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Volume 3, Número 3, 2017

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Dolphin 3D Volume 3, Number 1, 2017 - ISSN 2358-2782

ema de fixação bucomaxilofacial rtognática, trauma e reconstrução.

Journal of the Brazilian

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Planejamento preciso da osteotomia

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

dos no tratamento dos desarranjos ferenciais: permite sutura de disco pela pinça de biópsia, além de corte

College of Oral and Maxillofacial Surgery JBCOMS

Geração de guias cirúrgicos Imaging

Management

Aquarium ©

Foto: Mike Bueno

EDITOR-IN-CHIEF Belmiro Cavalcanti do Egito Vasconcelos

Universidade de Pernambuco - FOP/UPE - Camaragibe/PE - Brazil

ASSOCIATE EDITOR-IN-CHIEF Gabriela Granja Porto

Universidade de Pernambuco - FOP/UPE - Camaragibe/PE - Brazil

SECTION EDITORS

Oral Surgery and Implants Cláudio Ferreira Nóia Danilo Passeado Branco Ribeiro Fernando Bastos Pereira Júnior Luis Carlos Ferreira da Silva Waldemar Daudt Polido

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 Clínica particular - Porto Alegre/RS - Brazil

Trauma Liogi Iwaki Filho Márcio Moraes Nicolas Homsi Ricardo José de Holanda Vasconcellos

Universidade Estadual de Maringá - UEM - Maringá/PR - Brazil Universidade de Campinas - FOP/Unicamp - Piracicaba/SP - Brazil Universidade Federal Fluminense - UFF - Niterói/RJ - Brazil Universidade de Pernambuco - FOP/UPE - Camaragibe/PE - Brazil

rthognathic Surgery and Deformities O Fábio Gamboa Ritto Fernando Melhem Elias José Laureano Filho José Nazareno Gil José Thiers Carneiro Júnior

Hospital Universitário Pedro Ernesto - UERJ - Rio de Janeiro/RJ - Brazil Universidade de São Paulo - Hospital Universitário - São Paulo/SP - Brazil Universidade de Pernambuco - FOP/UPE - Camaragibe/PE - Brazil Universidade Federal de Santa Catarina - UFSC - Florianópolis/SC - Brazil Universidade Federal do Pará - UFPE - Belém/PA - Brazil

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

TMJ Disorders Eduardo Hochuli Vieira Eduardo Seixas Cardoso João Carlos Birnfeld Wagner Luis Raimundo Serra Rabelo

Pathologies and Reconstructions Darceny Zanetta Barbosa Universidade Federal de Uberlândia - UFU - Uberlândia/MG - 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 Sylvio Luiz Costa de Moraes Universidade Federal Fluminense - UFF - Niterói/RJ - Brazil Wagner Henriques de Castro Universidade Federal de Minas Gerais - UFMG - Belo Horizonte/MG - Brazil Ad-hoc Editors André Luiz Marinho Falcão Gondim Diogo Souza Ferreira Rubim de Assis Eider Guimarães Bastos Hernando Valentim da Rocha Junior

Universidade Federal do Rio Grande do Norte - UFRN - Natal/RN - 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

_______________________________________________________________________ Journal of the Brazilian College of Oral and Maxillofacial Surgery v. 1, n. 1 (jan./abr. 2015). – Maringá: Dental Press International, 2015. DIRECTOR: Teresa Rodrigues D’Aurea Furquim - EDITORIAL DIRECTOR: Bruno D’Aurea Furquim - Rachel Furquim Marson - MARKETING DIRECTOR: Fernando Marson - EDITORIAL PRODUCER: Júnior Bianco - DESKTOP PUBLISHING: Gildásio Oliveira Reis Júnior - ARTICLES SUBMISSION: Simone Lima Lopes Rafael - Kler Godoy

Quadrimestral ISSN 2358-2782

- REVIEW/COPYDESK: Ronis Furquim Siqueira - DATABASE: Cléber Augusto Rafael - COURSES AND EVENTS: Poliana Rocha dos Santos - COMMERCIAL DEPARTMENT: Roseneide Martins Garcia - LIBRARY/NORMALIZATION: Simone Lima Lopes Rafael - DISPATCH: Rui Jorge Esteves da Silva - FINANCIAL DEPARTMENT: Cléber Augusto Rafael - Lucyane Plonkóski Nogueira - RH: José Luiz da Luz Silva. 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

1. Cirurgia Bucomaxilofacial. I. Dental Press International.

e Pesquisa Ltda. – Av. Dr. Luiz Teixeira Mendes, 2.712 – Zona 05 – ZIP code: 87.015-001 – Maringá/PR – Brazil. All published articles are the exclusive responsibility of the authors. The opinions expressed do not necessarily

CDD 21 ed. 617.605005 _______________________________________________________________________

correspond to the opinions of the Journal. Advertising services are the responsibility of advertisers. Subscription: dental@dentalpress.com.br or Tel./Fax: +55 44 3033-9818.

table of contents

Editorial

Belmiro C. E. Vasconcelos Letter from the President

Sylvio Luiz Costa de Moraes Interview

Antônio Luiz Barbosa Pinheiro

Articles

Assessment of two palatoplasty techniques in patients with cleft palate

Surgical treatment of central giant cell lesions

Mandible first orthognathic surgery

Oroantral fistula treatment using palatal flap

Gummy smile: botulinum toxin and gingival surgery

Hyperbaric oxygen therapy and stereolithographic models in immediate mandibular reconstruction

Andréia Ferreira Ribeiro, Magno Liberato Silva, Fábio Ricardo Loureiro Sato, Érica Cristina Marchiori, Roger William Fernandes Moreira

André Luis Bim, Matheus Spinella, Carlos Eduardo de Souza, Liliane J. Grando, José Nazareno Gil

Aécio Abner Campos Pinto Júnior, Vitor José da Fonseca, Joanna Farias da Cunha, Luiz Felipe Cardoso Lehman, Felipe Eduardo Baires Campos, Wagner Henriques de Castro

Gustavo Boehmer Leite, João Manoel de Souza Mota, Gustavo Gomes Nardone Rodrigues, Wagner Hespanhol, Maria Aparecida de Albuquerque Cavalcante

Irineu Gregnanin Pedron

Luis Gustavo Jaime Paiva, Frederick Khalil Karam, Luiz Fernando Barbosa de Paulo, Maiolino Thomaz Fonseca Oliveira, Lucas do Nascimento Tavares, Darceny Zanetta-Barbosa

Calcifying cystic odontogenic tumor: case report

Frontal bone reconstruction with polymethyl methacrylate prosthesis: case report

Carlos Alberto Medeiros Martins, Ana Cláudia Farias Anhalt, Fernando Vacilotto Gomes

Ana Carolina Lemos Pimentel, Deyvid Silva Rebouças, Lucas Souza Cerqueira, Adriano Freitas de Assis

Editorial

The importance of inferences in scientific papers There is a constant search for scientific evidence in the health area, and descriptive manuscripts are not forbidden. The problem is that this type of study does not provide conclusions that allow extrapolation for the population. Thus, answering a guiding question (existing problem) is not simple. It is necessary to study a representative population sample and employ statistical analyses to achieve consistent conclusions. As explained above, inferences could be defined as the process of achieving information about a population from data observed in a sample. Studying a population would be very expensive and sometimes unfeasible. In general, there is a population with large number of individuals and, from a sample of this population, we aim to know some of its characteristics “as much as possible”. We need to notice that any conclusion drawn by sampling, when generalized to the population (external validity), will have an accompanying bias. This process is conducted using a set of techniques and procedures that allow the research team some reliability in their statements. Thus, the fundamental problem of statistics is to measure the degree of uncertainty or risk of such generalizations. Statistical inference instruments enable such conclusions by statistical statements.

How to cite: Vasconcelos BCE. A importância de inferências nos artigos científicos. J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):4-5. DOI: http://dx.doi.org/10.14436/2358-2782.3.1.004-005.edt

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):4-5

Editorial

However, in practice, how could we identify a paper with inferences? It should present the following characteristics: probabilistic samples, hypotheses tests, “p” value, among others. Of course, science is dynamic, and we need to keep our minds open for the evolutionary process of methodologies. Therefore, there is no doubt that scientific papers with statistical inferences will provide better responses to the question posed. We could consider papers with these characteristics as being stronger, more reliable, and indicating the novelties.

Prof. Dr. Belmiro C. E. Vasconcelos Editor-in-chief of JBCOMS - Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):4-5

Letter from the President

Dear colleagues, We begin this year with news! The Project of the Internal Guideline of the Dental Clinical Staff is under consultation, which is the outcome of the Commission on Bioethics and Good Practice Recommendations. This project will benefit all dental professionals working in hospitals. Suggestions may be sent through our webpage: http://www.bucomaxilo.org.br. The approval of new membership in the COPAC assembly provided adequate classification of the current members; the valuation of specialists and Full Members; and legal safety. The Commission of Informatics and Audiovisual Identity and the PRODWEB company – which developed and maintains our new website – are developing a contemporary tool: an app for smartphones and tablets, which will enhance the access to the members. The Commission of Residents Evaluation, Commission of Residency Teaching and Training, Commission of Relationship with the Ministry of Education and Culture (MEC) & Federal Dental Council (CFO) for Issues of Interest to the Specialty, Commission of Strategic Planning and the Executive Direction constituted a Working group for proposals of improvement in the training of specialists, based on seven goals: 1) to suggest the minimum curriculum and infrastructure of residency programs; 2) proposal for fellowships of residents between programs approved by the College; 3) creation of guidelines for the evaluation of residency programs who wish association with the College; 4) to prepare a proposal of international exchange of residents associated with the College; 5) to establish the inclusion of a Full Member of the College, linked to the residency in Oral and Maxillofacial Surgery and Traumatology, within the Teaching Commission of the Federal Dental Council; 6) to establish a work strategy with the Federal Dental Council to discuss the specialization courses in Oral and Maxillofacial Surgery and Traumatology; and 7) to establish a work strategy with the Ministry of Education to discuss the specialization courses in Oral and Maxillofacial Surgery and Traumatology. The Commission for Creation of the Quality Seal of the College is finalizing the tasks that will provide the criteria for assigning the quality seal to residency programs in line with the goals of the College. The E-learning commission has been working to provide an important contribution to the Distance Learning Commission, aiming to provide more benefits of continuing education to our members.

How to cite: Moraes SLC. Carta do presidente. J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):6-7. DOI: http://dx.doi.org/10.14436/2358-2782.3.1.006-007.crt

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):6-7

Carta do Presidente

By the Commission for Relationship with International Institutions, we reached an important conquest in Latin America: the association between the College and ALACIBU, an important alliance for the harmony and growth of the specialty in our continent. The current year of 2017 will be the year of our important XXIV COBRAC (www.cobrac2017.com.br), a Brazilian national event of international scope, which is being planned with dedication to be a wonderful congress, which will catch the interest not only of the specialty, but also of other fields. This will surely be a must-go event. We created the webpage of XXIV COBRAC in Facebook, which we invite you to access, like and ask your doubts: www.facebook.com/Cobrac2017emSP The Social Networks Commission and Social Commission have worked relentlessly. The highlight and visibility of the College in the internet were very important. The several homages and reminds of birthdays make us think that the daily life should be celebrated. The management emphasizes that, according to our commitment, some Regional and Chapter Coordinators who could not achieve the established goals, for several reasons, were replaced. Once again, some adjustments in the composition of Auxiliary Commissions were and still are being performed to provide better conditions to achieve the goals of this board. By our duty, we highlight that the results achieved so far are the result of an integrated work of the entire management team, including the Executive Board, General Council, Auxiliary Commissions, Chapter Coordinators, Editors of the JBCOMS, Event Organizing Commissions, Administrative Staff of our Headquarters, and also the Press and Juridical Advisory Boards. The Board highlights the thankfulness for the support received and restates that it expects to receive suggestions and constructive criticisms of institutional interest. After all, the College belong to all of us. Letâ&#x20AC;&#x2122;s go on! Working, building and growing!

Sylvio Luiz Costa de Moraes President of the Brazilian College of Oral and Maxillofacial surgery and Traumatology

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):6-7

PLANEJAMENTO VIRTUAL PARA CIRURGIASVIRTUAL PLANEJAMENTO PARA G U I A S C CIRURGIAS USTOMIZADAS U I A S C está U S Tcada O M vez I Z Amais D A Spróxima da área Médica AGtecnologia e Odontológica. A Smart Solutions Surgery tem como objetivo A tecnologia está cada vez mais próxima ideal da área auxiliar o cirurgião a obter o tratamento ao Médica paciente. eA Odontológica. A Smart Solutions Surgery tem como objetivo partir de um planejamento virtual, são geradas guias auxiliar o cirurgião a obterque o tratamento ao paciente. cirúrgicas customizadas, vão auxiliarideal o cirurgião A de um virtual, são guias a partir transferir os planejamento movimentos realizados nogeradas planejamento, cirúrgicas customizadas, que vão auxiliar o cirurgião para o trans-operatório. a transferir os movimentos realizados no planejamento, para o trans-operatório.

TOMOGRAFIA TOMOGRAFIA

PROTOCOLO FOTOGRÁFICO PROTOCOLO FOTOGRÁFICO

INDICAÇÕES INDICAÇÕES

CIRURGIA ESQUELÉTICA

PLANEJAMENTO VIRTUAL PLANEJAMENTO VIRTUAL

TRABALHO FINALIZADO TRABALHO FINALIZADO

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evista-cbct-2016-11-final-ok.pdf 1 21/11/2016 15:10:53

SORRIR! SORRIR!

Arte: David Normando - Foto: Everaldo Nascimento VER-O-PESO: entre os 10 melhores mercados de rua do mundo

Promoção:

ESTAÇÃO DAS DOCAS

Realização

“Cidade criativa da Gastronomia” (UNESCO, 2015)

Apoio

CÍRIO DE NAZARÉ

Patrocinadores Diamante:

INSCRIÇÕES: www.abor.org.br/congresso 2017

Cursos José Augusto Miguel

Carlos Flores-Mir

Carlo Marassi

Jorge Faber

Uso dos propulsores fixos para tratamento da Classe II.

Dicas para facilitar e melhorar a finalização ortodôntica!

Pós verdades ortodônticas dos 8 aos 80.

Kevin O’Brien

Leopoldino Capelozza

Marco Rosa

Marcos Janson

O tratamento interdisciplinar: da dentição mista ao paciente idoso.

Ortodontia de resultados: a arte da escolha.

Na terra da incerteza, o vendedor é rei?

A ortodontia, o tempo e a alquimia.

Novos recursos para ampliar os limites da compensação ortodôntica.

Data do curso: 11-10-2017 Ao realizar a inscrição até 31 de março, os sócios da ABOR receberão, gratuitamente, o curso do Prof. Marco Rosa. Aos não sócios, o desconto será de 50% até esta data.

Mario Polo

Nelson Mucha

Rodrigo Viecilli

Weber Ursi

Correção ortocirúrgica e estética facial.

Sorrisos - detalhes essenciais.

Controvérsias em biomecânica: salvando a ciência da técnica e do marketing.

Ortodontia: ontem, hoje e amanhã.

