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College of Oral and Maxillofacial Surgery Volume 6, Number 1, 2020 - ISSN 2358-2782

Aquarium @clearcorrect.br ©

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

Mandibular Advancement

Journal of the Brazilian

Maxillary Advancement with Mandibular

Total Arch Restoration (Implant Supported fixed bridge)

Airway Obstruction Airway Adenoids

Mandibular Advancement

Volume 6, Number 1, 2020

SIMPLES, © TRANSPARENTE & AMIGÁVEL. Patient education software ©

JBCOMS

J Braz Coll Oral Maxillofac Surg. 2020 January-April;6(1):1-80

ISSN 2358-2782

Journal of the Brazilian

College of Oral and Maxillofacial Surgery JBCOMS

Since 2016

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

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

Quarterly ISSN 2358-2782

(ISSN 2358-2782) Is a journal published three times a year of Dental Press Ensino e Pesquisa Ltda. – Av. Dr. Luiz Teixeira Mendes, 2.712 – Zona 05 – ZIP code: 87.015-001 – Maringá/PR – Brazil. All published articles are the exclusive responsibility of the authors. The opinions expressed do not necessarily correspond to the opinions of the Journal. Advertising services are the responsibility of advertisers. Subscription: dental@dentalpress.com. br or Tel./Fax: +55 44 3033-9818.

1. Cirurgia Bucomaxilofacial. I. Dental Press International. CDD 21 ed. 617.605005 _______________________________________________________________________

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

EDITOR-IN-CHIEF Sylvio Luiz Costa de Moraes

ASSOCIATE EDITOR-IN-CHIEF Jonathan Ribeiro

SECTION EDITORS

Oral Surgery Alejandro Martinez Andrezza Lauria de Moura Cláudio Ferreira Nóia Danilo Passeado Branco Ribeiro Fernando Bastos Pereira Júnior Luis Carlos Ferreira da Silva Marcelo Marotta Araújo Matheus Furtado de Carvalho

Universidade Federal Fluminense - Niterói/RJ / Centro Universitário São José - São José/RJ - Brazil UNIFESO / UNISJ - São José/RJ - Brazil

Private practice - Mexico Universidade Federal do Amazonas - UFAM - Manaus/AM - Brazil Faculdade Ciodonto - Porto Velho/RO - Brazil Universidade Estadual do Rio de Janeiro - UERJ - Rio de Janeiro/RJ - Brazil Universidade Estadual de Feira de Santana - UEFS - Feira de Santana/BA - Brazil Universidade Federal de Sergipe - UFS - Aracaju/SE - Brazil Universidade Estadual Paulista, Instituto de Ciência e Tecnologia - São José dos Campos/SP - Brazil Universidade Federal de Juiz de Fora - UFJF - Juiz de Fora/MG - Brazil

Implants Adrian Bencini Clarice Maia Soares Alcântara Darklilson Pereira Santos Leonardo Perez Faverani Rafaela Scariot de Moraes Ricardo Augusto Conci Rodrigo dos Santos Pereira Waldemar Daudt Polido Trauma Aira Bonfim Santos Florian Thieringer Leandro Eduardo Kluppel Liogi Iwaki Filho Márcio Moraes Nicolas Homsi Otacílio Luiz Chagas Júnior Ricardo José de Holanda Vasconcellos

Universidade Federal de Santa Catarina - UFSC - Florianópolis/SC - Brazil University Hospital Basel - Switzerland Universidade Federal do Paraná - UFPR - Curitiba/PR - Brazil Universidade Estadual de Maringá - UEM - Maringá/PR - Brazil Universidade de Campinas - FOP/Unicamp - Piracicaba/SP - Brazil Universidade Federal Fluminense - UFF - Niterói/RJ - Brazil Universidade Federal de Pelotas - UFPEL - Pelotas/RS - Brazil Universidade de Pernambuco - FOP/UPE - Camaragibe/PE - Brazil

rthognathic Surgery and Deformities O Fábio Gamboa Ritto Fernando Melhem Elias Gabriela Mayrink Joel Motta Júnior José Laureano Filho José Thiers Carneiro Júnior Paul Maurette Rafael Alcalde Rafael Seabra Louro

Hospital Universitário Pedro Ernesto - UERJ - Rio de Janeiro/RJ - Brazil Universidade de São Paulo - Hospital Universitário - São Paulo/SP - Brazil Faculdades Integradas Espírito-Santenses - FAESA Centro Universitário - Vitória/ES - Brazil Universidade do Estado do Amazonas - UEA - Manaus/AM - Brazil Universidade de Pernambuco - FOP/UPE - Camaragibe/PE - Brazil Universidade Federal do Pará - UFPE - Belém/PA - Brazil Centro Médico Docente La Trinidad - Venezuela South Miami Hospital - USA Universidade Federal Fluminense - UFF - Niterói/RJ - Brazil

TMJ Disorders Belmiro Cavalcanti do Egito Vasconcelos Carlos E. Xavier dos Santos R. da Silva Chi Yang Eduardo Hochuli Vieira Eduardo Seixas Cardoso João Carlos Birnfeld Wagner Luis Raimundo Serra Rabelo Sanjiv Nair

Universidade de Pernambuco - FOP/UPE - Camaragibe/PE - Brazil Instituto Prevent Senior – São Paulo/SP - Brazil Shanghai Jiao Tong University - China Universidade Estadual Paulista Júlio de Mesquita Filho - FOAR/Unesp - Araraquara/SP - Brazil Universidade Federal Fluminense - UFF - Niterói/RJ - Brazil Santa Casa de Misericórdia - Porto Alegre/RS - Brazil Universidade Federal do Maranhão - UFMA - São Luís/MA - Brazil Bangalore Institute of Dental Sciences - India

Universidad Nacional de La Plata - Argentina Faculdade Metropolitana da Grande Fortaleza - Fortaleza/CE - Brazil Universidade Estadual do Piauí - UESPI - Parnaíba/PI - Brazil Universidade Estadual Paulista - FOA/UNESP - Araçatuba/SP - Brazil Universidade Positivo - Curitiba/PR - Brazil Universidade Estadual do Oeste do Paraná - UNIOESTE - Cascavel/PR - Brazil Centro Universitário Serra dos Órgãos - UNIFESO - Teresópolis/RJ - Brazil Private practice - Porto Alegre/RS - Brazil

Pathologies and Reconstructions Darceny Zanetta Barbosa Universidade Federal de Uberlândia - UFU - Uberlândia/MG - Brazil Jose Sandro Pereira da Silva Universidade Federal do Rio Grande do Norte - UFRN - Natal/RN - Brazil Martha Alayde Alcântara Salim Universidade Federal do Espírito Santo - UFES - Vitória/ES - Brazil Renata Pittella Universidade Federal do Espírito Santo - UFES-Vitória/ES - Brazil Ricardo Viana Bessa Nogueira Universidade Federal de Alagoas - UFAL - Maceió/AL - Brazil Rui Fernandes University of Florida - USA

Ad-hoc Editors André Luiz Marinho Falcão Gondim Diogo Souza Ferreira Rubim de Assis Eider Guimarães Bastos Hernando Valentim da Rocha Junior

Universidade Federal do Rio Grande do Norte - UFRN - Natal/RN - Brazil Universidade Federal do Maranhão - UFMA - São Luís/MA - Brazil Universidade Federal do Maranhão - UFMA - São Luís/MA - Brazil Hospital Federal de Bonsucesso - Rio de Janeiro/RJ - Brazil

table of contents

The journal we aim for! Sylvio Luiz Costa de Moraes

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

Interview Adriano Rocha Germano

Bucomaxillofacial effort was held throughout Brazil in the week of February 13 – International Day of Bucomaxillofacial Surgeon Belmiro Cavalcanti do Egito Vasconcelos

Articles

Orthognathic surgery in patient with Down syndrome: case report

Therapeutic challenges of odontogenic keratocyst: Review of literature and case report using the decompression technique

Daniel Miranda de Paula, Marina Gonçalves de Andrade, Rodrigo Andrade Lima, Mariana Machado Mendes de Carvalho, Weber Ceo Cavalcante

Luísa Farina Reschke, Sérgio Antônio Schiefferdecker, Kelly Bienk Dias

Subcutaneous emphysema during surgical extraction of third molars: three case reports

A rare case of extensive mandibular and maxillary exostosis: case report

Maxillofacial trauma epidemiology: a retrospective analysis of 1,230 cases

Condylar hyperplasia treatment by means of proportional condilectomy and orthognathic surgery: case report

Rafael Saraiva Torres, Ariany Cristina Freitas Ribeiro, Hannah Marcelle Paulain Carvalho, Saulo Lôbo Chateaubriand do Nascimento, Gustavo Cavalcanti de Albuquerque, Valber Barbosa Martins, Marcelo Vinicius Oliveira, Joel Motta Junior, Paulo Matheus Honda Tavares

Ana Beatriz Colombari, Felippe Almeida Costa, Felipe Perraro Sehn, Cássio Edvard Sverzut, Alexandre Elias Trivellato

Primo Guilherme Pasqual, Roberta Brito Arguello, Karoline Weber Dos-Santos, Marília Gerhardt de-Oliveira, Caiton Heitz

Victor Hugo Nespoli Ferzeli, Maylson Nogueira Barros, Vitor Bruno Teslenco, Guilherme Nucci Reis, Everton Floriano Pancini, Herbert de Abreu Cavalcanti

Epidemiological study of pediatric odontogenic infections in Maringá

Comparison of diffusion capacity and efficacy of 4% articaine and 2% lidocaine on impacted maxillary third molars extraction

Marcelly Tupan Christoffoli, Gustavo Jacobucci Farah, Izabella Giannasi Farah, Caroline Resquetti Luppi, Andressa Bolognesi Bachesk

Gustavo Mascarenhas, Daniela Mascarenhas, Darceny Zanetta-Barbosa, Helvécio Marangon-Jr, Rafael Martins Afonso Pereira, Patricia Pereira

Information for authors

Editorial

The journal we aim for!

With great pleasure and aware of the extreme responsibility, I assume the position of Editor-in-Chief of the Journal of Brazilian College of Oral and Maxillofacial Surgery (JBCOMS) in this year 2020. To continue the excellent work developed by Prof. Dr. Belmiro Cavalcanti do Egito Vasconcelos and Prof. Dr. Gabriela Granja Porto, for the past five years, is certainly a challenging task. The legacy of these editors is translated into an elegant, well-structured journal with good content, a natural consequence of their management capacity and the notorious professional and academic competence of both. In this journey currently initiated, I will be partnered with Prof. Dr. Jonathan Ribeiro, a brilliant professional with great work capacity, as Associate Editor-in-Chief. To achieve the objectives of JBCOMS, we will also rely on the usual commitment of the editorial team of Dental Press, which has performed an extraordinary work since the onset of this journal. To adjust the journal to the inclusion criteria for indexing in the Latin American and Caribbean Center on Health Sciences Information (BIREME) and in the Scientific Electronic Library Online (SciELO), initially we need to put into practice some lines of action: 1) to perform some changes in the standards for publication; 2) to propose quarterly periodicity; 3) to adjust the content, favoring original articles; 4) to create the Letter to the Editor modality; and 5) to create an editorial board.

How to cite: Moraes SLC. The journal we aim for! J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):4-5. DOI: https://doi.org/10.14436/2358-2782.6.1.004-005.edt

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):4-5

Editorial

From a strategic point of view, other actions will be necessary to increase the impact factor and motivate collaborators to publish in the journal. The participation of stricto sensu post graduation centers is fundamental, since publication in the JBCOMS of parts of research developed and their later citation in other international publications will further boost us. The Residency programs are equally important, due to publications of both collective and individual interest. It is mandatory to keep in mind that JBCOMS is a patrimony of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology – thus, of its members – and is open to receive scientific contributions, both from its members and from external authors who are interested. Let’s move forward together to achieve the goals of this exciting journal!

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

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):4-5

Letter from the President

CBCTBMF supports Brazilian Consensus for Multisectoral Ethical Collaboration in the health sectors Dear members of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology, in last November I was a debater at the Ética Saúde Summit 2019, in São Paulo. The event gathered more than 200 guests and 100% of institutions that represent the Health value chain. The Instituto Ética Saúde, in which CBCTBMF is part, and FGV-Ethics promoted a wide discussion on the main conquests in ethics and integrity in Brazil, and the next steps for a sustainable future for the sector. Besides talking about the initiatives of our board in the favor of ethics and transparency, I highlighted the importance of new products and resources, explaining that, with technology, we are much more predictable, which brings benefits for the patient. I believe that thinking high is treating the patient well; for this reason, our College created the Parameters and Recommendations for Oral Maxillofacial Procedures and an Ethics Commission. We gathered all parts involved in the specialty (manufacturers, hospitals, health plans, among others) at the end of last year, to discuss a business model that may be good for everyone, always respecting the other parts of the chain. The College is one of the signatories of the ‘Mark of Brazilian Consensus for Multisectoral Ethical Collaboration in Health Sectors’, proposed by the Instituto Ética Saúde at the event. “The document, which is supported and endorsed by public and autonomous institutions that participate in the Brazilian Health System, recognizes the Statute and Normative Instructions of Instituto Ética Saúde as guidelines for Compliance and Integrity actions in the Health Sector”, explained the Institutional Relations executive, Carlos Eduardo Gouvêa. We and the other participating institutions agreed, among other things: to promote ethical competition, with fair prices and optimization of existing resources, by ethical processes throughout the cycle of supply and consumption; to encourage collaborative relationships in which transparency and

How to cite: Laureano Filho JR. CBCTBMF supports Brazilian Consensus for Multisectoral Ethical Collaboration in the health sectors. J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):6-7. DOI: https://doi.org/10.14436/2358-2782.6.1.006-007.crt

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):6-7

Carta do Presidente

integrity prevail among the different parts involved in the Health System, focused on the patient’s well-being; to support the development and proper implementation of ethics codes and integrity systems by organizations, consistent with the Brazilian legislation and best international practices; to value the ethical conduct, organizations, professionals and attitudes; to develop and promote mechanisms to facilitate the tracking and effective scrutiny of non-conformities by the society (accountability); and to create and encourage mechanisms for fair, fast and effective accountability for ethical and legal deviations, respecting the broad defense and contradiction. Finally, the Instituto Ética Saúde, in partnership with the Instituto Não Aceito Corrupção (INAC), launched the campaign ‘Ethics is not fashion, ethics is health!’, which we at CBCTBMF also support. “The goals are to diffuse and strengthen the actions conducted by the IES to prevent and fight against the misconduct in health and to raise awareness in society about the ethical culture in the segment, thus consolidating an environment of good practices, in which the greatest benefit will be for the individual. All of us, as citizens, by avoiding small practices that make the system more expensive, may disseminate the Ethics and help transforming the Health System in Brazil ”, said Gláucio Pegurin Libório, President of the Management Council of Instituto Ética Saúde. We are on the right way. Only with all health players united, doing their homework and setting new compliance goals, may we achieve the goal: sustainable health for all actors in the chain and more dignified for the population. Hugs for all!!! José Rodrigues Laureano Filho President of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):6-7

M E N SAGE M DO PR E SI DE N T E “Belém é a cidade mais incrível que o Brasil ainda não descobriu “ (Ricardo Freire). É com muita satisfação que lançamos oficialmente o XXV Congresso Brasileiro de Cirurgia e Traumatologia Buco-Maxilo-Facial que será realizado na cidade de Belém do Pará no período de 09 a 12 de junho de 2020. Belém é uma cidade com uma cultura própria que se desdobra em arquitetura, perfumes e sabores que podem ser vistos e sentidos em qualquer canto. Será uma oportunidade única de experimentar a rica culinária paraense conhecida mundialmente, contemplando a beleza de nossos rios e nossas florestas. Como se os encantos amazônicos não fossem suficientes, estamos preparando uma grade científica focada no que há de mais atual dentro de nossa especialidade onde teremos um expressivo número de palestrantes nacionais e internacionais. Aliado à parte científica, após a famosa “chuva da tarde”, teremos momentos de confraternização acompanhados de boa música. O Hangar Centro de Convenções, que abrigará o COBRAC, é considerado um dos maiores e mais modernos do país, com fácil acesso e circulação para os congressistas, próximo de pontos turísticos e do centro da cidade. Esperamos por você no maior congresso de nossa especialidade em uma das cidades mais exóticas Brasil. José Thiers Carneiro Junior - Presidente do XXV COBRAC

DIAGNÓSTICO E PLANEJAMENTO PARA CIRURGIA BUCO-MAXILO-FACIAL

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

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

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Interview

Millesi G, Porto GG

Interview with Adriano Rocha Germano

» Professor and Oral and Maxillofacial Surgeon. » Oral and Maxillofacial Surgery and Traumatology Area » Department of Dentistry, Hospital Universitário Onofre Lopes (DOD - HUOL). » Universidade Federal do Rio Grande do Norte (UFRN). » Coordinator of the Residency Program at CTBMF DOD/ HUOL-UFRN. » Permanent Professor of the Master's and Doctorate Program in Dental Clinics - UFRN. » Fellowship (Post-doctorate) Hospital 12 de Octubre / Universidad Camplutense de Madrid – Espanha. » Full member of the Colégio Brasileiro de Cirurgia e Traumatologia Bucomaxilofacial. » Oral and Maxillofacial Surgeon of the Orofacial Team / Natal/RN.

How to cite: Germano AR, Porto GG. Interview with Adriano Rocha Germano. J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):15-7. DOI: https://doi.org/10.14436/2358-2782.6.1.015-017.oar Submitted: November 30, 2019 - Revised and accepted: December 06, 2019

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):15-7

The Brazilian College of Oral and Maxillofacial Surgery and Traumatology interviews, in this issue of the Journal, Dr. Adriano Rocha Germano, General Secretary of the Executive Board of CBCTBMF, about the work that the College has been developing with the Federal Dental Council (CFO) and the Ministry of Education (MEC) to standardize the training of maxillofacial surgeons in Brazil.

riculum and necessary infrastructure were defined, besides suggestions for inspection and maintenance of authorization of these programs. In this board, this material was updated and has been widely debated with the CFO and more recently with MEC, to discuss how these actions may be implemented. To create a unique proposal in Brazil, we need to agree with the CFO, which must register the specialists, and also with MEC, who creates rules to define the functioning of courses, either residencies or specializations. We need to reach a consensus: the CFO cannot continue to register specialists who do not meet the MEC resolution, no. 1 of April 6th, 2018 (Higher Education Chamber). Also, the CFO cannot accredit specialization courses and/or residencies that are not supported by the current legislation, since only institutions linked to MEC can offer courses. This assignment is a prerogative of MEC. The CFO is responsible for defining which attributes are necessary for a CTBMF specialist to have his registration accepted. Even the MEC resolution n. 1 demonstrates, in article 8 paragraph III § 4, that “Certificates obtained in specialization courses are not equivalent to specialty certificates”. Therefore, it is currently possible to create rules to register a specialist with our board, as in Medicine. We also need to make it clear that residencies accredited to MEC are not affected by this resolution, and registration of the graduate in the CFO as CTBMF is mandatory. However, this is much less problematic, since MEC has already understood that the residencies in CTBMF have a duration of 3 years and weekly workload of 60 hours, totaling 8,640 hours, which is exactly the proposal of the College.

Why has CBCTBMF developed actions to standardize the training of maxillofacial surgeons in Brazil? The entity gathers professors and professionals and aims to ensure the maintenance of the practice of the specialty within the best standards of legal technical quality (Statute: chapter 2, article 5). Thus, to ensure that our specialist has an equal education and in accordance with the complexity required in the area of expertise, we have intensified our conversations with the CFO and MEC. Currently, the professional who wants to specialize in Oral and Maxillofacial Surgery and Traumatology (CTBMF) has two ways: one is to do a residency, which must be authorized by MEC. However, other institutions, also affiliated to MEC, are authorized to teach specialization courses. Thus, the two trainings, which may have different characteristics and workloads, enable their graduates to register as specialists in the CFO. MEC itself endorses the specialization and residency courses in our specialty. The difference between the two options is mainly the workload: the residency has about 8,640 hours in total, and the resident must work 60 hours/week, while specializations can have a minimum workload of 360 hours, even though we know it is impossible to train a surgeon with this workload. In practice, we see that most specializations have , a very reduced workload compared to a residency, which can greatly compromise the training of the surgeon, although these may register in our Council and entitle themselves oral and maxillofacial surgeons.

