Revista JBCOMS - Vol. 7, Número 1, 2021 by Prod

Congresso Adiado!

DIAGNÓSTICO E PLANEJAMENTO PARA CIRURGIA BUCO-MAXILO-FACIAL

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Felipe Villa Verde

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O PRIMEIRO SERVIÇO DE DIAGNÓSTICO E PLANEJAMENTO 3D PARA CIRURGIAS ORTOGNÁTICAS DO BRASIL AGORA É CERTIFICADO PELA ANVISA E ACEITO PELOS PRINCIPAIS PLANOS DE SAÚDE.

Luis Calicchio K

Maristela Lobo

Wagner Nhoncance

Ressalta-se que a Dental Press ficou impossibilitada de realizar o Congresso por determinação de decretos estaduais e municipais. Quando a Prefeitura de Maringá foi questionada quanto à realização do evento, o município aconselhou “o adiamento ou cancelamento do evento na data em questão”. Pedimos desculpas pelos transtornos, mas, na conjuntura geral do país, é necessário ter resiliência e cautela. Em 2022, a expectativa é de um grande Congresso, com uma grade de palestrantes excepcionais e com segurança. Agradecemos pela compreensão de todos.

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.

College of Oral and Maxillofacial Surgery Volume 7, Number 1, 2021 - ISSN 2358-2782

REGISTO ANVISA: B1103650004

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O QUE É BOM FICOU AINDA MELHOR!

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

Devido ao agravamento da pandemia de Covid-19, a Dental Press teve que, novamente, reagendar o Congresso Dental Press Specialties, que estava marcado para os dias 20, 21 e 22 de maio de 2021. A nova data está programada para os dias 11, 12 e 13 de agosto de 2022, quando acreditamos que — com um plano eficiente de vacinação — será seguro retomar as atividades em eventos desse porte.

Volume 7, Número 1, 2021

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JBCOMS

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qualidade relacionada à o científica e feira comercial. I amadurecimento e trabalho int Colégio Brasileiro de Cirurg Buco-maxilo-facial.

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Florianópolis apresenta todas Geograficamente bem localiza um dos aeroportos mais mod coração da cidade, com uma va disso, dispensando maior divu estrangeiros.

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/compasscomvoce /orthoaligner @co mpasscomvoce @orthoaligner

Presidente do COBRAC 2022

J Braz Coll Oral Maxillofac Surg. 2021 January-April;7(1):1-72

ISSN 2358-2782

Journal of the Brazilian

College of Oral and Maxillofacial Surgery JBCOMS

Since 2016

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

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

Quarterly ISSN 2358-2782

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

New Qualis periodics Sylvio Luiz Costa de Moraes

New CBCTBMF 2021/2022 board Marcelo Marotta Araújo

New CBCTBMF board and the formation of the oral and maxillofacial surgeon Liogi Iwaki Filho

Interview Mônica Diuana Calasans Maia

Tribute Prof. Dr. Francisco Eugênio Loducca Original Articles

Systematic review on firearm injuries in the face: state of the art and existing gaps

Prevalence of complications in oral surgeries performed by undergraduate students

Relevance of Oral and Maxillofacial Surgery dental records for trauma hospital

Bacterial adherence to silk and nylon sutures

Adriane Batista Pires Maia, Simone Gonçalves Assis, Cecília Minayo

Dyemes Cartegyano Gomes de-Souza, Carla Aline Chaves Batista, Allan Vinícius de Camargos Elizário, Nara Linne da Silva Folha, Douglas Rangel Goulart

Willian Martins Azeredo, Giuliano Teixeira Pacher, Antonio Eugênio Magnabosco-Neto

Lauane Alves, Ana Barbara Polo, Neuza Maria Souza Picorelli Assis, Breno Nogueira Silva, Ana Carolina Morais Apolônio, Matheus Furtado de-Carvalho

Case reports

Treatment of panfacial fracture and late reconstruction of frontal defect: Case report

Osteoid osteoma in the mandible: Case report

Well-differentiated lipossarcoma of soft palate: case report and literature review

Low-intensity LED therapy in facial paralysis: Case report

Information for authors

Rafael Saraiva Torres, Gustavo Cavalcanti de Albuquerque, Joel Motta Junior, Valber Barbosa Martins, Marcelo Vinicius Oliveira, Ingrid Soani Amaral de Couto Tenório, Denis Esteves Raid

Rafael Saraiva Torres, Saulo Lobo Chateubriand do Nascimento, Paulo Matheus Honda Tavares, Valber Barbosa Martins, Joel Motta Junior, Gustavo Cavalcanti de Albuquerque, Marcelo Vinicius Oliveira

Julio Claudio Sousa, Rogerio Costa Tiveron, Renato Queiroz Ramos, Renata Margarida Etchebehere

Marcello de Souza Silva, Renata Amadei Nicolau, Matheus Augusto Pereira, Carlos Eduardo Dias Colombo

Editorial

New Qualis periodics In 2018, the Coordination for the Improvement of Higher Education Personnel (CAPES) initiated actions to improve the assessment instruments, with the chief goal to increase the focus on the quality of training of PhD’s and MSc’s, and on the excellence of Brazilian postgraduate studies. This considered recommendations (focused on contributions from consulted entities) indicated by the report of the Special Monitoring Committee of the National Postgraduate Plan (PNPG 2011-2020). Thus, CAPES implemented the improvement of the postgraduate evaluation process; evaluation of intellectual production; and elucidated the Qualis Periódicos. Among the initiatives to improve the evaluation process, the new proposal for Qualis Periódicos is highlighted. It was observed that the evaluation of knowledge production in the fields adopted differentiated criteria for the classification of scientific production. This often resulted in distortions, since the same journal could be classified into completely different strata between areas. The new methodology sought more objective criteria, which allow greater comparability between assessment areas, also paying attention to internationalization. The proposal was based on four principles: 1) Each journal will receive only one classification,

How to cite: Moraes SLC. New Qualis periodics. J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):4-5. DOI: https://doi.org/10.14436/2358-2782.7.1.004-005.edt

J Braz Coll Oral Maxillofac Surg. Surg. 2021 Jan-Apr;7(1):4-5

Editorial

even if it has been informed by programs linked to more than one evaluation area; 2) The classification will be given by a “mother area”; 3) Qualis reference: the new methodology proposes a classification provided by the combined use of bibliometric indicators and a mathematical model; and 4) bibliometric indicators that are basically those that consider the number of citations of the journal within three bases: Scopus (CiteScore), Web of Science (Impact Factor) and Google Scholar (h5 index). In summary, the reference stratum was calculated using equal intervals (12.5%) of the final percentile, resulting in the following 8 classes: strata A1 (highest stratum, with minimum value of 87.5%), A2, A3 and A4 and also the strata B1, B2, B3 and B4 (the 8th stratum, with value lower than 12.5%). We shall continue united and focused on the continuous growth of our strong journal!

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

References:

1. Ofício nº 6/2019 - CGAP/DAV/CAPES (16 de julho de 2019). 2. Portaria CAPES nº 8, de 22 de janeiro de 2020. Diário Oficial [da] República Federativa do Brasil de 23 janeiro de 2020; Seção 2, p. 30.

J Braz Coll Oral Maxillofac Surg. Surg. 2021 Jan-Apr;7(1):4-5

Letter from the President

New CBCTBMF 2021/2022 board

Dear Members, We are starting our board! We are committed to work hard and we know the huge responsibility ahead. Yet it is also an honor for all of us to be able to contribute to the development of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology and our beautiful specialty. The Covid-19 pandemic brought great challenges for everyone in the most diverse areas across the planet. For health professionals, the difficulties are even greater, since we are in the middle of the storm, even for those who do not directly treat the disease. But the sanitary crisis will end and, while it lasts, we need to keep the new scientific and recycling activities, either online or in person, adopting all necessary safety measures. Several events are scheduled for the next two years (2021/22): Cobrac, in Belém/PA; Copac, in São Paulo/SP; Ennec, in João Pessoa/PB; Sul Brasileiro, in Curitiba/PR; and finally, Cobrac, in Florianópolis/SC. In this “new normal”, we will need to reinvent ourselves and we are already mobilizing ourselves in this sense, to maintain the high scientific standard of the College events, in a short period of time. We are planning a national continuing education project distributed across the Chapters, to be closer to the members and also to expand our membership, to be even more representative.