Simpósios:

• Antonio Carlos Ruellas • Flavia Artese • Márcio Almeida • Mario Polo • Mayra Seixas • Renato Martins

Minicursos:

• Adilson Ramos • Alexandre Moro • Carlos Câmara • Carlos Tavares • Daniela Garib • Ertty Silva • Flávio Cotrim-Ferreira • Guilherme Almeida • Guilherme Janson • Henrique Villela • Jonas Capelli • José Valladares • Júlio Gurgel • Laurindo Furquim • Leandro Marques • Liliana Maltagliati • Marco Almeida • Matheus Pithon • Paulo Conti • Roberto Brandão • Silvia Reis • Telma Martins

Conferências:

• Ana Conti • André Machado • Bruno Furquim • Carlos Flores-Mir • Carlos Câmara • Carlo Marassi • Cauby Júnior • Deise Cunha • Daltro Ritter • Dauro Oliveira • Enio Tonani Mazzieiro • Fábio Santana • Felipe Carvalho • Fernanda Angelieri • Flávio Calçada • Geórgia Thi Lau • Gerson Ribeiro • Gilberto Queiroz • Gladys Dominguez • Graziane Pereira • Flávio Ferrari • Haiane Cavalcante • Ildeu Andrade • João Milki Neto • Jorge Faber • José Rino Neto • Luciane Menezes • Lilian Martins • Lincoln Nojima • Luiz Guilherme Maia • Marcos Janson • Maurício Araújo • Maurício Sakima • Marcelo Freire • Omar Ayub • Orlando Tanaka • Ricardo Moresca • Romero Souto • Sabrina Gama • Vilmar Lima

Atividade Paralela - SIMPÓSIOS ABOL:

• Carla Melleiro Gimenez • Guaracy Fonseca • Lucilene Calliare • Luis Fernando Eto • Marcos Prieto • Marcelo Marigo • Rita Baratela Thurler • Rodrigo Prata Rocha • Silvana Kairalla

Conferências Expositores: • Alécia Louzada • Bruno Gribel • Daniel Tocolini • Marco Schroeder • Rowan Vilar

Até o dia 28 de abril

De 29 de abril a 31 de julho

De 01 de agosto a 29 de setembro

Após o dia 29 de setembro

Sócios ABOR/ALADO

R$ 590,00

R$ 700,00

R$ 770,00

R$ 850,00

Não sócios ABOR/ALADO

R$ 790,00

R$ 900,00

R$ 990,00

R$ 1.080,00

Pós-graduandos em Ortodontia

R$ 590,00

R$ 700,00

R$ 770,00

R$ 850,00

Acadêmicos de Odontologia

R$ 550,00

R$ 630,00

R$ 690,00

R$ 770,00

Curso Marco Rosa

R$ 120,00**

R$ 140,00

R$ 160,00

R$ 180,00

Formas de pagamento

Até 6 x no cartão Boleto à vista

Até 4 x no cartão Boleto à vista

Até 2 x no cartão Boleto à vista

Cartão à vista

* Para todas as categorias (exceto não sócios) é necessário a comprovação por documento;

** Ao realizar a inscrição até 31 de março, os sócios da ABOR receberão, gratuitamente, o curso do Prof. Marco Rosa. Aos não sócios, o desconto será de 50% até esta data. Marco Rosa

Patrocinadores Ouro:

Patrocinadores Prata:

www.orthocamp.com.br

Apoio:

Dental Research Center CPbio, at Uberlândia, is highlighted in national and international scenarios

What made the Research Center of the Dental School of University of Uberlândia one of the largest in Brazil?

At the Federal University of Uberlândia (MG), a dental research center was founded and developed with an innovative proposal. The CPbio (Research Center in Biomechanics, Biomaterials and Cell Biology) has been highlighted in the national and international scenarios for the quality of scientific publications achieved and the ability to integrate basic research and clinical application in diverse specialties and fields of knowledge. The CPbio is coordinated by Prof. Dr. Carlos José Soares, full professor of the Postgraduate Program of the Dental School at the Federal University of Uberlândia (UFU). To better know the work developed, we interviewed the coordinator of Chapter VI – Region of Uberlândia – of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology, Dr. Maiolino Thomaz Fonseca Oliveira, who is MSc in Dentistry by UFU and PhD in Dentistry by the same university. He is directly connected to the postgraduate program and also to the research lines of UFU and will explain why CPbio is an increasingly recognized and important research center for the specialty.

Dr. Maiolino Thomaz Fonseca Oliveira: The CPbio is a multi-user multidisciplinary laboratory that supports research, teaching and extension activities at the Dental School of UFU. It also works in partnership with different units of UFU and other research institutions in the country and abroad. This research center was based on basic principles of integration of human resources, infrastructure and equipment, allowing the rationalization of investments. There are nearly 600m2, ergonomically planned to gather six research laboratories and two support laboratories, for the development of studies in several research lines. The generation of knowledge, search for innovation and transfer of technology occur by substantial funding from FAPEMIG, CAPES and CNPQ, besides partnerships with dental companies. CPbio is

How to cite: Oliveira MTF, Soares CJ. Centro de Pesquisa Odontológica CPbio, de Uberlândia, se destaca nos cenários nacional e internacional. J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):14-7. DOI: http://dx.doi.org/10.14436/2358-2782.3.1.014-017.cne

Submitted: December 14, 2016 Revised and accepted: January 17, 2017

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):14-7

JBCOMS News

the use of hyperbaric oxygen therapy (HBO) has been an important adjunct to this type of treatment. Within this research line, by microtomography and histomorphometry studies, we have attempted to understand the effects of HBO on the incorporation and maintenance of volume of bone grafts used in large reconstructions.

equipped with modern research equipment and has a technical staff of investigators who interact in the different fields for knowledge generation and technological innovation. More than R$ 20 million have been used for physical infrastructure and equipment. The CPbio is composed of eight laboratories: - finite element laboratory; - cell biomimetics laboratory; - bacteriology laboratory; - sample processing laboratory; - biological samples storage laboratory; - microimaging laboratory; - mechanical testing laboratory; - microCT, scanning and prototyping laboratory.

Do other centers participate in this research line? Dr. Maiolino Thomaz Fonseca Oliveira: Yes, we have participation of two other partner centers. The Facial Reconstruction Center (RECONFACE), headed by Dr. Sylvio de Moraes, at Rio de Janeiro, and also a partnership with Prof. Dr. Rubens Spin Neto, from the University of Aarhus, Denmark. This research line has generated important studies, published in international journals and also in the Journal of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology.

Which research lines are currently developed at CPbio in the field of Oral and Maxillofacial Surgery and Traumatology? Dr. Maiolino Thomaz Fonseca Oliveira: In the fields of Oral and Maxillofacial Surgery and Traumatology and Implantology, there are studies on orthognathic surgery, bone reconstructions, improvements in macro, micro and nanogeometry of dental implants and bone repair. The final results of these studies have been published in the most important dental journals worldwide. Studies in the field of Orthognathic Surgery have provided an understanding of the effects of this surgical modality on the airway of patients, and also of their relationship with temporomandibular disorders. In partnership with large companies, such as Neodent (Curitiba/PR), we have developed important researches to improve the surface of dental implants, thus optimizing osseointegration and providing better clinical results to the patients. Another important research line – which is currently developed by me, under guidance of Prof. Dr. Darceny Zanetta Barbosa – refers to large bone reconstructions of the jaws in individuals submitted to resection of mandibular tumors. The reconstruction of major mandibular defects is challenging for the maxillofacial surgeon, especially when free grafts without vascularization are used, such as iliac crest grafts. In an attempt to overcome these difficulties,

Dr. Maiolino Thomaz Fonseca Oliveira, Coordinator of Chapter VI, Region of Uberlândia, of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology.

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):14-7

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):14-7

JBCOMS News

in a highly competitive call, this proposal being the best ranked of UFU among all fields of knowledge.

Another important research line in Oral and Maxillofacial Surgery and Traumatology is the study of bone alterations after head and neck radiotherapy and their interactions in the repair process and integration with dental implants. We also had the opportunity to publish an international book chapter addressing this research line. This results in an international highlight of our Postgraduate Program and CPbio, for its innovative and cutting-edge characteristic in Brazilian dental research.

Is the Center open to new projects, from other teaching institutions? Dr. Maiolino Thomaz Fonseca Oliveira: More than possible, this is desired and stimulated. This is a public space, which is open to partnerships. Public or private institutions should only present themselves and aid to afford the expenses of developing the established projects. CPbio is also open to the provision of services to private companies that seek to certify and develop new products and obtain certification for entry into the domestic market. We have worked with several companies in the field of implants, surgery and dental materials.

Are you reference for other national and international research centers? Dr. Maiolino Thomaz Fonseca Oliveira: Yes, CPbio is currently a model research center concerning the physical space management and equipment sharing. There is no owner of any equipment, all are multi-user and available to anyone who wishes to be a partner. We have partnerships with several Brazilian universities from Northeast, South and Southeast states, including major institutions as USP and UNICAMP, which use our facilities to conduct studies. In addition, we have partnerships with universities in Belgium (KU Leuven), Sweden (Malmö University), United States (Health Center of University of Tennessee), Michigan University (Ann Arbor, Michigan), New York University (New York), Oregon University (Portland), University of Iowa (Iowa) and Canada, Dalhousie University (Halifax, NS). From them, projects in partnership and comprising mobility of investigators and students are routinely established. In the last four years, more than fifty papers have been published in high impact journals, according to CAPES, which leads us to an important and advanced internationalization process. Recently, the CPbio obtained approval, by FINEP, of the INCT seal (National Institute of Science and Technology). The process was coordinated by Prof. Dr. Carlos José Soares, in partnership with several other investigators from the state of Minas Gerais,

What are the next challenges? Prof. Dr. Carlos José Soares (coordinator of CPbio): The challenges are to strengthen the competence, acquiring new and important equipment, which change the competence level of the established research. The fragmentation of resources will not change the positioning of large research centers in Brazilian science. The hallmark of the group of researchers of the Oral and Maxillofacial Surgery and Traumatology, Prosthodontics, Implantology and Restorative Biomechanics of UFU is not limited to the distinguished physical space of CPbio. It is also established by the integrated and shared way of thinking, designing and developing cutting-edge research. The technical capacity of this group, whose trajectory has always been linked to continuing education in the different specialties, makes the research presently developed to establish in a greatly applicable manner, answering important questions that directly impact the quality of life of people. The challenges are constant and increasing, but spaces like these, opened by the Brazilian College of Oral and Maxillofacial Surgery and Traumatology, make it easier to overcome them with quality and efficiency.

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):14-7

Interview

Laser therapy in Oral and Maxillofacial Surgery Antônio Luiz Barbosa Pinheiro » Full Professor of the Dental School of the Federal University of Bahia. » Researcher 1B of CNPq. » Editor of J Photochem Photobiol B. » Head of the Biophotonic Center of FOUFBA.

Dr. Pinheiro, considering that you are a Brazilian professor with international highlight in Laser in Dentistry, what is the current stage of laser appliances? And which significant changes occurred in the last ten years? Knowing that you are specialist in both laser and maxillofacial surgery, what is the present and future of the application of surgical laser in the specialty?

The laser/LED technology has significantly evolved in the last 20 years, in all aspects. In Surgery, it has a broad utilization and may be divided in two large fields: the accomplishment of surgical procedures and phototherapy for the treatment of disorders in the maxillofacial complex. In the case of surgical procedures, we basically use the CO2 laser; however, the Er:YAG and Nd:YAG lasers may be used in some procedures. Concerning the phototherapies, we may use both lasers and LEDs. This group of procedures include the treatment of facial pains of several origins (Fig 1), neuromotor and neurosensorial disorders (Fig 2, 3), bone repair and, more recently, for the treatment of infections, by photodynamic, antimicrobial, antiparasitic and antifungal therapy. Of course, the reduction in the size of appliances in the last years facilitated their utilization in the clinics.

The surgical utilization of lasers is a reality. We have been performing these procedures for 20 years with high success rate and rare complications. It is important to consider the reduction of costs for the accomplishment of procedures for the patients and the very low rate of postoperative complications. Any procedure in soft tissue performed by conventional methods may also be performed using the CO2 laser. We emphasize that the availability of the appliance absolutely does not qualify the professional to performs surgical procedures, therefore professional training is mandatory.

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):18-9

Interview

Figure 1: Laser therapy application for temporomandibular dysfunction.

Figure 2: Laser therapy application for trigeminal neuralgia.

Figure 3: Laser therapy application in facial nerve paralysis.

Prof. Dr. Belmiro C. E. Vasconcelos

How to cite: Pinheiro ALB, Vasconcelos BCE. Entrevista com AntĂ´nio Luiz Barbosa Pinheiro: Laserterapia em Cirurgia Bucomaxilofacial J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):18-9. DOI: http://dx.doi.org/10.14436/2358-2782.3.1.018-019.oar

- Editor-in-chief of JBCOMS. - Associate Professor of the University of Pernambuco. - Coordinator of the Postgraduate Programs (PhD and MSc degrees) in Dentistry (Oral and Maxillofacial Surgery and Traumatology) of the University of Pernambuco.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Submitted: November 24, 2016 Revised and accepted: December 26, 2016

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):18-9

Original article

Assessment of two palatoplasty

techniques in patients with cleft palate ANDRÉIA FERREIRA RIBEIRO1 | MAGNO LIBERATO SILVA2 | FÁBIO RICARDO LOUREIRO SATO3 | ÉRICA CRISTINA MARCHIORI3 | ROGER WILLIAM FERNANDES MOREIRA4

ABSTRACT Objective: The aim of this study was to perform a comparative study of two palatoplasty techniques — Von Langenbeck e Veau-Wardill-Kilner —, evaluating the effectiveness of these techniques for the closure of cleft palates and hypernasality correction. Methods: Patients submitted to palatoplasty in the period of 2011 to 2014 by the Oral and Maxillofacial Surgery Service from ‘Hospital dos Defeitos da Face’ were selected and asked to return for a new evaluation. The records from the patients were compared regarding the number of surgeries performed, and the patients were submitted to physical exams to verify the presence of residual fistula and also asked about the improvement of the hypernasality. Results: From the total of patients submitted to surgery, 10 returned to evaluation, any with residual fistula, and the Von Langenbeck technique was effective for 67% of primary closure of the cleft palate, and the Veau-Wardill-Kilner for 50%. About the correction of the hypernasality, Von Langenbeck was effective for 67% and Veau-Wardill-Kilner for 75%. Conclusion: The Von Langenbeck technique was more effective for the primary closure of the cleft palate, while Veau-Wardill-Kilner was more effective to correct hypernasality. Keywords: Cleft palate. Palate, hard. Velopharyngeal insufficiency.

Residency in Oral and Maxillofacial Surgery and Traumatology, Santa Casa de Misericórdia de São Paulo. Fellowship at the Oral and Maxillofacial Surgery and Traumatology Service, Facial Defects Hospital of the Brazilian Red Cross.

How to cite: Ribeiro AF, Silva ML, Sato FRL, Marchiori EC, Moreira RWF. Avaliação de duas técnicas de palatoplastia em pacientes portadores de fissuras palatinas. J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):20-4. DOI: http://dx.doi.org/10.14436/2358-2782.3.1.020-024.oar

Resident in Oral and Maxillofacial Surgery and Traumatology, Facial Defects Hospital of the Brazilian Red Cross.

Submitted: August 03, 2015 - Revised and accepted: February 14, 2017

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

Preceptor of the Residency Service of the Facial Defects Hospital of the Brazilian Red Cross.

Head of the Oral and Maxillofacial Surgery and Traumatology Service, Facial Defects Hospital of the Brazilian Red Cross.

» Patients displayed in this article previously approved the use of their facial and intraoral photographs. Contact address: Fábio Ricardo Loureiro Sato Av. Moreira Guimarães, 699 - São Paulo/SP - Brasil CEP: 04.074-031 – Email: frlsato@uol.com.br

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):20-4

Ribeiro AF, Silva ML, Sato FRL, Marchiori EC, Moreira RWF

INTRODUCTION Cleft lip and palate is the most common congenital anomaly affecting the face, with approximately prevalence of 0.5 individuals among every 1,000 livebirths.1 This malformation may present several extents, involving the lip, palate, or both. Clefts affecting the lip usually present greater esthetic and social impact; however, cleft palate present the greatest functional involvement. The goals of palatoplasty, besides closing the oronasal communication, are to achieve intelligible speech, as close to normality as possible, and to avoid interference on maxillary growth (which in the future might lead to the need of orthopedic maxillary expansion followed by orthognathic surgery). During palatoplasty, it is fundamental to anatomically re-position the levator veli palatini muscle, which is inserted on the posterior margin of the hard palate, with longitudinally arranged fibers. The detachment of these fibers and repositioning in transverse direction, joining them with fibers from the other cleft side, allows the sphincteric and elevator function of the palatal muscle, which is necessary for oronasal occlusion.2 Several palatoplasty techniques have been described in the literature, and their selection is based on different criteria, including the cleft type and extent, and surgeonâ&#x20AC;&#x2122;s preference and technical skill. Among the palatoplasty techniques available, the two most used for individuals with cleft palate at the Oral and Maxillofacial Surgery and Traumatology Service, Facial Defects Hospital of the Brazilian Red Cross are the Von Langenbeck and Veau with Wardill-Kiner modification, alike other services in Brazil.3 The Von Langenbeck technique was initially described in 18614 and advocated the utilization of bi-pedicle mucoperiosteal flaps and is still the most employed palatoplasty technique (Fig 1 and 2). The

Veau palatoplasty with two flaps associated with pushback procedures with V-Y palatal elongation, as suggested by Wardill5 and Kilner,6 is also very popular, since it would theoretically reduce the possibility of velopharyngeal insufficiency (Fig 3 and 4). Though widely used, few studies so far have compared the effectiveness of both techniques for the cleft palate repair. Thus, this paper comprised a retrospective investigation of the effectiveness of these techniques concerning two criteria: presence of residual fistula and improvement of hypernasality, from the patientâ&#x20AC;&#x2122;s standpoint. METHODS Initially, the study surveyed records from patients submitted to palatoplasty at the Oral and Maxillofacial Surgery and Traumatology Service, Facial Defects Hospital of the Brazilian Red Cross, in the period 2011 to 2014. The patients were then recruited for evaluation, to analyze the presence of possible remaining oronasal fistulae, and were invited to subjectively evaluate the improvement in relation to hypernasality. RESULTS Among all patients operated in this period, 10 patients returned and were again analyzed by the investigators and asked about the improvement in velopharyngeal function. Among these 10 patients, 8 were females and 2 were males, with mean age 14 years and 5 months. Concerning the type of technique employed, 6 were Von Langenbeck and 4 Veau-WardillKilner (Table 1). No patient presented remaining fistulae after the surgical procedures. After analysis of records, it was observed that 6 patients presented complete cleft closure in the first surgery, and 4 required a second surgery, due to the persistence of oronasal fistula (Table 1).