What is the proposal of the CBCTBMF? The proposal of the CBCTBMF is that now, with the new MEC RESOLUTION for lato sensu courses, the CFO may only register specialists in courses with a minimum workload of 8,640 hours, with training of 60 hours per week, for 3 years. Specialization courses may continue to exist, but for that they should have training characteristics similar to residencies. This would already be a great step and evolution to achieve this equality. However, this is only one of the actions; we need to standardize the training of the specialty by a curriculum and minimum infrastructure, equal for residencies and spe-

Which actions have been developed by CBCTBMF? In the previous board, a working group was created and produced a document for standardization of the training of CTBMF, in which a minimum cur-

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):15-7

Millesi G, Porto GG

ing was to understand the content of this regulation and, from there, to submit an official consultation to the National Council of Higher Education. The answer should support us for the next stage of standardizing the teaching in the field with the Federal Dental Council. On the following day, we had a meeting at EBSERH (Brazilian Hospital Services Company), which manages 40 among the 50 federal university hospitals in Brazil. We asked for equal wages and working hours. The third meeting, also on October 30 th, occurred with the General Manager of Institutional Relations of the National Supplementary Health Agency (ANS), Ana Carolina Rios Barbosa. We discussed several problems that arrive through our ombudsman, such as the tiebreaker model of ANS, questions about the clinical imperative and bone reconstructions. These points were elucidated, and we had the opportunity to make suggestions and generate some referrals. For November, we expect that our group may work with the Ministry of Health.

cializations in the residency modality, ensuring that the knowledge and training acquired are sufficient for the current moment of the specialty, and maintenance with credibility and within the domains of Dentistry. With the implementation of standardization, we can work on the inspection together with residency programs linked to MEC and also in specializations already adapted to the new requirement. While this is not possible, an annual selection (“exam”) applied by the College, which is a consultative institution of the specialty with greater representation in the country, must be implemented in a new format, evaluating the graduates of both training modalities, registering as specialists only those who reach approval. However, this proposal for the exam is still under discussion. What is the relevance of these actions? To generate quality of training for graduates in the specialty, eliminating discrepancies in quality between professionals who attended residency and those who attended specialization courses. There is an increased risk for the population when these professionals do not receive adequate knowledge and/or training for professional practice. The impact of this are problems occurring due to incorrect conduct, which influence the specialty as a whole. Is there a proposal to expand the training? Yes. In fact, some training centers have already included the fourth year in the course. For the current demands of the specialty and to assure the repetition of procedures, and/or better train the surgeon within an area of action in the specialty, this fourth year is seen as an important increase and brings us closer to what has been done in developed countries. We need to convince MEC that the financing of scholarships for the fourth year is a need to assure the quality of training of this noble specialty. Besides MEC, the College organized some meetings with ANS and EBSERH. What were the results of the last meetings in October? On October 29th, we met with Prof. Dr. Luiz Roberto Liza Curi at the National Teaching Council of MEC. We discussed the Regulation of 2018, which states that “specialist certificates are not equivalent to specialty certificates”. The purpose of this meet-

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

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):15-7

CBCTBMF

Bucomaxillofacial effort was held throughout Brazil in the week of February 13 – International Day of Bucomaxillofacial Surgeon

» Porto Alegre (RS) – Dr. Rogério Belle de Oliveira; » Piracicaba (SP) – Dr. Alexander Tadeu Sverzut; » Recife (PE) – Dr. José Rodrigues Laureano Filho; » Rio de Janeiro and Teresópolis (RJ) – Dr. Jonathan Ribeiro da Silva; » Salvador (BA) – Dr. Lucio Costa Safira Andrade; » Sorocaba (SP) – Dr. Geraldo Prestes de Camargo Filho; » Teresina (PI) – Dr. Julio Cravinhos.

The Brazilian College of Oral and Maxillofacial Surgery and Traumatology (CBCTBMF) promoted, in the week of February 13th, the Campaign 2020, in several Brazilian cities. The participating cities performed several types of actions, from lectures and outpatient screening to oral and maxillofacial surgeries. In some, the patients were treated by orthognathic surgery; in others, surgeons checked the presence of oral tumors due to Sexually Transmitted Diseases (STDs). Lectures were also promoted to caution motorcyclists and cyclists about the prevention of facial trauma, with the distribution of handouts containing information on the importance of the correct use of helmets. Cases of cleft lip and palate and third molars were evaluated and, when needed, surgery was indicated. Below is the list of members who organized the actions of the Campaign 2020 and the respective cities:

How to cite: Vasconcelos BCE. Bucomaxillofacial effort was held throughout Brazil in the week of February 13 – International Day of Bucomaxillofacial Surgeon. J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):18-20. DOI: https://doi.org/10.14436/2358-2782.6.1.018-020.oar Submitted: February 26, 2020 - Revised and accepted: February 28, 2020

» Campina Grande (PB) – Dr. Gustavo José de Luna Campos; » Curitiba (PR) – Dr. Laurindo Sassi and Dr. Luciana Signorini; » Florianópolis (SC) – Dr. Murillo Chiarelli; » Goiânia (GO) – Drs. Alan Paranello and Guilherme Scartezini; » João Pessoa (PB) – Dr. Aníbal Henrique Barbosa Luna; » Manaus (AM) - Dr. Andrezza Lauria; » Niterói (RJ) – Dr. Rafael Seabra;

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

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):18-20

CBCTBMF

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

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):18-20

CBCTBMF

Speech in Honor of the International Day of the Maxillofacial Surgeon

dedication of their professional practice, with ethics, dignity and humanism, contributing to the population well-being.

On February 13th 2020, deputy Eduardo da Fonte (PP/ PE) filed a speech in honor of the International Day of Oral and Maxillofacial Surgeon, recognizing and thanking one of the most important specialties of Dentistry, Oral and Maxillofacial Surgery and Traumatology, and congratulating the specialists for the commitment and

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Chamber of Deputies Office of Deputy Eduardo da Fonte

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):18-20

Andrea Brito

Antônio Sakamoto

Bruno Furquim

Bruno Maia

Carlos Francci

Dickson Fonseca

Diego Klee

Emerson Finholdt

Ewerton Nocchi

Fabiano Marson

Fernando Marson

Gustavo Giordani

Ivan Yoshio

Julio Cesar Joly

Laurindo Furquim

Marcelo Fonseca

Marcelo Gianini

Marcelo Giordani

Marco Bottino

Marcos Fadanelli

Oswaldo Scopin

Paulo Soares

Rafael Calixto

Rafael Monte Alto

Renata Faria

Renata Pascotto

Rodrigo Reis

Rogério Zambonato

Sidney Kina

Tipo

Módulos | 2020

Teórico e prático

1° módulo - 29 de abril a 2 de maio 2° módulo - 3 a 6 de junho

Carga Horária

3° módulo - 5 a 8 de agosto

173 horas-aula

4° módulo - 7 a 10 de outubro 5º módulo - 2 a 5 de dezembro

Thiago Ottoboni

(44) 99898-4875 cursos3@dentalpress.com.br cursos.dentalpress.com.br https://cursos.dentalpress.com.br/excelencia-na-estetica

CaseReport

Orthognathic surgery in

patient with Down syndrome: case report DANIEL MIRANDA DE PAULA1 | MARINA GONÇALVES DE ANDRADE1 | RODRIGO ANDRADE LIMA1 | MARIANA MACHADO MENDES DE CARVALHO1 | WEBER CEO CAVALCANTE1

ABSTRACT Introduction: Down syndrome (DS) is a congenital autosomal disease characterized by a deficiency of growth and mental development. These patients have a small skull, midface shortening, nasal bone depression, flattened malar, mandibular branch, body and symphysis decreased, and eyes tilted upward. The sagittal maxillary growth is closely related to the skull base growth. DS patients may have posterior cross bite, open bite, dental and/or skeletal Class III, underdevelopment of orofacial muscles, deficiency in the lip seal, tongue projection against the teeth, which carries a bad teeth positioning compromising the oral health. These patients also have a reduced airway, macroglossia, hypertrophy of the tonsils, suction problems, speech and chewing are usually related to Down syndrome. Objective: To report a case of a Angle Class III patient with SD. It was made a maxillary and chin advancement, also a bone graft on the chin. After the surgery the patient had a stable occlusion. Conclusions: It can be concluded that the benefits arising from orthognathic surgery to correct causes of disability in the physiological growth providing an improvement in function and aesthetics. Keywords: Orthognathic surgery. Down syndrome. Orthodontics.

Universidade Federal da Bahia, Departamento de Cirurgia Bucomaxilofacial (Salvador/BA, Brazil).

How to cite: De Paula DM, Andrade MG, Lima RA, Carvalho MMM, Cavalcante WC. Orthognathic surgery in patient with Down syndrome: case report. J Braz Coll Oral Maxillofac Surg. 2020 JanApr;6(1):22-7. DOI: https://doi.org/10.14436/2358-2782.6.1.022-027.oar Submitted: September 18/09/2018 - Revised and accepted: October 04, 2019 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. » Patients displayed in this article previously approved the use of their facial and intraoral photographs. Contact address: Daniel Miranda De Paula CCSW 2 lote 4, Condomínio Linea Studio Home, apto. 336 – CEP: 70.680-270 – Brasília/DF E-mail: danielmiranda.ctbmf@gmail.com

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):22-7

De Paula DM, Andrade MG, Lima RA, Carvalho MMM, Cavalcante WC

INTRODUCTION The Down Syndrome (DS), also called Trisomy 21, is an autosomal congenital disease and currently the most well-known chromosomal disorder. It is characterized by growth abnormalities and impaired physical and mental development.1 It affects nearly 1 in every 2,000 births, without ethnicity or gender predilection, yet with strong association between increased maternal age and higher occurrence of the disease. The mortality rate is higher, especially due to respiratory tract infections and cardiac malformations2. However, life expectancy has significantly increased in recent decades, due to advances in Medicine and improvement of maternal and child conditions.3 These patients usually have a small skull pattern, shortening and retraction of the midface, depression of nasal bone, flattened malar region, reduced mandibular ramus and body, reduced and anteriorly projected symphysis, upward eye inclination and strabismus4. Craniofacial dysplasia is present at birth and increases with age3. The sagittal maxillary growth is closely related to growth of the skull base; therefore, hypoplasia is present in both structures. Because of abnormalities in facial bone growth, individuals with Down Syndrome often have posterior crossbite, anterior open bite, dental and/or skeletal Class III malocclusion and hypodontia, delayed tooth eruption, altered sequence of tooth eruption, microdontia and abnormalities in tooth shape.2 Children with DS have complications in breastfeeding, due to difficulty in sucking, which leads to underdevelopment of orofacial muscles and fewer physiological stimuli for bone development of the mandible. The abnormal skeletal relationship, combined to the muscle deficiency, compromises the lip sealing and leads to systematic anterior tongue posture, which promotes the habit of tongue interposition.5 Persistence of the habit generates constant pressure on the lower teeth, resulting in anterior projection of these teeth.2 These individuals also have higher rates of non-nutritive sucking habits and tongue thrusting against the teeth, which leads to poor dental positioning, impairing the oral health and causing pain, infection and masticatory dysfunction. Reduced airway, respiratory complications, macroglossia, tonsil hypertrophy, speech and chewing problems are also usually related to DS.3 Dentofacial deformities (DFD) are severe occlusal changes that affect the entire stomatognathic system and thus require combined treatment, often between Orthodontics and Orthognathic Surgery.5,6

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

In patients with the syndrome, Orthodontics should intervene as early as possible, from the first months of life to adulthood. Permanent monitoring and control of the patient is essential to repair any functional abnormality that may appear during the development and maturation of dental and skeletal structures. 6 From this perspective, orthognathic surgery is a procedure indicated for correction of skeletal deformity in most syndromic patients. This surgical intervention may increase the airway permeability, providing lip sealing and a favorable tongue posture for speech and chewing, establishing a stable occlusion, favoring nasal breathing over mouth breathing, and determining a more harmonious facial pattern. 6,7 These changes imply a direct improvement in the patientsâ&#x20AC;&#x2122; quality of life and a therapeutic step that can be incorporated in cases of abnormal skeletal patterns. This syndrome requires an interdisciplinary treatment to stimulate the psychomotor and intellectual development, to facilitate inclusion and autonomy, since the change in facial pattern influences the formation of the individualâ&#x20AC;&#x2122;s body image, identity and self-esteem. 7 The aim of this study is to report the case of a patient with Down Syndrome, with Angle Class III malocclusion, submitted to orthognathic surgery. CASE REPORT Female patient, with mild Down Syndrome, without associated comorbidities, attended the Oral and Maxillofacial Surgery outpatient clinic of the Dental School of the Federal University of Bahia, referred by an assistant orthodontist, for evaluation regarding the accomplishment of orthognathic surgery, with the main goal of functional and consequently esthetic rehabilitation. The patient had complaints about the aspect of smile and difficulty in cutting food with her front teeth. Despite having syndrome, diagnosed at birth, as reported by the mother, the patient had good socialization, characteristic of the syndrome, and good understanding of orthodontic-surgical treatment. She had no other systemic comorbidities, such as cardiac or breathing problems. Prior to surgery, preoperative exams and consultations with a cardiologist and anesthesiologist were requested, which were favorable for the proposed surgery.

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):22-7

Orthognathic surgery in patient with Down syndrome: case report

performed, with an advance of 4 mm. The transoperative procedure was uneventful, with all movements as planned. In mentoplasty, there was a need to perform suspension with stainless steel wire n.. 1 at the posterior region, aiming at maintaining the bone contact. The maxilla was fixed using rigid internal fixation and interposition of bone graft harvested from the chin region. Maxillomandibular block (MMB) was used intraoperatively and in the first 15 days postoperatively. Even with the MMB, the patient was compliant, responding favorably to the guidelines regarding food and oral hygiene, with the help of the mother. After 2 years of postoperative follow-up, the patient progressed without complaints, satisfied with the result of the proposed treatment. On physical examination, a harmonious facial profile and satisfactory occlusion were observed.

In frontal facial analysis, a lateral nasal deficiency was observed, evidenced by a deep nasolabial fold, absence of exposure of upper incisors at rest (-1mm) and absence of upper or lower dental midline deviation in relation to the face. In lateral view, anteroposterior maxillary deficiency, acute nasolabial angle and anteroposterior pogonion deficiency were observed (Fig. 1). On intraoral examination, there was absence of teeth 13, 23, 18, 28, 38 and 48, no deviation of the intermaxillary midline and Class III dental relationship (overjet of 6 mm). After facial analysis, digital planning was performed with the aid of the Dolphin software, in which the following movements were defined: 6 mm of maxillary advancement to allow fit with the mandible and 3 mm of downward maxillary repositioning in the incisor region, resulting in clockwise rotation of the occlusal plane. Mentoplasty was also

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Figure 1: A) Lateral view: lateronasal deficiency. B) Frontal view: no lip sealing at rest. C, D) Intraoral views: Class III malocclusion.

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):22-7

De Paula DM, Andrade MG, Lima RA, Carvalho MMM, Cavalcante WC

Figure 2: A) Computed tomography (CT) after six months of surgery. B) In green, representation of the movement of bone bases, comparing the pre- and postoperative CTs.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Figure 3: A)Â Lateral view: improvement in projection of the lateronasal region. B) Front view: improvement in lip positioning. C, D) Intraoral views: Class I occlusion.

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):22-7

Orthognathic surgery in patient with Down syndrome: case report

DISCUSSION Patients with DS have craniofacial changes that affect the organism as a whole, especially the stomatognathic system. For Carvalho et al. 1, this occurrence predisposes these patients to an increased frequency of respiratory obstructions during sleep. Among these alterations, the most common are muscle hypotonia, hypodevelopment of the midface with palatal atresia, adenotonsillar hypertrophy and narrowing of the nasopharynx, which leads to an inadequate tongue posture. According to Santiago et al.7, the Class III dentoskeletal deformity generally results from anteroposterior maxillary deficiency and/or mandibular excess. In the present case, after evaluation and preoperative planning, it was decided to use maxillary advancement with downward repositioning, which allowed, in addition to occlusal fitting, more appropriate positioning of the upper incisors. Suri, Tompson and Cornfoot 4 conducted a retrospective and comparative study in which they analyzed panoramic and cephalometric radiographs of 25 individuals with Down Syndrome compared to non-syndromic individuals, to describe the craniofacial characteristics of these patients, and observed that 23 of the 25 individuals analyzed had one or more congenitally missing permanent teeth, in disagreement with the present case, in which the patient did not present any hypodontia. As in the present case, patients with DS in the study by Suri, Tompson and Cornfoot4 had deficiency in the middle and lower facial heights, especially the maxilla, in which the measurements obtained in patients with DS were smaller and statistically significant in relation to non-syndromic patients. In addition, they found that syndromic patients had a smaller mandibular body compared to non-syndromic patients. When analyzing the overjet of patients with DS, considerable variation was observed (from -0.26 to 2.96 mm), while the control group presented a smaller variation (from 1.09 to 2.52 mm). The patient in this study had an overjet of 6 mm. Lee et al.8 reported that single jaw surgeries are less invasive and more predictable; however, when the malocclusion is severe, to obtain a better esthetic result

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

and ideal occlusion, a bimaxillary approach is necessary. Compared with the present case, good skeletal and occlusal positioning were obtained by a more conservative surgery, in which only the maxilla and chin were treated, without the need to treat the mandibular body. Due to motor and neurological deficiencies and differences in bone bases, patients with Down syndrome are more likely to develop periodontal disease. Also, according to Camera et al. 9, the progression of periodontal disease is faster and more extensive when compared to non-syndromic subjects and can result in severe bone resorption, tooth mobility and presence of dental calculus. As advocated by Oliveira et al.10, the participation of parents, siblings and people who assist and live with DS should be constantly encouraged in prophylactic activities and maintenance of oral health. In the present case, mainly due to the use of maxillomandibular block in the postoperative period, the parents and patient were strongly instructed regarding the need of oral hygiene maintenance, which was understood and followed without major problems. The degree of understanding of family members and the patient herself is paramount throughout the pre- and postoperative process. This awareness promotes greater collaboration and consequently better orthodontic-surgical results. During the postoperative follow-up, the patient and her family were cooperative and satisfied, strictly attending the surgical revisions and with the orthodontist. Even though she is a patient with Down Syndrome, after orthognathic surgery, the patientâ&#x20AC;&#x2122;s socialization level was enhanced when she acquired more confidence during smile and chewing. FINAL CONSIDERATIONS Orthognathic surgery is a procedure capable of restoring the quality of life for individuals with dentofacial deformities, providing dentoskeletal balance and accommodation of soft tissues, resulting in improved chewing, swallowing, speech and breathing. This was a successful case of orthognathic surgery, with esthetic gain and solution of functional problems, performed on a patient with Class III Angle malocclusion and mild degree of Down syndrome.

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):22-7

De Paula DM, Andrade MG, Lima RA, Carvalho MMM, Cavalcante WC

References:

2. 3. 4.

Carvalho TM, Gadelha FP, Minervino BL, Gomes MS, Miranda AF. Síndrome da apnéia obstrutiva do sono em crianças portadoras de trissomia do cromossomo 21 Síndrome de Down. Rev ACBO. 2015;4(3)1-16. Berthold T, Araújo V, Robinson W, Hellwig I. Síndrome de Down: aspectos gerais e odontológicos. Rev Ci Méd Biol. 2004 Jul-Dez;3(2):252-60. Macho V, Seabra M, Soares D, De Andrade C. Alterações crâniofaciais e particularidades orais na trissomia 21. Acta Ped Port. 2008:39(5):190-4. Suri S, Tompson B, Comfoot L. Cranial base, maxillary and mandibular morphology in Down syndrome. Angle Orthod. 2010 June;80(5):861-9.

6. 7.

Alió J, Lorenzo J, Iglesias MC, Manso FJ, Ramírez EM. Longitudinal maxillary growth in Down syndrome patients. Angle Orthod. 2011 June;81(2):253-9. Matos C, Rosa M, Figueiredo S, Barbosa D. Cirurgia Ortognática e a imagem corporal. Rev Odontol Univ Cid. 2015 Jan-Abr;27(1):20-5. Santiago T, Moura L, Gabriella M, Spin-Neto R, Pereira-Filho V. Volumetric and cephalometric evaluation of the upper airway of Class III patients submitted to maxillary advancement. Rev Odontol UNESP. 2016 Nov-Dec;45(6):356-61. Lee CH, Park HH, Seo BM, Lee SJ. Modern trends in Class III orthognathic treatment:

10.