How to cite: Araújo MM. New CBCTBMF 2021/2022 board. J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):6-7. DOI: https://doi.org/10.14436/2358-2782.7.1.006-007.crt

J Braz Coll Oral Maxillofac Surg. Surg. 2021 Jan-Apr;7(1):6-7

Letter from the President

This new board will innovate and bring projects that enhance the visibility of the College and put it at the service of members. We will continue important works initiated in the previous and past boards. We will keep a dialogue with the Federal Dental Council, Ministries of Education and Health. The struggle of the College will continue to assure the training of specialists only in the residency format! My campaign promise was met, and the College doors were open to new members in the Board, the Council, Chapters and Commissions. Young people who will surely oxygenate the institution with new ideas, further modernizing our actions. The members today can be proud to be part of one of the most organized entities in Dentistry. We have our own headquarters, employees, legal support, civil liability insurance, scientific journal, press office, social media companies and the largest and best scientific events in our specialty. We are more than 1700 members, and many others can come and participate. Together, we can make the Brazilian College of Oral and Maxillofacial Surgery and Traumatology an even stronger entity. I am grateful for the trust in me for this important challenge that I am starting now, and I will continue to seek unity and strength to be more and more recognized. Marcelo Marotta Araújo President 2018/2020 Brazilian College of Oral and Maxillofacial Surgery and Traumatology

J Braz Coll Oral Maxillofac Surg. Surg. 2021 Jan-Apr;7(1):6-7

Confira mais!

www.dentalpress.com.br/dentalgo

CBCTBMF

New CBCTBMF board and the formation of the oral and maxillofacial surgeon In this sense, the Brazilian College of Oral and Maxillofacial Surgery and Traumatology has been negotiating, with CFO and MEC, a unification in the formation of the specialty, so that there is a single rule. In our understanding, all training programs should be at least three years long, with full time and exclusive dedication, with a workload of 60 hours per week and, if possible, implementing a fourth year. Then, our programs will be able to meet the guidelines suggested by the International Association of Oral and Maxillofacial Surgery, allowing exchanges between our resident students and resident students from other countries. The difference between Residency and Specialization would be that, in the Residency, the student would receive a scholarship, while in the Specialization the student would pay a monthly fee. The College is working to create a minimum program, which may guide the operation of all programs, with the suggestion of minimum disciplines and procedures for good training of a specialist. The proposal would be the formation of evaluation committees, constituted by MEC, CFO and CBCTBMF, to evaluate the residency and specialization programs. The idea is not to close programs or specializations, but to provide conditions for these courses to train their students well and thus improve the specialty level in our country. Obviously, this would benefit the patients. Programs that have deficit in any field of the specialty may exchange residents, to complement their training in another service that is well structured in that specific area. Another objective would be the return of the exam for registration of specialty, in which the graduates of Residency and Specialization programs should take an exam, and those approved could register their specialty.

The residency consists of a specialty program characterized by in-service training. In 2002, the Federal Dental Council (CFO) regulated Residencies in Oral and Maxillofacial Surgery and Traumatology with a workload of 6,000 hours and minimum duration of three years. In 2005, the Ministry of Education established the National Committee for Multiprofessional Residency and in Professional Health Area and established the operation of Residencies in Oral and Maxillofacial Surgery and Traumatology for three years, with a weekly workload of 60 hours, adding up to 8,640 hours, with 80% of such workload for practice or theoretical-practical. In Brazil there is a peculiarity, which is the training in Specialization modality, regulated by the CFO, with duration of two years, not being full-time or exclusive dedication, with a workload of 2,000 hours, which is well below that recommended by MEC. It is important to highlight that, in most countries, the training of an oral and maxillofacial surgeon takes at least four years. This difference in training between specializations and residencies caused problems in the daily routine of the specialty, since the professional trained by Specialization has the same rights and duties as that trained by Residency – however, with a much lower technical condition. But how can we state that? First, because many members of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology are professors and many of them had their training complemented in programs in other countries, having the knowledge to state that training in the specialty of Oral and Maxillofacial Surgery and Traumatology is very complex, requires a slow learning curve and there is a need to experience the various surgical procedures that involve the specialty as much as possible and repetitively. A period of two years, without exclusive dedication and with a workload of 2,000 hours, is not enough to provide such training.

Dr. Liogi Iwaki Filho Vice-president of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology

How to cite: Iwaki Filho L. New CBCTBMF board and the formation of the oral and maxillofacial surgeon. J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):11. DOI: https://doi.org/10.14436/2358-2782.7.1.011-011.cbc Submitted: February 22, 2021 - Revised and accepted: February 25, 2021

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):11

Interview

Interview with Mônica Diuana Calasans Maia » Specialist and MSc in Oral and Maxillofacial Surgery and Traumatology by the Federal University of Rio de Janeiro. » PhD in Pathology by Universidade Federal Fluminense. » Full Professor of the Discipline of Minor Oral Surgery at Universidade Federal Fluminense. » Research scholar of the State of Rio de Janeiro Research Support Foundation (FAPERJ). » Member of the Bioengineering network of the State of Rio de Janeiro and NanoSaúde Network. » Coordinator of the Animal Studies Laboratory of the Histology sector of the Applied Biotechnology Laboratory and Clinical Research Laboratory in Dentistry at Universidade Federal Fluminense.

the Bioengineering network of the State of Rio de Janeiro and NanoSaúde Network. She is Full Professor at the School of Dentistry at UFF, professor and former coordinator of the Graduate Program in Dentistry at UFF, coordinator of the Animal Studies Laboratory of the Histology sector of the Applied Biotechnology Laboratory and Clinical Research Laboratory in Dentistry, all at UFF.

In this issue of JBCOMS, the Brazilian College of Oral and Maxillofacial Surgery and Traumatology interviews Prof. Dr. Mônica Diuana Calasans Maia, specialist and MSc in Oral and Maxillofacial Surgery and Traumatology by the Federal University of Rio de Janeiro (UFRJ), PhD in Pathology by Universidade Federal Fluminense (UFF), research fellow at FAPERJ, member of

How to cite: Maia MDC, Ribeiro J. Interview with Mônica Diuana Calasans Maia. J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):12-3. DOI: https://doi.org/10.14436/2358-2782.7.1.012-013.ent Submitted: March 08, 2021 - Revised and accepted: March 11, 2021

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):12-3

Maia MDC, Ribeiro J

Was there investment in Translational Research in the past decade? In 2011, the National Institute of Health (NIH) invested U$650 million in translational research, aiming to bridge the gap between biomedical researchers and patients who need their discoveries. In Brazil, this gap still exists and there are many obstacles in the search for a new product until its registration and marketing. Besides all stages of research, we face the patent's delay until marketing.

How do you consider the transfer of knowledge from basic research to its clinical application? We have never heard so much about stages of clinical research, randomized studies, study subjects and placebo as we are experiencing in this pandemic moment. The SARS CoV-2 pandemic has brought a path for the non-scientific population previously known only by researchers. This path begins with basic research for the development of new products by in vitro studies; then tests on animal models (in vivo studies); in the case of promising results, it evolves into controlled, randomized and double-blind clinical trials; and if it is confirmed to be effective and safe, this new product is registered by the local regulation agency – in Brazil, ANVISA – for later distribution and application in the health system. The path herein described represents translation in research or Translational Research, defined as the transfer of knowledge from basic research to the improvement and creation of new methods for prevention, diagnosis and treatment of diseases, as well as the transfer of clinical problems, which create hypotheses, which can be tested and validated in basic research laboratories.

What is your opinion on the influence of SARS CoV2 pandemic on Translational Research? The SARS CoV-2 pandemic has shown that the creation of strong translational research programs is the key to fighting any pandemic. Translational research uses cutting-edge laboratory techniques to study patient samples and applies laboratory findings to new therapies for patients. Across the medical spectrum, from cancer to the human immunodeficiency virus, translational research has been fundamental to achieve the ultimate goal, which is to design new tests diagnostic tests; understand the mechanisms underlying the disease processes; and establish, improve and advance therapies. Despite the social tragedy in health and economy caused by the pandemic, I continue to believe that the technological development driven by the pandemic has accelerated changes and innovations that could take years to be implemented, besides valuing the importance of science and translational research for the health of mankind.