Table 1: Timing of cleft palate repair, according to the surgical technique. Technique employed

Operated (total)

Single-stage repair

Two-stage repair

Veau-Wardill-Kilner Von Langenbeck TOTAL

4 patients 6 patients 10 patients

2 patients 4 patients 6 patients

2 patients 2 patients 4 patients

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):20-4

Assessment of two palatoplasty techniques in patients with cleft palate

Figure 1: Drawing of palatoplasty by the Von Langenbeck technique (1861).

Figure 2: Palatoplasty of complete cleft palate by the Von Langenbeck technique (1861).

Other studies in the literature also compared palatoplasty techniques. Williams et al.7 compared the Von Langenbeck and Furlow techniques, being that the latter adopts principles of z-plasty for soft palate elongation. This study also demonstrated lower occurrence of fistula after the first surgery by the Von Langenbeck technique (14%) compared to the Furlow technique (23%). However, similar to the present study, the improvement in hypernasality was greater in the group submitted to the Furlow technique (82%) compared to the group operated by the Von Langenbeck technique (71%). According to Chen et al.8, the palatoplasty techniques that employ the concepts of pushback for soft palate elongation have the advantage of better

When both techniques were compared in relation to the number of surgeries for cleft palate repair, it was observed that the Von Langenbeck technique presented better rate of closure in the first surgery (67%) compared to the Veau-Wardill-Kilner technique (50%). However, when asked about the improvement in hypernasality, 75% of patients operated by the VeauWardill-Kilner technique presented improvement, while this number was 67% for the Von Langenbeck technique. DISCUSSION This study evaluated two of the primary objectives of palatoplasty, namely closure of the oronasal communication and normal speech development.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):20-4

Ribeiro AF, Silva ML, Sato FRL, Marchiori EC, Moreira RWF

Figure 3: Drawing of palatoplasty by the Veau-Wardill-Kilner technique (1937).

Figure 4: Palatoplasty of complete cleft lip and palate by the Veau-Wardill-Kilner technique (1937).

CONCLUSIONS Based on the present results, the Von Langenbeck palatoplasty technique presents the lower risk of persistence of residual fistulae after the first surgery; however, the Veau-Wardill-Kilner technique is more effective for prevention of velopharyngeal insufficiencies.

outcomes in relation to correction of velopharyngeal insufficiency; however, since they yield greater stress on the tissues, they present higher risk of fistulae in the postoperative period. Lage et al.9 compared two palatoplasty techniques with concepts of pushback (Veau and Furlow) and demonstrated no difference between these techniques concerning the presence of postoperative complications. Similar outcomes comparing these two pushback techniques were also demonstrated by Paniagua et al.10

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):20-4

Assessment of two palatoplasty techniques in patients with cleft palate

References:

1. Murray JC. Gene/environment causes of cleft lip and/or palate. Clin Genet. 2002 Apr;61(4):248-56. 2. Berkowitz S. Cleft Lip and palate: diagnosis and management. [Berlin-Heidelberg]: Springer, 2013. 3. Paranaíba LMR, Almeida H, Barros LM, Martelli DRB, Orsi JD Jr, Martelli H Jr. Técnicas cirúrgicas correntes para fissuras lábio-palatinas em Minas Gerais, Brasil. Braz J Otorhinolaryngol. 2009;75(6):839-43. 4. Von Langenbeck B. Die uranoplastik mittelst ablosung des mucoes-periostalen gaumenuberzuges. Arch Klin Chir. 1861;2:205-87. 5. Wardill WEM. The technique of operation for cleft palate. Br J Surg. 1937;25:117-30. 6. Kilner TP. Cleft lip and palate repair technique. St Thomas Hosp Rep. 1937;2:127-31.

7. Williams WN, Seagle MB, Pegoraro-Krook MI, Souza TV, Garla L, Silva ML, et al. Prospective clinical trial comparing outcome measures between Furlow and von Langenbeck Palatoplasties for UCLP. Ann Plast Surg. 2011 Feb;66(2):154-63. 8. Chen PK, Wu JT, Chen YR, Noordhoff MS. Correction of secondary velopharyngeal insufficiency in cleft palate patients with the Furlow palatoplasty. Plast Reconstr Surg. 1994 Dec;94(7):933-41. 9. Lage RR, Ferreira BM, Nassif AD, Rodrigues HLR, Heitor BS. Complicações agudas em palatoplastias: estudo comparativo prospectivo entre as técnicas de Veau modificada e de Furlow. Rev Bras Cir Craniomaxilofac. 2010;13(3):139-42.

10. Paniagua LM, Collares MVM, Costa SS. Estudo comparativo de três técnicas de palatoplastia em pacientes com fissura labiopalatina por meio das avaliações perceptivo-auditiva e instrumental. Arq Int Otorrinolaringol. 2010;14(1):18-31.

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):20-4

Original Article

Surgical treatment of

central giant cell lesions ANDRÉ LUIS BIM1 | MATHEUS SPINELLA1 | CARLOS EDUARDO DE SOUZA1 | LILIANE J. GRANDO2 | JOSÉ NAZARENO GIL1

ABSTRACT The aggressive central giant cell granuloma is an neoplasm with unknown origin, which affects the jaws. The diagnosis is based on routine exams as uni or multiocular lesion. It can be associated to syndromes and endocrine changes. It is classified as aggressive and non-aggressive, based on clinic and radiographic features. The treatment can be pharmacologic or surgical, based on features like size, localization and behavior. Keywords: Giant cell. Neoplasm. Tumor.

Department of Oral and Maxillofacial Surgery and Traumatology of the University Hospital at the Federal University of Santa Catarina - Florianópolis/SC.

How to cite: Bim AL, Spinella M, Souza CE, Grando LJ, Gil JN. Tratamento cirúrgico de lesão central de células gigantes. J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):25-9. DOI: http://dx.doi.org/10.14436/2358-2782.3.1.025-029.oar

Department of Pathology, Federal University of Santa Catarina - Florianópolis/SC.

Submitted: November 24, 2014 - Revised and accepted: May 26, 2015 » 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: André Luis Bim Av. Vereador José Diniz, 3457, sala 401 – Campo Belo, São Paulo / SP E-mail: andreluisbim@hotmail.com

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):25-9

Surgical treatment of central giant cell lesions

INTRODUCTION The aggressive central giant cell granuloma (CGCG) affects mainly female individuals between the second and third decades of life, and the mandible is twice more affected than the maxilla.2,3 It presents as an expansive lesion with faster growth than benign tumors, radiolucent, uni or multilocular, usually larger than 5 cm, causing bone and tooth resorption, tooth displacement and paresthesia3. Imaging examinations as facial tomographies, and complementary analyses – such as blood test, serum calcium, parathormone, alkaline phosphatase and phosphate – aid the differential diagnosis between CGCG and brown tumor, cherubism, aneurysmal cyst and ameloblastoma. Its etiology is still unknown, and the inflammatory and neoplastic theories are the most accepted. Histological evaluations indicate greater number and size of giant cells, higher number of nuclei per cells, greater density and high mitotic activity.4 Immunohistochemical studies indicate that mono- and multinucleated cells present specific receptors for glucocorticoids and calcitonin, and greater presence of hematopoietic precursors, assuring greater vascular component and a more aggressive behavior.5 The treatment may be surgical and/or pharmacological, depending on the clinical evolution. Thus, this paper presents the aggressive characteristics of the lesion, as well as the protocol to be followed for differential diagnosis, complementary examinations and surgical treatment.

molars, slight root resorption and rupture of cortical plates. Laboratory examinations – including PTH, calcium, phosphate and alkaline phosphatase – were requested, to aid the differential diagnosis. The patient was submitted to incisional biopsy of the region, for anatomo-histopathological analysis. The diagnosis of central giant cell granuloma was concluded, followed by immediate intralesional application of 2 ml of solution containing triamcinolone 10 mg/ml, diluted at 1:1 in anesthetic solution, and 200 UI of calcitonin in nasal spray. After 40 days, there was intense growth, pain, tooth mobility, dysphagia and malodor, with significant change in facial asymmetry (Fig 1). Due to the different evolution and aggressive growth of the lesion, another facial tomograph was requested for prototyping and planning of tumor resection. The tomographic findings and clinical behavior of the lesion confirmed it was an aggressive variant, since it presented fast growth, rupture of cortical plates, root resorption and size larger than 5 cm (Fig 2). The hypothesis of tumor infection due to the multiple punctures was ruled out, considering the absence of phlogistic signs at the region. The patient was submitted to segmental resection of the lesion, with a 5-mm safety margin by submandibular access. The entire tumor was exposed, and the resection was performed using a reciprocating chainsaw. The spatial maintenance of bone margins was provided by rigid internal fixation using a 2.7 mm reconstruction plate, previously molded and stabilized with four screws on each end (Fig 2). After checking the occlusion, irrigation, hemostasis and placement of a drain, the surgical wound was primarily closed by planes using resorbable 4.0 polyglactin suture, and intradermal suture with resorbable monofilament suture. The patient was discharged one day after surgery and is under regular outpatient follow-up without any sign of relapse. The mandibular reconstruction was performed with iliac crest bone 18 months after resection, and dental implants were placed after 4 months. The patient continued follow-up at every six months, without signs of relapse.

CASE REPORT Female patient, aged 22 years, Caucasoid, without systemic co-morbidities, was referred to the outpatient Oral and Maxillofacial Surgery and Traumatology service of the University Hospital at the Federal University of Santa Catarina, for evaluation of unilocular lesion at the posterior mandibular region. The chief complaint was “lip numbness, pain and volume increase”. Clinical examination revealed an expansive lesion, small asymmetry, blurring of the buccal sulcus and tooth mobility. Tomographic examination evidenced a small unilocular lesion involving the

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):25-9

Bim AL,Â Spinella M, Souza CE, Grando LJ, Gil JN

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Figure 1: A, B) Forty days after initial consultation. C) Observe the indentations on the lesion and tooth displacement. D) Axial tomographic section, demonstrating a large tumor.

Figure 2: A) Lesion exposure after mandibular resection. B) 3D reconstruction, with load-bearing fixation with 2.7 mm titanium plate. C) Intraoral aspect, demonstrating good healing and keratinized mucosa. D) One-year postoperative follow-up, without lesion of the marginal mandibular nerve.

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):25-9

Surgical treatment of central giant cell lesions

Figure 3: A) Mandibular reconstruction with anterior iliac crest bone, submitted to greenstick fracture, for better adaptation. B) Follow-up panoramic radiograph 24 months after mandibular resection.

DISCUSSION First described by Jaffe,1 the LLCG predominantly affects children and young adults, with slight predilection for the female gender, and the mandible is twice more affected than the maxilla. Usually, 75% of cases occur before 30 years of age, with an average of 23 years.1,2,3 The radiographic findings may vary, causing doubts in relation to the differential diagnosis with other lesions. It may present as small unilocular radiolucent lesions, up to extensive multilocular lesions, with well or poorly defined margins.3,4 Chuong et al.5 were the first to distinguish between aggressive and non-aggressive variant, considering clinical and radiographic characteristics as pain, rapid growth, tumor larger than 5 cm, tooth resorption, tooth displacement, cortical plate perforation and high relapse. The lesion is classified as aggressive in the presence of three or more of the aforementioned criteria.2,5,6,7 One in each five cases of CGCG present clinical and radiographic characteristics compatible with the aggressive variant, which is more common in young patients.6 Regardless of the clinical behavior, the variants present the same histological aspects.5,7

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Immunohistochemical analyses revealed that both mononucleated and multinucleated cells present specific receptors for glucocorticoids and calcitonin. Studies demonstrate that the greater presence of hematopoietic precursors, such as glycoprotein CD34, indicates the presence of a greater vascular component and more aggressive behavior.2,7,8 Currently, CGCG may be treated by pharmacological therapies/intralesional corticoids, calcitonin applied subcutaneously or in nasal spray, and interferon alpha-2a; or surgically, with curettage associated with peripheral ostectomy or cryotherapy.6 The pharmacological therapy with corticoid was suggested by Jacoway in 1988, yet its mode of action is still not understood.2,8 The therapy comprises the application of triamcinolone 10 mg/ml diluted in anesthetic solution, at a ratio of 1:1m, and 2 ml of solution should be applied weekly at every 2 cm of lesion, for six weeks. However, there are not well-controlled and randomized studies evidencing statistically significant outcomes. The treatment with calcitonin was first described by Harris.6 It presents antagonistic function to parathormone, thus inducing calcium inflow to the bone with direct inhibition of osteoclasts. Several

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):25-9

Bim AL, Spinella M, Souza CE, Grando LJ, Gil JN

selecting the technique, and currently the most used are curettage and resections.5,6 The relapse rates for lesions treated by curettage vary from 16% to 49%.3,5,6 Aggressive lesions treated by curettage present extremely high relapse rate, reaching 70% of cases.6 Segmental resection is still the gold standard for cure. In a study on 18 patients with aggressive CGCG, treated with resection with 5-mm margin, only one patient presented relapse.2,9 However, ablative surgery is still extremely morbid, causing esthetic, functional and psychological damage to the patient.

papers using immunohistochemistry demonstrated, by specific markers, that multinucleated giant cells are osteoclasts that express receptors for calcitonin.8 It has been observed that some lesions do not respond to pharmacological therapy and follow their developmental process.2 It has been assumed that CGCG is a proliferative vascular lesion, or at least antiogenesis-dependent.2 The interferon alpha-2a is an antiviral and antiangiogenic drug used in the treatment of hemangiomas and several types of vascular tumors. It has been frequently cited as treatment for more aggressive lesions, interrupting the growth and reducing the lesion size. Additional surgical treatment is always necessary to achieve the cure.2 Currently, there are no known biological markers to predict the clinical behavior of the lesion. The standard histological techniques still cannot determine the prognosis of the lesion.5,7 Surgical treatment is still a therapeutic option for the cure of CGCG. However, some criteria – such as aggressiveness of the lesion, location, size and radiographic aspects – play a fundamental role in

CONCLUDING REMARKS The early diagnosis and treatment should be the main objective in the presence of a potentially aggressive lesion. The clinical and radiographic follow-up should not be neglected, and any sign of aggressive behavior should be immediately identified. The surgical therapy initiated at proper time favors a better prognosis, with possibility to reduce the morbidity and provide greater success in the physical and psychological rehabilitation of the patient.

References:

1. Jaffe HL. Giant-cell reparative granuloma, traumatic bone cyst, and fibrous (fibro-osseous) dysplasia of the jawbones. Oral Surg Oral Med Oral Pathol Oral radiol. 1953 Jan;6(1):159-75. 2. Kaban LB, Troulis MJ, Ebb D, August M, Hornicek FJ, Dodson TB. Antiangiogenic therapy with interferon alpha for giant cell lesions of the jaws. J Oral Maxillofac Surg. 2002 Oct;60(10):1103-11; discussion 1111-3. 3. Whitaker SB, Waldron CA. Central giant cell lesions of the jaws. A clinical, radiologic, and histopathologic study. Oral Surg Oral Med Oral Pathol. 1993 Feb;75(2):199-208. 4. Rawashdeh MA, Bataineh AB, Al-Khateeb T. Long-term clinical and radiological outcomes of surgical management of central giant cell granuloma of the maxilla. Int J Oral Maxillofac Surg. 2006 Jan;35(1):60-6.