A time series analysis. Angle Orthod. 2017 Mar;87(2):269-78. Camera GT, Mascarello AP, Bardini DR, Fracaro GB, Boleta-Ceranto DCF. O papel do cirurgiãodentista na manutenção da saúde bucal de portadores de síndrome de Down. Rev Odontol Clín-Cient. 2011 Jul-Set;10(3):247-50. Oliveira AC, Luz CLF, Paiva SM. The meaning of the oral health in the quality of life of the individual with Down syndrome. Arq Odontol. 2007 Out-Nov;43(4):162-8.

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OriginalArticle

Therapeutic challenges of odontogenic keratocyst: Review of literature and case report using the

decompression technique LUÍSA FARINA RESCHKE1 | SÉRGIO ANTÔNIO SCHIEFFERDECKER1,2 | KELLY BIENK DIAS1,2

ABSTRACT Introduction: odontogenic keratocyst (OK) is a benign lesion that occurs in the jaws aggressively and infiltratively. Often discovered by imaging tests, it has unpredictable and recurrent behavior. Due to its characteristics, there are difficulties to indicate the therapy for this pathology, and there is no consensus on the best form of treatment. Methods: literature review of original articles published in the last 10 years in the databases Medline / Pubmed, Cochrane, Embase and Bireme with keywords used according to their specific descriptors. In parallel, we aimed to present a clinical case of OK decompression as an alternative therapy. Results: Of the total of 08 articles selected, 01 literature review, 03 systematic reviews of literature, 03 retrospective studies and 01 cohort study were identified, reporting and analyzing different treatment modalities. Conclusions: Considering the possible comorbidities of patients and technical limitations, it is suggested that minor lesions can be submitted to single enucleation procedure with a combination of one or more adjuvant and extensive lesions can be submitted to decompression before definitive surgery, restricting resection to the cases of lesions that do not respond to decompression or when there is a pathological fracture. Keywords: Odontogenic cysts. Combined modality therapy. Mandibular diseases.

Odontopós – Post Graduation Dental Institute, Specialization Course in Oral and Maxillofacial Surgery and Traumatology (Porto Alegre/RS, Brazil).

How to cite: Reschke LF, Schiefferdecker SA, Dias KB. Therapeutic challenges of odontogenic keratocyst: Review of literature and case report using the decompression technique. J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):28-35. DOI: https://doi.org/10.14436/2358-2782.6.1.028-035.oar

Ernesto Dornelles Hospital, Maxiface – Service for Oral and Maxillofacial Diagnosis and Treatment and Hospital Dentistry (Porto Alegre/RS, Brazil).

Submitted: September 27, 2018 - Revised and accepted: December 20, 2018 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. » Patients displayed in this article previously approved the use of their facial and intraoral photographs. Contact address: Kelly Bienk Dias E-mail: bienk.kelly@gmail.com

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):28-35

Reschke LF, Schiefferdecker SA, Dias KB

INTRODUCTION The odontogenic keratocyst (OK) is a benign lesion that affects the jaws in an aggressive and infiltrative manner. Its unstable and peculiar behavior elicited a long history of nomenclature variations and reclassifications, since this pathology varied from cystic to tumor on several occasions.1 It has similar characteristics to benign tumors and represents 3 to 11% of lesions originating from the odontogenic epithelium of the face. It is a lesion often discovered occasionally, by imaging examinations, presenting a uni or multilocular radiolucent area surrounded by a radiopaque cortex, ranging from small and less invasive to aggressive and relapsing lesions, requiring several treatment modalities, since it does not follow a pattern.2 As a result of these characteristics, there are difficulties related to the indication of therapy for this pathology and, even though there is great variability in the literature on the description of these modalities, there is no high-quality evidence to assess the relapse rates related to them and consensus on the best manner to treat patients affected by OK.3

Thus, the aim of this was to review the published scientific literature and present a case report of decompression of OK as a therapeutic option. METHODS Original papers published in the past 10 years were selected from the databases of the United States National Library of Medicine (Medline/ Pubmed; www.pubmed.gov), Cochrane Controlled Register of Trials (Cochrane; www.mrw.interscience. wiley.com/cochrane), Biomedical Research Database of Elsevier (Embase; www.elsevier.com/solutions/ embase-biomedical-researc) and the Virtual Health Library (Bireme; bvsalud.org). The keywords were defined according to the specific descriptors presented in Table 1. RESULTS Among the 8 papers selected from the databases, 1 was a literature review, 3 systematic literature reviews, 3 retrospective studies and 1 cohort study, reporting and analyzing different treatment modalities. Data for these studies are shown in Table 2.

Table 1: Keywords employed in the searches in electronic databases. Medline/Cochrane

#1 Odontogenic cysts #2 Odontogenic cyst #3 Keratocyst #4 Keratocysts #5 Treatment #6 Treatments #7 Therapeutics #8 #1 OR #2 OR #3 OR #4 #9 #5 OR #6 OR #7 #10 #8 AND #9

Embase

#1 Odontogenic keratocyst #2 Odontogenic keratocysts #3 Keratocystic odontogenic tumor #4 Keratocystic odontogenic tumors #5 Treatment #6 Treatments #7 Therapy #8 Therapies #9 #1 OR #2 OR #3 OR #4 #10 #5 OR #6 OR #7 OR #8 #11 #9 AND #10

Bireme

#1 Cisto odontogênico #2 Cistos odontogênicos #3 Ceratocisto #4 Ceratocistos #5 Tratamento #6 #1 OR 2# OR #3 OR #4 #7 #5 AND #6

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Therapeutic challenges of odontogenic keratocyst: Review of literature and case report using the decompression technique

Table 2: Data collected from selected papers. Author

Patients (n)

Abdullah2 (2011)

Guimarães et al.4 (2013)

Ledderhof et al.6 (2017)

Awni e Conn8 (2017) Lee et al.9 (2017)

Technique

Decompression with draining device, marsupialization, enucleation with Literature review or without adjutant (Carnoy’s solution or cryotherapy) and resection

OK can be treated conservatively by enucleation and application of Carnoy’s solution or cryotherapy and may be used especially in larger lesions that might be candidates for resection.

Resection

The present review sought for high-level evidence on the effectiveness of OK control, comparing different interventions and adjutants for their treatment. No eligible studies were found for inclusion.

Resection

The main reason for OK resection was the involvement of pterygoid muscles. The authors believe that malignancy is the only indication for resection, stating that this procedure can be very radical and represent overtreatment in a benign case.

Topical fluorouracil

Fluorouracil (5-FU) is a new, effective and targeted treatment for OKs, which has lower relapse rates and less morbidity, compared to the modified Carnoy’s solution.

Systematic review

Carnoy’s solution

The lack of randomized clinical trials, methodological differences and low level of evidence from the included studies allow to conclude that the use of Carnoy’s solution as an adjutant therapy for the treatment of OKs does not offer a clear reduction in the relapse rates of the lesion.

Retrospective clinical study

Marsupialization

Changes in the epithelium of the OK capsule after marsupialization facilitate the lesion enucleation, reducing the possibility of residues and thus relapse.

Systematic review

Decompression and enucleation

Decompression is an effective method for the initial treatment of mandibular cysts.

Systematic review

Cohort study

Conclusion

The benign nature of these tumors justifies more conservative treatments, even in large lesions. Knowledge on the profile of OKs is important to better understand the evolution of this pathology, thus establishing a more accurate treatment and prognosis.

Retrospective clinical study

Diaz-Belenguer et al.7 (2016)

Type of study

Retrospective clinical study

Sharif et al.3 (2015)

Warburton et al.5 (2015)

Papers (n)

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):28-35

Reschke LF, Schiefferdecker SA, Dias KB

CASE REPORT Male patient, aged 85 years, hypertensive, with prostate adenocarcinoma and chronic renal failure, was referred to the Orofacial Surgery Service of Hospital Ernesto Dornelles (Porto Alegre/RS) after an episode of pain and swelling in the right mandibular body, presenting panoramic radiograph (Fig. 1) with an image suggesting a cystic lesion. To assess the mandibular structure, a computed tomography was requested (Fig. 1). The diagnostic hypotheses were odontogenic keratocyst or unicystic ameloblastoma, and the proposed procedure was incisional biopsy with concomitant

insertion of a decompression device (Fig. 2). After defining the final diagnosis by anatomopathological examination, odontogenic keratocyst (Fig. 3), the patient was instructed to irrigate the cystic cavity twice daily with 0.12% aqueous chlorhexidine solution and received outpatient follow-up for a period of 180 days (Fig. 4). At the end of the 180-day follow-up, the enucleation procedure was performed followed by curettage (Fig. 5). The material obtained in the second surgical period was referred to a new anatomopathological examination, with diagnosis of inflammatory cyst (Fig. 6).

Figure 1: Radiolucent unilocular lesion in the mandible, limited by radiopaque cortex with areas of discontinuity that suggest fenestration and communication with the oral environment (A). In 3D reconstruction (B) and sagittal sections (C, D), there is an intense osteolytic area, resorption of the mandibular canal roof and little basilar structure, representing an imminent risk of mandibular fracture.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):28-35

Therapeutic challenges of odontogenic keratocyst: Review of literature and case report using the decompression technique

Figure 2: A) The cystic content is observed after removal of the biopsied material. B) Placement of a probe as a decompression device.

Figure 3: A) Histological section (HE, 100X) showing: (1) submucosal connective tissue, (2) remaining bone of the buccal mandibular wall, (3) fibrous capsule and (4) cystic cavity. B) Greater magnification (HE, 400X) reveals lining of the cavity composed of parakeratinized epithelial cells with a corrugated aspect. The basal layer is composed of cells with hyperchromatic nuclei in palisade, which form a flat epithelial-connective junction. Note the absence of inflammatory infiltrate in the fibrous capsule.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Figure 4: Radiographic control at 90 days (A) and 180 days (B).

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):28-35

Reschke LF, Schiefferdecker SA, Dias KB

Figure 5: Preoperative computed tomography: A) 3D reconstruction and B) sagittal section, where new bone formation is observed, with mandibular canal roof regeneration and structural gain in the basilar, buccal and lingual regions. An intraoperative view evidences C) preserved mandibular remnant and D) the lesion after enucleation and curettage.

1 2

Figure 6: A) Histological section (HE, 100X) showing: 1) fibrous connective tissue capsule and 2) the cystic cavity. B) Greater magnification (HE, 400X), we observe the cavity covered by stratified non-keratinized epithelial tissue and fibrous capsule containing intense mononuclear inflammatory infiltrate.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):28-35

Therapeutic challenges of odontogenic keratocyst: Review of literature and case report using the decompression technique

DISCUSSION Selection of decompression as the therapy used for the present case was based on studies that suggest the technique for extensive pathologies, particularly in elderly or clinically compromised patients. Decompressing a cyst consists of relieving the internal pressure of its cavity, preventing its growth. The growth of cysts is believed to occur by a combination of intralesional osmotic pressure and resorption of the adjacent bone walls, along with release of prostaglandins and growth factors. Decompression therapy can be performed making a small opening in the cyst (marsupialization) or keeping it open by inserting a drain, a treatment conducted to reduce the dimensions of large lesions, promoting a second less complex procedure with lower morbidity.2,9 The ideal opportunity for application of this technique is during the accomplishment of incisional biopsy.10 Although some authors report that decompression can be used as the only therapy for OK,10 due to the large proportion of the lesion and the large period required for its total regression, the second surgical time was performed after observation of decreased risk of mandibular fracture, since the patient was not complying with the treatment time, which is fundamental to maintain the technique.8 Also, the curettage technique performed after cystic decompression presents effective results in the published literature.11 Parallel to the visible and significant reduction of the lesion, in which the applied therapy provided new bone formation, recovery of the mandibular structure and preservation of the inferior alveolar nerve by repair of the mandibular canal, the success of decompression was confirmed by the occurrence of squamous metaplasia, in which the parakeratinized epithelium that involves the cystic cavity undergoes changes that no longer characterize OK, as confirmed by anatomopathological examination (inflammatory cyst, Fig 6). This transformation tends to make the cystic capsule less friable, facilitating the complete lesion removal, significantly decreasing the chance of relapse.8 Due to the clinical aspects, the therapeutic option would be resection of the involved mandibular segment; however, complete resections can be very rad-

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

ical and even classified as overtreatment, although this type of technique presents relapse rates of zero in most published studies.4,5 Surgery is the therapy of choice recommended for the treatment of OK, yet it presents failure rates due to the complex management of the pathology. The surgical techniques for the treatment of OK can be classified as conservative or aggressive, in which the conservative treatment consists of simple enucleation, in which previous decompression is indicated for extensive lesions.8-10 Aggressive treatment, in varying degrees, includes enucleation associated with Carnoyâ&#x20AC;&#x2122;s solution,2,7 fluorouracil6 or cryotherapy2 and resection.4,5 Regardless of the technique, the treatment goals must involve eliminating the possibility of recurrence and minimizing the surgical morbidity. The high relapse rate is reported in many cases in the literature, without significant differences between the techniques described. The explanation for this relapse characteristic would be the odontogenic nature of the lesion (remnants of dental lamina) and not the treatment method. It was described that, between 3 months and 16 years of follow up, the combination of one or more adjutants to enucleation has significantly low recurrence rates, between 0 and 7.9%.7 Within a rational perspective, given the need to assure the quality of life of patients, considering the lack of randomized clinical trials that compare less radical techniques with combinations of one or more adjutants, as well as their benefits, there is no single therapy established for the treatment of OK, therefore the surgeon should customize the treatment employed.4,7 CONCLUSION Based on the information achieved, considering the definitive diagnosis of OK, the possible comorbidities of patients and technical limitations, it is suggested that minor lesions may be submitted to a single enucleation procedure with a combination of one or more adjutants, and extensive lesions should be submitted to decompression prior to definitive surgery, restricting the resection technique for lesions that may not respond to decompression and in cases of pathological fracture.

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):28-35

Reschke LF, Schiefferdecker SA, Dias KB

References:

2. 3.

Wright JM, Vered M. Update from the 4th edition of the World Health Organization classification of head and neck tumours: odontogenic and maxillofacial bone tumors. Head Neck Pathol. 2017 Mar;11(1):68-77. Abdullah WA. Surgical treatment of keratocystic odontogenic tumour: a review article. Saudi Dent J. 2011;23(2):61-65. Sharif FN, Oliver R, Sweet C, Sharif MO. Interventions for the treatment of keratocystic odontogenic tumours. Cochrane Database Syst Rev. 2015 Nov 5;(11):CD008464. Guimarães AC, Santos MDCF, Carvalho GM, Chone CT, Pfeilsticker LN. Giant keratocystic odontogenic tumor: three cases and literature review. Iran J Otorhinolaryngol. 2013 Oct;25(73):245-52.

Warburton G, Shihabi A, Ord RA. Keratocystic Odontogenic tumor (KCOT/OKC): clinical guidelines for resection. J Oral Maxillofac Surg. 2015 Sept;14(3):558-64. Ledderhof NJ, Caminiti MF, Bradley G, Lam DK. Topical 5-fluorouracil is a novel targeted therapy for the keratocystic odontogenic tumor. J Oral Maxillofac Surg. 2017 Mar;75(3):514-24. Diaz-Belenguer A, Sanchez-Torres A, Gay-Escoda C. Role of Carnoy’s solution in the treatment of keratocystic odontogenic tumor: A systematic review. Med Oral Patol Oral Cir Bucal. 2016 Nov 1;21(6):e689-95. Awni S, Conn B. Decompression of keratocystic odontogenic tumors leading to increased fibrosis, but without any change in epithelial proliferation. Oral Surg Oral Med Oral Pathol Oral Radiol. 2017 June;123(6):634-44.

10.

11.

Lee ST, Kim SG, Moon SY, Oh JS, You JS, Kim JS. The effect of decompression as treatment of the cysts in the jaws: retrospective analysis. J Korean Assoc Oral Maxillofac Surg. 2017 Apr;43(2):83–7. Medeiros JR, Nogueira CBP, Emim E, Bezerra MF, Soares ECS. Marsupialização como tratamento definitivo para ceratocisto odontogênico: relato de caso e revisão de literatura. J Braz Coll Oral Maxillofac Surg. 2017 Set-dez;3(3):72-8. Barbosa SM, Medeiros PJ, Ribeiro DPB, Ritto FG. Abordagem conservadora no tratamento do tumor ceratocístico odontogênico. J Braz Coll Oral Maxillofac Surg. Jan-Abr;1(1):65-70.

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):28-35

CaseReport

Subcutaneous emphysema during surgical extraction of third molars:

three case reports

ABSTRACT Introduction: Subcutaneous emphysema is a rare accident that occurs during dental treatments in which forced passage of air and/or other gases into the soft tissues occurs. It can have several causes, but the most common occur from the air released during the use of high-speed turbines or triple syringes. Usually treatment is symptomatic, presenting spontaneous remission over time. However, they may present complications that progress to severe conditions that put the patient’s life at risk, and a rigorous follow-up is necessary until its complete regression. Description: Three clinical cases of female patients, who developed subcutaneous emphysema during the use of high-speed turbine in third molar extraction procedures, are reported. All were diagnosed immediately during the surgeries, with symptoms of facial volume increase and crepitation on palpation. Results: The treatments performed were satisfactory, which included the use of associated anti-inflammatory and antibiotic medications. Conclusion: After a follow-up period, complete remission of the symptoms was observed without the appearance of complications. The correct surgical planning is fundamental to avoid this type of complication. Keywords: Emphysema. Oral surgical procedures. Preprosthetic. Accidents.

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

How to cite: Torres RS, Ribeiro ACF, Carvalho HMP, Nascimento SLC, Albuquerque GC, Martins VB, Oliveira MV, Motta Junior J, Tavares PMH. Subcutaneous emphysema during surgical extraction of third molars: three case reports. J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):36-41. DOI: https://doi.org/10.14436/2358-2782.6.1.036-041.oar Submitted: April 08, 2019 - Revised and accepted: August 09, 2019 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. » Patients displayed in this article previously approved the use of their facial and intraoral photographs. Contact address: Rafael Saraiva Torres E-mail: saraivatorres@gmail.com

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):36-41

Torres RS, Ribeiro ACF, Carvalho HMP, Nascimento SLC, Albuquerque GC, Martins VB, Oliveira MV, Motta Junior J, Tavares PMH

INTRODUCTION The extraction of third molars is the procedure most frequently performed in the dental office in Oral and Maxillofacial Surgery and Traumatology, and even if the surgeon is skilled and experienced, this procedure is subject to complications.1 Among the most frequent, swelling, pain, bleeding, infection and injury to the alveolar or lingual nerve are cited. However, rarer complications, such as subcutaneous emphysema, may also occur.2 Subcutaneous emphysema is an accident in which air and/or other gases are forced into the soft tissues, below the dermal or mucous layer. The accidental introduction of air from the high-speed turbine is usually the most common cause; however, several factors, such as air from the air-water syringe, facial trauma, strong sneezing or postoperative vomiting can result in subcutaneous emphysema.3 Although the most common cause is the use of a handpiece to remove bone, emphysema can also occur during endodontic therapy, periodontal treatment, restorative treatment, after trauma or as a complication of orthognathic surgery.4 Clinically, it presents as a sudden increase in volume in the affected region, discomfort, local pain and crepitation on palpation.5 The degree of air diffusion within the tissues is variable and may remain close to the site of penetration and result in local swelling and crepitation. Additional air diffusion along the fascial planes is possible, causing inflation of the fascial spaces. In extreme cases, passage of air from the masticatory space to the parapharyngeal and retropharyngeal spaces has been reported, penetrating the mediastinum. If the air contains microorganisms, serious infections can occur.4 Crepitation is a pathognomonic finding and distinguishes emphysema from other diagnostic possibilities.3,6 Imaging examinations, such as conventional radiographs, ultrasound and especially computed tomography, contribute significantly to complement the diagnosis.3 The treatment of subcutaneous emphysema is usually only symptomatic, while waiting for its spontaneous remission.3 However, antibiotic therapy is indicated to prevent the development of infections, such as necrotizing fasciitis, as well as a strict monitoring of cardiorespiratory functions, especially if the air reaches fascial spaces in the cervical and tho-

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

racic regions, since some cases can evolve to serious life-threatening conditions.4,7 CASE REPORT Case 1 A 19-year-old female patient attended the service for the extraction of third molars. The patient did not report any systemic disorders or allergies. Treatment planning comprised extraction of all third molars in a single surgical procedure, in an outpatient setting. Preoperatively, one hour before surgery, two 500mg amoxicillin capsules and two 4mg dexamethasone tablets were prescribed. The extraction of teeth 18, 48 and 28 evolved simply without complications. Then, extraction of tooth 38 was initiated. The surgical technique involved making a buccal mucoperiosteal flap by an incision over the ridge and releasing the mesial aspect of the second molar. During buccal and distal osteotomy on the lower third molar, using high-speed turbine under thorough irrigation, the patient reported pain and discomfort in the left periorbital region. Then, a marked increase in volume was observed in the left hemiface, involving part of the periorbital and zygomatic regions (Fig 1A). At this moment, to avoid possible additional introduction of air through the high-speed handpiece, the extraction of tooth 38 was suspended. The affected regions were normal in appearance; however, there was crepitation on palpation, and subcutaneous emphysema was diagnosed. The patient did not report any respiratory distress. An immediate computed tomography was requested, which evidenced dissection of periorbital spaces involving the eyelids, temporal region and oral space (Fig 1B). The prescription included antibiotic therapy (Amoxicillin, 500mg 8/8 h, for 7 days), anti-inflammatory drugs (Dexamethasone, 4mg, 8/8 h, for 3 days) and pain control (Dipyrone 1g, 6/6 h, for 2 days), in addition to instructions on postoperative care related to extraction. The first outpatient return occurred after two days. The patient presented regression of the volumetric increase in the periorbital region, few pain complaints and absence of signs and symptoms of infection. After 15 days, there was total reduction in the emphysema (Fig 1C). Â

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):36-41

Subcutaneous emphysema during surgical extraction of third molars: three case reports

Figure 1: A) Extraoral appearance immediately after the diagnosis of emphysema. B) Tomography of the face showing air present between the facial tissues, showing emphysema. C) 15 days postoperatively showing complete resolution of the case.