When did the concept of Translational Research appear? When we search in research history, we find the important citation by Claude Bernard (1813-1878): "The experiment is nothing more than the provoked observation with the objective of rising an idea". He himself introduced the study of evidence-based experimental medicine with the cycle: a fact is observed > an idea arises > of the hypothesis, an experiment; and, from the experiment, new facts and new ideas. This cycle, or model, has undergone several conceptual changes and the circular model is the current model, where research (knowledge) generates technology (application), and vice versa. However, only about 30 years ago the concept of translational research appeared in all life sciences, first appearing in PubMed in 1993 to support the increase in the number of scientific discoveries for the benefit of patient and society. The translation of basic research into clinical application has always been a priority in the scientific community. In Brazil and in the world, we can observe a great amount of basic research and few products reaching the shelves to be marketed and used in public and private health systems.

Interviewer: Prof. Dr. Jonathan Ribeiro - Associate Editor-in-Chief of JBCOMS Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):12-3

Tribute

Prof. Dr. Francisco Eugênio Loducca Dr. Francisco Eugênio Loducca, a redeemed member of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology, who passed away at the age of 91, on November 14, 2020, was an exceptional health professional. He has worked in dentistry for more than 60 years. Specialist, MSc and PhD in Oral and Maxillofacial Surgery and Traumatology, he graduated in 1954 from the School of Dentistry of the University of São Paulo (FO-USP), where he was professor of Oral and Maxillofacial Surgery and Traumatology. He also taught at Camilo Castelo Branco University and at the University of Guarulhos (UNG). Professor Dr. Francisco Eugênio Loducca also established and coordinated the first Residency Program in Oral and Maxillofacial Surgery in São Paulo, at the Municipal Hospital of Tatuapé, besides being a Full Member

of the Technical Chamber of the Regional Dental Council of the State of São Paulo (CRO-SP). He was one of the individuals responsible for the implementation of most dental emergency rooms in the city of São Paulo, besides being member of the Deliberative Council of the São Paulo Dental Association (APCD) in several boards and vice-president of the Studies and Research Center “Dr. João Amorim” (CEJAM). In recognition of his work, APCD established, in 2014, the “Dental Clinic Prof. Dr. Francisco Eugênio Loducca”. A joyful and collaborative person, he loved teaching and trained several generations of surgeons. A dear friend for all members of Surgery and of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology, Dr. Francisco Eugênio Loducca will always be remembered for his competence, ethics and professionalism.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):14

Original Article

Systematic review on firearm injuries in the face: state of the art and existing gaps ADRIANE BATISTA PIRES MAIA1 | SIMONE GONÇALVES ASSIS2 | CECÍLIA MINAYO2

ABSTRACT Introduction: The treatment of patients with gunshot wounds (GSW) in the face usually represents one of the greatest challenges for the surgeon. Given this challenge, it is necessary to know what the scientific literature recommends about the treatment of these injuries. Objectives: To systematize the bibliographic production on the occurrence of gunshot wounds in the face, map the existing evidence in the literature, identify the main sources, the themes studied and the existing gaps. Methods: The review uses the Scoping method, having been performed in Brazilian and international electronic bibliographic databases and gray literature (BVS, Scopus, Web of Science, Pubmed, Lilacs, SciELO, Medline, Sociological Abstract, Cochrane Library, Brazilian Digital Library of Theses and Dissertations (BTDB), Fiocruz Theses Collections) without stipulation of temporal or territorial cut. Results: A total of 111 documents were found and analyzed, with an increasing number of publications between 2010 and 2019, most of them published in English, from North American origin. Gunshot wounds in the face (GSWF) are more frequent among male patients, about 29-39 years old. The most researched themes found on facial ballistic trauma were, in descending order: surgical treatment, complications, reconstructions and grafts, demographic profile, suicide attempts, complementary exams for diagnosis and surgical planning and other themes. Conclusion: Despite of the increasing number of publications about GSWF in the face, there is a relevant knowledge gap regarding studies about prevention and that evaluate the functional and psychosocial repercussions of this type of morbidity. Keywords: Firearms. Facial injuries. Surgery, oral.

How to cite: Maia ABP, Assis SG, Minayo C. Systematic review on firearm injuries in the face: state of the art and existing gaps. J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):15-22. DOI: https://doi.org/10.14436/2358-2782.7.1.015-022.oar

Hospital Central da Polícia Militar, Secretaria de Polícia Militar (Rio de Janeiro/RJ, Brazil).

Fundação Oswaldo Cruz (Fiocruz), Departamento de Estudos sobre Violência e Saúde Jorge Careli, Escola Nacional de Saúde Pública Sergio Arouca (Rio de Janeiro, Brazil).

Submitted: January 29, 2020 - Revised and accepted: July 19, 2020 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. Contact address: Adriane Batista Pires Maia E-mail: adrianepmaia@gmail.com

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Systematic review on firearm injuries in the face: state of the art and existing gaps

INTRODUCTION Firearm injuries (FAI) in the face are perforating injuries that sometimes also cause avulsion of maxillofacial segments, which usually result in the most devastating type of facial trauma, thus constituting a challenge for the surgeon.1 These injuries are uncommon outside war areas, accounting for about 6% to 10% of firearm injuries.2 However, when they do occur, they are usually associated with serious risks to the patients’ physical and emotional health, due to the frequent esthetic and functional impairment.3 The treatment of this type of morbidity requires multidisciplinary teams in all its phases, from procedures to save the patient’s life, which follow the recommendations of the Advanced Life Support Protocols (airway control, hemodynamic control, etc.) until primary reconstructions (treatment of wounds and fixation of fractures) and secondary reconstructions (grafts, implants, prosthetic rehabilitation).4,5 This review aims to map the existing evidence in the literature, besides identifying the main sources, themes studied and existing gaps on the treatment of FAI in the face.

(BTDB) and Acervos de Teses Fiocruz. The search strategy employed included: (“Ferimentos por arma de fogo em face” OR “Fraturas em face por arma de fogo” OR “Cirurgia e traumatologia bucomaxilofacial” OR “Fraturas mandibulares por arma de fogo” OR “Trauma balístico”) AND (Armas OR “Arma de fogo” OR “Armas de fogo”); and in English: (“Ballistic trauma” OR “Firearm Fractures in face” OR “facial firearm wounds” OR “facial firearm fracture” OR “maxillofacial firearm” OR “firearm wounds to the face”) AND (Firearms OR Firearms OR Guns) . No time or place were determined. It was conducted by the title, abstract and keywords. For inclusion or exclusion of documents, the following criteria were used: a) inclusion: studies presenting occurrence of morbidity due to firearm in the face, with “face” being understood superiorly by the limits of the frontal bone, inferiorly by the lower edge of the mandible and laterally by the external auditory canal from one side to the other; 2 b) exclusion: documents on FAI in anatomical region other than the face; texts dealing with non-firearm projectile injuries, such as rubber bullets, pressure guns, among others; forensic studies; ballistic studies on cadavers, specimens or animals; and articles not available in English, Spanish or Portuguese; articles not found. Based on the search criteria adopted, 344 studies were identified. Among these, 93 were excluded because they were duplicated between databases. The remaining 248 titles and abstracts were read by two reviewers. For articles whose abstracts indicated the possibility of selection, the full version was obtained to confirm the eligibility and inclusion in the study. If reading the abstract was not sufficient to establish whether the study should be included, the article was also obtained and read in full to determine its eligibility. Among the remaining 149 articles, after applying the exclusion criteria, 111 were selected (Fig 1) and made up the base analyzed in this review. The question that moved the research conducted in this scoping review was: what are the main sources of information, the themes studied and the gaps in the scientific literature on FAI in the face?

METHODS Scoping review was used in this work, since it provides broad and deep, rather than focused, information about all existing literature on a topic. It was performed according to the methodology proposed by Arksey and O’Malley6 and followed the phases: 1) establishment of the research question; 2) search for relevant studies; 3) selection of studies based on the pre-established inclusion criteria; 4) data analysis and elaboration; and 5) summary and communication of information. The search was carried out in July 2019, on the bases: Regional Website of the Virtual Health Library (BVS) – which incorporates Lilacs, SciELO, Medline and other types of information sources, such as open educational resources, internet sites and scientific events – Scopus, Web of Science, Pubmed, Sociological Abstract, Cochrane Library, Biblioteca Digital Brasileira de Teses e Dissertações

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ELIGIBILITY

IDENTIFICATION

Maia ABP, Assis SG, Minayo C

Studies identified by search in the databases: BVS (n = 10), Scopus (n = 126), Web of Science (n = 60), PubMed (n = 141), Scielo (n = 3), Sociological abstract (n = 1), Cochrane Library (n = 3) TOTAL (n = 344)

INCLUDED

SELECTION

Articles excluded after reading abstracts (n = 102)

Eligible articles (n = 149)

Articles excluded after applying the exclusion criteria (n = 38)

Total studies included in the review (n = 111)

Exclusion of duplicates between databases (n = 93)

Reasons for exclusion: Documents on firearm injuries in anatomical region other than the face (n = 60) Ballistic studies conducted on cadavers, specimens or animals (n = 23) Forensic studies (n = 21) Documents on the occurrence of facial injuries produced by non-firearm projectiles, such as rubber and pressure projectiles (n = 19) Failure to obtain the articles (n = 10) Articles not available in Portuguese, English or Spanish (n = 7)

Figure 1: Flowchart for identification and selection of articles in the review on firearm wounds in the face.

