beam computed tomography evidenced ongoing local new bone formation (Fig 3).

ter 10 days postoperatively, suture dehiscence occurred in the region, since it was left without support of healthy bone tissue and tissue healing occurred by second intention. The patient and family members were instructed to perform daily hygiene and irrigation with 0.12% chlorhexidine digluconate in the region, until closure by sec-

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Figure 3: 1-year postoperative aspect. A) Intraoral aspect after 1-year follow-up. B) CBCT axial section, showing total removal of the lesion. C) Panoramic reconstruction of CBCT.

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Hemophiliac patient with extensive complex odontoma in mandible

DISCUSSION Odontomas are considered the most common odontogenic tumors affecting the oral cavity and represent about 22% of documented cases. Of these data, the incidence of complex odontomas represents the minority, around 37.7% of cases reported in the literature.1,7 The site most affected by complex odontoma is the posterior mandibular region, corroborating the described case, in which the lesion was located in the mandibular angle and ramus region.

They do not present great differences in relation to sex, affecting men and women in the same proportion.

Most cases are diagnosed in the first decades of life during routine radiographic examinations, which is not consistent with the reported case, since at the time of diagnosis the patient was an adult, aged 43 years, and only sought treatment after 10 years of evolution, when painful symptoms started, indicated as the main complaint.1-5 In general, odontomas are asymptomatic lesions; however, they occasionally manifest signs and symptoms resulting from their existence. Painful symptoms may be associated with nerve compression or secondary infection, due to bone replacement by hard avascular tissue. Other signs and symptoms may include paresthesia, expansion of cortical bone, retention of primary teeth or failed eruption of permanent teeth.5,7,9 In the present case, the patient complained of pain and “bad taste in the mouth”, due to the presence of ulceration in the retromolar mucosa, with drainage of secretion from the lesion, besides an increase in volume in the left mandibular ramus as a result of bone expansion caused by the tumor extension.

Odontomas are typically small lesions, ranging from few millimeters to up to 4 cm in diameter.8 In the present case, an atypical odontoma lesion was excised due to its dimensions, namely 34.3 mm, 23.8 mm, and 17.8 mm in its largest proportions.

The treatment recommended in the literature is total surgical excision of the lesion. In addition, according to the lesion extent and location, the literature mentions alternative techniques, such as sagittal ramus osteotomy, Le Fort I osteotomy and corticotomy.2,10 It is important to state that, due to the size and location of the lesion to be removed and its relationship with important adjacent structures, such as the neurovascular bundle of the inferior alveolar nerve and the lingual nerve, the patient was informed about the risks of injury to such structures, as well as eventual trans- and postoperative mandibular fracture, thus requiring additional treatment.

In general, the treatment of odontomas is performed

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under local anesthesia on an outpatient basis; however, in the present case, the patient was operated in a hospital environment under general anesthesia, due to the possibility of mandibular fracture during surgery or postoperatively, as well as the possibility of performing sagittal osteotomy of the mandibular ramus to remove the tumor and also due to the systemic conditions of the patient, with hemophilia A, requiring additional care during surgery.1,8,10 Hemophilia is an autosomal recessive congenital coagulopathy linked to the X chromosome, due to deficiency of factor VIII (hemophilia A) or factor IX (hemophilia B). The dental treatment of patients with hemophilia must be performed with special care, by a multidisciplinary team, in which health professionals must have medical experience and adequate hematological support. In the present case, the patient had hemophilia A or classic hemophilia, characterized by decrease in factor VIII – a disorder caused by a genetic alteration that causes prolonged bleeding, due to decrease or absence of clotting factors. Thus, some preoperative care was taken to minimize the risks of prolonged bleeding, such as replacement of the missing clotting factor.6 Under guidance of the hematologist assisting the patient, Factor VIII 1,500 IU was administered 30 minutes before surgery. After receiving factor VIII, the patient is considered to have normal circulating levels of clotting factors; therefore, the risk of bleeding is related to the proposed surgical procedure, and no longer to coagulopathy – i.e., the administration of Factor VIII, it is expected that there will be no occurrence related to hemodynamic problems, such as excessive bleeding, during or after surgery. The prognosis is totally favorable when prioritizing a conservative surgical technique combined with local maneuvers for hemostasis, e.g., the use of hemostatic agents and compressive suture.

The 1,500 IU replacement protocol was maintained with applications at every 24 hours for three days after surgery, as proposed by the hematologist. There were no postoperative complications related to bleeding or hematoma formation not proportional to the surgical procedure; the patient evolved satisfactorily, showing that, with factor VIII replacement therapy, small and medium-sized oral surgeries can be performed safely and predictably with good results.

The surgical enucleation of odontomas is facilitated due to the presence of a fibrous capsule covering them, often eliminating the need for lesion sectioning during surgery.10 However, in the reported case, due to its extent, the tumor was sectioned into several smaller portions, to avoid mandibular fragility and application of excessive force.