Case 2 A female patient, aged 26 years old, attended the service with indication for extraction of teeth 28 and 38. She did not report systemic changes. It was planned to extract these teeth. First, extraction of 28 was performed without complications. During extraction of tooth 38, after using high-speed handpiece for osteotomy, the patient reported changes in visual acuity, besides discomfort and edema in the left infraorbital region. On immediate clinical examination, distension of the periorbital tissues and the left midface were observed with crepitation on pal-

pation, in addition to reddish color of the region (Fig 2A). The extraction was completed and computed tomography was immediately requested, in which a diffuse hypodense image was observed in the periorbital spaces, involving the upper and lower eyelids, temporal, oral, submandibular and sublingual regions with cervical extension, confirming the diagnosis of emphysema (Fig 2B ). The same prescription protocols were adopted, besides care and instructions as in Case 1. The patient evolved well and, after 15 days of follow-up, no clinical signs of emphysema were observed (Fig 2C). Â

Figure 2: A) Extraoral appearance of the emphysema. B) Tomography of the face showing air present between facial tissues, characteristic of emphysema. C) 15 days postoperatively showing complete resolution of the case.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):36-41

Torres RS, Ribeiro ACF, Carvalho HMP, Nascimento SLC, Albuquerque GC, Martins VB, Oliveira MV, Motta Junior J, Tavares PMH

DISCUSSION The subcutaneous emphysema is a rare accident, resulting from complications during dental procedures, in which forced air passes into the soft tissues.3 It may occur due to the routine use of high-pressure air instruments and also the use of an air-water syringe during dental treatments.4 The dental procedures most related to the occurrence of subcutaneous emphysema are extractions of impacted or unerupted third molars, when a highspeed handpiece is used for osteotomies and tooth sectioning. In these procedures, undue lacerations in the periosteum, which can occur due to lack of gentleness and precision in their detachment, may also favor the penetration of air. In the three cases reported here, subcutaneous emphysema occurred due to extraction of the lower third molar, in which flaps were raised with total mucoperiosteal detachment followed by osteotomy, which possibly contributed to the condition.3,9 Also, the proximity of lower third molars and the submandibular facial space may lead to the spread of emphysema to deeper regions, such as the lateral pharyngeal space and the retropharyngeal space, with possible extension to the mediastinum.3 If the air contains microorganisms, an infectious condition may appear, even risking the patient’s life.4 Other authors report the occurrence of this complication in endodontic treat-

Case 3 Female patient, aged 28 years old, attended the service indicated by her orthodontist for extraction of the third molars due to recurrent episodes of pericoronaritis. During anamnesis, she did not report any comorbidity that precluded the extractions. During buccal and distal osteotomy on the lower third molar using high-speed handpiece and thorough irrigation, the patient reported pain and discomfort on the right periorbital region. Then, a marked increase in volume was observed in the left hemiface, involving part of the periorbital, temporal and zygomatic regions, associated with crepitation on palpation, with diagnosis of subcutaneous emphysema (Fig. 3A). The patient did not report any respiratory distress. Because of the patient’s psychological condition due to emphysema, the surgery was suspended, and a computed tomography was requested. The imaging examination showed dissection of periorbital spaces, involving the eyelids, oral, submandibular, temporal and sublingual regions, with cervical extension, confirming the diagnosis of subcutaneous emphysema (Fig. 3B). The same drug protocol was prescribed as in cases 1 and 2, besides the same care and instructions. The patient had a strict postoperative follow-up and, after seven days, presented significant reduction in periorbital edema. After fifteen days, she had no symptoms related to emphysema (Fig. 3C).

Figure 3: A) Extraoral appearance immediately after the diagnosis of emphysema, showing increase in facial volume on the left side. B) Tomography of the face showing air present between the facial tissues, showing emphysema. C) 15 days postoperatively showing complete resolution of the case.

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):36-41

Subcutaneous emphysema during surgical extraction of third molars: three case reports

ti-inflammatory and antibiotic medications. Usually, the cases showed spontaneous remission between 7 and 10 days.1,3 Antibiotic medication is administered prophylactically, because the compressed air inside the tissues contains microorganisms that can develop infectious conditions, such as necrotizing fasciitis and mediastinitis.3 All patients were followed in an outpatient setting. The therapeutic protocol in all cases associated anti-inflammatory, antibiotic and analgesic medications and, after 15 days of follow-up, all showed complete remission of signs and symptoms associated with subcutaneous emphysema, without developing any type of complication.

ments, periodontal treatment, restorative treatment, after trauma and as complications of orthognathic surgery.3,4,9 All reported cases presented air injection by a high-speed handpiece during osteotomy. The diagnosis is achieved by the associated clinical and imaging examinations. The most common symptoms related to the onset of emphysema include diffuse increased volume, crepitation, lack of firmness on palpation, besides discomfort or local pain.1,3,4,8 In the present clinical cases, all patients had a marked volume increase in the affected regions, crepitation on palpation, discomfort and pain. In addition, in case 2, there was also a change in visual acuity. In imaging examinations, computed tomography has become a reference standard for the study and diagnosis, since it assesses the extent of affected regions and the fascial spaces involved, with high precision. In all cases, computed tomography examinations were requested after the occurrence of emphysema, in which it was possible to visualize all affected areas. The periorbital, temporal and oral spaces were affected in all cases. In cases 2 and 3, there was extension to the submandibular, sublingual and cervical spaces.3,9 The treatment of subcutaneous emphysema is palliative and includes follow-up and associated an-

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

FINAL CONSIDERATIONS Even though subcutaneous emphysema requires daily clinical follow-up, its regression usually occurs without complications. Though infrequent, subcutaneous emphysema after dental procedures should always be diagnosed quickly since it can pose a risk of death for the patient. This condition, per se, is relatively innocuous, regressing spontaneously. To prevent this complication, the professional should avoid very extensive flaps and manipulate the tissues gently, avoiding undue lacerations in the periosteum.

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):36-41

Torres RS, Ribeiro ACF, Carvalho HMP, Nascimento SLC, Albuquerque GC, Martins VB, Oliveira MV, Motta Junior J, Tavares PMH

References:

2. 3.

Ferreira PHS, Oliveira D, Momesso GAC, Bonardi JP, Pastori CM, Faverani LP. Enfisema subcutâneo durante exodontia de terceiro molar: relato de caso. Arch Health Invest. 2016;5(1):33-6. Jerjes W, Upile T, Nhembe F, Gudka D, Shah P, Abbas S, et al. Experience in third molar surgery: an update. Br Dent J. 2010 July 10;209(1):E1. Costa RR, Oliveira JCS, Rodrigues WC, Gabrielli MAC. Enfisema subcutâneo abrangendo os espaços temporal, orbital, bucal, submandibular e cervical após cirurgia para extração de terceiro molar. Rev Cir Traumatol Buco-Maxilo-Fac. 2017;17(3):7-10. Kreisner PE, Martins CAM, Pagnoncelli RM. Enfisema em decorrência de procedimentos Odontológicos - revista de literatura. Rev Odonto Ci. 2005;20(50)384-7.

Heyman SN, Babayof I. Emphysematous complications in dentistry, 1960-1993: An illustrative case and review of the literature. Quintessence Int. 1995 Aug;26(8):535-43. Aslaner MA, Kasap GN, Demir C, Akkas M, Aksu NM. Occurrence of pneumomediastinum due to dental procedures. Am J Emerg Med. 2015 Jan;33(1):125.e1-3. Chebel NA, Ziade D, Achkouty R. Bilateral pneumothorax and pneumomediastinum after treatment with continuous positive airway pressure after orthognathic surgery. Br J Oral Maxillofac Surg. 2010 Jun;48(4):e14-5. Lima RL, Fonseca VR, Malucelli DA, Amaral Y, Cavalheiro MN, et al. Enfisema tecidual odontogênico de face, faringe e pescoço - relato de caso e revisão da literatura. Rev Bras Cir Cabeça Pescoço. 2016;45(4):136-8.

Costa Filho JZ, Milhazes Filho AL, Silva CLCM, Costa PJC. Enfisema sub-cutâneo provocado por instrumento de alta rotação: relato de caso. Rev Bras Cir Buco-Maxilo-Fac. 2011;1(1):33-8.

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):36-41

CaseReport

A rare case of extensive mandibular and maxillary exostosis:

case report

ANA BEATRIZ COLOMBARI1 | FELIPPE ALMEIDA COSTA1 | FELIPE PERRARO SEHN1 | CÁSSIO EDVARD SVERZUT1 | ALEXANDRE ELIAS TRIVELLATO1

ABSTRACT Introduction: Exostoses and mandibular torus have uncertain and multi-factorial etiology, but it is believed that environmental and genetic factors are related. They are more common in the male sex, prevailing from 0.09 to 19% in the former and from 5 to 40% in the case of mandibular torus. Objective: The present study aimed to investigate a clinical case of surgical removal of extensive exostosis of maxilla and mandibular torus. Method: Patient attended the CTBMF with complaint of impossibility of prosthetic rehabilitation. After the clinical examination, a maxillary edentulous arch with large lobulated-looking bone volume was observed. In the mandibular arch, bone protuberance was observed along the lingual surface in the premolar region and surgical removal of the maxillary, and mandible exostoses under local anesthesia was indicated. There were no intercurrences in the postoperative period. Histopathological examination revealed fragments of lamellar bone tissue, with predominantly compact areas in the peripheral regions. Results: The inflammation was minimal and the patient reported little postoperative discomfort. Conclusion: The exostosis are common physiological changes that make prosthetic rehabilitation impossible, and the maxillary complex surgery is indicated to rehabilitation. Keywords: Exostoses. Surgery, oral. Alveoloplasty.

University of São Paulo, Ribeirão Preto School of Dentistry, Department of Periodontology and Oral and Maxillofacial Surgery (Ribeirão Preto/SP, Brazil).

How to cite: Colombari AB, Costa FA, Sehn FP, Sverzut CE, Trivellato AE. A rare case of extensive mandibular and maxillary exostosis: case report. J Braz Coll Oral Maxillofac Surg. 2020 JanApr;6(1):42-6. DOI: https://doi.org/10.14436/2358-2782.6.1.042-046.oar Submitted: April 08, 2019 - Revised and accepted: August 09, 2019 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. » Patients displayed in this article previously approved the use of their facial and intraoral photographs. Contact address: Felippe Almeida Costa E-mail: felippeodonto@gmail.com

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):42-6

Colombari AB, Costa FA, Sehn FP, Sverzut CE, Trivellato AE

INTRODUCTION Maxillary exostosis is characterized by a benign growth, of unknown origin, which may present a nodular, flat or pedunculated aspect, located on the buccal aspect of the alveolar ridges, and is usually asymptomatic. 1 The changes found in the maxilla and mandible include the palatal torus and mandibular torus, of unknown origin. The mandibular torus affects the lingual aspect of the mandible, and its removal is necessary in cases of instability, lack of retention and support of prosthetic devices. The etiology of torus is associated with several environmental and genetic factors.2 When planning the replacement of missing teeth with dentures, either conventional or implanted, the alveolar crest shape and the presence of irregularities in the alveolar ridge, vestibule or palate that prevent correct insertion must be corrected by surgical procedures, and regularization of the denture contacting area is recommended, allowing for support, retention and prosthetic stability. Pre-prosthetic surgery is defined as any surgical procedure performed to enable or favor the patientâ&#x20AC;&#x2122;s oral rehabilitation, aiming to facilitate the denture adaptation, either in bone or soft tissue. 2 Thus, the objective of this study is to report a clinical case of exuberant maxillary exostosis and mandibular torus.

Bullet fragments were observed in the left midface, resulting from interpersonal violence. The surgical procedure was performed in an outpatient setting, under local anesthesia, in two stages, due to the volume of bone exostosis. An incision was made in the alveolar bone crest, from the midline to the tuber, exposing the entire lesion. Then, osteotomy was performed in channels, with the aid of a drill n. 702 and removal of fragments with a straight chisel, followed by osteoplasty with a multilaminated truncated cone bur in the entire alveolar ridge area (Fig 2). The procedure finished after gingivectomy and continuous suture interspersed with simple suture. The patient was instructed on postoperative care and prescribed anti-inflammatory and analgesic drugs for three days. Follow-up was performed on the 7 th and 14 th postoperative days, with favorable healing only in the second period. Contralateral surgery was scheduled 21 days after the first surgical procedure, with repetition of all previously mentioned steps. During mandibular surgery, lobular images were observed without involvement of adjacent roots, being clinically confirmed by exploration during surgery. Under local anesthesia, the mandibular torus was removed, and the area was regularized using drills. The postoperative instructions were reinforced, and antibiotic, anti-inflammatory and analgesic drugs were prescribed for three days. Follow-up was carried out after seven days, and surgery on the other side was performed on the same way. All materials collected during surgeries were submitted to histopathological analysis at the Department of Stomatology, Public Health and Legal Dentistry of the same institution. Histopathological examination revealed fragments of lamellar bone tissue, with areas predominantly compacted in the peripheral regions. The follow-up of each surgery was done after seven days, to remove the suture and evaluate the healing process. After six months, the patient returned to the institution for reevaluation (Fig 3).

CASE REPORT A 64-year-old patient with uneventful medical history attended the Department of Oral and Maxillofacial Surgery and Traumatology at RibeirĂŁo Preto School of Dentistry-FORP/USP with the chief complaint of impossibility of rehabilitation with upper and lower partial dentures. On intraoral examination, a very bulky and lobulated edentulous upper alveolar ridge was observed on both sides. The lower arch revealed bilateral mandibular tori across the lingual alveolar ridge surface (Fig 1). As complementary examination, a panoramic radiograph was obtained, which revealed an irregular bilateral maxillary ridge.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):42-6

A rare case of extensive mandibular and maxillary exostosis: case report

Figure 1: Bilateral maxillary and mandibular exostosis, with large volume and lobulated aspect.

Figure 2: Transoperative aspect of maxillary and mandibular exostoses.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):42-6

Colombari AB, Costa FA, Sehn FP, Sverzut CE, Trivellato AE

Figure 3: Final appearance after removal of maxillary exostosis and mandibular torus.

DISCUSSION It is known that the etiology of exostoses remains uncertain and may be multifactorial, caused by the influence of genetic and environmental factors.3 However, it is believed that nutritional and inflammatory aspects are related to the occurrence of these changes in the jaws, 4 since it has been suggested that there is a possible relationship between chronic inflammation of periodontal origin and the occurrence and marked development of buccal exostosis and mandibular torus. In the present case, the patient only had lower teeth with periodontal disease. However, since this is a slow developmental alteration, the occurrence and development of maxillary exostosis may have occurred due to the chronic periodontal inflammatory process, which was the reason for the extraction of upper teeth. According to Neville et al.1, the mandibular torus shows peak prevalence in early adulthood, with a decrease over the years, and surgical intervention is not usually performed, except in cases of prosthetic rehabilitation, traumatic ulcer, difficult hygiene and adjacent periodontal disease. In this case report, the patient had as main complaint the masticatory difficulty and the interest in performing rehabilitation of the upper arch with full mucosa-supported denture, as well as chronic periodontal inflammation in the remaining teeth, indicating the surgical procedure. Jaw exostoses are diagnosed by clinical examina-

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

tion and biopsy is unnecessary in most cases, except in cases where other bone lesions are suspected, such as osteochondroma and osteosarcoma. In addition, the patient should be evaluated for the possibility of Gardner syndrome, which is characterized by the occurrence of nodule growth outside the oral cavity, skin cysts and multiple intestinal polyps, which have high potential for malignant transformation. When this syndrome is suspected, the patient should be referred to the dermatologist for evaluation.4 Lee et al. 5 reported a clinical case of removal of exostosis that presented postoperative complications similar to that found in this case, with a small dehiscence. Chandna et al. 6 reported a clinical case of surgical removal of the maxillary exostosis, with smaller extension, with good results after surgical removal. Isolated cases of exostosis of the jaws are common in the literature, being atypical with exuberance as in the present case. FINAL CONSIDERATIONS Thus, we conclude that exostosis in the maxilla and mandibular torus are physiological changes that require surgical procedures with good resolution on an outpatient basis for patients who need rehabilitation of the jaws, promoting better quality of life for these patients. Adequate clinical examination should always be performed to rule out other pathologies that may have similar characteristics.

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):42-6

A rare case of extensive mandibular and maxillary exostosis: case report

References:

1. 2. 3.

Neville BW, Damm DD, Allan CM, Bouquot JE. Patologia Oral e Maxilofacial. 3a ed. Rio de Janeiro: Elsevier; 2009. Meza-Flores JL. Torus palatinus and Torus mandibularis. Rev Gastroenterol Peru. 2004 Oct;24(6):343-8. Pechenkinz E, Benfer RA. The role of occlusal stress and gingival infection in the formation of exostoses on mandible and maxilla from Neolithic China. Homo. 2002;53(2):112-30.

Fotiadis C, Tsekouras DK, Antonakis P, Sfiniadakis J, Genetzakis M, Zografos GC. Gardner’s syndrome: a case report and review of the literature. World J Gastroenterol. 2005;11(34):5408-11. Lee KH, Lee JH, Lee HJ. Concurrence of torus mandibularis with multiple buccal exostoses. Arch Plast Surg. 2013;40(4):466-8.

Chandna S, Sachdeva S, Kochar D, Kapil H. Surgical management of the bilateral maxillary buccal exostosis. J Indian Soc Periodontol. 2015;19(3):352-5.

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ArtigoOriginal

Maxillofacial trauma epidemiology:

a retrospective analysis of 1,230 cases PRIMO GUILHERME PASQUAL1 | ROBERTA BRITO ARGUELLO1 | KAROLINE WEBER DOS-SANTOS2 | MARÍLIA GERHARDT DE-OLIVEIRA3 | CAITON HEITZ3

ABSTRACT Introduction: Trauma represents a considerable public health issue due to its elevated morbidity, incidence and prevalence, besides the elevated hospital assistance cost. When analyzing this subject, one should consider the geographical and cultural variations, as well those inherent to the studied sample. Objective: The purpose of this study was to present the epidemiological profile of facial fracture inpatients treated in a Brazilian tertiary hospital. Methods: All patients sustaining facial fractures treated at Cristo Redentor Hospital, Porto Alegre, Brazil from May 2013 to April 2018 had their electronic records retrospectively reviewed. Demographic data, etiological factors, affected anatomical sites and treatment methods were collected and analyzed. Results: 1,230 patients presenting a total of 2,241 facial fractures were included. The mandible was the most frequent affected site (45.65%), followed by the zygomaticomaxillary complex (31.28%). The most observed etiological factor was motor vehicle accidents (32.2%). And open reduction with internal fixation (ORIF) was the treatment method utilized with the highest frequency (30.65%). Conclusions: The results of this analysis associated to the continuous outreach of current data reflecting local realities are crucial to improve the comprehension of these traumatic events and development of public policies focused on the control, prevention and rehabilitation of this patients. Keywords: Facial injuries. Jaw fractures. Epidemiology.