RESULTS The 111 documents found were produced in 21 different countries: the USA was the country with the largest number of publications (n = 67); followed by Turkey (n = 7); Brazil and France (4 articles each); United Kingdom, South Africa, China and India (3 documents per country); Iran, Russia, Israel and Germany, with 2 documents per country; besides 9 different countries that produced only 1 document each (Lithuania, Bosnia, Iraq, Greece, New Zealand, Malaysia, Libya, Pakistan and Mexico). Concerning the year of publication of documents (n = 111), studies were found between the years 1970 and 2019. When the publications were distributed by decade, it was found that two documents were released between 1970 and 1979; 10 between 1980 and 1989; 29 between 1990 and 1999; 26 between 2000 and 2009; and 44 between 2010 and the first semester of 2019 (40%), showing significant growth in publications on FAI in the past decade.

Concerning the type of document, 6 are editorial letters for scientific journals; 2 book chapters and 103 scientific articles. Despite the fact that a search was performed on the basis of theses and dissertations, no documents were found. Regarding the methodological design of articles (n = 109), there were 50 case studies, 43 analytical (observational) studies, 3 experimental studies, 7 literature reviews and 6 editorial letters. For analysis of the themes reported by the documents, after reading the titles, abstracts and study objectives, the central and objective subjects were identified, classifying them into 7 categories. A total of 142 thematic approaches were found in the 111 studies, showing that some address more than one subject. They are categorized in the results below, in descending order: 1) surgical treatment of FAI in the face (n = 61); 2) vascular, nervous, infections and other complications (n = 26); 3) reconstructions and grafts (n = 16); 4) demographic profile of patients

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Systematic review on firearm injuries in the face: state of the art and existing gaps

with FAI in the face (n = 13); 5) suicide attempts (n = 13); 6) complementary exams for diagnosis and surgical planning (n = 9); and 7) other themes (n = 5). In the “others” category, the least reported topics were included, which address strategies on preventing FAI in the face (n = 1) and research that analyzes psychosocial and functional repercussions of FAI in the face (n = 1). The main approaches used in the papers are presented below, in decreasing order of frequency.

were very limited when early management of injuries was made,17,20 -22 and when reconstructions were performed earlier and more aggressively.12. Shvyrkov23 related complications to the conservative approach in debridement of high-speed injuries, and for Sokoya et al.24 the complication rates were significantly higher in the self-inflicted group compared to the non-self-inflicted group. The complications reported were: vascular complications, facial nerve injuries, neurological complications, airway-related, infection, ophthalmology, limited mouth opening, complications related to fracture fixation and wound dehiscence.9,10,12,16,17,25 The need for urgent airway control ranged from 22.5%26 to 70%.21 However, the most repeated results showed a variation close to 33%.14,15,19 The most used strategy for airway control was orotracheal intubation.10,14,15,19,21,26 Surgical access to the airway was a rarely necessary option.8,10,14,15,25 The results on the mortality of patients with FAI in the face did not follow a pattern between studies, ranging from 0 to 22.7%.8,10,19,21,22,25,27 Hollier, Grantcharova, Kattash;25 Norris, Mehra, Salama21 and Orthopoulos, Sideris, Velmahos, Troulis8 found low mortality rates (11%, 9%, 0%, respectively), while Pereira et al.10; Shackford, et al.19 and Ugboko et al.27 reported mortality rates above 20%. Mortality by firearms in the face was related to the presence of other associated skull injuries.10,19,22,25,27

Considerations on the surgical treatment of FAI (n = 61) Regarding wound debridement, a careful and early approach is recommended to remove unviable tissues.1-4,7,8-15 In cases of injuries caused by weapons with high kinetic energy, further interventions for late debridement may be necessary.12,13 In general, the recommendation is that wounds undergo conservative debridement and only circumscribed to devitalized tissues. Regarding the location of facial fractures caused by a firearm, Dolin et al.14 and Burke et al.15 reported the maxilla, followed by the mandible, as the most commonly fractured bones. Lauriti et al.16 and Khalil17 first found the mandible as the most affected anatomical region, followed by the maxillary, zygomatic, orbital and nasal regions. Clearly, there is a strong consensus that self-inflicted FAIs result in preferentially mandibular and comminuted type fractures.4,11,14 Guevara, Pirgousis and Steinberg18 showed a significant difference regarding the anatomical region of the FAI in the face between civilians and military: among civilians, the most affected region was the mandible and, among the military, the maxilla. Regarding the method of repairing facial fractures by firearms, only in 2 studies14,15 the authors recommend that open reductions should not be performed in the initial treatment. In general, there is consensus among researchers that fractures should be treated early and, when necessary, preferably by open reduction and rigid internal fixation, by osteosynthesis with titanium plate and screw fixation devices.

Reconstructions and grafts (n = 16) For the reconstruction of wounds that caused bone loss, the use of free, microvascular bone grafts and the use of osteogenic distractors were indicated.4,8,23,28-33 For dental reconstruction, the use of endosseous implants has been described.31 Most authors indicate that reconstructions should be performed in a second surgical procedure, as early as possible.4,9,12,23,28,32 Only Gurunluoglu and Gatherwright29 recommended immediate bone reconstruction. For the reconstruction of facial deformities in soft tissues, as in cases of avulsion or necrosis with significant loss of soft tissue, the use of free and microvascular grafts and flaps has been described.4,10,13,19,23,33

Studies addressing the complications of FAI (n = 26) Complications were found in 39% of patients with FAI in the face by Burke et al.15, 38% by Shackford et al.19 and 25% by Laurite et al.16 Complications

Profile of patient affected by FAI in the face (n = 13) Concerning age, only 11 articles provided information about the mean or median age of patients affected by FAI.4,10,13,14,16,19,26,34-7 In these studies, people

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Other themes (n = 5) The least found themes include three articles on the occurrence of FAI in war situation (n = 3),18,41,42 an editorial letter that discusses the role of maxillofacial surgeons in the prevention of FAI in the face (n = 1)43 and one article that evaluated the psychiatric conditions among patients with FAI due to a failed suicide attempt (n = 1).38

with minimum age of 12 years14 and a maximum of 82 years were found.35 The average age range of 2029 years was the most found in studies.10,14,34,36,37 Two studies indicated 30-39 years as the average age4,13 and one35 study conducted in patients with self-inflicted injuries indicated 40-43 years. Only 13 articles reported the prevalence by sex among patients. In all of them, there was a strong male predominance.4,10,13,14,16,17,19,21-23,26,35-37 Only two studies presented the ethnicity/color of patients.26,37 In South Africa, FAI in the face were more found among blacks26 and, in the USA, there was no significant difference in the distribution by ethnicity.37

DISCUSSION Firearm injuries, which are very common in Brazil, are considered a public health problem.44 However, they are rare in most countries in the world.20,30,45 The high number of publications on FAI in the United States (n = 67), compared to other countries in the world, can be partly understood by the fact that there, as in Brazil, this is a public health problem because of the widespread possession of weapons by the population.43 FAI in the face can result from accidents, interpersonal violence, self-inflicted violence, collective and state violence. Firearm injuries, concerning the shape, extent and degree of tissue destruction, depend on the amount of kinetic energy transferred to the tissues by the projectile; the ability to fragment into secondary projectiles; the speed of the projectile; the type of cavitation that can result in crushing, destroying and perforating the tissues; and the type of surface on which the energy is transferred.7 The formula Ec=M/2.V2 provides the most reliable estimate to measure the capacity of ballistic injury, in which Ec represents energy; M, the mass and V, the speed. From this perspective, speed substantially increases the energy transfer from the projectile to the target. Additionally, since the human body is made of tissues with different densities, the particular type of tissue that interacts with the projectile must also be considered: harder tissues, such as some facial bones, are associated with a greater exponent, which culminates in severe fractures, usually comminuted, generating multiple bone fragments, which can behave as secondary projectiles, besides usually presenting severe impairments of tissue vitality, allowing to maintain them during the fixation of fractures.7,9,32,35,40,41,42 Concerning the type of firearm involved in FAI in the face, a common pattern was not found among studies on which types of firearms are most found. Mainly, three categories were identified: rifles (high-