5. Chuong R, Kaban LB, Kozakewich H, Perez-Atayde A. Central giant cell lesions of the jaws: a clinicopathologic study. J Oral Maxillofac Surg. 1986 Sept;44(9):708-13. 6. De Lange J, Van den Akker HP. Clinical and radiological features of central giant-cell lesions of the jaw. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005 Apr;99(4):464-70. 7. Ficarra G, Kaban LB, Hansen LS. Central giant cell lesions of the mandible and maxilla: a clinicopathologic and cytometric study. Oral Surg Oral Med Oral Pathol. 1987 July;64(1):44-9. 8. de Lange J, van den Akker HP, van den Berg H. Central giant cell granuloma of the jaw: a review of the literature with emphasis on therapy options. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007 Nov;104(5):603-15.

9. Bataineh AB, Al-Khateeb T, Rawashdeh MA. The surgical treatment of central giant cell granuloma of the mandible. J Oral Maxillofac Surg. 2002 July;60(7):756-61. 10. Kaban LB, Dodson TB. Management of giant cell lesions. Int J Oral Maxillofac Surg. 2006;35(11):1074-5.

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):25-9

Case Report

Mandible first

ABSTRACT This paper discusses, presenting a case report, the criteria that should be considered in the clinical decision regarding the surgical approach, initiating the procedure in the mandible or maxilla. Case report: 27-year-old female diagnosed as having vertical maxillary excess, anteroposterior mandible deficiency, and Angle Class II dental malocclusion. The patient was offered a bimaxillary orthognathic surgery. Due to the uncertainty in determining the centric relation of the patient, we chose to perform the procedure starting from the mandible. The surgical procedure was performed successfully, without trans and/or postoperative complications and all aesthetic-functional complaints of the patient were healed. Orthognathic surgery starting in the mandible has been presenting more common among surgeons. Despite having some specific indications, these are not strict and should be available within the surgical strategies of the maxillofacial surgeon. Keywords: Orthognathic surgery. Planning. Mandible.

Resident in Oral and Maxillofacial Surgery and Traumatology of the Clinics Hospital at the Federal University of Minas Gerais, Belo Horizonte - MG.

How to cite: Pinto Júnior AAC, Fonseca VJ, Cunha JF, Lehman LFC, Campos FEB, Castro WH. Cirurgia ortognática bimaxilar iniciando pela mandíbula. J Braz Coll Oral Maxillofac Surg. 2017 janapr;3(1):30-5. DOI: http://dx.doi.org/10.14436/2358-2782.3.1.030-035.oar

Preceptor of the Oral and Maxillofacial Surgery and Traumatology Service of the Clinics Hospital of UFMG. MSc in Stomatology by the Federal University of Minas Gerais - Belo Horizonte - MG.

Submitted: December 14, 2015 - Revised and accepted: May 17, 2016

Preceptor of the Oral and Maxillofacial Surgery and Traumatology Service of the Clinics Hospital of UFMG. PhD in Stomatology by the Federal University of Minas Gerais - Belo Horizonte - MG.

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

Preceptor of the Oral and Maxillofacial Surgery and Traumatology Service of the Clinics Hospital of UFMG. PhD in Dentistry by the Federal University of Minas Gerais - Belo Horizonte - MG.

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

Coordinator of the Oral and Maxillofacial Surgery and Traumatology Service of the Clinics Hospital of UFMG. PhD in Oral Pathology by the Federal University of Minas Gerais - Belo Horizonte - MG.

Contact address: Aécio Abner Campos Pinto Júnior Av. Prof. Alfredo Balena, nº 110, Santa Efigênia, Belo Horizonte/MG – CEP: 30.130-100 E-mail: aeciocampos@gmail.com

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):30-5

Pinto JĂşnior AAC, Fonseca VJ, Cunha JF, Lehman LFC, Campos FEB, Castro WH

INTRODUCTION The dentofacial-skeletal deformities (DFSD) affect a significant part of the world population. Considering the severity of these alterations, their treatment often requires a combination of orthodontic and surgical approaches, aiming to correct the masticatory, respiratory, articular and speech functional aspects of the individual. Also, these approaches aim to achieve harmonious dental and facial esthetics, providing psychosocial welfare to the patient.1 The orthognathic surgery (CO) is a modality of oral and maxillofacial surgery that aims at the treatment of DFSDs. This treatment has been increasingly searched by the patients, thus requiring professionals who perform this procedure to keep updated with the constant innovations.2 Great evolutions in OS have occurred in the last years, concerning the diagnosis, planning and accomplishment of surgical techniques. These advances include new diagnostic tools and development of rigid internal fixation (RIF) and the advent of new therapeutic approaches. For several years, in bimaxillary surgeries, the maxilla-first approach has been advocated. However, new concepts regarding the diagnosis, planning and surgical technique in these procedures have indicated a paradigm shift, with a mandible-first approach. Some authors have advocated this sequence for several situations.3-7 Thus, this paper reports the case of a patient treated by mandible-first bimaxillary OS, discussing the criteria that should be considered to adopt this sequence in bimaxillary surgery.

projection, mild paranasal deficiency, absence of maxillary cant, open nasolabial angle, lip incompetence (8 mm), gingival exposure of 5 mm when smiling, little chin projection, adequate mentolabial groove, well-positioned chin in relation to the lower lip, reduced chin-neck distance and open cervicofacial angle, mesial occlusion of canines and first molars, and overjet of 6 mm (Fig 1). The lateral cephalogram (Fig 2A) demonstrated incisor angulation in relation to the occlusal plane within normal standards and satisfactory dimensions of the upper airway. The panoramic radiograph and tomographic images did not reveal alterations in the mandibular condyles or other bone or dental pathologies. The patient was diagnosed with vertical maxillary excess, anteroposterior mandibular deficiency and Class II Angle dental malocclusion. The proposed treatment planning comprised orthodontic preparation aiming at bimaxillary OS for upper maxillary repositioning and mandibular advancement. During mounting of dental casts in the semiadjustable articulator, aiming at dental cast surgery (DCS), the centric relation (CR) could not be adequately determined. For this reason, it was decided to plan a mandible-first OS. The DCS was performed as usual, with mounting of two maxillary and one mandibular dental casts, on which the surgical guides were fabricated (Fig 2B, 2C). The surgical procedure was performed as planned and was uneventful. The planned movements could be achieved by the utilization of sagittal osteotomies in the mandibular ramus (SOMR) and Le Fort I (LFIO). The bone segments received rigid fixation in the new position with titanium plates and screws (2.0 mm system) (Fig 2D, 2E). The patient recovered uneventfully and, after three months of postoperative orthodontic treatment, the orthodontic appliance was removed. The treatment corrected the gingival smile, retrognathism, reduced chin-neck distance and open cervicofacial angle, mesial occlusion of canines and first molars, and increases overjet of 6 mm. The follow-up 12 months after surgery revealed stable occlusion, without complaints, and the patient was satisfied with the result achieved (Fig 3).

CASE REPORT A Caucasoid female patient aged 27 years attended the Oral and Maxillofacial Surgery and Traumatology Service of the Clinics Hospital of the Federal University of Minas Gerais, referred for evaluation of orthodontic-surgical treatment, presenting esthetic and functional complaints related to mandibular retrognathism, increased gingival exposure in smile and masticatory disorders. The patient did not report complaints related with the temporomandibular joint (TMJ). In facial and dental analysis, the patient exhibited Pattern II facial growth with proportional facial thirds, closed facial profile angle, adequate zygomatic

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):30-5

Mandible first orthognathic surgery

Figure 1: Preoperative images: A) right lateral view at rest; B) frontal view at rest; C) frontal view smiling; D) preoperative dental occlusion

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Figure 2: Preoperative planning and surgical procedure. A) Dental cast surgery: operated mandible, non-operated maxilla. Fabrication of intermediate surgical guide. B) Dental cast surgery: operated mandible and maxilla: final occlusion planned. C) Transoperative image: maxillomandibular fixation, with the fixated mandible and non-operated maxilla. D) Transoperative image: fixated maxilla.

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):30-5

Pinto JĂşnior AAC, Fonseca VJ, Cunha JF, Lehman LFC, Campos FEB, Castro WH

Figure 3: Postoperative images: A) right lateral view at rest; B) frontal view at rest; C) frontal view smiling; D) postoperative dental occlusion.

DISCUSSION The orthognathic surgery has bene greatly advanced along the years. One of the greatest advances was the introduction of rigid internal fixation (RIF), which allowed an extension of the surgical protocol used so far.5 For several years, the bimaxillary orthognathic surgery (OS) comprised a maxilla-first approach. However, some studies have suggested an inversion of this approach.3-8 The planning of OSs is based on accurate collection of clinical, radiographic and laboratory data from the patient. Borba et al.9 divided the parameters of mandibular positioning into centric occlusion (CO), maximum intercuspation (MI) and centric relation

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

(CR) and concluded that MI should not be used for interocclusal recording in the planning of OSs. The authors stated that most patients presented marked divergence between MI and CO, which may influence the outcome of planning. In these individuals, the mandible in CO is usually more posteriorly positioned, when compared to the MI position. These authors recommend that recording should be obtained in centric occlusion, which occurs when the teeth are in contact and the condyles are positioned in centric relation in the glenoid fossa.9 In the present case, the patient did not have any complaint related with the temporomandibular joint (TMJ); therefore, the achievement of CR and consequently of the CO relation were inaccurate.

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):30-5

Mandible first orthognathic surgery

The dental cast surgery (DCS) is a procedure that aims to simulate and reproduce the movements to be accomplished during OS. Based on this, the surgeon fabricates acrylic guides to transfer the laboratory-determined parameters during surgery. The DCS may be performed by several manners, by mounting the case in one or two maxillary and mandibular arches. In the present case, two maxillary and one mandibular dental cast were mounted on a semi-adjustable articulator. Several authors described their protocols for this laboratory process.3-5 The surgical protocol employed depends on each surgeon’s experience and skill, or even specific indications.3,6,10 Cottrell and Wolford3 advocate that mandible-first bimaxillary OS are more reliable, since they avoid stresses on a recently fixated maxilla – especially in cases of large mandibular advancement and/ or when the maxillary structure is fragile. Perez and Ellis6 discussed the main indications for the mandible-first surgery and reported the advantages of maxilla-first surgery in some cases. The advantages of the mandible-first surgery include: » Greater predictability in patients in which the CR may not be established. » Greater reliability in cases with questionable maxillary fixation (e.g. thin bone walls or maxillary segmentation).3,6 » In procedures comprising counterclockwise rotation of the maxillomandibular complex, the maxilla-first approach creates an anterior open bite that may remove the condyles from centric relation, and the intermediate splint would be very thick, complicating the transoperative maxillomandibular fixation (MMF).6,10

» Large bimaxillary advancements, especially in individuals with facial pattern II, may be more easily performed by the mandible-first approach. The MMF is impaired in the maxilla-first approach, due to the maxillomandibular discrepancy caused by the maxillary advancement, considering the unoperated mandible.6 » In cases of concomitant TMJ surgery, only one kit of instruments is used, and maintenance of a sterile surgical field is facilitated.3,6,10 » In cases of mandibular segmentation concomitantly with bimaxillary OS.10 For maxilla-first bimaxillary OSs, the mandible guides the maxillary positioning during its skeletal fixation. Therefore, for the correct treatment planning, the transoperative mandibular positioning should be the same as that established during DCS. The CR is the mandibular position of choice, because it may be reproduced transoperatively. In the present report, the mandible-first protocol was indicated due to the difficulty to achieve the CR in this patient during the laboratory stage of preoperative preparation. The disadvantages of this approach include the need of RIF in the mandible; occurrence of undesired segmentation (“bad split”) during sagittal osteotomy, in which the procedure should be interrupted in case the “bad split” may not be fixated;3,6 clockwise rotations of the maxillomandibular complex may yield anterior open bite by the mandible-first approach, complicating the procedure6. CONCLUDING REMARKS Mandible-first orthognathic surgery has bene increasingly frequent among surgeons. Despite some specific indications, these are not strict, and the technique should be available within the surgical strategies of the maxillofacial surgeon.

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):30-5

Pinto Júnior AAC, Fonseca VJ, Cunha JF, Lehman LFC, Campos FEB, Castro WH

References: 1. Arnett GW, McLaughlin RP. Planejamento facial e dentário para ortodontistas e cirurgiões-dentistas. São Paulo: Artes Médicas; 2004. 2. Araújo RZ, Pinto-Jr AAC, Leham LFC, Campos FEB, Cunha JF, Castro WH. Análise epidemiológica de 132 casos de cirurgia ortognática. J Braz Coll Oral Maxillofac Surg. 2015 Maio-Ago;1(2):30-5. 3. Cottrell DA, Wolford LM. Altered orthognathic surgical sequencing and a modified approach to model surgery. J Oral Maxillofac Surg. 1994 Oct;52(10):1010-20; discussion 1020-1. 4. Posnick JC, Ricalde P, Ng P. A modified approach to “model planning” in orthognathic surgery for patients without a reliable centric relation. J Oral Maxillofac Surg. 2006 Feb;64(2):347-56.

5. Sant’Ana E, Rodrigues MTV, Ferreira GR, Gurgel JA. Cirurgia ortognática de modelos: protocolo para mandíbula. Rev Dental Press Ortod Ortop Facial. 2007;12(5):151-8. 6. Perez D, Ellis E 3rd. Sequencing bimaxillary surgery: mandible first. J Oral Maxillofac Surg. 2011 Aug;69(8):2217-24. 7. Trevisiol L, D’Agostino A, Arnett GW, Nocini PF. The “mandible first” sequence in bimaxillary orthognathic surgery. J Cranio-Maxillofac Surg. 2006;34:15. Oral presentations. 8. Cottrell DA, Wolford LM. Altered orthognathic surgical sequencing and a modified approach to model surgery. J Oral Maxillofac Surg. 1994 Oct;52(10):1010-20; discussion 1020-1.

9. Borba AM, Ribeiro-Junior O, Brozoski MA, Cé PS, Espinosa MM, Deboni MC, et al. Accuracy of perioperative mandibular positions in orthognathic surgery. Int J Oral Maxillofac Surg. 2014 Aug;43(8):972-9. 10. Turvey T. Sequencing of two-jaw surgery: the case for operating on the maxilla first. J Oral Maxillofac Surg. 2011 Aug;69(8):2225.

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):30-5

Case Report

Oroantral fistula treatment

using palatal flap GUSTAVO BOEHMER LEITE1 | JOÃO MANOEL DE SOUZA MOTA2 | GUSTAVO GOMES NARDONE RODRIGUES1 | WAGNER HESPANHOL3 | MARIA APARECIDA DE ALBUQUERQUE CAVALCANTE4

ABSTRACT The objective of the present paper was to describe the application of a cleft palate repair technique in an oroantral communication treatment. A patient from an Oral Surgery department presented oroantral fistula in the midline palate after removal of a cystic lesion. The oroantral communication was closed using a modified palatal flap rotation. The use of this technique proved to be an effective treatment for this type of pathology. Keywords: Frontal sinus. Sinusitis. Oroantral fistula.

¹ Resident of the Oral Surgery Service, Hospital Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro/RJ - Brazil.

How to cite: Leite GB, Mota JMS, Rodrigues GGN, Hespanhol W, Cavalcante MAA. Tratamento de fístula bucossinusal com retalho palatino lateral. J Braz Coll Oral Maxillofac Surg. 2017 janapr;3(1):36-9. DOI: http://dx.doi.org/10.14436/2358-2782.3.1.036-039.oar

Specialization student in Oral and Maxillofacial Surgery, Federal University of Rio de Janeiro, Rio de Janeiro/RJ - Brazil.

Submitted: February 18, 2016 - Revised and accepted: November 29, 2016

Staff of the Oral Surgery Service, Hospital Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro/RJ - Brazil.

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

Head of the Oral Surgery Service, Hospital Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro/RJ - Brazil.