Hospital Cristo Redentor, Residency Program in Oral and Maxillofacial Surgery and Traumatology (Porto Alegre/RS, Brazil).

How to cite: Pasqual PG, Arguello RB, Dos-Santos KW, De-Oliveira MG, Heitz C. Maxillofacial trauma epidemiology: a retrospective analysis of 1230 cases. J Braz Coll Oral Maxillofac Surg. 2020 JanApr;6(1):47-53. DOI: https://doi.org/10.14436/2358-2782.6.1.047-053.oar

Hospital Cristo Redentor, Rehabilitation Service (Porto Alegre/RS, Brazil).

Hospital Cristo Redentor, Service of Oral and Maxillofacial Surgery (Porto Alegre/RS, Brazil).

Submitted: 23/06/2019 - Revised and accepted: 13/12/2019 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. Contact address: Primo Guilherme Pasqual Rua Gomes Jardim 280, apto 7 - Porto Alegre/RS E-mail: primopasqual@hotmail.com

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):47-53

Maxillofacial trauma epidemiology: a retrospective analysis of 1,230 cases

INTRODUCTION Trauma to the maxillofacial complex is an important public health problem and a constant challenge for responsible professionals.1 Described since the oldest available surgical treaty, the papyrus of Edwin Smith (Egypt, 1600 BC),2 in which a complex mandibular fracture was classified as untreatable and defining a poor prognosis for this condition, the diagnosis and treatment of facial fractures has presented constant evolution and currently, despite the associated comorbidities, facial fractures alone have low mortality. 3 The incidence, etiology and morbidity vary across geographical regions and populations studied.5,6 However, the negative social and functional consequences of facial fractures are apparently global. Facial disfigurement, deformities, occlusal changes, speech and swallowing disorders are possible sequelae of these fractures. 5,7 The treatment of traumatized patients primarily aims to acquire a safe airway and control bleeding, following the principles of ATLS (Advanced Trauma Life Support).8 The objectives of treatment of patients with facial fractures are: recovery of esthetics and facial symmetry, stabilization of unstable segments and reconstruction of the pillars of facial support, ensuring occlusal stability and functional rehabilitation of the stomatognathic system.9 The definition, by epidemiology, of the demographic distribution of facial fractures in different populations, main risk groups and etiological factors is fundamental for the establishment of strategies for prevention of these injuries and to guide the assistance in specialized services that provide care to traumatized patients. Therefore, this study presents an epidemiological survey of patients with facial injuries assisted at the Oral and Maxillofacial Surgery and Traumatology service of Hospital Cristo Redentor in Porto Alegre/ RS, during a 5-year period.

Patients with fractures of facial bones treated at the Oral and Maxillofacial Surgery and Traumatology Service of Hospital Cristo Redentor in Porto Alegre/RS from May 2013 to April 2018 were included. The study excluded patients hospitalized for conditions other than facial fractures, such as soft tissue injuries, maxillofacial pathologies, osteomyelitis, abscesses, as well as incomplete or inaccessible medical records for the established outcomes. Data were collected regarding age, gender, date of hospitalization and hospital discharge (to establish the length of stay), etiological factor of the fracture, anatomical site of fractures and treatment method per affected site, number of hospitalizations required for treatment and number of outpatient consultations after hospital discharge. The affected anatomical regions were classified into: mandible (condylar process, coronoid process, mandibular ramus, body, symphysis, parasymphysis and lower dentoalveolar), Le Fort I, Le Fort II, Le Fort III, orbital-zygomaticomaxillary complex, naso-orbital-ethmoidal complex, nasal , dentoalveolar, blow-out, nasal bones (NB), and frontal. The treatment methods were classified as: open reduction without fixation, open reduction with internal fixation (ORIF), maxillomandibular block (MMB), and conservative treatment. The choice of treatment was based on the affected anatomical site, fracture morphology, bone availability and professional preference. Open reduction without fixation was reserved for cases of isolated zygomatic arch fractures, mostly performed by intraoral access. The osteosynthesis methods performed in the ORIF group included microplate systems, eligible for fractures of the midface and frontal bone; miniplate systems, eligible for mandibular and zygomaticomaxillary fractures; and titanium screens, indicated for orbital floor reconstructions. Reconstruction plates were available for cases of complex fractures of the mandible associated with bone comminution, segmental defects and/or contraindications concomitant to maxillomandibular block (MMB). MMB was performed using Erich arches associated with orthodontic elastics or locking screws. Even though the intraoperative intermaxillary block was performed routinely, only patients who underwent

METHODS This cross-sectional study was approved by the Institutional Review Board of the Conceição Hospital Group (CAAE: 80994117.6.0000.5530, CEPGHC), according to the Declaration of Helsinki and resolution 466/12 of the National Health Council/ Ministry of Health/Brazil .

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):47-53

Pasqual PG, Arguello RB, Dos-Santos KW, De-Oliveira MG, Heitz C

titative variables were described by median and interquartile range, due to the non-parametric data distribution; and categorical variables by absolute and relative frequencies. The software used for data analysis was SPSS version 21.0.

postoperative MMB were included in this group. Conservative treatment consisted of prescribing a soft diet and was only indicated for compliant patients, who presented simple/non-displaced fractures. Evasion prior to treatment and death prior to treatment were also considered. The etiological factors were classified, according to data obtained from the sample, into: car accidents, interpersonal aggression, sports accidents, work accidents, firearm injuries, knife wounds, fall from own height, fall from height, falling object on the face, accidents with animals, extraction of third molar and others. The normality of the sample distribution was verified using the Kolmogorov-Smirnov test. Quan-

RESULTS A total of 1,408 records were evaluated, 178 of which were excluded for not complying with the inclusion criteria. Data from the medical records of 1,230 patients were analyzed. Evasion prior to treatment was observed in 5.37% of the sample (n = 66), and 3.01% of these (n = 37) died during hospitalization. There was predominance of young adults (25 to 44 years old), males (85.2%), with car accidents

Table 1: Distribution of demographic data and etiological factors.

Age (years)

Gender

Etiological factor

0 -11

12 - 24

327

26.6

25 - 44

526

42.8

45 - 64

264

21.5

65 - 99

7.2

Female

182

14.8

Male

1048

85.2

Car accident

396

32.20

Interpersonal violence

339

27.56

Firearm wound

173

14.07

Fall from own height

110

8.94

Fall from height

6.75

Sports accident

5.69

Work accident

1.46

Fall of object on the face

1.22

Accident with animals

0.89

Knife wounds

0.33

Third molar extraction

0.16

Not informed

0.33

Others

0.41

Total

1.230

100

Q1 = first quartile; Q3 = third quartile; n (%) = sample size (percentage of the sample).

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J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):47-53

Maxillofacial trauma epidemiology: a retrospective analysis of 1,230 cases

(22.54%), followed by fractures of the body (18.75%), parasymphysis (17.90%) and angle (17.61%). Among patients who completed the proposed treatment (1,127 cases), the length of stay required for the treatment of 50% of the sample was up to 7 days, ranging from 1 to 306 days. Only 54 patients (4.79%) required more than one hospitalization to complete the treatment Among these 54 patients, osteomyelitis and/or surgical site infection were the cause of reintervention in 14 cases (25.92%), mostly (85.71%, n = 12) related to complex mandibular fractures. The remov-

(32.2%) and interpersonal aggressions (27.5%) being the main causes of facial fractures requiring hospitalization (Table 1). A total of 2,241 fractures were identified in the studied population. The distribution of these fractures is shown in Table 2. The mandible was the main affected anatomical site with 45.56% (n = 1021), followed by orbital-zygomaticomaxillary (OZM) fractures, with 31.28% (n = 701). The subdivisions of mandibular bone were analyzed separately and are shown in Table 3. Fractures of the condylar processes were the most prevalent

Table 2: Distribution of frequencies of fractures in the groups.

Mandible Orbital-zygomaticomaxillary Frontal Dentoalveolar NB Blow out Naso-orbital-ethmoidal Le fort I Le fort II Le fort III Lannelongue (maxillary sagittal) Total

1021 701 102 119 83 76 43 43 31 10 12 2.241

45,56 31,28 4,55 5,31 3,70 3,39 1,92 1,92 1,38 0,45 0,54 100

n (%) = sample size (sample percentage). NB = nasal bones. Table 3: Distribution of frequencies of mandibular fractures according to anatomical site.

Condylar process Body Parasymphysis Angle Ramus Coronoid process Symphysis Dentoalveolar mandibular Total

238 198 189 186 78 71 61 35 1.056

22,54 18,75 17,90 17,61 7,39 6,72 5,78 3,31 100

n (%) â&#x20AC;&#x201C; sample size (sample percentage).

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Pasqual PG, Arguello RB, Dos-Santos KW, De-Oliveira MG, Heitz C

Table 4: Treatment methods.

Open reduction with internal fixation (ORIF) Conservative treatment Open reduction with internal fixation + MMB Maxillomandibular block (MMB) Open reduction without fixation Evasion before treatment Death before treatment Skeletal suspension Total

377 376 173 115 82 66 37 4 1.230

30,65 30,57 14,07 9,35 6,67 5,37 3,01 0,33 100

n (%) – sample size (sample percentage).

al of osteosynthesis material due to exposure without signs of infection required rehospitalization of 18 patients (33.33%). Among the patients who required more than one hospitalization to complete the treatment, 55.55% (n = 30) were victims of high energy impacts, such as car accidents and firearm wounds. A second surgical procedure was necessary in 9 cases (0.74%). Other causes for additional hospitalization were surgical correction of lagophthalmos (n = 1), in one patient sustaining a complex zygomaticomaxillary fracture, and dacryocystorhinostomy (n = 2) in victims of NOE fractures. The distribution of treatment methods used is shown in Table 4. Open reduction with internal fixation (ORIF) was the most prevalent treatment method, applied to 377 patients (30.65%). ORIF was associated with maxillomandibular block in 173 more cases (14.07%), and conservative treatment was chosen for 376 patients (30.57%). DISCUSSION Traumas involving the face affect an essential component for self-recognition, identity and social relationships.10 Patients who are victims of facial trauma should be evaluated, diagnosed and treated properly and at a favorable time, in order to avoid, or even mitigate, the functional and esthetic sequelae. The situations that result in permanent facial changes and functional impairments constantly accompany important psychological sequelae.11

The divergence of epidemiological results presented in the literature occurs regardless of geographical, cultural and specific variations of the samples collected. However, it is consensus that most samples of victims of facial fractures are composed of male subjects aged between 20 and 40 years. 1,4,5,12 In the sample of 530 patients with maxillofacial injuries analyzed by Leles et al. 1, 75.8% were males, and the peak incidence of trauma occurred between 21 and 30 years of age, adding up to 171 cases (32.3%). By a review of the database of the Department of Oral and Maxillofacial Surgery at the University Hospital of Innsbruck (Austria), Gassner et al. 12 demonstrated that the mean age of victims of craniofacial trauma was 25.8 years. In the present study, 85.2% of patients who suffered facial fractures were male and the age group 25-44 years accounted for 42.8% (n=526) of hospitalizations. The results of this study confirm data presented in the literature, which indicate traffic accidents and interpersonal violence as the main etiological factors of facial fractures. The epidemiological analysis conducted by Brasileiro and Passeri 4 revealed that 45% of patients admitted with facial fractures were due to traffic accidents. Bonavolonta et al. 13, in a retrospective review of the attendance records of patients admitted for facial skeletal fractures at a trauma referral hospital in Naples (Italy), also demonstrated that the most prevalent etiological factors were car accidents (57.1%)

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Maxillofacial trauma epidemiology: a retrospective analysis of 1,230 cases

preference of the specialist surgeon, as well as the patientâ&#x20AC;&#x2122;s clinical conditions. 17 Since the pioneering studies of Champy et al.18 and Michelet et al.19, osteosynthesis using plates and screws has been the treatment of choice for facial fractures. The main advantages involve the absence of unfavorable scars, due to the possibility of trans/intraoral access to the facial skeleton, the possibility of shortening or discarding intermaxillary fixation, early recovery of the masticatory function and consequent return of the patient to his social activities. Mijiti et al.20 reviewed 1,350 patients with 1,860 facial fractures, of which 1,064 were treated by open reduction and internal fixation, while another 97 were treated by the association of ORIF with MMB. Despite the advantages and popularity of the treatment based on open reduction and internal fixation, maxillomandibular block remains as an effective treatment method for facial fractures, considering its effectiveness in restoring the occlusion and masticatory function. 17 This study contributes to the assessment of main risk factors, etiological factors and anatomical sites most frequently affected in facial injuries. However, it only presents the frequency distributions of variables of interest. Future studies are still needed, proposing the investigation of complications and negative outcomes, comparing treatments and longitudinal monitoring of patients.

and aggressions (21.7%). Wulkan et al. 5, however, reported aggression as the main etiological factor, which accounted for 48.8% of fractures assessed, while traffic accidents added up to 12.9%. In the sample studied by Kontio et al. 14, interpersonal violence was responsible for 42% of evaluated traumas. In this study, the main etiological factor for maxillofacial fractures was car accidents, which accounted for 32.2% of fractures. Interpersonal violence was the second most frequent factor, with 27.56%. Noteworthy, in this study, was the finding that firearm injuries accounted for 14.07% of hospitalizations, while the literature has a frequency of 0.5% to 1.2%. 5,15 The relevance of this type of trauma reflects the rise in the number of crimes, high mortality and the direct impact on individual health and society as a whole, either due to the constant presence of victims in health services or the daily emotional influence on people. Regarding the anatomical regions most frequently involved, the mandible and zygomatic complex are the most affected, both in the sample studied and in previous studies.4,13 Maliska et al.16, in a retrospective review of 132 patients who totaled 185 facial fractures, demonstrated that 54.6% of fractures involved the mandible, while the zygoma represented 27.6% of fractures. Analyzing the traumas to the mandibular bone separately, the condylar process was the most affected site (22.54%), followed by body (18.75%) and parasymphyseal (17.9%) fractures. Besides frequent, mandibular fractures are related to sensorineural sequelae, masticatory dysfunctions, limited mouth opening and occlusal changes. Several treatment methods are available for maxillofacial fractures. The choice depends on the fracture location, its characteristics, experience and

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

CONCLUSION The results of this analysis associated with the continuous diffusion of updated data that reflect local realities are fundamental for a better understanding of these events and guidance of public health policies focused on the control, prevention and recovery of these patients, allowing the development of new approaches according to changes in the frequencies of causative factors.

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Pasqual PG, Arguello RB, Dos-Santos KW, De-Oliveira MG, Heitz C

References:

1. 2. 3. 4.

5. 6. 7.

Leles JLR, Santos ÊJ, Jorge FD, Silva ET, Leles CR. Risk factors for maxillofacial injuries in a Brazilian emergency hospital sample. J Appl Oral Sci. 2010 Jan-Feb;18(1):23-9. Rowe NL. The history of the treatment of maxillo-facial trauma. Ann R Coll Surg Engl. 1971;49(5):329-49. Phillips BJ, Turco LM. Le Fort Fractures: a Collective Review. Bull Emerg trauma. 2017;5(4):221-30. Brasileiro BF, Passeri LA. Epidemiological analysis of maxillofacial fractures in Brazil: A 5-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;102(1):28-34. Wulkan M, Parreira JG Jr, Botter DA. Epidemiologia do trauma facial. Rev Assoc Med Bras. 2005;51(5):290-5. Ellis E, El-Attar A, Moos KF. An Analysis of 2,067 cases of zygomatico-orbital fracture. J Oral Maxillofac Surg. 1985;43(6):417-28. Conforte JJ, Alves CP, Sánchez MPR, Ponzoni D. Impact of trauma and surgical treatment on the quality of life of patients with facial fractures. Int J Oral Maxillofac Surg. 2016;45(5):575-81. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support ATLS Student Course Manual. 9th ed. Washington, DC: American College of Surgeons; 2012.

10. 11. 12.

13.

14.

Melo MR, Gignon VF, Loredo BAS, Costa SAA, Costa JMC, Patrocínio LG. Tratamento cirúrgico da fratura de maxila: estudo prospectivo de 1 ano em um centro de treinamento em cirurgia crânio-maxilo-facial. Rev Bras Cir Craniomaxilofac. 2011;14(4):179-82. Sugiura M, Sassa Y, Jeong H, Wakusawa K, Horie K, Sato S, et al. Self-face recognition in social context. Hum Brain Mapp. 2012;33(6):1364-74. Sousa A. Psychological issues in acquired facial trauma. Indian J Plast Surg. 2010 July-Dec; 43(2): 200-5. Gassner R, Tuli T, Hächl O, Rudisch A, Ulmer H. Cranio-maxillofacial trauma: a 10 year review of 9543 cases with 21 067 injuries. J Cranio-Maxillofacial Surg. 2003;31(1):51-61. Bonavolontà P, Dell’aversana Orabona G, Abbate V, Vaira LA, Lo Faro C, Petrocelli M, et al. The epidemiological analysis of maxillofacial fractures in Italy: The experience of a single tertiary center with 1720 patients. J Cranio-Maxillofac Surg. 2017;45(8):1319-26. Kontio R, Suuronen R, Ponkkonen H, Lindqvist C, Laine P. Have the causes of maxillofacial fractures changed over the last 16 years in Finland? An epidemiological study of 725 fractures. Dent Traumatol. 2005;21(1):14-9.

15. 16. 17. 18.

19. 20.

Allareddy V, Allareddy V, Nalliah RP. Epidemiology of facial fracture injuries. J Oral Maxillofac Surg. 2011;69(10):2613-8. Maliska MCDS, Lima Júnior SM, Gil JN. Analysis of 185 maxillofacial fractures in the state of Santa Catarina, Brazil. Braz Oral Res. 2009;23(3):268-74. Mukerji R, Mukerji G, McGurk M. Mandibular fractures: Historical perspective. Br J Oral Maxillofac Surg. 2006;44(3):222-8. Champy M, Loddé JP, Schmitt R, Jaeger JH, Muster D. Mandibular osteosynthesis by miniature screwed plates via a buccal approach. J Maxillofac Surg. 1978 Feb;6(1):14-21. Michelet FX, Deymes J, Dessus B. Osteosynthesis with miniaturized screwed plates in maxillo-facial surgery. J Maxillofac Surg. 1973 June;1(2):79-84. Mijiti A, Ling W, Tuerdi M, Maimaiti A, Tuerxun J, Tao YZ, et al. Epidemiological analysis of maxillofacial fractures treated at a university hospital, Xinjiang, China: A 5-year retrospective study. J Craniomaxillofac Surg. 2014 Apr;42(3):227-33.

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CaseReport

Condylar hyperplasia treatment by means of proportional condilectomy and orthognathic surgery:

case report

ABSTRACT Introduction: Condylar hyperplasia describes the pathological condition caused by overgrowth of the mandibular condyle, with a higher prevalence between 10 and 20 years of age. This factor can be attributed to the effects of puberty and exponential increase in body growth rate, facial asymmetry may be apparent at this age and with this the search for treatment begins. Several treatments have been proposed for this type of pathology. Objective: To report a case report discussing current treatment protocols for condylar hyperplasia. Case report: A 20-year-old female leukoderma patient referred to the Bucomaxillofacial Surgery and Traumatology service with a history of facial asymmetry. Physical examination revealed severe facial asymmetry and significant laterognathism with left shift, and complementary exams were requested. After diagnosis of mandibular condylar hyperplasia, the patient underwent proportional condilectomy and orthognathic surgery in a second time. Conclusion: The use of proportional condilectomy to treat facial asymmetry caused by unilateral condylar hyperplasia may be satisfactory, since its reduced invasiveness and good success rate. Keywords: Temporomandibular joint disorders. Temporomandibular joint. Maxillofacial abnormalities.

Beneficent Association of the Santa Casa de Campo Grande, Resident of the Oral and Maxillofacial Surgery and Traumatology Service (Campo Grande/MS, Brazil).