Suicide attempt (n = 13) There was a significant number of texts specifically reporting cases of FAI in the face caused by attempted suicides (n = 13). The self-inflicted FAI denote the recent proportional growth in this theme, which was 10% in the 1980s, 3.4% in the 1990s and 12% between 2000 and 2009, reaching 18.2% in the 2010-19 decade. Regarding patients with self-inflicted FAI as a result of a failed suicide attempt, there was predominance of males and over 40 years of age. 11,24,34-36,38 Concerning the location of injuries related to the penetration of the projectile, there was a recurrent pattern of positioning the weapon barrel in the submandibular region, causing comminuted mandible fracture. However, there was no pattern for the projectile’s exit orifice. 24,35-38 Among patients who survived the suicide attempt, most were diagnosed with depression. 38 Descriptions of new suicide attempts were uncommon.38 It should be noted that all 13 articles refer to suicide attempts as the cause of FAI in the face, and no article has associated it as a consequence of suffering resulting from this type of morbidity. Complementary exams for diagnosis and surgical planning (n = 9) Nine studies were related to diagnostic methods and surgical planning of FAI in the face, with emphasis on the largest number of publications with reports of the use of innovative imaging exams published in the last decade (2012-2018). There is consensus on the indication of computed tomography exam for better localization of firearm projectiles in the face.3,39,40

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Systematic review on firearm injuries in the face: state of the art and existing gaps

habilitation.8,10,13,16,18 Due to the delicate psychological issues of depressive spectrum disorders involved in suicide attempts, some authors recommend to perform reconstructions early and in a minimum number of stages.11,38,45 Psychiatric follow-up is also indicated since the onset of treatment of these patients for prevention of recurrences, despite the fact that these are scarcely reported.38 Despite the increase in publications on the subject, it is highlighted that little has been considered about the emotional condition before and after the facial trauma suffered, and there is complete absence of suicide prevention strategies. Concerning the treatment of FAI in the face, it is not possible to establish a rigid protocol guiding the treatment, due to the individual peculiarities of each injury. However, in general, the treatment of these patients can be divided into three phases, with specific objectives, described below. Primary care aims at maintaining the patient’s life. Studies do not reach a consensus on the implications of FAI concerning the mortality rate and risk of airway obstruction. Notwithstanding, they agree that the primary moment of patient care is the most critical, because of the hemodynamic and airway complications that can lead to death in the patient soon at this stage.2,8,15,16,19 The second stage of care comprises surgeries for the treatment of wounds and facial fractures. There is consensus among contemporary authors that ballistic injuries are highly contaminated and thus must be approached according to criteria of careful exploration of wounds, debridement of devitalized and unviable tissue, abundant irrigation of wounds with saline, primary soft tissue suture whenever possible and antibiotic therapy. Facial fractures produced by firearms are usually of comminuted type and most often affect the mandible and maxilla.15-18,21 It is recommended that facial bone fractures should be reduced and stabilized early, using rigid internal fixation devices.7,10,12-16,20,22 The spaces related to bone defects must be maintained by reconstruction plates and subsequently bone grafting must be performed to recover the facial shape and function.17,20 There is a tendency to recommend the accomplishment of immediate microvascular bone grafting to reduce and fixate the fractures; however, more studies should be conducted on this practice.29 It is also worth noting that the main complications from FAI in the face were reported in the second phase of treatment.

speed weapons, greater than 600 m/s2); pistols (medium-speed weapons, between 350 and 600 m/s2) and shotguns (low-speed weapons, less than 350 m/s2). All authors dealing with the subject state that injuries caused by high-speed weapons, such as rifles, tend to be more serious.9,10,12,19,26,36,37 Regarding the profile of patients affected by morbidity due to FAI, the literature presents predominance of young men (20-39 years).4,10,13,14,16,17,19,21-23,26,34-37 In general, there is lack of information on other profile data, such as social strata/income, occupation and education. Observational studies are the research designs most frequently used in the medical literature and as methodology applied to this topic. Individual case studies methodologically occupy hierarchical positions of less complexity, due to their low level of evidence.46 However, this type of research was the most found in the set of studies (n = 50). Although the reports should at first provide a detailed and deep description of a case,46 none of them considered the psychosocial factors related to firearm wounds in the face. In this review, the case studies prioritized techniques and treatment sequence, serious and/or rare complications found and innovations in diagnosis and surgical planning. None of the literature review articles (n = 7) described a clear methodological design (systematic, integrative review, scoping, etc.), which shows a gap in the method of elaboration and publication. Two of these reviews were conducted based on a described clinical case. The few experimental studies found (n = 3) were obtained from the exclusion of ballistic studies in specimens or animals. The documents that make up this scoping review also showed a significant increase in publications in the last decade on FAI in the face due to suicide attempts. Self-inflicted injuries are usually caused by short-range shots (<10 cm),34 which produce a triangular entry orifice in the submental region, and the projectile exit locations are different among patients. These self-inflicted injuries result in preferentially mandibular and comminuted type fractures, which produce severe avulsions.11,34-38 The treatment of these patients must follow the same steps, namely: primary care for patient stabilization, reconstructions for wound treatment and fixation of fractures and secondary reconstructions, when necessary, for complete esthetic-functional re-

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bility. It is this part of the body that we do not cover and that identifies and differentiates us”. Within this perspective, which considers the representativeness of the face as the “subject’s epiphany”47 and facing a growing process of individualization that reaches a peak in times of “selfies” and exposure in social media, we might consider the hypothesis that individuals affected by FAI in the face potentially have an even greater impact on their life. These people are required to re-signify their own identity relationship, from the face, which demands a subjective work about themselves. However, further studies should be conducted to build scientific knowledge to support this recurring statement.

The third moment comprises the late approaches that seek at the esthetic-functional improvement of the face. This type of treatment requires the participation of multidisciplinary health teams and must aim at the full esthetic-functional and psychological restoration of the patient, to enable their full social reintegration. This phase involves the biggest research gap on ballistic traumas in the face. The studies found aim at describing techniques for reconstruction of missing tissues and cosmetic repairs. There is lack of bibliographic production that addresses the management and the functional and psychosocial impacts of this type of morbidity on the lives of these people. Also, it is interesting to note that, despite the frequent narrative found in documents that patients who survive FAI in the face usually carry some esthetic deformity that hinders their socialization and psychic health, 5,8,31,35,46 there are very few studies specifically analyzing this type of statement and evaluating the associated psychosocial repercussions. Among the 111 documents analyzed, only the text by Ozturk et al. 38 objectively analyzed the psychiatric conditions of patients who had FAI in the face due to attempted suicide. Vayvada et al. 45 and Zor et al. 11, when presenting the surgical approaches adopted, also analyzed, albeit superficially, the psychosocial repercussions in patients affected by FAI due to different causes. However, no study was found specifically analyzing the psychosocial repercussions of patients who suffered FAI in the face in groups of patients with FAI unrelated to attempted suicide. Thus, so far, it is not known if in fact this type of trauma produces psychosocial repercussions. In summary, the surgeon’s assumption that FAI in the face produce a psychosocial impact on the patients is empirical (coming from sensory knowledge), yet it can find argumentative support from sociology of the body and anthropology. Le Breton47 reported that, after the 15th century, the body and especially the face gained more and more importance in the construction of modern society. The face became the most individualized and unique part of the body and played an important role in the transition from the great social body to an individual body. According to Elias,48 “the face is one of the most important representations of who we are; it plays a central role in the construction of the identity of the self and in socia-

CONCLUSION The documents included in this review show that there has been a significant growth in publications on ballistic trauma in the past decade, in particular scientific articles reporting suicide attempts. The most investigated topics refer to surgical treatment and complications. The research gaps identified are studies that analyze the functional and psychosocial repercussions for the victims, as well as articles that address measures to prevent this type of morbidity. Concerning the research methods used, the study found mostly observational studies. There is a need for studies with more reliable methodological designs, since observational studies have low level of evidence. Regarding the treatment of FAI, an early approach with careful wound debridement is recommended in order unviable tissues, early treatment of fractures and, when necessary, preferably by open reduction and use of devices for rigid internal fixation. There is a high reported percentage of complications in cases of self-inflicted FAI. The most recommended strategy for airway control was orotracheal intubation. Alike any scientific work, this has limitations: the methodological weaknesses arising from the reviewed articles precluded the establishment of evidence, especially in the case of countless individual studies. This review included only studies from indexed scientific portals and included from the search strategy created for this review, which excluded studies published in journals not indexed in the chosen databases. The analysis of articles considered only the essential references for writing, due to the limit of references of the journal.