» Patients displayed in this article previously approved the use of their facial and intraoral photographs. Contact address: Gustavo Boehmer Leite Av. das Américas, 1155, sala 1210 – Barra da Tijuca, Rio de Janeiro/RJ – CEP: 22.631-000 E-mail: gustavoboehmer@gmail.com

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):36-9

Leite GB, Mota JMS, Rodrigues GGN, Hespanhol W, Cavalcante MAA

INTRODUCTION The maxillary sinuses are physiological cavities filled with air, lined by pseudo-ciliated stratified epithelium with mean volume of 15cm3. These anatomical structures are located laterally to the nasal cavity and present close relationship with the maxillary posterior teeth.1 The oroantral communication is defined as the space created between the maxillary sinus and the oral cavity. The chronification of this process occurs by migration of maxillary sinus epithelium toward the oral cavity through this communication. This condition is called oroantral fistula.2 The main etiologic factors include extraction of maxillary molars, pathologies, traumas and other oral surgeries.3 The routine radiographic findings include discontinuity of the sinus floor, sinus opacification, focal alveolar atrophy with associated periodontal disease. The utilization of antibiotics per se does not lead to closure of the communication, and surgical treatment is often performed for the closure of oroantral communication.4 Several surgical techniques have been described in the literature for the treatment of this pathology.2,5 Selection of the technique depends on the location and extent of the fistula or communication, availability of tissue for coverage and surgeon’s experience. The goal of surgery for treatment of such communication is to preclude the migration of maxillary sinus epithelium toward the oral epithelium, preventing the formation of a fistula and its consequences. When surgery is performed for fistula treatment, the goal is to eliminate the cause of chronic sinusitis, removing the epithelium from the fistula pathway and promoting closure of the communication between oral cavity and maxillary sinus, assuring normal ventilation and aeration.6

CASE REPORT Female patient, aged 36 years, Caucasoid, with history of surgery for removal of residual cyst at the anterior maxillary region six months earlier, confirmed by histological examination, attended the Oral Surgery service with complaint of difficulty to drink liquids and feed, because they would be expelled during ingestion. Clinical examination revealed a fistula close to the palatal midline (Fig 1). Radiographic examination evidenced thickening of the maxillary sinus mucosa and discontinuity of the maxillary sinus floor (Fig 2). As an approach for closure of the oroantral communication, preoperatively, the patient performed inhalation with nasal decongestant (Penetro Inalante, Laboratórios Daudt, Rio de Janeiro/RJ) once a day, at nighttime, for seven days; antibiotic therapy with amoxicillin 500mg, at every eight hours, for seven days; and mouthrinsing with 5 ml of 0.12% chlorhexidine digluconate (Rioquímica, São Paulo/SP), twice a day, for seven days. Due to the location and availability of tissue, it was decided to use the technique of lateral displacement of palatal tissue. The patient was operated under general anesthesia, with accomplishment of fistulectomy (surgical removal of the fistula epithelium), incisions parallel to the fistula, flap detachment and mobilization, and closure of the area by flap displacement and suture (Fig 3). Postoperatively, the patient received prescription of amoxicillin 500mg + potassium clavulanate 125mg, at every eight hours, for 15 days, besides anti-inflammatory and analgesics drugs and mouthrinse with 0.12% chlorhexidine digluconate solution (Rioquímica, São Paulo/SP). Regular follow-up revealed the evolution of palatal healing and absence of significant signs and symptoms, even after 36 months (Fig 4).

Figure 1: Clinical and radiographic aspect of oroantral fistula.

Figure 2: Panoramic radiograph evidencing lack of continuity of the right maxillary sinus floor.

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):36-9

Oroantral fistula treatment using palatal flap

Figure 3: Photograph after fistulectomy, tissue displacement toward the fistula, suture for closure and suture of parallel incisions. These areas heal by second intention. The dotted lines indicate the sites of incision. The tissue was detached, medially pulled and sutured for fistula closure.

Figure 4: 36-month postoperative follow-up, without signs of relapse.

DISCUSSION The literature reports several types of surgical procedures for the treatment of oroantral fistulas, including buccal flaps, rotated palatal mucosa flaps, trapezoidal flaps and pedicle flaps from the buccal fat pad.2,5 The buccal and trapezoidal flaps are simple to perform, with minimum postoperative pain and edema. The main disadvantage is the reduced vestibule depth. Also, the flap is relatively thin and contains little keratinized tissue, and manipulation at the third molar region may easily cause suture dehiscence.6 The pedicle flap from the buccal fat pad is an alternative for the closure of oroantral communication.7 The technique is not difficult to perform and presents a high success rate. The postoperative period with hematoma, edema, infection or even neurological lesion are some disadvantages.6 Other technique that may be used is the paddle-shaped flap,8 or its modifications.9,10 The main disadvantage is the great quantity of tissue available for closure. However, the disadvantages include the altered pathway of palatine artery and wound area with exposed bone. The palatal bone exposed in this technique is often related with painful symptomatology and extended healing period6.

Due to the location of the fistula in the present case, these techniques could not be applied, since it would not be possible to achieve tissue displacements until such region. The flap used in the present case was lateral displacement of palatal tissue, or modified von Langenbeck technique, which is commonly applied for the closure of small cleft palate.11 This type of flap presented to be useful for the closure of oroantral communication in such location.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

CONCLUDING REMARKS The simple closure of the oroantral fistula is not an indicator of success. Previous treatment of sinus disorders is fundamental. Specific antibiotics, instillation and inhalation, oral and sinus irrigations improve the sinus drainage and its clinical condition. Closure is only possible after this procedure, when the maxillary sinus presents clinically healthy without purulent exudate.

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):36-9

Leite GB, Mota JMS, Rodrigues GGN, Hespanhol W, Cavalcante MAA

References:

1. Kaufman E. Maxillary sinus elevation surgery: an overview. J Esthet Restor Dent. 2003;15(5):272-82; discussion 283. 2. Skoglund LA, Pedersen SS, Holst E. Surgical management of 85perforations to the maxillary sinus. Int J Oral Surg. 1983 Feb;12(1):1-5. 3. Rothamel D, Wahl G, d’Hoedt B, Nentwig GH, Schwarz F, Becker J. Incidence and predictive factors for perforation of the maxillary antrum in operations to remove upper wisdom teeth: prospective multicentre study. Br J Oral Maxillofac Surg. 2007 July;45(5):387-91. 4. Meirelles RC, Neves-Pinto RM. Oroantral fistula and genian mucosal flap: a review of 25 cases. Braz J Otorhinolaryngol. 2008 Jan-Feb;74(1):85-90. 5. Amaratunga NA. Oro-antral fistulae--a study of clinical, radiological and treatment aspects. Br J Oral Maxillofac Surg. 1986 Dec;24(6):433-7.

6. Salim MAA, Prado R, Gadioli B, AlmeidaTM. Tratamento de fístula buco-sinusal: revisão de literatura e relato de caso clínico. Rev Bras Odontol. 2008;65(1):101-5. 7. Horowitz G, Koren I, Carmel NN, Balaban S, AbuGhanem S, Fliss DM, et al. One stage combined endoscopic and per-oral buccal fat pad approach for large oro-antral-fistula closure with secondary chronic maxillary sinusitis. Eur Arch Otorhinolaryngol. 2016 Apr;273(4):905-9. 8. Ashley REA. A method of closing antroalveolar fistulae. Ann Otol Rhinol Laryngol. 1939;48:632-5. 9. Danieletto CF, Ferreira GZ, Luppi CR, Rosso K, Iwaki Filho L. Retalho palatino modificado para fechamento de fístula buconasal. J Braz Coll Oral Maxillofac Surg. 2016 Jan-Abr;2(1):38-43.

10. Kiran Kumar Krishanappa S, Prashanti E, Sumanth KN, Naresh S, Moe S, Aggarwal H, et al. Interventions for treating oro-antral communications and fistulae due to dental procedures. Cochrane Database Syst Rev. 2016 May 27;(5):CD011784. 11. Ruiz RL, Costello BJ. Reconstruction of cleft lip and palate: secondary procedures. In: Miloro M, Ghali GE, Larsen P, Waite P. Peterson’s principles of oral and maxillofacial surgery. 2nd ed. New York: Decker; 2004.

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):36-9

Case Report

Gummy smile:

botulinum toxin and gingival surgery IRINEU GREGNANIN PEDRON1

ABSTRACT In Dentistry, the search for aesthetic excellency is increasingly growing in our specialties. The beauty of the smile is not only related to the shape, position and color of the teeth, but also to the characteristics of the gingival tissue which should be as harmonious as the teeth. The gummy smile is one of the complaints from patients, and may influence the self-esteem and social relationship. The development of new techniques such as the application of botulinum toxin may be a therapeutic option in the treatment of gummy smile. The purpose of this paper is to report the case of a patient with dentogingival discrepancy and gummy smile, which was treated by means of gingival resection surgery and application of botulinum toxin. The gingival resection surgery promoted the correction of dental zenith, and the application of botulinum toxin favored the dehiscence of the upper lip and reduction of the gummy smile. The association between gingival resection surgery and application of botulinum toxin reduced the gummy smile, optimizing the harmony of the smile, and reaching satisfaction of patient and contributing to the her life quality. Keywords: Gingival overgrowth. Botulinum toxin, type A. Esthetics, dental.

MSc in Dental Sciences by FOUSP. Professor of the Course Toxina Botulínica em Odontologia - Bottoxindent/SP.

How to cite: Pedron IG. Sorriso gengival: toxina botulínica e cirurgia gengival. J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):40-4. DOI: http://dx.doi.org/10.14436/2358-2782.3.1.040-044.oar Submitted: July 24, 2015 - Revised and accepted: February 06, 2017 » 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: Irineu Gregnanin Pedron Rua Flores do Piauí, 508 - São Paulo/SP - CEP: 08.210-200 E-mail: igpedron@usp.br

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):40-4

Pedron IG

INTRODUCTION Currently, the search for esthetic procedures has been dramatically increasing. The dental and medical procedures, besides aiming at health promotion, also search to achieve the esthetics of smile, which is a means of communication and socialization that expresses several feelings.1,2 The facial esthetic harmony is directly related with the smile, which in turn is constituted by three components: teeth, gingiva and lips.1,2,3 The smile is esthetically pleasant when these teeth are in adequate proportion, and the gingival tissue exposure is limited to 3 mm. When the gingival exposure is greater than 3 mm, there is an unaesthetic condition called gummy smile, which psychologically affects some patients.4-7 Several therapeutic modalities have been proposed for correction of gummy smile, including gingivectomy or gingivoplasty,4,5,7 myectomy5,7 and orthognathic surgery,5,7,8 yet the two latter are more invasive procedures with high morbidity.6 Conversely, the utilization of botulinum toxin may be considered a therapeutic option to the surgical procedure, being a more conservative, effective, fast and safe method, when compared to surgical procedures.4,9 The botulinum toxin is synthesized by the anaerobic Gram-positive bacteria Clostridium botulinum,5,7,8 and acts inhibiting the release of acetylcholine at the neuromuscular junction, preventing muscle contraction. There are seven different serotypes of the toxin (A, B, C1, D, E, F and G). However, type A is the subtype most frequently employed in the clinics and is also the most powerful.5 Currently, botulinum toxin was shown to be effective in the treatment of gummy smile, in patients with hyperfunction of muscles involved in smile, as well as other disorders, such as temporomandibular dysfunctions (hypertrophy of the masseter muscle, nocturnal/ daytime bruxism) and myofascial pain.5,8 Thus, this paper reports the case of a patient with dentogingival discrepancy and gummy smile, which was treated by the association of gingival resection surgery (gingivectomy) and application of botulinum toxin.

Clinically, the patient presented anatomical discrepancy between the length of teeth #12 and #21 (compared to teeth #22 and #11, respectively), besides 3 mm of marked gingival exposure, characterizing the gummy smile (Fig 1 and 2A). Additionally, the anamnesis revealed inhibition and insecurity of the patient, as well as retention of the upper lip during smile, characterizing the dentogingival alteration and gummy smile as causes of introspection. The proposed treatment planning included gingival resection surgery (gingivoplasty) and application of botulinum toxin for correction of gummy smile. However, the patient was informed about the relapse of gummy smile six months after the application. Under local infiltrative anesthesia, gingival resection surgery was performed, and the bleeding points were determined using a periodontal probe. These points were joined by electrosurgery (BE 3000®, KVN, São Paulo, Brazil),1,2 only on teeth #12 and #21, according to the size and shape of teeth #22 and #11. The tooth length was increased, characterizing the dental zenith. Thereafter, scraping was performed, similar to the external bevel technique, aiming to enhance the tissue repair (Fig 2B). There was no need to use surgical dressing, since the wound heals by second intention. Postoperative prescriptions comprised only the association of analgesics and anti-inflammatories (ketorolac tromethamine, Toragesic® 10mg, EMS Sigma Pharma, São Paulo, Brazil). The patient did not report complaints or complications postoperatively. Botulinum toxin was applied in the same session. Before application, the skin surface was disinfected with ethanol to avoid local infection and remove the skin grease, and the points of application were marked beside each nostril. Thereafter, local anesthetics (Emla®, Astra, São Paulo, Brazil) was applied to provide comfort during the procedure. The botulinum toxin type A (Dysport®, Ipsen Biopharm Ltd., Wrexham, United Kingdom) was diluted in 1.7 ml of saline, according to the manufacturer’s guidelines, and two units were injected in the aforementioned site, laterally to each nostril. After application, the patient was instructed to avoid laying her head during the first 4 hours and to avoid physical activities during the first 24 hours after the procedure. After 14 days the patient was analyzed and presented uniform lower positioning of the upper lip (Fig 3). There were no reports of side effects or complaints.

CASE REPORT Caucasoid patient, of female gender, aged 25 years, attended a private clinic with complaint of gummy smile and dentogengival discrepancy in teeth #12 and #21 (Fig 1).

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):40-4

Gummy smile: botulinum toxin and gingival surgery

Figure 1: Patient presenting gummy smile.

Figure 3: Clinical aspect 14 days after application of botulinum toxin.

DISCUSSION Botulinum toxin has been an excellent auxiliary technique for the treatment of several dental disorders. Even though it is known by the cosmetic utilization for reduction of hyperkinetic facial lines, it may also be used for therapeutic purposes in patients with bruxism, temporomandibular dysfunction, masseter hypertrophy and marked gingival exposure,3-10 as in the present case. The gummy smile is defined as the exposure of more than 3 mm of gingival tissue during smile,4,6 and is often observed in females.9 The higher frequency in females may be explained by the fact that male individuals usually present a lower smile line.3,4 Several etiologies have been suggested for the gummy smile, including vertical maxillary excess,3-5,7,8 late passive eruption,3,5,6,8 hyperfunction of smiling muscles5,6,8 and reduced length of clinical crowns,1,2,6 which may occur individually or in combination, and determine the type of treatment to be performed.

Figure 2: Initial clinical aspect, evidencing anatomical discrepancy between the length of teeth #12 and #21 (A). Immediate postoperative aspect in teeth #12 and #21 (B).

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):40-4

Pedron IG

In the case of gummy smile caused by muscle hyperfunction, the application of botulinum toxin was indicated as first choice, due to the easy and safe application, fast effect and because it is a more conservative method compared to surgical procedures (myectomy or Le Fort I osteotomy).3-10 The smiling activity is determined by several facial muscles, such as the levator labii superioris, zygomaticus major and minor, levator anguli oris, orbicularis oris and risorius muscles.3-5,7-9 Among these, the three former play the major function and determine the extent of lip elevation, and thus they should be affected by the toxin injection. The fibers of these muscles converge to the same area, forming a triangle, suggesting that the adequate point of injection should include the three muscles in a single injection. When injected, the toxin may spread across an area of 10 to 30 mm, allowing an effective reach.3,4 The proposed site of injection was laterally to the nasal ala.3,7-9 When injected in predetermined sites, the toxin reduces the contraction of muscles in charge of upper lip elevation, reducing the gingival exposure.3-10 Each muscle involved in upper lip elevation plays a role during smile. The sites for injections are determined by the contraction of specific muscle groups, which yield different areas of gingival exposure. Several classifications have been proposed for gummy smile: anterior, posterior, mixed and asymmetric, involving different muscle groups.3,9 The anterior gummy smile should be treated by the conventional technique, with applications laterally to the nasal ala. In patients with posterior gummy smile, the application should reach the zygomaticus major and minor, with application of toxin in two different sites: at the point of greater contraction of the nasolabial groove during smile, and the second point at 2 cm laterally to the first, at the level of the tragus line. In patients with mixed gummy smile, the toxin should be applied in all aforementioned points. However, the dose should be reduced to 50% in the point lateral to the nasal ala.4 In cases of lip asymmetry, which occur due to differences in muscle activity,3 the patients should receive injections with different doses at each side of the face.4,9 The botulinum toxin type A is a hydrophilic powder, vacuum-stored, sterile and stable.5,7 It is reconstituted by mild injection of the diluent (0.9% sodium chloride) inside the flask; it should be stored at 2 to 8oC and be used in 4 to 8 hours to assure its efficacy.8

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

At treatment onset, extraoral photographs were obtained, including close up of the smile. Some authors mention the importance to achieve smiling photographs before and after toxin application.5,9,10 It has been suggested that the smiling photograph should be obtained by individually stimulating the muscles with an electric current, to assure controlled, accurate and reproducible muscle contraction, since the spontaneous smile is hardly replicated.10 The patients understand that the treatment is performed to achieve a different smile, and thus unconsciously tend to smile differently in photographs after treatment. The clinical effects appear in 2 to 10 days after injection, and the maximum visible effect occurs 14 days after the injection. 3,5 This first effect, which aims to be progressive, is also reversible, with approximate duration of 3 to 6 months.4,5,8 Even though the injection of botulinum toxin is a simple and safe procedure, it may be associated with some adverse effects, including pain at the site of injection, hematomas, infection, edema, dysphonia, dysphagia, ptosis or elongation of the upper lip and smile asymmetry. The dentist should be attentive to the posology, accuracy of the technique and location of puncture. 4,5,8,10 In the present report, there were no complaints or alterations caused by the application. The contraindications of utilization of botulinum toxin include pregnancy, breastfeeding, hypersensitivity (allergy) to the botulinum toxin, lactose and albumin; muscular and neurodegenerative diseases (myasthenia gravis and Charcot disease); and simultaneous utilization of aminoglycoside antibiotics, which potentiates the action of the toxin.8 In the present report, satisfactory result was achieved concerning the harmony of smile, by the association of gingival resection surgery and application of botulinum toxin type A. The establishment of isolated therapies might not provide the excellent outcome achieved. A priori, the creation of a new dental zenith during gingival resection surgery promoted a new dental outline, favoring the dentogingival and facial harmony. Subsequently, the application of botulinum toxin type A reduced the gummy smile, by the uniform lower positioning of the upper lip, also assigning mildness to the facial lines of smile, as observed in the nasolabial groove, adjacent to the nostrils, as compared to Figures 1 and 3.