How to cite: Ferzeli VHN, Barros MN, Teslenco VB, Reis GN, Pancini EF, Cavalcanti HA. Condylar hyperplasia treatment by means of proportional condilectomy and orthognathic surgery: case report. J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):54-60. DOI: https://doi.org/10.14436/2358-2782.6.1.054-060.oar

Beneficent Association of the Santa Casa de Campo Grande, Preceptor of Residency in Oral and Maxillofacial Surgery and Traumatology (Campo Grande/MS, Brazil).

Submitted: July 25, 2019 - Revised and accepted: October 03, 2019

Beneficent Association of the Santa Casa de Campo Grande, Coordinator of the Residency in Oral and Maxillofacial Surgery and Traumatology (Campo Grande/MS, 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: Maylson Nogueira Barros E-mail: maylson.bucomaxilofacial@gmail.com

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):54-60

Ferzeli VHN, Barros MN, Teslenco VB, Reis GN, Pancini EF, Cavalcanti HA

INTRODUCTION Condylar hyperplasia describes the pathological condition caused by excessive growth of the mandibular condyle. Indicating an increase in the production and growth of normal cells, the term hyperplasia is used when there is a volumetric increase in a tissue or organ, still maintaining its natural shape.1,2 Facial asymmetry is a striking feature in these patients, who have a disharmonious face due to uncontrolled growth of bone tissue.3 According to epidemiological data, there is predisposition to condylar hyperplasia in patients with a mean age of 27.8 years, with higher prevalence between 10 and 20 years. This factor can be assigned to the effects of puberty and exponential increase in the rate of body growth. Thus, facial asymmetry may become apparent at this age and thus the search for treatment begins. A higher prevalence rate in females is reported in some studies. Some authors attribute this to the greater demand for treatment by female patients; others correlate the higher production of estrogen in women as an inducing factor of exacerbated condylar growth. This hormone has a growth regulating and bone maturation factor and may be directly related to the appearance of this pathology in women, especially during the age of greater concentration of this hormone in the body. A meta-analysis was carried out, proving a clear greater appearance of condylar hyperplasia in females, in a ratio of 2:1.4.5 Besides the link between sex hormones and condylar growth, several other causes have already been hypothesized as causing hyperplasia: trauma, genetic origin, mechanical origin, yet without conclusive evidence. Insulin-like growth factors (IGF-1) have been associated with the development of condylar hyperplasia, with high concentrations found in the proliferation zones of these condyles and their chondrocytes. 5 Considering these complications, several treatments have been proposed for this type of pathology. Therefore, this paper aims, by a case report, to discuss the current treatment protocols for condylar hyperplasia and to present some characteristics of the mentioned treatment lines.

matology service of the Beneficent Association of Hospital Santa Casa de Campo Grande/MS, with history of facial asymmetry. She denied history of condylar hyperplasia in the family, previous trauma to the region or other comorbidities. Physical examination revealed severe facial asymmetry and significant laterognathism, with deviation to the left (Fig 1). The patient reported intense bilateral intra-articular pain in the temporomandibular joints, with greater intensity on the left side â&#x20AC;&#x201C; characteristic signs of anteriorization of the disc without reduction; masticatory difficulty, due to the unfavorable occlusal pattern, and left lateral crossbite. Magnetic resonance imaging of the joints allowed to confirm the right condylar hyperplasia, together with anteriorization of the articular disc, not reducing the mouth opening movement, in the left temporomandibular joint (Fig 2B). A bone scintigraphy exam was requested to assess the condylar bone hyperactivity, a situation confirmed in the right mandibular condyle, showing an osteogenic process in the projection of the referred condyle (Fig 2A). The treatment plan initially included orthodontic treatment for aligning the dental arches and surgical procedures on the temporomandibular joints: direct visualization of the right mandibular condyle through modified endaural access, proportional condylectomy and discopexy of right and left articular discs, and therapy with elastic bands to maintain the occlusal position. The anatomical specimen obtained by condylectomy was sent for histopathological analysis, presenting findings consistent with mandibular condylar hyperplasia. The patient showed rapid recovery from the surgical procedure and no injury to any procedure-related innervation (Fig 3A, 3B). During a follow-up period of 30 months, monthly evaluations were performed, which evidenced a significant improvement in laterognathism (from 10 mm to 4.5 mm in the dental midline and from 16 mm to 6 mm in the facial midline) and alteration of the occlusal pattern, with crossbite correction in the region contralateral to the condylar hyperplasia and concomitant improvement of painful symptoms in the contralateral temporomandibular joint. During the follow-up period, the patient revealed excessive vertical maxillary growth. Combined to this, deviation of the dental and facial midline still persisted, despite the standards within a clinically acceptable limit (up to 5 mm deviation of the dental midline),

CASE REPORT A 20-year-old Caucasoid female patient was referred to the Oral and Maxillofacial Surgery and Trau-

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):54-60

Condylar hyperplasia treatment by means of proportional condilectomy and orthognathic surgery: case report

occlusal function and facial asymmetry. It was still possible to observe a slight mandibular deviation, probably due to the patientâ&#x20AC;&#x2122;s low compliance with rehabilitation with elastics. The patient was instructed to resume therapy with elastics, and a new assessment would be made (Fig 3C to 3H).

added to an excessive maxillary growth. Thus, a bimaxillary repositioning surgical procedure was indicated, with maxillary impaction of 5 mm and anterior mandibular repositioning. After a 90-day postoperative follow-up, the patient responded well to the procedure, with no paresthesia, improved facial pattern,

Figure 1: Initial photographs: A) frontal view, B) frontal view smiling, C) left lateral view, D) right lateral view.

Figura 2: A) Scintigraphy. B) Magnetic resonance of the joints.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):54-60

Ferzeli VHN, Barros MN, Teslenco VB, Reis GN, Pancini EF, Cavalcanti HA

Figure 3: Photographs after condylectomy: A) frontal view, B) profile in smiling. Photographs after orthognathic surgery: C) left lateral view, D) frontal view, E) half lateral view, F) approximate frontal view, G) intraoral right lateral, H) intraoral left lateral.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):54-60

Condylar hyperplasia treatment by means of proportional condilectomy and orthognathic surgery: case report

DISCUSSION Unilateral condylar hyperplasia is characterized by chin deviation in the opposite direction to the affected side and ipsilateral volumetric increase in the hemiface in the lower middle third, with contralateral flatness. The abnormal growth can be vertical or horizontal; therefore, it may alter the pattern of changes in facial appearance. Studies report predominance of one of these growth vectors or even a mixed form. Obwegeser and Makek,6 in 1986, classified such characteristics as hemimandibular hyperplasia, hemimandibular stretching and hybrid mandibular hyperplasia; later, also being called Type I, II and III, respectively. Other authors have also created classifications of condylar hyperplasia. Nitzan et al.4, in 2008, clearly and simply classified these terms, and the present study adopts such classification: vertical condylar hyperplasia, horizontal condylar hyperplasia, and combined condylar hyperplasia.4,6,7,8 In its vertical form, there is inferior growth ipsilateral to the mandibular growth, minimal lateral mandibular deviation of the chin or dental midline, and substantial inclination of the ipsilateral mandibular occlusal plane. The entire hemimandible has the appearance of a three-dimensional volumetric increase in its side of involvement, initially causing an ipsilateral open bite, and consequently a compensatory maxillary growth, resulting in inclination of the occlusal plane. In its horizontal form, deviation of the chin and midline is much more marked, presenting contralateral crossbite. In its combined form, it presents excessive growth of both planes and clinical characteristics of vertical and horizontal growth.6 The horizontal form has higher prevalence in some studies and is more common than the vertical. In all cases, the increase in functional load can cause contralateral temporomandibular disorder, which is confirmed in the present case, since the patient had severe temporomandibular disorder with anterior disc displacement without reduction in the contralateral temporomandibular joint, confirmed by magnetic resonance imaging.6 The treatment depends on careful evaluation, including patient concerns and confirmation of the presence of active growth of the mandibular condyle. Some authors claim that condylar hyperplasia should be treated by condylar reduction followed by monitoring. Inactive disease, or residual asymmetry, can

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

be corrected according to conventional orthognathic principles.8 Higginson et al.7, in 2018, divided the treatment plans for condylar hyperplasia into two groups: active disease and inactive disease. Initially, each patient would be evaluated by clinical examinations, radiographs, dental casts and three-dimensional computed tomography images, confirming the abnormal growth of the mandibular condyle. These patients would then have a scintigraphy to confirm the state of disease, active or not. In cases of active disease, an evaluation of facial asymmetry would be performed. If there was horizontal and/or vertical discrepancy greater than or equal to 5mm, a condylar reduction procedure would be performed. If the discrepancy was less than 5mm, the patient would undergo an evaluation period of 12 months and, if a discrepancy of less than 5mm was maintained after that period, a reassessment would be performed to check the need for additional treatment, such as orthodontics, orthognathic surgery, reduction of the lower mandibular border or genioplasty. If in these 12 months of evaluation there was an increase in discrepancy greater than or equal to 5mm, a condylar reduction would be performed. After condylar reduction, the case would be observed for further 12 months and then the need for additional treatment would be assessed. In cases of inactive disease with a horizontal discrepancy of less than 5mm, complementary treatment would be indicated; if the discrepancy was greater than 5mm, the condylar reduction protocol would apply.7 FariĂąa et al.9, in 2016, conducted a study on 49 patients with condylar hyperplasia, dividing into two groups: Group 1 â&#x20AC;&#x201C; treatment only with high condylectomy (removal of approximately 5mm), with 11 patients; Group 2 - treatment with proportional condylectomy (condylar removal corresponding to the difference in vertical height of the condylar process and mandibular ramus on the side with condylar hyperplasia and on the unaffected side), with 38 patients. The results show that 90.9% of patients who underwent high condylectomy required secondary orthognathic surgery, and only 15.8% of patients in Group 2, i.e. who underwent proportional condylectomy, presented the need to undergo surgery bimaxillary repositioning. They concluded that proportional condylectomy is a rational procedure for the treatment of unilateral condylar hyperplasia, significantly reducing the need for posterior orthognathic surgery.9

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):54-60

Ferzeli VHN, Barros MN, Teslenco VB, Reis GN, Pancini EF, Cavalcanti HA

treatment and the follow-up of long-term stability of two groups of patients diagnosed with condylar hyperplasia. Fifty-four patients were treated: Group 1, with 12 patients (mean age 17.5 years), was treated only by orthognathic surgery with bimaxillary mandibular retrusion; Group 2, with 42 patients (mean age 16.6 years), underwent high condylectomy, articular disc repositioning and orthognathic surgery. There was significant difference in the long-term stability. Group 2 showed statistically significant difference in cephalometric stability, being much more stable in the long run. All patients in Group 1 returned to their Class III dentofacial pattern, requiring a new surgical procedure for correction. Only 1 patient in Group 2 needed a new surgical intervention. As a result, this study showed that patients with active condylar hyperplasia treated with high condylectomy, disc repositioning and orthognathic surgery had more predictable and stable results in the long term, compared to those treated only with orthognathic surgery. This same study proposes three treatment options: 1) Eliminate any future mandibular growth, with high condylectomy and simultaneous orthognathic surgery; 2) Postpone corrective surgery until condylar growth is complete; 3) Only orthognathic surgery during a period of activity of condylar hyperplasia, with mandibular overcorrection.11

Posnick, Perez and Chavda,2 in 2017, reported a divergent approach, stating that cases of condylar hyperplasia can be treated only with the use of the standard bimaxillary orthognathic technique. The authors report that, in most cases, favorable occlusion can be achieved reliably and maintained over the long term. A retrospective study was carried out on 76 patients with hemimandibular elongation, operated between 1999 and 2013, all treated by bimaxillary repositioning, excluding patients older than 26 years. Among these patients, only 1 showed signs of progressing mandibular growth after the surgical procedure and in a follow-up of up to 5 years and 8 months. The authors concluded that the need for mandibular retrusion, even in cases of simultaneous maxillary advancement, proved to be a long-term recurrence factor of malocclusion, despite the low risk. In addition, they report that there is no need for an open TMJ procedure to prevent condylar growth.2 Mouallem et al.10, in 2017, stated that the treatment protocol using â&#x20AC;&#x2DC;proportional condylectomyâ&#x20AC;&#x2122; allowed both the etiological treatment of condylar overgrowth and the restoration of facial architecture. They reported that, when needed, the use of associated orthognathic techniques can improve the occlusal and esthetic characteristics.10 The treatment performed in the present case is similar to that proposed by Mouallem et al.10 The choice was based on the preference to a stepped approach, in which more invasive procedures (orthognathic surgery) could be ruled out in case of stability and satisfactory result for both professional and patient. However, a second surgical procedure was performed to finalize the correction of discrepancies still present. Thus, space is open by case report for a discussion on the main lines of treatment currently proposed.10 Another study aimed to compare the outcome of

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

FINAL CONSIDERATIONS There are divergences in the literature regarding the need for high condylectomy and discopexy to control condylar growth in cases treated only with orthognathic surgery in patients with active condylar hyperplasia. However, recent studies demonstrate long-term stability only with the use of bimaxillary repositioning surgery. The use of proportional condylectomy, to treat facial asymmetry caused by unilateral condylar hyperplasia, may be satisfactory, given its reduced invasiveness and good success rate.

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):54-60

Condylar hyperplasia treatment by means of proportional condilectomy and orthognathic surgery: case report

References:

1. 2.

Wolford LM, Movahed R, Perez DE. A classification system for conditions causing condylar hyperplasia. J Oral Maxillofac Surg. 2014 Mar;72(3):567-95. Posnick JC, Perez J, Chavda A. Hemimandibular elongation: is the corrected occlusion maintained long-term? Does the mandible continue to grow? J Oral Maxillofac Surg. 2017;75(2):371-98. Wagner JCB, Volkweis MR, Zamboni RA, Lepper TW, Zaffari L, Brandalise JRK. Facial asymmetry corrected with orthognathic surgery. J Braz Coll Oral Maxillofac Surg. 2018 Sept-Dec;4(3):48-52. Nitzan DW, Katsnelson A, Bermanis I, Brin I, Casap N. The clinical characteristics of condylar hyperplasia: experience with 61 patients. J Oral Maxillofac Surg. 2008 Feb;66(2):312-8.

6. 7. 8.

Raijmakers PG, Karssemakers LH, Tuinzing DB. Female predominance and effect of gender on unilateral condylar hyperplasia: a review and meta-analysis. J Oral Maxillofac Surg. 2012 Jan;70(1):e72-6 Obwegeser HL, Makek MS. Hemimandibular hyperplasia--hemimandibular elongation. J Maxillofac Surg. 1986 Aug;14(4):183-208. Higginson JA, Bartram AC, Banks RJ, Keith DJW. Condylar hyperplasia: current thinking. Br J Oral Maxillofac Surg. 2018 Oct;56(8):655-62. Saridin CP, Raijmakers PG, Tuinzing DB, Becking AG. Bone scintigraphy as a diagnostic method in unilateral hyperactivity of the mandibular condyles: a review and meta-analysis of the literature. Int J Oral Maxillofac Surg. 2011 Jan;40(1):11-7.

10.

11.

Fariña R, Olate S, Raposo A, Araya I, Alister JP, Uribe F. High condilectomy versus proportional condilectomy: is secondary orthognathic surgery necessary? Int J Oral Maxillofac Surg. 2016 Jan;45(1):72-7. Mouallem G, Vernex-Boukerma Z, Longis J, Perrin JP, Delaire J, Mercier JM, et al. Efficacy of proportional condilectomy in a treatment protocol for unilateral condylar hyperplasia: a review of 73 cases. J Craniomaxillofac Surg. 2017 July;45(7):1083-93. Wolford LM, Morales-Ryan CA, García-Morales P, Perez D. Surgical management of mandibular condylar hyperplasia type 1. Proc (Bayl Univ Med Cent). 2009 Oct;22(4):321-9.

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):54-60

OriginalArticle

Epidemiological study of pediatric

odontogenic infections in Maringá MARCELLY TUPAN CHRISTOFFOLI1 | GUSTAVO JACOBUCCI FARAH1 | IZABELLA GIANNASI FARAH1 | CAROLINE RESQUETTI LUPPI1 | ANDRESSA BOLOGNESI BACHESK1

ABSTRACT Introduction: Maxillofacial infections in pediatric patients are serious clinical situations, characterized by the spread of the infectious process to adjacent tissues, usually with odontogenic origin. Objective: The aim of this study was to evaluate the causes, clinical condition and treatment performed in pediatric patients with maxillofacial disease treated by the Maringá Bucomaxilofacial Surgery and Traumatology Service from 2007 to 2017. Methods: The methodology used was the retrospective analysis of medical records, with the help of a structured form. The research form considered the variables: age, sex, admission temperature, etiology tooth, duration of infection, therapy and prognosis. Results: As a result, there was a slight predilection for males (52.2%); the average age found was 7.3 years; the most affected teeth were the lower first deciduous molars (#75 and #85); the most common etiology was pulp involvement through caries. The average admission temperature was 37.9ºC and infections lasted an average of 3 days. Regarding applied therapy, the most used antibiotic was amoxicillin and the approach was abscess drainage and dental treatment. Conclusion: Knowledge about this subject is necessary by the dentist because pediatric patients with odontogenic infections become systemically affected very quickly. Keywords: Abscess. Pediatric dentistry. Signs and symptoms. Conservative treatment.

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

How to cite: Christoffoli MT, Farah GJ, Farah IG, Luppi CR, Bachesk AB. Epidemiological study of pediatric odontogenic infections in Maringá. J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):61-8. DOI: https://doi.org/10.14436/2358-2782.6.1.061-068.oar Submitted: August 02, 2019 - Revised and accepted: September 02, 2019 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. Contact address: Gustavo Jacobucci Farah E-mail: gujfarah@gmail.com

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):61-8

Epidemiological study of pediatric odontogenic infections in Maringá

INTRODUCTION Odontogenic infections represent a common clinical problem in patients of all ages. The presence of teeth allows the direct spread of inflammatory products from dental caries, trauma and/or periodontal disease to the maxilla and mandible.1 Such infections are usually localized, and patients recover without complications when given appropriate antibiotics. However, dental infections can spread, leading to serious complications.2 In pediatric facial infections, the disease can progress rapidly, producing significant systemic symptoms, including fever, dehydration and airway involvement.3,4 Due to the possibility of progression to systemic disease, early management and recognition of orofacial infections in children is necessary.5 Many studies report reviews and clinical trials on odontogenic infections affecting adult patients. However, few report the incidence and epidemiology of orofacial infections in children.6 According to a study by Al-Malik and Al-Sarheed,7 in 2017, dental caries is the most common cause of infections that affect the maxillomandibular complex. The actors also concluded that antibiotic therapy is the first-line treatment for orofacial infections. In addition, it can shorten the hospital stay and delay dental or surgical interventions.7 Seeking to understand the epidemiology, clinical characteristics, biological behavior and possible treatments and prognosis, the present study aimed to analyze the cases of maxillofacial infections in pediatric patients treated by a Maxillofacial Surgery and Traumatology team =in Maringá/PR, responsible for care in hospitals in the city and the region. This study aimed to relate the clinical aspects of each case of infection with the treatments applied and their effectiveness, in addition to surveying data as age, gender, temperature at admission, affected tooth, duration of infection/hospitalization, applied therapy (therapeutic and conduct), prognosis and comorbidities. Finally, comparative analyses were performed with other published studies, to draw conclusions about the theme.

Plataforma Brasil, having a favorable opinion about the approval of the study protocol presented under n. 2.403.569. The research consisted of a retrospective analysis of medical records of patients treated by a Surgery and Traumatology team in Maringá, Paraná, from July 2007 to July 2017. The analysis of medical records was performed by two examiners, previously calibrated by specialized training and using a structured questionnaire. Overall, 4,693 records were previously analyzed in the different hospitals served by the aforementioned team. All underwent a thorough analysis and some were selected for the study, according to the following inclusion criteria: 1. Diagnosis of odontogenic infection. 2. Age range from 0 to incomplete 12 years, considered as ‘children’ by the Statute of Children and Adolescents (ECA - Brazil, 2017). Other criterion used to include the medical records was to present, during medical evaluation for admission, two or more common symptoms in odontogenic infections, such as: 1. Axillary temperature higher than or equal to 37ºC. 2. Edema in face or neck. 3. Airway involvement. 4. Dysphagia (difficult swallowing) or dyspnea (difficult breathing). 1. Axillary temperature greater than or equal to 37ºC. 2. Edema on the face or neck. 3. Airway compromise. 4. Dysphagia (difficulty in swallowing) or dyspnea (difficulty in breathing). Medical records insufficiently or inadequately filled, as well as those whose Informed Consent Form was not signed, were excluded. Of the initial sample of patients admitted to hospitals diagnosed with odontogenic infection (4,693), 53 were children, 7 of whom did not meet all inclusion criteria and thus were excluded from the study, yielding a sample of 46 medical records to be analyzed. With the sample established, the study evaluated the following variables: 1. Age. 2. Sex. 3. Location of infection (affected tooth). 4. Etiology. 5. Temperature at admission.