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Systematic review on firearm injuries in the face: state of the art and existing gaps

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17. Khalil AF. Civilian gunshot injuries to the face and jaws. Br J Oral Surg. 1980;18(3):205-11. 18. Guevara C, Pirgousis P, Steinberg B. Maxillofacial gunshot injuries: a comparison of civilian and military data. J Oral Maxillofac Surg. 2016;74(4):795-7. 19. Shackford SR, Kahl JE, Calvo RY, Kozar RA, Haugen CE, Kaups KL, et al. Gunshot wounds and blast injuries to the face are associated with significant morbidity and mortality: results of an 11-year multiinstitutional study of 720 patients. J Trauma Acute Care Surg. 2014;76(2):347-52. 20. Rana M, Warraich R, Rashad A. Management of comminuted but continuous mandible defects after gunshot injuries. Injury. 2014;45(1):206-11. 21. Norris O, Mehra P, Salama A. Maxillofacial gunshot injuries at an urban level i trauma center - 10-year analysis. J Oral Maxillofac Surg. 2015;73(8):1532-9. 22. Glapa M, Kourie JF, Doll D, Degiannis, E. Early management of gunshot injuries to the face in civilian practice. World J Surg. 2007;31(11):2104-10. 23. Shvyrkov MB. Facial gunshot wound debridement: Debridement of facial soft tissue gunshot wounds. J Cran Maxillofac Surg. 2013;41(1):8-16. 24. Sokoya M, Vincent AG, Joshi R. Higher Complication rates in self-inflicted gunshot wounds after microvascular free tissue transfer. Laryngoscope. 2019;129(4):837-40. 25. Hollier L, Grantcharova EP, Kattash M. Facial gunshot wounds: a 4-year experience. J Oral Maxillofac Surg. 2001;5993):277-82. 26. Tsakiris P, Cleaton-Jones PE, Lownie MA. Airway status in civilian maxillofacial gunshot injuries in Johannesburg, South Africa. S Afri Med J. 2002; 92(10):803-6. 27. Ugboko VI, Owotade FJ, Oginni FO, Odusanya SA. Gunshot injuries of the orofacial region in Nigerian civilians. SADJ. 1999;54(9):418-22. 28. Kassan AH, Lalloo R, Kariem G. A retrospective analysis of gunshot injuries to the maxillo-facial region. SADJ. 2000;55(7):359-63. 29. Gurunluoglu R, Gatherwright J. Microsurgical reconstruction of complex maxillofacial gunshot wounds: outcomes analysis and algorithm. Microsurgery. 2019 Jul;39(5):384-94. 30. Benateau H, Chatellier A, Caillot A, Labbe D, Veyssiere A. Computer-assisted planning of distraction osteogenesis for lower face reconstruction in gunshot traumas. J Craniomaxillofac Surg. 2016;44(10):1583-91. 31. Balla V, Daniel AY, Kurian N. Prosthodontic rehabilitation of accidental maxillofacial gunshot injury using dental implants: a five year follow-up clinical report. J Clin Diagn Res. 2016;10(9):6-8. 32. Firat C, Geyik Y. Surgical modalities in gunshot wounds of the face. J Craniofac Surg. 2013;24(4):1322-6.

33. Fernandes R, Lee J. Use of the lateral circum-flex femoral artery perforator flap in the reconstruction of gunshot wounds to the face. J Oral Maxillofac Surg. 2007;65(10):1990-7. 34. Yuksel F, Celikoz B, Ergun O, Peker F, Açikel C, Ebrinc S. Management of maxillofacial problems in self-inflicted rifle wounds. Ann Plast Surg. 2004;53(2):111-7. 35. Murphy JA, McWilliams SR, Lee M, Warburton G. Management of self-inflicted gunshot wounds to the face: retrospective review from a single tertiary care trauma centre. Br J Oral Maxillofac Surg. 2018;56(3):173-6. 36. Shuck LW, Orgel MG, Vogel AV. Self-inflicted gunshot wounds to the face: a review of 18 cases. J Trauma. 1980;20(5):370-7. 37. Chen AY, Stewart MG, Raup G. Penetrating injuries of the face. Otolaryngol Head Neck Surg. 1996;115(5):464-70. 38. Oztürk S, Bozkurt A, Durmus M, Deveci M, Sengezer M. Psychiatric analysis of suicide attempt subjects due to maxillofacial gunshot. J Craniofac Surg. 2006;17(6):1072-5. 39. Xing L, Duan Y, Zhu F, Shen M, Jia T, Liu L, et al. Computed tomography navigation combined with endoscope guidance for the removal of projectiles in the maxillofacial area: a study of 24 patients. Int J Oral Maxillofac Surg. 2015;44(3):322-8. 40. Edetanlen BE, Saheeb BD. Lead diagnostic testing and maxillofacial gunshot wounds. Br J Oral Maxillofac Surg. 2017;55(1):106. 41. Casapi N, Zeltser R, Regev E, Shteyer A. Maxillofacial gunshot injuries in hostility activities in 2000-2003. Refuat Hapeh Vehashinayim. 2004;21(1):47-53. 42. Wordsworth M, Thomas R, Breeze J, Evriviades D, Baden J, Hettiaratchy S. The surgical management of facial trauma in British soldiers during combat operations in Afghanistan. Injury. 2017;48(1):70-4. 43. Assael LA. Gun safety and social responsibility: a means to reduce maxillofacial trauma. J Oral Maxillofac Surg. 2008;66(1):1-2. 44. Cerqueira D, Bueno S, Lima SR, Palmieri AP, Reis M, Cypriano O, et al: Atlas da violência 2019. Brasília: Ipea; 2019. 45. Vayvada H, Menderes A, Yilmaz M, Mola F, Kzlkaya A, Atabey A. Management of close-range, high-energy shotgun and rifle wounds to the face. J Craniofac Surg. 2005;16(5):794-804. 46. Grimes DA, Schulz KF. Descriptive studies: what they can and cannot do. Lancet. 2002;359(9301):145-9. 47. Le Breton D. Antropologia del cuerpo y modernidade. Buenos Aires: Nueva Visión; 2002. 48. Elias N. A sociedade dos indivíduos. Rio de Janeiro: Jorge Zahar; 1994.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):15-22

Original Article

Prevalence of complications in oral surgeries performed by undergraduate students DYEMES CARTEGYANO GOMES DE-SOUZA1 | CARLA ALINE CHAVES BATISTA1 | ALLAN VINÍCIUS DE CAMARGOS ELIZÁRIO1 | NARA LINNE DA SILVA FOLHA1 | DOUGLAS RANGEL GOULART1,2

ABSTRACT Objective: The aim of this study was to evaluate the prevalence of complications related to oral surgery performed by undergraduate students in a dental school. Methods: A retrospective study was carried out with medical records of patients treated at the dental clinic of the Euro-American University Center, from January 2011 to April 2018. Medical records have been selected of patients who had undergone oral surgery procedures, which presented description of the procedure and minimum follow-up of one week. Sociodemographic and surgical procedure data were collected. Descriptive and comparative statistical analysis was performed with the SPSS 18.0 program. Results: A total of 1,300 medical records were analyzed, and 319 met the inclusion criteria, with a total of 1,132 extracted teeth and two cases of frenectomy. The prevalence of females was observed (58.3%), the average age of the patients was 41.28 ± 14.59 years, men were older (p=0.01). Most patients did not report systemic disease (68.6%), the women presented more systemic disease (X2=5.71; p=0.01). Most of patients underwent one (27.9%), two (23.8%) or three (12.5%) tooth extractions. Three cases of intraoperative complications were identified, one patient had vasovagal syncope, one case had oralantral communication and one case of intraoperative hemorrhage. Conclusion: There was a low prevalence of complications related to oral surgery, which is related to the implementation of a care protocol that includes detailed anamnesis, measurement of vital signs, selection of cases with less complexity and monitoring by specialized professionals. Keywords: Dentistry education. Postoperative complications. Oral surgery.