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Ribeiro ACF, Tavares PMH, Albuquerque GC, Oliveira MV, Oliveira DV, Martins VB

disorders to patients, such as pain, facial asymmetry and even infections. They are easily diagnosed by the characteristics presented in imaging examinations. The request for complementary exams, such as computed tomography, is essential to assess the lesion extent and thus plan a good surgical approach, avoiding complications and undesirable sequelae to the patient. Patients with coagulopathies can undergo any dental procedure, provided the necessary care is taken. Multidisciplinary treatment is essential to obtain general control of the patient’s health and must be well planned by the dentist, together with the hematologist, aiming at greater safety and comfort for the patient and professional team. Therefore, the dental professional should be aware of existing hemorrhagic pathologies, as well as their clinical manifestations and possible complications related to them.

Some authors advocate the use of maxillomandibular block for three to four weeks postoperatively to remove extensive tumors, due to mandibular fragility.1,4,10 However, in the exposed case, after removing the lesion, it was observed that the buccal and basilar cortical bone remained intact with good thickness, without the need for block.

Also, the patient was instructed to perform postoperative care to avoid any type of late mandibular fracture.

The prognosis is considered favorable and recurrences are rare, since most odontomas are benign tumors.

CONCLUSION Complex odontoma is a common tumor that affects the maxillofacial region; however, its presentation in large extensions is relatively rare. These lesions are usually asymptomatic; but, when diagnosed late, they can cause

References:

1. Pires WR, Motta-Júnior J, Martins LP, Stabile GAV. Odontoma complexo de grande proporção em ramo mandibular: relato de caso. Rev Odontol UNESP. 2013;42(2):138-43.

2. Alves PM, Santos PPA, Cavalcanti AL, Queiroz LMG, Souza LB. Estudo clínico-histopatológico de 38 odontomas. Rev Odontol UNESP. 2008;37(4):357-61.

3. Cé PS, Prazeres C, Santos FE, Woltmann M. Odontoma complexo: relato de caso clínico atípico. RFO. 2009;14(1):56-60.

4. Mendonça JCG, Lima CMC, Böing F, Bento LA, Santos AA. Odontoma complexo gigante em corpo de mandíbula: relato de caso. Rev Cir Traumatol Buco-Maxilo-Fac. 2009;9(2):67-72.

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5. Santos DLN, Dantas-Neta NB, Gomes LCL, Moraes LD, Lopes MCA, Barros SSLV. Odontoma complexo extenso causando assimetria facial: relato de caso. Rev Cir Traumatol Buco-Maxilo-Fac. 2012;12(4):39-44.

6. Bravo MLO, Montoya ALB, Rivera TR, Uribe IMP, Shitsuka CS, Carmem CA, et al. Reabilitação odontológica multidisciplinar em paciente pediátrico com hemofilia: relato de caso. Rev Assoc Paul Cir Dent.

2016;70(2):210-214.

7. Amado-Cuesta S, Gargallo-Albiol J, Berini-Aytés L, Gay-Escoda C. Revisión de 61 casos de odontoma.

Presentación de un odontoma complejo erupcionado. Med Oral. 2003;8:366-73

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8. Pereira LC, Miceli ALC, Louro RF. Odontoma complexo extenso em mandíbula: revisão e relato. Rev Cir Traumatol Buco-Maxilo-Fac. 2015;15(4):49-52.

9. Vengal M, Arora H, Ghosh S. Large erupting complex odontoma: a case report. J Can Dent Assoc.

2007;73(2):169-72.

10. Kuramochi MM, Vanti LA, Berenguel IA, Pereira WL, Zangrando D. Acesso extraoral para reconstrução primária em odontoma complexo raro em mandíbula.

Rev Port Estomatol Medic Dent Cir Maxilofacial.

2006;47(1):35-40.

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Information Information for authorsfor authors

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

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

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

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

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

• The manuscripts should be submitted in Portuguese.

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

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

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

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

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

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

• The figures should be submitted as separate files.

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

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

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

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

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

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

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

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Information for authors

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

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

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

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

• They should be submitted as separate files.

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

• All figures should be cited in the text.

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

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

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

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

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

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

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

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

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

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

• Each table should have a short title.

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

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

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

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

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

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

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Information for authors

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

- All references should be cited in the text.

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

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

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

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

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

- Use the examples below:

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

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

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

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

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

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

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

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Notice to Authors and Consultants Registration of Clinical Trials

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

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

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

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

At the same time, the International Committee of Medical Journal Editors (ICMJE) has suggested that editors of scientific journals require authors to produce

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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 Registry), www.clinicaltrials.gov and http://isrctn.org (International Standard Randomized Controlled Trial Number Register (ISRCTN). The creation of national registers is underway and, as far as possible, registered clinical trials will be forwarded to those recommended by WHO.

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Comunicado aos Autores e Consultores - Registro de Ensaios Clínicos

itors - 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.

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.

3. Journal of the Brazilian College of Oral and Maxillofacial Surgery Dental Journal of the Brazilian College of Oral and Maxillofacial Surgery endorses the policies for clinical trial registration enforced by the World Health Organization - WHO (http://www.who.int/ictrp/en/) and the International Committee of Medical Journal Ed-

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

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