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):40-4

Gummy smile: botulinum toxin and gingival surgery

CONCLUDING REMARKS The application of botulinum toxin is a less invasive, fast, safe and effective technique that produces harmonious and pleasant results when applied in target muscles (levator labii superioris, zygomaticus major and minor),

respecting the appropriate dose and type of smile. Despite the temporary effect for correction of gummy smile, the botulinum toxin is a useful complement for the esthetic improvement of smile and provides better outcomes when associated with gingival resection surgery.

References:

1. Pedron IG, Utumi ER, Tancredi ARC, Perrella A, Perez FEG. Sorriso gengival: cirurgia ressectiva coadjuvante à estética dental. Rev Odonto. 2010;18(35):87-95. 2. Pedron IG, Utumi ER, Silva LPN, Moretto EML, Lima TCF, Ribeiro MA. Cirurgia gengival ressectiva no tratamento da desarmonia do sorriso. Rev Odontol Bras Central. 2010;18(48):87-91. 3. Hwang WS, Hur MS, Hu KS, Song WC, Koh KS, Baik HS, et al. Surface anatomy of the lip elevator muscles for the treatment of gummy smile using botulinum toxin. Angle Orthod. 2009 Jan;79(1):70-7. 4. Mazzuco R, Hexsel D. Gummy smile and botulinum toxin: a new approach based on the gingival exposure area. J Am Acad Dermatol. 2010 Dec;63(6):1042-51.

5. Polo M. Botulinum toxin type A in the treatment of excessive gingival display. Am J Orthod Dentofacial Orthop. 2005 Feb;127(2):214-8. 6. Mangano A, Mangano A. Current strategies in the treatment of gummy smile using botulinum toxin type A. Plast Reconstr Surg. 2012 June;129(6):1015e. 7. Indra AS, Biswas PP, Vineet VT, Yeshaswini T. Botox as an adjunct to orthognathic surgery for a case of severe vertical maxillary excess. J Maxillofac Oral Surg. 2011 Sept;10(3):266-70. 8. Jaspers GWC, Pijpe J, Jansma J. The use of botulinum toxin type A in cosmetic facial procedures. Int J Oral Maxillofac Surg. 2011 Feb;40(2):127-33.

9. Sucupira E, Abramovitz A. A simplified method for smile enhancement: botulinum toxin injection for gummy smile. Plast Reconstr Surg. 2012 Sept;130(3):726-8. 10. Niamtu J 3rd. Botox injections for gummy smiles. Am J Orthod Dentofacial Orthop. 2008 June;133(6):782-3.

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):40-4

Case Report

Hyperbaric oxygen therapy and stereolithographic

ABSTRACT Defects caused by surgical treatment of tumors in the bones of the face can cause important sequelae to the patient. Reconstruction of segmental mandible defects after ablative tumor surgery remains a challenge for the maxillofacial surgeon. The association between autograft and hyperbaric oxygen therapy seems to be a good alternative for mandible defects reconstruction. This article describes an immediate mandible reconstruction associated with hyperbaric oxygenation A 70-year-old patient underwent mandible segmental resection due to a calcifying cystic odontogenic tumor, and primary reconstruction with iliac crest bone. The patient underwent 10 postoperative sessions of hyperbaric oxygen therapy. After 10 months the patient restored function and had no signal of tumor recurrence or surgical complications. Mandible bone reconstruction in association with hyperbaric oxygenation is an interesting alternative for the rehabilitation of mandible defects, providing life quality restoration. Keywords: Bone transplantation. Hyperbaric oxygenation. Mandibular reconstruction. Dental implants.

MSc and Specialist in Oral and Maxillofacial Surgery and Traumatology by the Brazilian College of Oral and Maxillofacial Surgery and Traumatology and Federal University of Uberlândia.

How to cite: Paiva LGJ, Karam FK, Paulo LFB, Oliveira MTF, Tavares LN, Zanetta-Barbosa D. Oxigenoterapia hiperbárica e prototipagem na reconstrução mandibular imediata. J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):45-9. DOI: http://dx.doi.org/10.14436/2358-2782.3.1.045-049.oar

Specialist in Implantology by ABO-Uberlândia. MSc in Integrated Dental Clinics, Federal University of Uberlândia.

Submitted: July 29, 2015 - Revised and accepted: February 16, 2017

PhD student in Integrated Dental Clinics, Federal University of Uberlândia. Resident in Oral and Maxillofacial Surgery and Traumatology, Federal University of Uberlândia.

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

PhD student in Oral and Maxillofacial Surgery and Traumatology, Federal University of Uberlândia.

MSc student in Integrated Dental Clinic, Federal University of Uberlândia.

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

Full Professor, Residency Program in Oral and Maxillofacial Surgery and Traumatology, Clinics Hospital, Federal University of Uberlândia.

Contact address: Luis Gustavo Jaime Paiva Av. Pará, nº 1720 - Bloco 4L - anexo B, sala 39 - Campus Umuarama - Uberlândia/MG CEP: 38.400-902 - E-mail: lg.jp@hotmail.com

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):45-9

Hyperbaric oxygen therapy and stereolithographic models in immediate mandibular reconstruction

CASE REPORT Female patient, aged 70 years, complained of a mild volume increase at the mandibular symphysial region for 6 months. The patient reported great discomfort during feeding and denied other systemic alterations. Extraoral examination revealed mild asymmetry on the left chin. The intraoral examination revealed expansive tumor at the mandibular symphysial region on the left side, without inflammation or infection. The panoramic radiograph revealed a radiolucent image with irregular borders, containing radiopaque regions. Tomographic examination evidenced expansion and destruction of the buccal and lingual bone plates at the mandibular symphysial region, as well as formation of mineralized material inside the lesion (Fig 1). The incisional biopsy was performed under local anesthesia for diagnostic confirmation, and histopathological examination revealed a calcifying cystic odontogenic tumor. The treatment comprised segmental mandibular resection under general anesthesia and primary reconstruction with autogenous graft from the iliac crest. Before surgery, mandibular prototyping of the patient was obtained from a computed tomography, to aid the pre-impression of the fixation material (2.4-mm profile reconstruction plate with locking system). By a submandibular access, tumor resection was performed, and a reconstruction plate was placed, acting as material for fixation of autogenous bone graft from the iliac crest, in the same surgical procedure (Fig 2). The hyperbaric oxygen therapy protocol comprised ten postoperative sessions at every two days, adding up to 20 days of hyperbaric oxygen therapy. Seven months after bone reconstruction, endosseous implants were placed and an immediate load implant-supported denture was placed (Fig 3). After 10-month postoperative follow-up, the patient did not present signs of tumor relapse or complications from the reconstructive procedure. The masticatory and speech functions and esthetics were restored at treatment completion.

INTRODUCTION The calcifying odontogenic cyst was first described by Gorlin et al.1, in 1962. Currently, the World Health Organization (WHO) defines it as a mixed odontogenic neoplasia, assigning the name calcifying cystic odontogenic tumor (CCOT).2 The CCOT may be subdivided in two variants, one cystic and one neoplastic, originated from remnants of odontogenic epithelium, which may present central occurrence, which is more common, or peripheral.2 The surgical treatment of tumors in the maxillofacial region may lead to large bone defects, causing functional (e.g. impairment of speech and feeding), esthetic (e.g. facial asymmetry) and psychological sequelae to the patient, directly affecting his or her quality of life.3 The mandibular bone reconstruction with utilization of autogenous grafts, especially from the iliac crest and fibula, is considered as gold standard due to the osteogenic, osteoinductive and osteoconductive properties of autogenous bone, and by the anatomical similarity between thee donor sites and the mandible.4,5 It is known that the larger the bone defect, the lower is the osteogenic and revascularization capacity of the grafted bone; thus, bone reconstruction of extensive mandibular defects is a challenging procedure.6-8 Currently, the hyperbaric oxygen therapy has been used in combination with non-vascularized bone reconstruction in mandibular bone defects, achieving high success rate in the rehabilitations.6,7,8 The hyperbaric oxygen therapy is indicated for the treatment of lesions with impaired vascularization, stimulating the angiogenesis and osteogenesis, enhancing the repair capacity of affected tissues. This therapy comprises the administration of 100% oxygen under an atmospheric pressure of 2.5 ATA (absolute atmosphere). The hyperbaric oxygen therapy sessions are conducted in containers, also called hyperbaric chambers, which may host one or several patients.6-8 Therefore, this paper presents a case of reconstructive treatment of a mandibular defect caused by resection of a CCOT, using prototyping and autogenous bone graft from the iliac crest associated with hyperbaric oxygen therapy, and posterior placement of dental implants and dentures.

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J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):45-9

Paiva LGJ, Karam FK, Paulo LFB, Oliveira MTF, Tavares LN, Zanetta-Barbosa D

Figure 1: Preoperative computed tomography and panoramic radiograph: radiolucent area with irregular borders, containing radiopaque areas. Observe the expansion and destruction of buccal and lingual cortical plates at the mandibular symphysial region.

Figure 2: A) Biomodel/prototype employed for impression of the fixation material. B, C, D) Transoperative aspect: segmental resection of the mandibular tumor and bone reconstruction.

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J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):45-9

Hyperbaric oxygen therapy and stereolithographic models in immediate mandibular reconstruction

Figure 3: Postoperative clinical and radiographic images. A) 7-month postoperative panoramic radiograph, demonstrating good positioning and volume of the bone graft. B) Panoramic radiograph after placement of endosseous implants. C, D) Placement of dental implants and occlusal rehabilitation with implant-supported denture.

DISCUSSION In some cases, the treatment of mandibular tumors involves bone resection, which may be marginal, when the mandibular base is maintained, or segmental, when there is complete discontinuity of the bone segments.3-8 The reconstruction of these mandibular defects is one of the most difficult tasks in Oral and Maxillofacial Surgery.3-8 The mandibular reconstruction methods include microvascular bone graft, free bone graft, distraction osteogenesis and utilization of bone substitutes, such as the recombinant human Bone Morphogenetic Protein â&#x20AC;&#x201C; 2 (rhBMP2).3-8 Concerning the segmental mandibular defect, the challenge of reconstruction is related to the selection and optimization of available techniques, to produce the best functional and esthetic outcome to the patient. The literature disagrees concerning the ideal moment for bone reconstruction.9 Authors who perform secondary/late reconstruction report lower risk of relapse and especially lower possibility of intraoral contamination of the graft by salivary bacteria, which

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would increase the failure rate.9 Authors performing primary/immediate reconstruction report smaller cicatricial shrinkage, offering greater quantity and better quality of soft tissue to line and nourish the grafted bone tissue.9 The procedure also allows lower morbidity, because of the need of a single surgical procedure, and avoids functional and esthetic sequelae while the patient is waiting for reconstruction, such as in cases of secondary reconstruction.9 Some authors also mention, as advantages of primary reconstruction, the lower possibility of fracture exposure of fixation materials and screw loosening, since part of the material would not be supported by bone contact. In the present case, it was decided to perform immediate bone reconstruction due to the absence of teeth, which reduces the risk of intraoral contamination, and due to the reduced size of the lesion.9 The bone graft employed was obtained from the iliac crest and, as reported in the literature, it provided adequate anatomy for the defect, due to its natural curvature, besides abundant vertical and horizontal bone tissue.4,5

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):45-9

Paiva LGJ, Karam FK, Paulo LFB, Oliveira MTF, Tavares LN, Zanetta-Barbosa D

and frequency of sessions required to achieve results from this therapy. Investigations on the ideal number of sessions, both pre and postoperatively, should be conducted to elucidate the sufficient number of sessions to optimize the incorporation of grafted bone tissue.6-8 The high cost of hyperbaric oxygen therapy is still limiting in the application of this treatment, which is usually not available by the Brazilian Public Health System. In the present case, ten postoperative sessions were performed, a lower number compared to other studies;6,8 however, the number of sessions corresponds to that allowed by the Public Defense Section of the State of Minas Gerais, to be performed in a private clinic, since this procedure is not available in public services. The improved vascularization of the grafted tissue implies smaller resorption of the bone graft, which provides better maintenance of tissues that may eventually receive dental implants. The hyperbaric oxygen therapy associated with mandibular bone reconstructions is an interesting option for rehabilitation, since it provides maintenance of the grafted bone volume, favoring the placement of dental implants and providing better quality of life for the patients.

Three-dimensional models created by milling machines and stereolithography, based on computed tomography images, are important for preoperative diagnosis and planning in some oral and maxillofacial procedures.10 The biomodels/prototypes fabricated aid the pre-impression of the fixation material before surgery, reducing the operative time and providing an anatomically adapted fixation plate.10 In the present case, a prototype of the patient’s mandible was fabricated for that purpose, facilitating and optimizing the surgical procedure. Mandibular bone defects larger than 9 cm pose greater risk of failure when non-vascularized grafts are employed.4-9 It is known that, after accomplishment, the bone graft presents a hypoxic state in relation to other body tissues.6-8 This hypoxic state allows the effective action of hyperbaric oxygen therapy, thanks to hyperoxygenation of all body tissues, which stimulates the collagen synthesis and boosts the angiogenesis and osteogenesis, favoring the graft incorporation, by increasing the vascularization and reducing the resorption potential, besides stimulating the leukocyte activity and presenting bactericidal and bacteriostatic effects.6,7,8 There are few studies on the quantity

References:

1. Gorlin RJ, Pindborg JJ, Clausen FP. The calcifying odontogenic cyst--a possible analogue of the cutaneous calcifying epithelioma of Malherbe. An analysis of fifteen cases. Oral Surg Oral Med Oral Pathol. 1962 Oct;15:1235-43. 2. Tomich CE. Calcifying odontogenic cyst and dentinogenic ghost cell tumor. Oral Maxillofac Surg Clin North Am. 2004;16:391-7. 3. Pogrel MA, Schmidt BL. Reconstruction of the mandibular ramus/condyle unit following resection of benign and aggressive lesions of the mandible. J Oral Maxillofac Surg. 2007 Apr;65(4):801-4. 4. Peled M, El-Naaj IA, Lipin Y, Ardekian L. The use of free filular flap for functional mandibular reconstruction. J Oral Maxillofac Surg. 2005 Feb;63(2):220-4.

5. Kademani D, Keller E. Iliac crest grafting for mandibular reconstruction. Atlas Oral Maxillofac Surg Clin North Am. 2006 Sept;14(2):161-70. 6. Oliveira MT, Rocha FS, de Paulo LF, Rodrigues AR, Zanetta-Barbosa D. The approach of ameloblastoma of the mandible: a case treated by hyperbaric oxygen therapy and bone graft reconstruction. Oral Maxillofac Surg. 2013 Dec;17(4):311-4. 7. Salgado CJ, Raju A, Licata L, Patel M, Rojavin Y, Wasielewski S, et al. Effects of hyperbaric oxygen therapy on an accelerated rate of mandibular distraction osteogenesis. J Plast Reconstr Aesthet Surg. 2009;62(12):1568-72.