How to cite: De-Souza DCG, Batista CAC, Elizário AVC, Folha NLS, Goulart DR. Prevalence of complications in oral surgeries performed by undergraduate students. J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):23-31. DOI: https://doi.org/10.14436/2358-2782.7.1.023-031.oar

Centro Universitário Euro-Americano, Faculdade de Odontologia (Brasília/DF, Brazil).

Universidade Federal de Goiás, Faculdade de Odontologia (Goiânia/GO, Brazil).

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

Contact address: Douglas Rangel Goulart Faculdade de Odontologia da Universidade Federal de Goiás Av. Universitária, s/n - Setor Leste Universitário Goiânia - Brazil – CEP: 74.605-020 E-mail: douglasrgoulart@gmail.com

Submitted: December 19, 2019 - Revised and accepted: April 24, 2020

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):23-31

Prevalence of complications in oral surgeries performed by undergraduate students

INTRODUCTION Tooth extraction is one of the most common procedures performed by dentists, with most surgeries performed without trans- or postoperative difficulties. Few dental procedures have the potential to result in life-threatening complications, with emphasis to oral and facial surgeries.1 Hemorrhage is a rare but serious complication that can affect patients who have coagulopathies, with thrombocytopenia or using anticoagulants. Patients with active bleeding after tooth extraction may require laboratory tests (complete blood count and hemostasis), imaging tests, such as angiotomography, evaluation by an oral and maxillofacial surgeon and hospital admission.2 Another potentially serious complication is postoperative odontogenic infection. Rettore et al.3 investigated infections on the face of odontogenic origin that required hospital care and found that, among the 142 cases studied, 18% were infections after extractions. Other potential complications may represent serious discomfort to patients, such as alveolitis and paresthesia of the inferior and lingual alveolar nerves, which are more associated with extractions of unerupted teeth.4 Information about complications related to tooth extractions and mainly the predisposing factors are essential for the establishment of preventive measures. Also, determination of the clinical outcome of treatment of complications will provide better conditions for clinical decision for professionals involved in the treatment of patients undergoing extractions. The predisposing factors identified may prompt further research to reduce the frequency or even eliminate certain complications. Thus, the aim of the present study was to assess the

prevalence of trans- and postoperative complications in patients undergoing oral surgery by undergraduate Dentistry students at Centro Universitário Euro-Americano. METHODS A retrospective study was conducted on the medical records of patients undergoing oral surgery at the Dental Clinic by undergraduate Dentistry students from the seventh to the tenth semester of the Centro Universitário Euro-Americano, Brasília/DF. Medical records of patients who underwent surgery, of both sexes, above 18 years of age, from January 2011 to April 2018 were selected. The selected records should present full information, including the informed consent form, sociodemographic data, clinical data and complementary exams. The medical records should have postoperative follow-up of at least seven days. Incomplete and illegible medical records and those without adequate imaging tests for evaluation of the case were excluded. A specific data collection instrument was developed for this work (Table 1) and based on the collected information a database was created on the Microsoft Excel software. Information on sexes, age, existing systemic diseases, use of medications, quantity and number of extracted teeth, trans- and postoperative complications, and the treatment used for complications were subjected to descriptive and comparative analysis. Statistical analysis was performed with the aid of the computer program SPSS 18.0 for Windows, using the t and chi-square tests. Results with p<0.05 were considered statistically significant. The study was approved by the Institutional Review Board of Centro Universitário Euro-Americano, under protocol number 2.737.610.

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De-Souza DCG, Batista CAC, Elizário AVC, Folha NLS, Goulart DR

Table 1: Form for collection of sociodemographic data and related to the surgical procedure for patients undergoing surgery at the UNIEURO dental clinic.

Record: Name: SEX: ( ) Male ( ) Female Age: Systemic problems: ( ) Yes ( ) No Which? Use of medications: ( ) Yes ( ) No Which? Use of contraceptives: ( ) Yes ( ) No Blood pressure on the day of surgery: Systolic: Diastolic: Surgery performed: Number of extracted teeth: Anesthetic solution employed: Preoperative medication: ( ) Yes ( ) No Which? Preoperative medication: ( ) Yes ( ) No Which? Complications: ( ) Yes ( ) No Which? Treatment of complication:

RESULTS A total of 1,300 medical records were analyzed and, among these, 319 medical records of patients who underwent oral surgery were selected. The total number of extracted teeth was 1,132 teeth; Also, a lingual frenectomy and an upper lip frenectomy were identified. Table 2 presents data regarding the procedures performed. There was predominance of females (n=186, 58.3%); the patients were aged between 18 and 91 years, with a mean of 41.28±14.59 years. Men were older than women, with a statistically significant difference (F=6.52; p=0.01). Only 11 female patients reported using contra-

ceptives. For 298 patients, blood pressure (BP) information was found in the chart: the mean systolic pressure was 122.66±13.84 mmHg, and the mean diastolic pressure was 79.24±11.91 mmHg. Men had higher systolic BP than women, with a statistically significant difference (F=8.15; p <0.01), as shown in Table 3. Most patients did not have systemic problems (68.65%). Table 4 presents the list of systemic problems found in the medical records analyzed. Women had a higher prevalence of systemic problems (n=61), with a statistically significant difference (X2=5.71; p=0.01) compared to men (n = 28).

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Prevalence of complications in oral surgeries performed by undergraduate students

Three cases of transoperative complication were identified. One patient felt ill during the procedure, with a condition compatible with vasovagal syncope. She returned to consciousness after positioning the dental chair in Trendelenburg position and wished to perform the surgical procedure at another appointment. A case of orosinusal communication was identified after extraction of tooth 17, which was closed using an advancing buccal flap; and one case of postoperative hemorrhage. The hemorrhage occurred in a 29-year-old male patient, without systemic problems, with advanced periodontal involvement in tooth 27, who presented hemorrhage shortly after extraction, during surgery, being controlled with local pressure with gauze and fibrin sponge (Hemospon®). The patient evolved uneventfully in the postoperative period. In the immediate preoperative period, the patient was normotensive (122/78 mmHg).

Surgeries were performed with a local anesthetic containing vasoconstrictor. The most used solution was 2% lidocaine associated with epinephrine 1:100,000 (n=290; 90.90%), followed by 2% mepivacaine associated with epinephrine 1:100,000 (n=15; 4.70%), articaine 4% associated with epinephrine 1:100,000 (n=9; 2.82%), prilocaine 3% associated with felypressin (n=2; 0.62%) and, for three cases, this information was absent. Concerning the use of antibiotic prophylaxis, only three patients received preoperative medication; all were medicated with amoxicillin 2g one hour before the procedure. Regarding the prescription of postoperative medication, most patients received analgesic and non-steroidal anti-inflammatory drugs. Table 5 presents data regarding the prescribed medication.

Table 2: Description of procedures performed by undergraduate Dentistry students at UNIEURO. Procedure

Tongue frenectomy Upper lip frenectomy Extraction of one tooth or remaining root Extraction of two teeth or remaining roots Extraction of three teeth or remaining roots Extraction of 4 or more teeth

01 01 89 76 40 112

0.3 0.3 27.9 23.8 12.5 35.2

*n = number of patients.

Table 3: Comparative data of the sample of 319 patients undergoing oral surgery by undergraduate Dentistry students at UNIEURO.