METHODS This study was approved by the Permanent Ethics Commission of Human Beings Studies of the State University of Maringá (COPEP-UEM), together with the Institutional Review Board (CEP), subscribed to

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Christoffoli MT, Farah GJ, Farah IG, Luppi CR, Bachesk AB

Age

6. Duration of infection. 7. Therapy used (drug therapy and conduct). 8. Prognosis. 9. Comorbidities. The age of patients could vary from 0 to 12 years, both in males and females. Regarding the affected tooth, it was considered that any of teeth erupted in the oral cavity could trigger infectious processes. The bones considered were the maxilla and mandible. The etiology of infections was divided into traumatic or carious injury. The duration of infection was considered from the moment of patient’s admission to hospital discharge. The applied therapy was divided into therapeutic, with the therapeutic drugs used during the infection being especially antimicrobials, and the conduct adopted by the dentist regarding the infection and the tooth that triggered the infection. The prognosis refers to the course of evolution of the infectious process, and comorbidities were defined as disorders associated with odontogenic infection.

Regarding age, the highest was 12 years old, and the lowest 2 years old. Calculating a simple mean of ages, a value of 7.3 years was found. The details of findings regarding this variable are shown in Table 1 Site of infection The variable “site of infection” was subdivided into “tooth of etiology” and “affected bone”. The involved bone considered the maxilla or mandible. The results showed considerable predilection for the mandible, with 32 (69.6%) cases. The other 14 cases (30.4%) occurred in teeth in the upper arch. A large variety of teeth triggered the infectious process; however, the most common were the deciduous lower first molars (85 and 75), with 7 cases for each tooth, totaling 15.2% each. The details of each tooth are shown in Table 2, organized in descending order, according to the percentage of each tooth. Etiology The etiology of infections was based on what triggered the inflammatory reaction. Briefly, cases of endodontic origin were found, i.e. a pulp affected by the carious lesion causing pulp lesion, and periapical lesions due to previous trauma.

RESULTS Sex Of the final sample of 46 children, 24 were males, totaling 52.2% of cases; and 22 were females, in a total of 47.8% of the sample.

Table 1: Number of cases and percentage according to patient’s age (in years). AGE (YEARS)

NUMBER OF CASES (n)

PERCENTAGE (%)

0 1 2 3 4 5 6 7 8 9 10 11 12

0 0 2 2 2 10 6 7 2 5 2 4 4

0 0 4.34 4.34 4.34 21.75 13.04 15.21 4.34 10.90 4.34 8.70 8.70

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Epidemiological study of pediatric odontogenic infections in Maringá

Table 2: Number of cases and percentage per tooth in the etiology of infections. TOOTH OF ETIOLOGY

NUMBER OF CASES

PERCENTAGE (%)

#75 #85 #46 #36 #64 #55 #74 #65 #26 #84 #51 #62 #54 #47 #21

7 7 6 5 3 3 3 3 2 2 1 1 1 1 1

15.22 15.22 13.04 10.87 6.52 6.52 6.52 6.52 4.35 4.35 2.17 2.17 2.17 2.17 2.17

regulatory center (anterior hypothalamus), causing the body temperature to rise two or three degrees above the usual values. According to the results, the lowest temperature found was 36ºC and the highest temperature was 39.5ºC, with a mean temperature of 37.9ºC.

Other authors mentioned that the most frequent cause of abscess formation is the presence of microorganisms – first, caused by a carious lesion that, when not properly treated, affects the pulp organ, crossing from the interior of the root canal to the apical region4. This information was confirmed by the present study, since 96% (n = 44) of cases were due to endodontic lesions caused by carious lesions. Another 4% (n = 2) of cases had a traumatic etiology.

Duration of infection Regarding the variable duration of infection, the longest period observed was 7 days, and the shortest 1 day. The mean duration of infections in pediatric patients was approximately 3 days.

Temperature at admission Since one of the inclusion criteria was to have an admission temperature (hospitalization) of at least 37.5ºC, few cases had a lower temperature, but were included in the study even if they did not reach that temperature because they had two other symptoms of infection, as explained in the methodology. Fever is a common feature of infectious processes, since it occurs in response to pyrogenic substances secreted by macrophages in response to inflammation. These substances act to provide the release of prostaglandins, which act in the thermo-

Therapy applied The treatment adopted for odontogenic infection in each patient was subdivided into therapy and management. Therapy consists of the drugs used, especially antimicrobials. The conduct was based on what was applied to treat the cause of infection, i.e. the tooth that triggered it. As treatment choice, 80.4% (n = 37) of cases were solved with abscess drainage, antibiotic therapy and endodontics of the involved tooth, and

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Christoffoli MT, Farah GJ, Farah IG, Luppi CR, Bachesk AB

Therapy

Ceftriaxone

Metronidazole

Cephalexin

Ampicillin

Cefalotin

Amoxicillin

Graph 1: Therapy used in patients hospitalized with odontogenic infections

atric patients, who tend to become systemically affected more quickly,9 an early diagnosis and knowledge about the epidemiological data of this pathology is necessary. In the present study, for discussion, the length of stay found was compared to the length of stay of another study conducted on adult patients. This other study evaluated the same variables and was conducted in the same hospitals and in the same period.10 After data collection and comparison of results of the two studies, the statistical analysis was performed by the Fisher’s exact test, at a significance level of 0.05. The mean length of hospital stay found in the pediatric group was 3 days, and the average in the adult group was 5.1 days. The results were divided into three groups: Group 1, composed of patients who had an infection duration of 1 to 3 days; Group 2, duration of infection from 4 to 6 days; and Group 3, infection lasting 7 days or more. After applying the statistical test, significant variance was found only in Group 3 (7 days or more). There were 11 adults in this group and only 1 child,

in 20.6% (n = 9) it was decided to extract the affected tooth, instead of preserving it in the oral cavity. As a drug therapy, there was considerable discrepancy in the preference of antibiotics. Antibiotic therapy is believed to have varied according to the hospitalization dates of and hospitals where the cases were treated. The results are shown in Graph 1. Prognosis and comorbidities The prognosis for all cases (n = 46) was very favorable. A variety of therapeutic approaches and duration of infection have been observed. However, all cases evolved as expected. No case found had any comorbidity and no patient died. DISCUSSION Maxillofacial infections represent a relevant field of medical and dental knowledge, since they can progress to high morbidity and mortality. Therefore, they require full professional training in both prevention and diagnosis and, above all, in clinical resolution.8 In the case of pedi-

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Epidemiological study of pediatric odontogenic infections in Maringá

ment of both sexes. Therefore, the present results, for this variable, corroborate the findings of most studies available in the literature. In addition, it was found that the mean age was quite variable, around 7/8 years in most studies, except for Lin et al.14, who reported a mean of 5.7 years, and Scutari et al.16, with a mean of 3.9 years. It is observed that the mean age found in the present study is within the means found in other comparative studies. There was no discrepancy in relation to the bone region that the studies pointed as the most affected. Three studies (50%) indicated the maxilla with greater involvement and three (50%) indicated the mandible. The findings of the present study corroborate the findings of Kara et al.12 and Scutari et al.16 Furthermore, the temperature also agreed with the means of other studies, all of which remained between 37.5 and 38.4ºC.

concluding that pediatric patients respond better to antibiotic therapy and need shorter hospital stays, corroborating the findings of Martini and Migliari11, who evaluated the hospital admission time according to the age group and registered the highest mean length of stay in the older age groups.11 Besides the intergroup comparison, a comparison was made with other studies on pediatric patients, who used the same methodology, to compare the findings of all. The collected data are shown in Tables 1 and 2. From the tabulation of data, it was observed that the samples were variable according to the place where the study was performed and the study period, in years. The male gender was more affected in the findings of all aforementioned researches, except for the study by Lin et al.14, which showed equal involve-

Author

Region

Period (years)

Sample

Sex

Mean age (years)

This study Kara et al.12 (2014) Thikkurissy et al.13 (2010) Lin et al.14 (2006) Unkel et al.15 (1997) Scutari et al.16 (1996)

Brazil Turkey United States Taiwan United States United States

10 15 6 1 9 4

46 106 63 56 47 143

Male (52%) Male (59%) Male (51%) Male and Female (50%) Male (53%) Male (58%)

7.3 7.2 8.3 5.7 8.8 3.9

Chart 1: Comparison of results with findings of other authors.

Author

Most affected bone

Mean temperature(ºC)

Treatment

Antimicrobial

Duration (days)

This study

Mandible

37.9

Endodontics

Amoxicillin

Kara et al.12 (2014)

Mandible

38.1

Extraction

Ampicillin + Sulbactam

5.8

Thikkurissy et al.13 (2010)

Maxilla

37.5

Extraction

Ampicillin + Sulbactam

3.4

Lin et al. (2006)

Maxilla

37.7

Endodontics

Unkel et al. (1997)

Maxilla

38.4

Scutari et al. (1996)

Mandible

38.3

Extraction

Clindamycin

4.4

Chart 2: Comparison of results with findings of other authors.

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Christoffoli MT, Farah GJ, Farah IG, Luppi CR, Bachesk AB

ic infections, since it is effective against the aerobic and anaerobic bacteria responsible for the infection.18

Regarding the treatment adopted, the present study showed predilection for a more conservative approach, i.e. keeping the tooth in the oral cavity after endodontic treatment. Conversely, most authors considered tooth extraction as the best treatment for the tooth that triggered the infection. However, it is worth to emphasize that the deciduous teeth should remain in place until the natural period of exfoliation, and how their early loss can be harmful to the infant patient, since they assist in esthetics, chewing and speech, besides functioning as natural space maintainers and guides for the eruption of permanent teeth.17 The most used antibiotic agents were Ampicillin + Sulbactam and Amoxicillin and Clindamycin. In the records, frequent use of Ampicillin and Sulbactam was observed. This antibiotic is indicated for cases in which the presence of microorganisms resistant to Ă&#x;-lactam antibiotics is suspected; it is a well-tolerated and safe drug for the empirical therapy of odontogen-

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

CONCLUSION Pediatric maxillofacial infections present fast evolution, with caries and other infectious disorders as the main etiology. There is predilection for males, and the mean age of affected patients is around 7 years. The teeth most commonly affected are the deciduous lower first molars, and the mandible is more affected when compared to the maxilla. Early diagnosis and treatment are critical, because pediatric patients with facial infections become dehydrated and have systemic problems very quickly. The antimicrobial of choice is Amoxicillin. In addition, the established conduct should, whenever possible, be based on more conservative treatments, focused on maintaining the teeth and their correct treatment. With this, the prognosis will be more favorable, and comorbidities will be avoided.

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Epidemiological study of pediatric odontogenic infections in Maringá

References:

1. 2. 3.

4. 5.

Mardini S, Gahel A. Imaging of odontogenic infections. Radiol Clin North Am. 2018 Jan;56(1):31-44. Alise A, Linda V, Marks R, Gunta S. Deep neck infections: review of 263 cases. Otolaryngol Pol. 2017;71(5):37-42. Sandor GK, Low DE, Judd PL, Davidson RJ. Antimicrobial treatment options in the management of odontogenic infections. J Can Dent Assoc. 1998 July-Aug;64(7):508-14. Dodson TB, Kaban LB. Special considerations for the pediatric emergency patient. Emerg Med Clin North Am. 2000 Aug;18(3):539-48. Parker MI, Khateery SM. A retrospective analysis of orofacial infection requiring hospitalization in Al-Madinah, Saudi Arabia. Saudi Dent J 2001;13:96-110. Achembong LN, Kranz AM, Rozier RG. Office-based preventive dental program and statewide trends in dental caries. Pediatrics. 2014; 133(4):e827-34. Al-Malik M, Al- Sarheed M. Pattern of management of orofacial infection in children: a retrospective. Saudi J Biol Sci. 2017 Sept;24(6):1375-9.

8. 9.

10.

11. 12.

13.

Lian HT, Tsai CS, Chen YL, Liang JG. Influence of diabetes mellitus on deep neck infection. J Laryngol Otol. 2006 Aug;120(8):650-4. Dodson TB, Barton JA, Kaban LB. Predictors of outcome in children hospitalized with maxillofacial infections: a linear logistic model. J Oral Maxillofac Surg. 1991 Aug;49(8):838-42. Farah GJ, Quinto JHS, Farah IG, Christoffoli MT, Luppi CR. Estudo epidemiológico de pacientes portadores de infecção do complexo buco-maxilo-facial tratados no Hospital Universitário de Maringá: estudo retrospectivo ao longo de 08 anos. RFO UPF. 2018;23(3):280-3. Martini MZ, Migliari DA. Epidemiology of maxillofacial infections treated in a public hospital in the city of São Paulo. Rev Assoc Paul Cir Dent. 2012;66(1):66-72. Kara A, Ozsurekci Y, Tekcicek M, Karadag Oncel E, Cengiz AB, Karahan S, et al; Length of hospital stay and management of facial cellulits of odontogenic origin in children. Pediatr Dent. 2014 Jan-Feb;36(1):18E-22E. Thikkurissy S, Rawlins JT, Kumar A, Evans E, Casamassimo PS. Rapid treatment reduces hospitalization for pediatric patients with odontogenic based cellulitis. Am J Emerg Med. 2010 July;28(6):668-72.

14. 15.

16.

17.

18.

Lin YT, Lu PW. Retrospective study of pediatric facial cellulitis of odontogenic origin. Pediatr Infect Dis J. 2006 Apr;25(4):339-42. Unkel JH, McKibben DH, Fenton SJ, Nazif MM, Moursi A, Schuit K. Comparison of odontogenic and nonodontogenic facial cellulitis in a pediatric hospital population. Pediatr Dent. 1997 NovDec;19(8):476-9. Scutari P Jr, Dodson TB. Epidemiologic review of pediatric and adult maxillofacial infections in hospitalized patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996 Mar;81(3):270-4. Cardoso L, Zembruski C, Fernandes DSC, Boff I, Pessin V. Avaliação da prevalência de perdas precoces de molares decíduos. Pesqui Bras Odontoped Clín Integr. 2005;5(1):17-22. Larawin V, Naipao J, Dubey SP. Head and neck infections. Otolaryngol Head Neck Surg. 2006;135:889-93.

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):61-8

OriginalArticle

Comparison of diffusion capacity and efficacy of 4% articaine and 2% lidocaine on impacted maxillary

third molars extraction

ABSTRACT Introduction: Anesthetic solutions have their own characteristics regarding properties such as latency, potency, and duration of action. Many authors have demonstrated the superiority of diffusion of 4% articaine solutions, although there is controversy in the scientific literature about this discussion. Objective: The purpose of this study was to compare the ability to induce palatal mucosa anesthesia and the anesthetic efficacy after superior alveolar posterior nerve block of two anesthetic solutions: 4% articaine with epinephrine 1:100,000 and 2% lidocaine with epinephrine 1:100,000. Methods: This original experiment is a cross-sectional, double-blind, randomized study of eighteen healthy volunteers, aged 14 to 26 years, with impacted maxillary third molar extraction indications. The diffusion ability and the efficacy of anesthetic solutions were verified by the 11-point Box Scale, and the anxiety degree was evaluated with the Corah Dental Anxiety Scale. Results: Results showed that in healthy patients, both anesthetic solutions had the same diffusion to palatal mucosa and, presented similar clinical behavior. Conclusion: Both tested solutions showed similar diffusion capacity and anesthetic efficacy, proving to be equally suitable for use in extraction of impacted maxillary third molars. Keywords: Lidocaine. Articaine. Anesthetics. Pain.

Private practice (Salvador/BA, Brazil).

How to cite: Mascarenhas G, Mascarenhas D, Zanetta-Barbosa D, Marangon-Jr H, Pereira RMA, Pereira P. Comparison of diffusion capacity and efficacy of 4% articaine and 2% lidocaine on impacted maxillary third molars extraction. J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):69-75. DOI: https://doi.org/10.14436/2358-2782.6.1.069-075.oar

Federal University of Uberlândia (Uberlândia/MG, Brazil).

University Center of Patos de Minas, Dentistry (Patos de Minas/MG, Brazil).

Submitted: August 14, 2019 - Revised and accepted: November 17, 2019 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. Contact address: Rafael Martins Afonso Pereira E-mail: rafaelmap@unipam.edu.br

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):69-75

Comparison of diffusion capacity and efficacy of 4% articaine and 2% lidocaine on impacted maxillary

INTRODUCTION Pain is one of the oldest concerns of human beings, with several historical records showing the search for methods to control it. In dental treatment, the expectation of pain is one of the factors that increase the anxiety of patients, being related to past traumatic experiences, concerns about physical injuries and even observation of anxiety or pain in other people.1,2 One of the best options for pain control in dentistry is the use of local anesthetic solutions, making the procedures more acceptable to the patient.3 Anesthetic solutions have their own characteristics, with specific properties regarding the latency period, power and duration of anesthesia. The choice of a particular solution is made according to the patient’s systemic condition and the clinical procedure to be performed.4,5 Some authors claim that articaine has greater diffusion capacity than other local anesthetics, due to its chemical conformation,6,7 even though other authors claim that the option for articaine, instead of lidocaine, should not be based on its diffusion capacity, without difference in the parameters used to assess anesthetic efficiency (latency, duration of action).8-12 Considering this and clinical reports that articaine has great diffusion capacity, allowing more satisfactory transoperative step and better quality of anesthesia, it is important to compare these two anesthetics and establish their clinical efficiency in extractions of impacted upper third molars. Therefore, this study comparatively evaluated 4% articaine with epinephrine 1:100,000 and 2% lidocaine with epinephrine 1:100,000, to establish its efficiency in the extraction of impacted upper third molars.