8. Oliveira MTF, Paulo LFB, Rodrigues AR, Mendonça LS, Zanetta-Barbosa D. Oxigenoterapia hiperbárica associada a reconstrução mandibular. J Braz Coll Oral Maxillofac Surg. 2015;1(1):46-52. 9. Schlieve T, Hull W, Miloro M, Kolokythas A. Is immediate reconstruction of the mandible with nonvascularized bone graft following resection of benign pathology a viable treatment option? J Oral Maxillofac Surg. 2015 Mar;73(3):541-9. 10. Peckitt NS. Stereoscopic lithography: customized titanium implants in orofacial reconstruction. Br J Oral Maxillofac Surg. 1999 Oct;37(5):353-69.

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):45-9

Case Report

Calcifying cystic

odontogenic tumor: case report CARLOS ALBERTO MEDEIROS MARTINS1 | ANA CLÁUDIA FARIAS ANHALT2 | FERNANDO VACILOTTO GOMES3

ABSTRACT The oral cavity can present a lot of cysts and odontogenic tumors in various structures composing it. One of them, the calcifying cystic odontogenic tumor (CCOT), represents approximately 2% of these injuries. CCOT usually affects Caucasian, young adults in the third and fourth decades of life with no gender preference. Due to the absence of painful symptoms, the patient does not notice changes and can overlook some research on local involvement. Radiographs or CTs are essential for the diagnosis and the surgical treatment with enucleation; histopathological and immunohistochemical tests are performed after the lesion removal for final diagnosis. The purpose of this article was to present a case report in which the patient was stricken with TOCC associated with a retained canine in the left jaw. Another important aspect is the discussion of the difficulty in diagnostic, due to the differences between histopathological and immunohistochemistry results. Keywords: Odontogenic cyst, calcifying. Odontogenic tumors. Jaw.

Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, RS, Brazil.

How to cite: Martins CAM, Anhalt ACF, Gomes FV. Tumor odontogênico cístico calcificante: relato de caso. J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):50-6. DOI: http://dx.doi.org/10.14436/2358-2782.3.1.050-056.oar

Federal University of Pelotas, Pelotas, RS, Brazil.

Professor of Specialization in Implantology, Associação Gaúcha de Ortodontia (AGOR), RS, Brazil.

Submitted: January 16, 2016 - Revised and accepted: February 16, 2017 » 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: Fernando Vacilotto Gomes Rua Manduca Rodrigues 500/403 - Centro, Sant’Ana do Livramento, RS - Brasil CEP: 97.573-560 - E-mail: fernandovg2005@yahoo.com.br

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):50-6

Martins CAM, Anhalt ACF, Gomes FV

INTRODUCTION The oral cavity may present several odontogenic cysts and tumor in its several structures, complicating the diagnosis by the general dentist. 1 One such lesion whose diagnosis may be confounded with several other pathologies is the calcifying odontogenic cyst, which was thus named in its first description. 2 The World Health Organization (WHO) defined this pathology as a new clinical disorder, which may be associated with odontomas, ameloblastomas or impacted teeth, and is currently named calcifying cystic odontogenic tumor (CCOT). 3 The clinical characteristics of CCOT are very similar to the odontogenic cysts in general, impairing the diagnosis without histopathological examination. 4 Thus, this tumor is manifested as a painless, slow-growing lesion, which equally affects the maxilla and mandible, with predilection for the anterior segment. 5 It occurs predominantly in young adults in the third and fourth decades of life, without gender predilection, accounting for 2% of odontogenic tumors, thus being a rare disorder. 6,7 Radiographically, the CCOT is not very peculiar, presenting a radiolucent unilocular structure, which may be multilocular in some cases. 5,8 It presents a radiopaque halo with well-defined borders, usually associated with odontomas, ameloblastomas, impacted teeth or other odontogenic tumors of the maxillomandibular complex. 5 The tomographic examination also demonstrates similar characteristics; it is not expansive, does not cause tooth mobility or lack of pulp sensitivity in affected teeth.5,7,8 The lesion is usually diagnosed by imaging examinations due to the lack of exfoliation of some deciduous tooth, which is retained beyond its period of permanence in the mouth.4,5,8 The histological characteristics of CCOT demonstrates a cystic cavity with fibrous lining capsule containing odontogenic epithelium, besides typically exhibiting variable quantity of non-nucleated aberrant epithelial cells, called ghost cells. 5-9 Similarly, it may present dysplasia dentin and occasional association with an area of hard dental tissue, similar to an odontoma.5-10 The treatment of choice for this type of lesion is complete enucleation and combined removal of impacted teeth affected or associated odontomas, which should later be sent to histopathological examination.5,9 There are reports in the literature

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or marsupialization in cases of lesions with large volumes, in which the remaining bone defect may suffer fracture or difficult repair, depending on the location. 5,9 Thus, this paper presents the case of a patient affected by CCOT associated with an impacted canine on the left maxilla. Another important aspect is discussing the diagnostic difficulty of the present case, due to the difference between histopathological examination and immunohistochemistry. CASE REPORT Anamnesis Male patient, aged 19 years, Caucasoid, attended a private dental clinic after referral from the general dentist. During anamnesis, the patent did not report any systemic alterations or routine utilization of drugs. He had been referred by the clinician due to retention of tooth #63 after 18 years of age. A panoramic radiograph was requested and revealed the presence of impaction of tooth #23 (permanent maxillary left canine) associated with a radiolucent lesion of significant size. Clinical examination evidenced retention of tooth #63, slight volume increase on the buccal region on the apex o this tooth, absence of overt infectious or inflammatory process, as well as any periodontal alteration in the maxillary or mandibular alveolar ridges (Fig 1). During palpation of the region, the patient did not report any painful symptomatology, there was no exudate of pus or citrine liquid, as well as absence of fistula in loco. Pulp sensitivity testing was performed, which revealed vitality of teeth affected by the lesion, namely teeth #22, #24, #25 and #26. Blood tests did not reveal evidences of systemic alterations in either red or white blood cells or blood clotting tests. Imaging examination comprising panoramic radiograph and cone beam computed tomography (CBCT) revealed impaction of tooth #23 in horizontal position, immediately below the nasal floor ono the left side, above the tooth apices in the left maxillary alveolar ridge. There was also a small radiolucent halo around the crown of tooth #23 and a large radiolucent area of 2cm x 4cm extending from the cementoenamel region of tooth #23 toward its apex, contouring the roots of teeth #22 to #26. The lesion was not multilobular, there was no periapical alteration

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Calcifying cystic odontogenic tumor: case report

in the other teeth, and all other teeth were properly positioned. The tomography did not reveal expansive increase that might cause rupture of the buccal plate, nor communication with the nasal cavity. Surgical procedure After antisepsis of the perioral region with 0.2% chlorhexidine digluconate and strong mouthrinsing with 0.12% chlorhexidine digluconate for one minute, regional anesthesia was performed with 2% articaine with 1:100,000 epinephrine, applied on the left maxillary alveolar ridge, in both buccal and palatal sides. An angular flap was raised and mucoperiosteal detachment was performed from tooth #27, with a mesial releasing incision on the anterior midline, on the upper lip frenum. After location and probing of tooth #23, ostectomy was performed to expose the crown of this tooth. Thereafter, the lesion was exposed along the buccal plate and its detachment was initiated, avoiding rupture of the lining capsule. Complete enucleation of the lesion was then performed, tooth #23 was extracted and sent to histopathological and immunohistochemistry analyses. Simple sutures were made with polyglactin 910 suture, which were removed after 14 days. Postoperative prescription comprised amoxicillin 500mg at every 8 hours for 7 days, nimesulide 100mg at every 12 hours for 3 days, acetaminophen 750mg at every 6 hours for 3 days, and 0.12% chlorhexidine digluconate mouthrinse at every 12 hours for 7 days, as well as care during feeding and rest for a period of 72 hours. Follow-up after 14 and 45 days demonstrated adequate patient recovery and good repair of affected tissues (Fig 2).

Histopathological examination The macroscopic examination revealed a cystic structure with approximately 2cm x 4cm of length, containing the tooth. The histopathological diagnosis included the possibility of an adenomatous odontogenic tumor, thus immunohistochemistry was then indicated to refine the investigation and provide a more accurate diagnosis (Fig 3).

Figure 1: A) Clinical examination demonstrating the initial occlusion of the patient, evidencing anterior open bite and posterior crossbite on the left side, and presence of tooth #63 with consequent absence of tooth #23. It was not possible to observe significant increase in volume in these regions. B) Panoramic radiograph demonstrating impaction of tooth #23, retention of tooth #63, presence of radiolucent lesion from the mesial aspect of tooth #22 to the mesial aspect of tooth #26, with evident radiolucent halo. Also, the crown of retained tooth #23 presented thickening of the pericoronal follicle at a different site than the lesion. C) Sagittal section revealing positioning of impacted tooth #23 associated with the lesion, and proximity with important structures as the maxillary sinus and nasal floor; and parasagittal section presenting impaction of tooth #23, the associated lesion and small calcifications inside the lesion.

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J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):50-6

Martins CAM, Anhalt ACF, Gomes FV

Figure 2: Surgery under local anesthesia, in outpatient surgery clinic. A) Wide surgical access with mesial releasing incision and mucoperiosteal detachment, ostectomy on the lesion region until exposure of the fibrous capsule. B) Careful curettage, attempting to maintain the integrity of the lesion capsule. C) Enucleation of lesion associated with tooth #23. D) Completely removed lesion.

Immunohistochemistry The results of immunohistochemistry analysis, which involved the 2cm x 4cm soft tissue structure and the related tooth, revealed cystic lesion characterized by a cavity lined by pavement stratified epithelium, with atrophic and hyperplastic areas. The epithelium and connective tissue exhibited groups

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of ghost cells, individually or concentrically grouped, some with mineralization. The basal layer of the lining epithelium exhibited ameloblastoma-like morphology. Immunohistochemistry revealed expression of cytokeratin and protein p63. The findings favored the diagnosis of calcifying cystic odontogenic tumor.

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Calcifying cystic odontogenic tumor: case report

Figure 3: A) Image of histopathological examination (400X). B) Immunohistochemical examination (400X), evidencing the expression of cytokeratin and protein p63, characteristics of calcifying cystic odontogenic tumor.

DISCUSSION The calcifying cystic odontogenic tumor is an uncommon lesion, first described by Gorlin et al. 2, in 1962. Since its discovery, this condition received different nomenclatures, being named Gorlin cyst, calcifying odontogenic cyst and ghost cells calcifying odontogenic cyst. 2 Finally, this lesion was classified as odontogenic tumor in 2005 by the WHO.2-4 The demographic aspects demonstrate that the CCOT represents approximately 2% of odontogenic tumors, occurring more frequently at the anterior maxillary and mandibular regions, especially affecting the incisors and canines. 10,11 A high percentage (62%) presents this pathology in Caucasoid young adults, usually in the third and fourth decades of life, without gender predilection. 9-11 The clinical characteristics of CCOT are similar to odontogenic tumors and cysts, in which the absence of painful symptomatology may preclude the patient from observing alterations, consequently neglecting investigation of the affected site. 12-14 The main characteristic to be observed, in general, is the absence of some tooth in the affected region, when there is alteration in the conventional eruption process. 10,15 Usually there is no association with infection or localized inflammation, and the expansion of

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

alveolar ridges is only observed in vert large lesions, thus not being a common feature.1-3 This type of lesion usually presents characteristics of developmental tumors, being more easily observed in imaging examination. 3-5 The present case presented several of these features, in which the pathology was only diagnosed after routine radiographic examination, on the panoramic radiograph.7-10 The patient did not report significant painful symptomatology, nor alterations in tooth or tissue color, nor tooth mobility or occlusal alterations. 4-6,8 Percussion, apical pressure and pulp sensitivity testing were performed and did not reveal significant alterations in the affected teeth. The retention of tooth #63, deciduous maxillary left canine, was observed. 4-6,8 Usually, the CCOT is discovered after dental imaging examinations, usually on routine evaluations. 7-9 Currently, besides conventional radiographs usually requested in orthodontic record taking, such as panoramic radiograph and lateral cephalogram, the cone beam computed tomography may also be requested, which allows evaluation in axial, coronal and sagittal directions, allowing a more accurate diagnosis and facilitating the location of the lesion during surgery. 7-9 In the present case, the first examination requested was panoramic radiograph, due

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Martins CAM, Anhalt ACF, Gomes FV

the possibility of an adenomatous odontogenic tumor, exhibiting some histological aspects similar to this pathology; however, the same report indicated a complementary assessment by immunohistochemistry, which revealed the final diagnosis of CCOT. There is disagreement in the literature concerning the treatment of CCOT, regarding a single approach, if possible, allowing complete enucleation of the lesion. 10-15 There are reports of lesions in children or cases of extremely large lesions, in which the treatment of choice is marsupialization, which takes nearly 2 to 6 months until substantial regression of the lesion size to allow a second approach for complete enucleation, when associated with other pathologies such as odontoma or other odontogenic tumors.7-9 There is history of relapse after treatment in both short and medium term, yet this is rare. 7-9 In the present case, due to the location and size of the lesion and its association with an impacted tooth without indication for orthodontic treatment, the preferred approach was the most described in the literature, i.e. complete enucleation of the lesion with simultaneous extraction of tooth #23. This report presents a rare lesion of CCOT associated with an impacted tooth, which was discovered after achievement of a panoramic radiograph. The report evidences the difficulty to achieve a final diagnosis, which was provided by immunohistochemical analysis, with a different outcome compared to histopathological examination. Thus, it was concluded that an interdisciplinary approach is fundamental between the general dentist, maxillofacial surgeon, radiologist and pathologist, in which the deep analysis of all clinical, imaging and histological aspects led to the final diagnosis, thus allowing treatment and a more accurate analysis of the prognosis.

to the easy and fast achievement, which allowed fast diagnosis about the absence of a permanent tooth and retention of the respective deciduous tooth. Thereafter, a CBCT was requested for a more specific investigation of the lesion associated with tooth #23 and important anatomical structures, which revealed close relationship with the nasal floor and lateral wall, contouring the roots of teeth #22, #24, #25, #26 and maxillary sinus floor, without communication with any of these structures. Usually, as in the present case, the lesion may be associated with impacted teeth and present as a unilocular cyst with a radiopaque halo contouring the tumor, with presence of radiopaque bodies representing 50% of investigated cases. In other situations, there is possibility of mutual involvement between the CCOT and odontogenic cysts, odontomas and other benign tumors of the maxillomandibular complex.1-6 The histological aspect of CCOT is very characteristic, allowing a more accurate diagnosis by the presence of some specific cells. The basal layer of the epithelium presented cuboid or cylindrical hyperchromic cells, very similar to ameloblasts. 10-15 The overlying layer contained loosely arranged angulated cells, with a similar aspect as the stellate reticulum of the enamel organ. 10-14 The epithelium exhibited eosinophilic and non-nucleated cells called ghost cells, which develop from degeneration caused by coagulation necrosis.10-14 The presence of basophilic calcifications within the epithelium and ghost cells is also an important characteristic for the definitive diagnosis of the lesion. 7-9 In the reported case, there was discordance between histopathological and immunohistochemical analyses, presenting similar histological characteristics, yet with different diagnosis. The histopathological examination evidenced

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Calcifying cystic odontogenic tumor: case report

References:

1. Guimarães DM, Antunes DM, Saturno JL, Massuda F, Paiva KB, Nunes FD. Immunohistochemical expression of WNT5A and MMPs in odontogenic epithelial tumors and cysts. Acta Histochem. 2015 Oct;117(8):667-74. 2. Gorlin RJ, Pindborg JJ, Clausen FP, Vickers RA. The calcifying odontogenic cyst: a possible analogue of the cutaneous calcifying epithelioma of Malherbe: An analysis of fifteen cases. Oral Surg Oral Med Oral Pathol. 1962;15(10):1235-43. 3. Pindborg JJ, Kramer IRH, Torloni H. Histologic typing of odontogenic tumours, jaw cysts and allied lesions. 1st ed. Geneva: World Health Organization; 1971. 4. Khandelwal P, Aditya A, Mhapuskar A. Bilateral calcifying cystic odontogenic tumour of mandible: a rare case report and review of literature. J Clin Diagn Res. 2015 Nov; 9(11): ZD20–ZD22. 5. Phulambrikar T, Vilas Kant S, Kode M, Magar S. Cone Beam Computed Tomography findings in calcifying cystic odontogenic tumor associated with odontome: a case report. J Dent (Shiraz). 2015;16(4):374-9.

6. Tarakji B, Ashok N, Alzoghaibi I, Altamimi MA, Azzeghaiby SN, Baroudi K, et al. Malignant transformation of calcifying cystic odontogenic tumour: a review of literature. Contemp Oncol (Pozn). 2015;19(3):184-6. 7. Masuda K, Kawano S, Yamaza H, Sakamoto T, Kiyoshima T, Nakamura S, et al. Complete resolution of a calcifying cystic odontogenic tumor with physiological eruption of a dislocated permanent tooth after marsupialization in a child with a mixed dentition: a case report. World J Surg Oncol. 2015;13:277. 8. Radheshyam C, Alokenath B, Kumar H, Abikshyeet P. Calcifying cystic odontogenic tumor associated with an odontome – a diverse lesion encountered. Clin Cosmet Investig Dent. 2015;7(1):91-5. 9. Gadipelly S, Reddy VB, Sudheer M, Kumar NV, Harsha G. Bilateral calcifying odontogeni ccyst: a rare entity. J Maxillofac Oral Surg. 2015;14(3):826-31. 10. Dantas RC, Ramos-Perez FM, Perez DE, Durighetto AF Jr, Vargas PA. Cystic variant of calcifying epithelial odontogenic tumor. J Craniofac Surg. 2015;26(5):1722-3.

11. Devaraju RR, Duggi LS, Gantala R, Sanjeevareddygari S, Potturi A. Ameloblastoma tous calcifying cystic odontogenic tumour: a rarevariant. J Clin Diagn Res. 2015;9(3):ZD20- ZD21. 12. Desai RS, Sabnis R, Bhuta BA, Yadav A. Calcifying cystic odontogenic tumor in a 5-year-old boy: a case report. J Maxillofac Oral Surg. 2015 Mar;14(Suppl 1):348-51. 13. Jaafari-Ashkavandi Z, Dehghani-Nazhvani A, Razmjouyi F. CD56 expression in odontogenic cysts and tumors. J Dent Res Dent Clin Dent Prospects. 2014 Autumn;8(4):240-5. 14. Neuman AN, Montague L, Cohen D, Islam N, Bhattacharyya I. Report of two cases of combined odontogenic tumors: ameloblastoma with odontogenic keratocyst and ameloblastic fibroma with calcifying odontogenic cyst. Head Neck Pathol. 2015 Sept;9(3):417-20. 15. Carvalhosa AA, Estrela CRA, Borges AH, Guedes OA, Estrela C. 10-year follow-up of calcifying odontogenic cyst in the periapical region of vital maxillary central incisor. J Endod. 2014 Oct;40(10):1695-7.

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Case Report

Frontal bone reconstruction with

polymethyl methacrylate prosthesis: case report ANA CAROLINA LEMOS PIMENTEL1 | DEYVID SILVA REBOUÇAS2 | LUCAS SOUZA CERQUEIRA1 | ADRIANO FREITAS DE ASSIS3

ABSTRACT This study aimed at reporting the clinical case of a frontal bone reconstruction using a customized polymethyl methacrylate (PMMA) prosthesis that after 12 months presented fracture. Male patient, 42 years old, attended the maxilofacial surgery service ambulatory in the General Hospital Roberto Santos (HGRS) in Salvador, Bahia (Brazil), with an esthetic alteration complaint in the frontal region of the face. Patient reported a bicycle accident fours years ago, being submitted to an emergency craniotomy. The proposed treatment was the reconstruction of the frontal bone with customized PMMA prosthesis, constructed from a rapid prototyping biomodel. However, after 12 months postoperatively the patient attended the CTBMF clinic at HGRS reporting fall from height where the physical examination showed fracture of PMMA prosthesis. The cranioplasty is the treatment of craniofacial deformities that promotes morphological and functional rehabilitation of the skull. The craniofacial reconstruction techniques are complex and can be made with autogenous grafts or biomaterials. Among the biomaterials, there is polymethyl methacrylate (PMMA), which is biocompatible, easy handling and have low cost. Keywords: Biocompatible materials. Craniotomy. Polymethyl methacrylate. Reconstruction.

Resident of the Oral and Maxillofacial Surgery and Traumatology Service of Escola Bahiana de Medicina e Saúde Pública, Department of Dentistry, Salvador, Bahia, Brazil.

How to cite: Pimentel ACL, Rebouças DS, Cerqueira LS, Assis AF. Reconstrução de osso frontal com prótese em polimetilmetacrilato: relato de caso. J Braz Coll Oral Maxillofac Surg. 2017 janapr;3(1):57-61. DOI: http://dx.doi.org/10.14436/2358-2782.3.1.057-061.oar

MSc student in Implantology, University of Santo Amaro, Department of Dentistry, São Paulo, SP, Brazil.

Submitted: May 01, 2016 - Revised and accepted: February 16, 2017

Professor, PhD and preceptor of the Oral and Maxillofacial Surgery and Traumatology Service of Escola Bahiana de Medicina e Saúde Pública, Department of Dentistry, Salvador, Bahia, Brazil.

» The authors report no commercial, proprietary or financial interest in the products or companies described in this article. » Patients displayed in this article previously approved the use of their facial and intraoral photographs. Contact address: Ana Carolina Lemos Pimentel Rua Dr. Raimundo Magald, 194, ed. Mar del Plata, apt. 1002, Costa Azul, Salvador, Bahia CEP: 41.760-020 – E-mail: anacarolinalemosp@gmail.com

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Frontal bone reconstruction with polymethyl methacrylate prosthesis: case report

INTRODUCTION Traumas to the frontal facial region are frequent, especially depending on the population, geographic area, age range and socioeconomic-cultural level. It is estimated that 6 to 12% of facial fractures involve the frontal bone. Currently, the most known causes of facial trauma in the world are car accidents and physical aggresions.1-4 The treatment of fractures and facial deformities has considerably evolved after the introduction of computed tomography (CT) to aid the diagnosis and planning. It may also be associated with the possibility of fabricating a three-dimensional prototype, reproducing the observed conditions and allowing customized prostheses and orthoses before the procedure, and simulating the procedure required, thus reducing the surgical time and morbidity of the procedure. 2,4 For craniofacial reconstructions, there are two large groups of bone substitutes that may be used, depending on the best cost-benefit relationship for each case, including: autologous, allogeneic or heterologous grafts; and alloplastic materials, such as titanium, hydroxyapatite, and polymethyl methacrylate (PMMA).5 The main alloplastic materials used for facial reconstructions include the PMMA, due to its high availability, low cost, reduced inflammatory response, good adaptation to the bone contour of the region and excellent esthetic results. However, the PMMA presents disadvantages as the high rate of bacterial adhesion, low tolerance to infection, low osteogenic induction, strong smell during handling and contact dermatitis after manipulation – which are mainly observed when the prosthesis is fabricated transoperatively. Thus, this paper reports a case of reconstruction of extensive facial defect, as a sequel of frontal-naso-orbital fracture, using a customized PMMA prosthesis. The male patient, aged 42 years, of male gender, attended the outpatient Oral and Maxillofacial Surgery and Traumatology (CTBMF) service of Hospital Geral Roberto Santos (HGRS), in Salvador/BA, with complaint of esthetic alteration at the frontal region. The patient reported a bicycle accident four years earlier, when he was submitted to an emergency

craniotomy. The proposed treatment was reconstruction of the frontal bone with customized polymethyl methacrylate (PMMA) prosthesis, constructed from a rapid prototyping biomodel. However, at 12 months postoperatively, the patient attended the outpatient CTBMF clinic at HGRS reporting fall from his own height, exhibiting fracture of the PMMA prosthesis. CASE REPORT A male patient, aged 42 years, of male gender, attended the outpatient Oral and Maxillofacial Surgery and Traumatology (CTBMF) service of Hospital Geral Roberto Santos (HGRS), in Salvador/BA, with report of a bicycle accident four years earlier, when an emergency craniotomy was performed. Physical examination revealed an extensive defect on the frontal region, with complete loss of bone tissue, affecting the upper orbital ridge bilaterally, orbit floor and frontonasal region; loss of anteroposterior projection of the zygomatic bone; ocular dystopia; and enophthalmos. The suggested approach comprised reconstruction of the frontal bone using a customized polymethyl methacrylate (PMMA) prosthesis. Planning was performed using a rapid prototyping biomodel, provided by the Research Center Renato Archer, of the Brazilian Ministry of Science and Technology, and customized PMMA prosthesis, which was finished in a dental prosthesis laboratory and sterilized by physicochemical process at low temperature (STERRAD®). The surgical procedure was performed in combination involving the CTBMF and neurosurgery teams: the neurosurgery team of HGRS separated the scalp tissue from the remaining dura-mater; the CTBMF team, by bicoronal access, once again fractured, repositioned and fixated the right zygomatic bone. Thereafter, the PMMA prosthesis was fabricated to reconstruct the frontal bone defect. Postoperatively, the patient recovered uneventfully, and the outcome of surgery was considered satisfactory. However, after 12 months, the patient reported fall from his own height, and physical examination revealed fracture of the PMMA prosthesis. The patient is currently being followed to plan the correction of the fractured prosthesis, using polymethyl methacrylate by the direct technique.

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Pimentel ACL, RebouĂ§as DS, Cerqueira LS, Assis AF

Figure 1: Photographs obtained on physical examination, presenting the lateral right, frontal, lateral left and caudocranial views, evidencing the loss of frontal bone projection.

Figure 2: Tomographies demonstrating absence of frontal bone in sagittal, coronal and axial sections. Observe the fracture of right zygomatic bone on the axial section of the tomography.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Frontal bone reconstruction with polymethyl methacrylate prosthesis: case report

Figure 3: Fast prototyping biomodel provided by the Research Center Renato Archer, of the Brazilian Ministry of Science and Technology, used in planning the fabrication of customized PMMA prosthesis.

Figure 4: Transoperative photograph with bicoronal access and PMMA prosthesis being placed (A); patient at seven days postoperatively, with reestablishment of the frontal bone contour (B), and at 12 months postoperatively (C), demonstrating fracture of the PMMA prosthesis, with loss of frontal bone projection.

DISCUSSION Cranioplasties are reparative surgeries that pose a great challenge for surgeons, especially in the management of extensive defects.8 Selection of the substitute material may vary according to the objectives of reconstruction and according to the availability of resources.2

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Autogenous bone grafts are historically preferred to alloplastic materials for cranial reconstruction, due to their mechanical and biological properties.7 However, the disadvantages of this type of graft include the risk of bone graft resorption and also the insufficient availability of bone on the donor site.6

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Pimentel ACL, Rebouças DS, Cerqueira LS, Assis AF

According to Caro-Osorio,7 the most common complication with PMMA prostheses is infection, which accounts for 9.2 to 19% of complications. Other complications include chronic pain, hematoma, scalp erosion and prosthesis migration. The present case exhibited a rare complication in the literature, namely fracture of the PMMA prosthesis after 12 months, due to fall from his own height.

When the autogenous bone graft is not feasible, the alloplastic materials are necessary. These materials should be biocompatible, inert, not thermally conductive, rigid, radiolucent, simple to apply and sterilizable. Currently, the titanium, high-density polyethylene and PMMA are the most employed alloplastic materials; however, the titanium and high-density polyethylene present higher cost and more difficult fabrication compared to PMMA.7 In the present case, a PMMA prosthesis was used due to its low cost, availability of material and easy handling. The PMMA prostheses may be pre-fabricated or molded transoperatively. The prefabrication presents several advantages, including better esthetic result, shorter surgical time, lower infection rate and smaller blood loss.2 Prefabrication of these prostheses is performed by prototyping, which simulates the patient’s defect. and allows a reconstruction very close to normal, thus being customized.6 In the present case, prototyping was requested to the Information Technology Center Renato Archer (CTI), without costs to patients from the Brazilian Public Health System, and the PMMA prosthesis was fabricated preoperatively, to reduce the morbidity of the surgical procedure. The PMMA also presents the following disadvantages: high rate of bacterial adhesion, low tolerance to infection, low osteogenic induction, strong smell during manipulation and contact dermatitis after manipulation. These advantages are mainly related to utilization of the direct technique, i.e. prosthesis fabrication transoperatively. These findings corroborate the utilization of the prefabricated prosthesis in the present case, to reduce the possibility of failure.

CONCLUSION Bone defects caused by motorcycle or car accidents, physical aggressions and craniotomy cause esthetic damages that require reconstruction for the rehabilitation of patients. Selection of the ideal material for reconstruction should consider the physical, chemical and biological characteristics, selecting the material that may provide lower morbidity to the patient and higher viability for the surgeon. The PMMA is the most indicated material due to its cost-benefit relationship, compared to other alloplastic materials, in the public setting.

References:

1. Montovani JC, Nogueira EA, Ferreira FD, Lima Neto AC, Nakajima V. Cirurgia das fraturas do seio frontal: estudo epidemiológico e análise de técnicas. Rev Bras Otorrinolaringol. 2006;72(2):204-9. 2. Cerqueira A, Pereira Júnior FB Azevêdo MS, Ferreira TG. Reconstrução de bossa frontal com implante de polimetilmetacrilato: relato de dois casos. Rev Cir Traumatol Buco-Maxilo-Fac. 2011;11(3):61-8. 3. Hallur N, Goudar G, Sikkerimath B, Gudi SS, Patil RS. Reconstruction of large cranial defect with alloplastic material (Bone Cement-Cold Cure Polymethyl-Methacrylate Resin). J Maxillofac Oral Surg. 2010 June;9(2):191-4.

4. Cavalieri-Pereira L, Assis A, Olate S, Asprino L, de Moraes M. Surgical treatment of frontal sinus fracture sequelae with methyl methacrylate prosthesis. Int J Burns Trauma. 2013 Nov 1;3(4):225-31. eCollection 2013. 5. Dantas RMX, Melo MNB, Pimentel ACL, Aguiar JF. Reconstrução com implante de polimetilmetacrilato: relato de caso. Rev Cir Traumatol Buco-Maxilo-Fac. 2014;14(2):19-24. 6. Silva ALF, Borba Am, Simão NR, Pedro FLM, Borges AH, Miloro M. Customized polymethyl methacrylate implants for the reconstruction of craniofacial osseous defects. Case Reports Surg. 2014(2014): Article ID 358569, 8 pages.

7. Caro-Osorio E, De la Garza-Ramos R, Martínez-Sánchez SR, Olazarán-Salinas F. Cranioplasty with polymethylmethacrylate prostheses fabricated by hand using original bone flaps: Technical note and surgical outcomes. Surg Neurol Int. 2013 Oct 8;4:136. 8. Lee SC, Wu CT, Lee ST, Chen PJ. Cranioplasty using polymethyl methacrylate prostheses. J Clin Neurosci. 2009 Jan;16(1):56-63.

J Braz Coll Oral Maxillofac Surg. 2017 jan-apr;3(1):57-61

Information for authors

OBJECTIVE AND EDITORIAL POLICY The Journal of the Brazilian College of Oral and Maxillofacial Surgery is the official publication of the Brazilian College of oral and Maxillofacial Surgery and Traumatology targeted to the publication of relevant papers for education, information and science of the academic practice of surgery and related areas, aiming at the promotion and exchange of knowledge between the university community and health professionals. • The publication categories include original papers (systematic reviews, clinical trials, experimental studies and case series with at least 9 clinical cases) and case reports. • The manuscripts submitted to the Journal will be analyzed by the Editorial Board, which decides if the paper is acceptable for publication. • The declarations and opinions expressed by the author(s) do not necessarily correspond to those of the editor(s) or publisher(s), who will not take responsibility over them. Neither the editor(s) nor the publisher offers guarantee of any product or service announced in this publication, or any statement of their respective manufacturers. Each reader should determine if he or she should act according to the information presented in the publication. The Journal or announcers are not responsible for any harm caused by the publication of mistaken information. • The submitted manuscripts should be original, not previously published nor under consideration by another journal. The manuscripts will be analyzed by the editor and consultants and are subject to editorial review. The authors should follow the guidelines described below. • The manuscripts should be submitted in Portuguese. GUIDELINES FOR MANUSCRIPT SUBMISSION • The manuscripts should be submitted through the website: www.dentalpressjournals.com.br. • The manuscripts should be written in a concise, clear and correct manner, in formal language, avoiding colloquial expressions. • Whenever applicable, the text should be organized as follows: Introduction, Material and Methods, Results, Discussion, Conclusions, References, and Figure Legends.

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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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