2004. The study lasted 4 months. Assessment of the volunteers’ anxiety before dental treatment was performed using the Corah Dental Anxiety Scale (CDAS).13 This study was performed by a previously calibrated dentist, using the standardized technique, with modification only on the side of intervention and using an anesthetic solution. The decision on the side and the solution to be used was made by drawing lots, characterizing a cross-sectional, double-blind study with random distribution. The anesthetic technique used was the posterior superior alveolar nerve block, using 1.8 mL, with slow injection (approximately 1 mL/minute), resulting in greater safety and less trauma. Five minutes after anesthetic infiltration, a new sensitivity test was performed with the Molt detacher in the same region. The surgical procedure was started when the sensitivity test was negative. Complementing the anesthetic technique on the palatal mucosa was only performed if the volunteer reported extreme discomfort, described as pain, and not as pressure, during incision and manipulation of the palatal mucosa. For anesthetic supplementation, 1/4 of the anesthetic tube was used. Two anesthetic solutions were used: 4% articaine with epinephrine 1:100,000 (Articaine®, DFL, Lot 0411F02) and 2% lidocaine with epinephrine 1:100,000 (Alphacaine®, DFL, Lot 0508D12), marked A and B, respectively. The anesthetic solutions administered were not identifiable, masking the cartridges with opaque labels, allowing a double-blind study. A short 30G needle (BD®) and a carpule syringe with suction device (Duflex®) were used. The anesthetic solutions were administered by infiltration at 30-day intervals, to allow adequate repair of operated tissues. A sensitivity test with mucosal detachment was performed on the palatal-distal aspect of the upper second permanent molar, before anesthetic infiltration, to ensure that the patient did not present any change in sensitivity in the region of interest. The painful sensitivity of the palatal mucosa and the sensitivity of the surgical procedure were evaluated using the 11-point Box Scale (BS), applied at two different times (BS1 and BS2) on each side: » BS1: after incision in the alveolar ridge region and detachment of the palatal mucosa, when the palatal infiltration had not yet been performed; the volunteers were asked to complete this scale to quantify the sensation of pain and thus identify which of the

METHODS This study included 18 healthy volunteers with surgical indication for impacted upper third molars, in similar positions on both sides of the arch, according to the classification of Pell and Gregory. One of the inclusion criteria was that all individuals were Pell and Gregory Class A. Volunteers using systemic medication (except birth control pills) were excluded from the study. The sample consisted of individuals of both sexes (83.3% females and 16.7% males), aged 14 to 26 years (median 19.5 ± 5.5 years). This study was approved by the Institutional Review Board of the Federal University of Uberlândia (process n. 038/04, CEP registration 062/04) in July

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):69-75

Mascarenhas G, Mascarenhas D, Zanetta-Barbosa D, Marangon-Jr H, Pereira RMA, Pereira P

RESULTS Table 1 presents the values obtained for the variables age, CDAS and BS for the articaine and lidocaine solutions. The median age was 19.5 years (± 5.5 years). The values obtained with the CDAS ranged from 14 to 18, with most of the sample having little anxiety, with a median of 7.5. Figures 1 and 2 illustrate the values obtained by BS with the two anesthetic solutions at the time of incision and detachment and after suture, respectively. No evaluated patient required complementary anesthesia during the procedure. There was no statistically significant difference between the anesthetic solutions 4% articaine with epinephrine 1: 100,000 and 2% lidocaine with epinephrine 1: 100,000, in relation to the diffusion capacity (BS1) and anesthetic efficacy (BS2) (Table 2). Figure 3 illustrates the efficiency of the two anesthetic solutions for sensitivity to pain at the time of incision and detachment and after suturing. There was no significant difference in CDAS between males and females (p = 0.232). The same result was found when comparing gender and pain (articaine: BS1 p = 0.477, BS2 p = 1.0; lidocaine: BS1 p = 0.554, BS2 p = 0.619). The Spearman correlation test did not show any correlation between CDAS, BS (at either time) and the age of volunteers.

solutions was most effective in diffusing it to the palatal mucosa. » BS2: at completion of the surgical procedure, volunteers were asked to quantify the discomfort during surgery, so that it was possible to identify whether any of the solutions offered greater transoperative comfort. The statistical analysis of data was performed using the software R 2.4.1. A descriptive analysis was performed (absolute and relative frequency; median, minimum and maximum values) to identify the general and specific characteristics of the sample. Any statistically significant differences between the Pain Scale, in the two moments of measurement, between articaine and lidocaine, was verified using the Wilcoxon test for paired samples. The Mann-Whitney test was used to verify the existence of associations between the variables studied, according to gender. The Spearman correlation was used to identify the existence of linear relationship between the CDAS and the patient’s age. Associations with a p-value <0.05 were considered statistically significant. Since this is a non-inferiority study, in which the objective was to prove that there is no difference in the effectiveness of the two local anesthetics tested, a sample power analysis was performed, considering the mean of each group and the standard deviation, at a significance level of 5% and an inferiority limit of 1 score. Thus, a result of 100% of power was obtained for the BS1 and BS2 results.

Table 1: Maximum, minimum and median values of age, CDAS and BS. Variables

Age

CDAS

BS1 Articaine

BS2 Articaine

BS1 Lidocaine

BS2 Lidocaine

Minimum value Maximum value Median

14 26 19.5

4 18 7.5

0 4 0.5

0 4 1

0 8 1

CDAS: Corah Dental Anxiety Scale. BS1: 11-point Box Scale after incision and detachment. BS2: 11-point Box Scale at completion of surgery.

Table 2: Wilcoxon test to evaluate the anesthetic solution. Diffusion (BS1)

Median p-valor

Articaine 0.50

Efficacy (BS2)

Lidocaine 1.00 0.329

Articaine 0.50

Lidocaine 1.00 0.393

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):69-75

Comparison of diffusion capacity and efficacy of 4% articaine and 2% lidocaine on impacted maxillary

articaine

lidocaine

Figure 1: Anesthetics without identification (double-blind study).

Articaine Lidocaine

Figure 2: BS1: Pain intensity values obtained after incision and detachment, to assess diffusion.

Articaine Lidocaine

Figure 3: BS2: Pain intensity values obtained at completion of surgical procedures, to assess the anesthetic effectiveness.

Articaine Lidocaine

Figure 4: Pain intensity assessed by BS, depending on the anesthetic solutions used.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):69-75

Mascarenhas G, Mascarenhas D, Zanetta-Barbosa D, Marangon-Jr H, Pereira RMA, Pereira P

DISCUSSION The standard anesthetic solution of 2% lidocaine is an amide anesthetic, which has a latency time of two to three minutes. When associated with a vasoconstrictor, its duration is approximately one hour in pulp anesthesia and three to five hours in soft tissues. The 2% lidocaine solution associated with epinephrine 1:100,000 assures good results in most dental procedures, not justifying the use of 3% solution. In addition, due to its great vasodilating activity, its use is not advisable without a vasoconstrictor, since this combination increases the duration of anesthesia and minimizes its toxicity.4,5 Around 1999, a new local anesthetic, articaine, appeared on the Brazilian market. Articaine was synthesized in 1969, introduced in Germany in 1976, gradually expanded to Europe and South America, and was approved for sale in the United Kingdom in 1999.8,12,14 It is classified as an anesthetic solution of amide type with the addition of thiophene ring, which increases its liposolubility and power. It has good tissue penetration and binds to 95% of plasma proteins excreted by the kidneys. It is clinically available at a concentration of 4% associated with epinephrine 1:100,000 or 1:200,000.5,10,11,12,14 Studies comparing the anesthetic solutions 2% lidocaine and 4% articaine for the pain control of irreversible pulpitis have found conflicting results, even in systematic reviews on the subject.15,16 Rathi et al.17 comparatively evaluated 2% lidocaine and 4% articaine solutions for pain control in the extraction of deciduous molars, with superiority of articaine for the control of intraoperative pain. Some studies have also evaluated the effectiveness of single oral infiltration using anesthetic solutions 2% lidocaine and 4% articaine. Kolli et al.18 demonstrated the effectiveness of anesthetic solutions in extractions of deciduous maxillary molars, in suppressing palatal injection during the accomplishment of these procedures. However, a randomized, double-blind, controlled clinical trial did not observe the same result, which does not justify the non-palatal administration of the solutions.19 The results obtained in the present study showed absence of statistical difference for the anesthetic solutions used, with regard to the effectiveness of solutions for the control of pain and anesthetic diffusion to the palatal mucosa. Such results corroborate the suppression of palatal administration of anesthetic salts in procedures for extraction of upper third molars.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Pain is a subjective, multifactorial sensation, influenced by biological, affective, cultural and evolutionary factors, making it difficult to measure.20,21 Pain analysis instruments are critical for the correct assessment and must be carefully selected. In this study, the volunteers remained in horizontal position, with the surgical field on their body transoperatively and, consequently, when filling the pain assessment scale. This position could hinder the movement of upper limbs, leading to a lack of motor coordination. Although the Visual Analog Scale is known as the most used instrument to measure pain, reliability and sensitivity,22-24 it is difficult to be understood, requiring a large expenditure of cognitive energy and may be influenced by problems of motor incoordination, making it less reliable than a fixed interval scale.20-22 Scales with fixed intervals are easier to understand, since the numbers are more familiar for the participants. In the literature consulted, scales with fixed intervals, such as the NRS-11, did not present good motor coordination as a prerequisite to be applied, which justified their use in this study. There is a correlation between several scales evaluated, without difference in the ability to measure pain, although this scale seems to pose the least difficulty in understanding and leads to fewer errors by patients.20 In fact, in this study, none of the volunteers had difficult to understand and respond to the scale, as reported in the literature. Some authors reported that the hormonal effects on pain perception are complex and dynamic, and researchers should always determine the phases of menstrual periods in studies related to pain perception.21 Since it was predicted that many volunteers could be females (n = 15, 83.33%), in a sample composed of people aged 14 to 26 years (of reproductive age), this research was carried out in equal periods of menstrual cycle of each patient. In addition, all procedures were performed in the morning, to avoid changes related to the circadian rhythm of catecholamine secretion and cell membrane permeability.25 One factor that could interfere with the single session study was the surgical time. However, this was not a variable, since the operator was a specialist with a lot of experience in the extraction of third molars. The mean time of surgery was 37.7 minutes, much less than the time of action of anesthetics involved in this study. In addition, it is known that extraction of impacted upper third molars is generally faster than that of lower teeth,

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):69-75

Comparison of diffusion capacity and efficacy of 4% articaine and 2% lidocaine on impacted maxillary

CONCLUSION According to the methodology and results of this study, 2% lidocaine solutions with 1:100,000 epinephrine and 4% articaine with 1:100,000 epinephrine showed the same performance regarding painful sensitivity in palatal manipulation, demonstrating that there was a difference in diffusion capacity. Both solutions had similar anesthetic effectiveness and ability to promote anesthesia; and both solutions tested were similar transoperatively, demonstrating that the option for one solution or the other should not be based on the diffusion capacity and anesthetic efficacy. Also, the cost-benefit relationship does not justify the choice of articaine over lidocaine, since the cost of articaine is higher than that of lidocaine and no advantages were found to support its use.

and it is unlikely that the assessment of transoperative sensitivity of pain on one side could be influenced by the postoperative sensitivity on the opposite operated side. To assure this, volunteers who had a surgical time (tooth 18 or 28) lasting more than 20 minutes were excluded from the sample, avoiding the total procedure time (tooth 18 + 28) from exceeding the duration of the anesthetic effect on the pulp and soft tissues of both anesthetics, as described in the literature.5,9 The posterior alveolar nerve block on both sides was preceded by a sensitivity test on the palatal-distal mucosa of the second molar, with a Molt detacher. Thus, it was possible to ensure that the anesthetic applied from the first operated side did not interfere with sensitivity of the opposite side. The latency time found in the literature for both anesthetics ranged from 1.5 to 4 minutes.5,7,9,26-29 For this reason, a period of 5 minutes after completion of anesthetic infiltration was standardized.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):69-75

Mascarenhas G, Mascarenhas D, Zanetta-Barbosa D, Marangon-Jr H, Pereira RMA, Pereira P

References:

1. 2.

3. 4.

8. 9.

10.

11.

Bare LC, Dundes L. Strategies for combating dental anxiety. J Dent Educ. 2004;68(11):1172-7. Schuller AA, Willumsen T, Holst D. Are there differences in oral health and oral health behavior between individuals with high and low dental fear? Community Dent Oral Epidemiol. 2003;31(2):116-21. Malamed SF. Handbook of local anesthesia. 6th ed. Los Angeles: Elsevier; 2013. McLean C, Reader A, Beck M, Meyers WJ. An evaluation of 4% prilocaine and 3% mepivacaine compared with 2% lidocaine (1:100.000 epinephrine) for inferior alveolar nerve block. J Endod. 1993;19(3):146-50. Ranali J, Volpato MC, Ramacciato JC, Groppo FC, Andrade ED. Medicação e interações medicamentosas em implante dental. Implant News 2005;2(6):636-45. Potocnik I, Tomsic M, Sketelj J, Barjrovic FF. Articaine is more effective than lidocaine or mepivacaine in rat sensory nerve conduction block in vitro. J Dent Res. 2006;85(2):162-6. Kanaa MD, Whitworth JM, Corbett IP, Meechan JG. Articaine and lidocaine mandibular buccal infiltration anesthesia: a prospective randomizes doubleblind cross-over study. J Endod. 2006;32(4):296-8. Malamed SF, Gagnon S, Leblanc D. Efficacy of articaine: a new amide local anesthetic. J Am Dent Assoc. 2000;131(5):635-42. Oliveira PC, Volpato MC, Ramacciato JC, Ranali J. Articaine and lignocaine efficiency in infiltration anaesthesia: a pilot study. Brit Dent J. 2004;197(1):45-6. Claffey E, Reader A, Nusstein J, Beck M, Weaver J. Anesthetic efficacy of articaine for inferior alveolar nerve blocks in patients with irreversible pulpitis. J Endod. 2004;30(8):568-71. Mikesell P, Nusstein J, Reader A, Beck M, Weaver J. A comparison of articaine and lidocaine for inferior alveolar blocks. J Endod. 2005 Apr;31(4):265-70.

12. 13. 14. 15.

16.

17.

18.

19.

20. 21.

Ram D, Amir E. Comparison of articaine 4% and lidocaine 2% in paediatric dental patients. Int J Paed Dent. 2006;16(4):252-6. Corah NL, Gale EN, Illig SJ. Assessment of a dental anxiety scale. J Am Dent Assoc. 1978;97(5):816-9. Schertzer ER, Malamed SF. Articaine vs. Lidocaine. J Am Dent Assoc. 2000;131(1):1248-50. Nagendrababu V, Pulikkotil SJ, Suresh A, Veettil SK, Bhatia S, Setzer FC. Efficacy of local anaesthetic solutions on the success of inferior alveolar nerve block in patients with irreversible pulpitis: a systematic review and network meta-analysis of randomized clinical trials. Int Endod J. 2019 June;52(6):779-89. Su N, Li C, Wang H, Shen J, Liu W, Kou L. Efficacy and safety of articaine versus lidocaine for irreversible pulpitis treatment: A systematic review and meta-analysis of randomised controlled trials. Aust Endod J. 2016 Apr;42(1):4-15. Rathi NV, Khatri AA, Agrawal AG, M SB, Thosar NR, Deolia SG. Anesthetic efficacy of buccal infiltration articaine versus lidocaine for extraction of primary molar teeth. Anesth Prog. 2019 Spring;66(1):3-7. Kolli NK, Nirmala SV, Nuvvula S. The effectiveness of articaine and lidocaine single buccal infiltration versus conventional buccal and palatal injection using lidocaine during primary maxillary molar extraction: a randomized control trial. Anesth Essays Res. 2017 Jan-Mar;11(1):160-4. Majid OW, Ahmed AM. The anesthetic efficacy of articaine and lidocaine in equivalent doses as buccal and non-palatal infiltration for maxillary molar extraction: a randomized, double-blinded, placebo-controlled clinical trial. J Oral Maxillofac Surg. 2018 Apr;76(4):737-43. Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain. 1986;27(1):117-26. Fillingim RB, Ness TJ. Sex-related hormonal influences on pain and analgesic responses. Neurosci Biobehav Rev. 2000;24(4):485-501.

22. 23.

24.

25.

26.

27. 28.

29.

Newton JT, Buck DJ. Anxiety and pain measures in Dentistry: a guide to their quality and application. J Am Dent Assoc. 2000;131(10):1449-57. Laureano Filho JR, O’Brien PM, Allais M, Oliveira Neto PJ. Comparação entre cetorolaco e paracetamol na dor pós-operatória. J Braz Coll Oral Maxillofac Surg. 2015 Jan-Abr;1(1):28-35. Mayrink G, Nicolai B, Aboumrad JP Júnior. Comparative study of dipyrone and paracetamol pain control after third molar extraction. J Braz Coll Oral Maxillofac Surg. 2018 May-Aug;4(2):32-7. Lemmer, B, Wiemers R. Circadian changes in stimulus threshold and in the effect of a local anaesthetic drug in human teeth: studies with an electronic pulp tester. Chronobiol Int. 1989;6(2):157-62. Berlin J, Nusstein J, Reader A, Beck M, Weaver J. Efficacy of articaine and lidocaine in a primary intraligamentary injection administered with a computer-controlled local anesthetic delivery system. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;99(3):361-6. Malamed SF, Gagnon S, Leblanc D. Articaine hydrochloride: a study of the safety of a new amide local anesthetic. J Am Dent Assoc. 2001;132(2):177-85. Sierra Rebolledo A, Delgado Molina E, Berini Aytís L, Gay Escoda C. Comparative study of the anesthetic efficacy of 4% articaine versus 2% lidocaine in inferior alveolar nerve block during surgical extraction of impacted lower third molars. Med Oral Patol Oral Cir Bucal. 2007 Mar 1;12(2):E139-44. Rosenberg PA, Amin KG, Zibari Y, Lin LM. Comparison of 4% articaine with 1:100,000 epinephrine and 2% lidocaine with 1:100,000 epinephrine when used as a supplemental anesthetic. J Endod. 2007 Apr;33(4):403-5. Epub 2007 Feb 20.

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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.

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J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):76-80

Notice to Authors and Consultants Registration of Clinical Trials

1. Registration of clinical trials Clinical trials are among the best evidence for clinical decision making. To be considered a clinical trial a research project must involve patients and be prospective. Such patients must be subjected to clinical or drug intervention with the purpose of comparing cause and effect between the groups under study and, potentially, the intervention should somehow exert an impact on the health of those involved. According to the World Health Organization (WHO), clinical trials and randomized controlled clinical trials should be reported and registered in advance. Registration of these trials has been proposed in order to (a) identify all clinical trials underway and their results, since not all are published in scientific journals; (b) preserve the health of individuals who join the study as patients and (c) boost communication and cooperation between research institutions and other stakeholders from society at large interested in a particular subject. Additionally, registration helps to expose the gaps in existing knowledge in different areas as well as disclose the trends and experts in a given field of study. In acknowledging the importance of these initiatives and so that Latin American and Caribbean journals may comply with international recommendations and standards, BIREME recommends that the editors of scientific health journals indexed in the Scientific Electronic Library Online (SciELO) and LILACS (Latin American and Caribbean Center on Health Sciences) make public these requirements and their context. Similarly to MEDLINE, specific fields have been included in LILACS and SciELO for clinical trial registration numbers of articles published in health journals. At the same time, the International Committee of Medical Journal Editors (ICMJE) has suggested that editors of scientific journals require authors to produce

a registration number at the time of paper submission. Registration of clinical trials can be performed in one of the Clinical Trial Registers validated by WHO and ICMJE whose addresses are available at the ICMJE website. To be validated, the Clinical Trial Registers must follow a set of criteria established by WHO.

2. Portal for promoting and registering clinical trials With the purpose of providing greater visibility to validated Clinical Trial Registers, WHO launched its Clinical Trial Search Portal (http://www.who. int/ictrp/network/en/index.html), an interface that allows simultaneous searches in a number of databases. Searches on this portal can be carried out by entering words, clinical trial titles or identification number. The results show all existing clinical trials at different stages of implementation with links to their full description in the respective Primary Clinical Trials Register. The quality of information available on this portal is guaranteed by the producers of the Clinical Trial Registers that form part of the network recently established by WHO, i.e., WHO Network of Collaborating Clinical Trial Registers. This network will enable interaction between the producers of the Clinical Trial Registers to define the best practices and quality control. Primary registration of clinical trials can be performed at the following websites: www.actr.org.au (Australian Clinical Trials Registry), www.clinicaltrials.gov and http://isrctn.org (International Standard Randomized Controlled Trial Number Register (ISRCTN). The creation of national registers is underway and, as far as possible, registered clinical trials will be forwarded to those recommended by WHO.

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):76-80

Comunicado aos Autores e Consultores - Registro de Ensaios Clínicos

WHO proposes that as a minimum requirement the following information be registered for each trial. A unique identification number, date of trial registration, secondary identities, sources of funding and material support, the main sponsor, other sponsors, contact for public queries, contact for scientific queries, public title of the study, scientific title, countries of recruitment, health problems studied, interventions, inclusion and exclusion criteria, study type, date of the first volunteer recruitment, sample size goal, recruitment status and primary and secondary result measurements. Currently, the Network of Collaborating Registers is organized in three categories: » Primary Registers: Comply with the minimum requirements and contribute to the portal; » Partner Registers: Comply with the minimum requirements but forward their data to the Portal only through a partnership with one of the Primary Registers; » Potential Registers: Currently under validation by the Portal’s Secretariat; do not as yet contribute to the Portal.

the International Committee of Medical Journal Editors - ICMJE (# http://www.wame.org/wamestmt. htm#trialreg and http://www.icmje.org/clin_trialup. htm), recognizing the importance of these initiatives for the registration and international dissemination of information on international clinical trials on an open access basis. Thus, following the guidelines laid down by BIREME / PAHO / WHO for indexing journals in LILACS and SciELO, Dental Journal of the Brazilian College of Oral and Maxillofacial Surgery will only accept for publication articles on clinical research that have received an identification number from one of the Clinical Trial Registers, validated according to the criteria established by WHO and ICMJE, whose addresses are available at the ICMJE website http://www.icmje.org/about-icmje/faqs/ clinical-trials-registration/. The identification number must be informed at the end of the abstract. Consequently, authors are hereby recommended to register their clinical trials prior to trial implementation.

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

Yours sincerely,

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

J Braz Coll Oral Maxillofac Surg. 2020 Jan-Apr;6(1):76-80