Age (years) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg)

SEX

Mean

Standard deviation

Male Female Male Female Male Female

42.98 39.97 125.82 120.53 79.22 79.25

16.14 13.26 15.70 12.02 12.64 11.43

0.01 <0.01 0.06

*p = t test.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):23-31

De-Souza DCG, Batista CAC, Elizário AVC, Folha NLS, Goulart DR

Table 4: Frequency of systemic problems found in the 319 medical records of patients undergoing oral surgery at Centro Universitário UNIEURO. Systemic problem

Anemia Allergy Aphthous ulcer Arthritis Arthrosis

7 3 2 6 1

2.19 0.94 0.62 1.88 0.31

Asthma Bronchitis Depression Diabetes mellitus Psychiatric disorder Blood disorder Bacterial endocarditis Herpes Kidney disorder Hypothyroidism Hypertension Gastritis Fibromyalgia Endometriosis Non-specified cyst Anxiety Ulcer Hemorrhage Hepatitis Rhinitis Prostate problem Rheumatism No report of systemic problem Total

14 1 7 8 2 1 1 2 4 8 33 14 3 1 2 1 1 1 2 2 1 1 219 319

4.38 0.31 2.19 2.50 0.62 0.31 0.31 0.62 1.25 2.50 10.34 4.38 0.94 0.31 0.62 0.31 0.31 0.31 0.62 0.62 0.31 0.31 68.65 100

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):23-31

Prevalence of complications in oral surgeries performed by undergraduate students

Table 5: Drugs prescribed for patients after the oral surgery procedure. Postoperative drug

Amoxicillin

5.64

Sodium diclofenac Sodium dipyrone Nimesulide Acetaminophen

1 28 237 260

0.31 8.77 74.29 81.50

Potassium diclofenac Chlorhexidine digluconate Ketorolac Ibuprofen Not informed Total

3 3 1 18 15 319

0.94 0.94 0.31 5.64 4.70 100

DISCUSSION In this study, a low rate of trans- and postoperative complications was observed: three cases were found, and none at risk of death. This may be related to the care protocol adopted by the institution and the degree of complexity of surgeries performed. The service is based on the review of systems, with a detailed anamnesis and measurement of vital signs of heart rate and blood pressure in the preoperative period. Also, since this is an undergraduate clinic, the cases of extractions do not include surgery for unerupted teeth. The students are followed by professors specialists in Oral and Maxillofacial Surgery, who have experience and can assist in the identification of factors that predispose to complications. Another aspect is that, since this is a review of medical records, part of data may have been lost, due to lack of adequate record completion by the students. Another point of view related to the selection of less complex cases refers to the low frequency of complications to which students are exposed. Thus, when faced with a complication, what is the safety and ability of this student to treat it? Prasad et al.5 conducted a survey of 400 students to assess the number of complications they had been exposed to so far, and the safety of performing their treatments. Almost all

students (93.4%) were practicing extractions in their clinical routine, and 32.5% had some complications. Among students who had complications, only 20% felt safe in treating them. In addition, 64.8% of students who did not have complications also do not feel safe to treat them. An important factor is that 54% of students feel that they can predict cases that could potentially evolve with complications. Thus, the introduction of more complex cases according to the learning curve is as important as the ability of these students to identify risk factors and prevent complications. Most of the literature focuses on complications related to lower third molar surgeries, which is one of the most difficult procedures in oral surgeries. Few studies focus on the complications of routine tooth extractions. Tong et al.6 evaluated data from 454 patients submitted to 598 extractions by students from the University of Otago and identified a prevalence of 12.2% of complications. The main complication was alveolitis (32 cases), followed by pain and trismus (23 cases) and two cases of infection. The authors mention that graduation has insufficient time for students to gain adequate experience in oral surgery. This could be achieved by increasing the number of patients, which represents costs and expenses for teachers. Another factor mentioned by the authors is

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De-Souza DCG, Batista CAC, Elizário AVC, Folha NLS, Goulart DR

flammatories. Another issue refers to the control of anxiety, which can avoid complications such as the vasovagal syncope described in this article because, even though there are other triggering factors, anxiety is one of the main factors related to dental care. Thus, measures such as the use of benzodiazepines or nitrous oxide can be beneficial in these cases.9 The dental professional must be able to recognize when a patient needs additional tests in the preoperative consultation. The benefits of examinations in surgical planning should always be considered. Also, the ability to feel the patient’s resistance to present a complete medical history is fundamental, as well as being able to determine the safety of performing the surgical treatment with the available information.10 Cases that are part of this study follow an institutional protocol and are presented by students to professors. Decompensated patients are promptly identified before the procedures and referred for further tests and for treatment and medical advice. Also, the service has a glucometer, which allows the performance of capillary blood glucose test when needed. High blood glucose levels reduce the secretion of nitric oxide (a powerful vasodilator) in the body, which leads to poor circulation and slow healing of the tooth socket. Thus, diabetic patients were operated according to the literature recommendation. Fasting blood glucose levels above 240 mg/dl are detrimental to dental care, and the accepted levels for extraction are up to 180 mg/dl (before meals) and up to 234 mg/ dl (2 h after meals).11 Vettori et al.12 conducted a study to assess factors related to complications in oral surgery, in which they evaluated the medical records of 1,701 patients submitted to 2,322 extractions. They found that the main complication was alveolitis, which was related to the following risk factors: patients with coagulopathies; smoking; under chemotherapy; and tooth fracture during extraction. The authors emphasize that complications occur due to the medical history or pharmacological treatment of patients, or may be related to the surgical site, such as third molars close to the mandibular canal. Although hemorrhage is a rare complication, the dental professional must always analyze the anamnesis responses and, if necessary, request further exams to identify factors at risk for bleeding, such as the use of anticoagulants and presence of hematological

a more efficient screening of cases, which could separate patients according to the difficulty and distribute to students according to the learning curve. The authors indicate to insert cases of greater complexity in the context of learning. However, this theme requires a broader view, since the training model for dentists in Brazil is generalist, with a focus on public health, which provides a comprehensive view of the patient. Thus, the selection of cases does not contribute to this formation. Thus, it is necessary to create instruments for the assessment of students during graduation and to indicate deficiencies, so that they can be solved by professors. Majid et al.7 conducted a study to assess the students’ ability for low complexity extractions. A structured clinical evaluation was performed using an instrument that covered the following areas: students’ ability to collect patient data; anesthetic technique; appropriate selection of instruments; operator position; extraction technique; use of extractors (when indicated); careful tissue manipulation; communication with the patient; confidence; and ethics. A total of 340 extractions were performed; the failure rate of students was 28% for the fifth year of graduation and 38% for the fourth year. Fifth year students were more effective in the items confidence and use of extractors. The authors emphasize that this type of evaluation is important in the formation and direction of teaching and mention that other authors have already noted the need for more training of students in the use of extractors. Also, some students who were not in a good level of learning in surgery improved their level of knowledge after the exercise feedback and after doing it repeatedly. It should be noted that there were no cases of postoperative infection, even though antibiotics were not used for most patients, either pre- or postoperatively. This fact may be related to maintenance of the aseptic chain, which is supervised within the institution; and the low complexity of cases, which allows for less invasive surgery with shorter surgical time. In addition, it is noted that pain control was performed mainly with acetaminophen and nimesulide, which are options with low cost and proven efficacy.8 An appropriate prescription is essential for successful extractions. Often, more important than knowing how to prescribe is knowing when not to prescribe some drugs, such as antibiotics and anti-in-

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Prevalence of complications in oral surgeries performed by undergraduate students

When acute hemorrhage is observed, the surgeon must remain calm, temporarily stop the bleeding and finally use surgical maneuvers and hemostatic substances to definitively control the hemorrhage.15 In general, the causes of bleeding are: 1) rupture of large blood vessels; 2) platelet dysfunction; 3) abnormal blood clotting; and 4) fibrinolytic abnormality.17 The most immediate danger for a healthy patient with severe bleeding is airway compromise. Active bleeding that is not controlled by local measures in the dental office should be referred to the nearest hospital, so that the airway can be protected and the hemorrhage properly managed.1 Information about complications associated with oral surgery and mainly predisposing factors are essential for the establishment of preventive measures. Also, determination of the clinical outcome of the treatment of complications will provide better conditions for clinical decision for professionals involved in the treatment of patients undergoing extractions. The predisposing factors identified may prompt further research, to decrease the frequency or even eliminate some trans- and postoperative complications.

diseases. Although professionals are familiar with the main coagulopathies, there are cases of hemorrhage associated with hemorrhagic dengue. Thus, dentists need to be careful about the implications when performing minor oral surgery in patients at risk or with signs and symptoms of this disease.13 In the present study, one case of abnormal bleeding was identified, which was controlled with the basic hemostasis maneuver, namely local pressure and the use of a hemostatic agent. Clamping and ligation, electrocoagulation and other hemostatic substances may be used, as well as bone wax, oxidized and regenerated cellulose. Absorbable gelatin sponge particles are a temporary material used mainly for inaccessible bleeding sites or in patients with multiple bleeding sites that require rapid hemostasis.14 Blood vessel embolization can also be performed. This is the initial treatment of choice for the management of severe acute maxillofacial hemorrhage or when direct vessel ligation is not possible.15 In the case described, it was not possible to observe whether the patient had any peak blood pressure during the surgical procedure. It is known that, before surgery, the patient was normotensive. The combination of stress and local anesthesia with vasoconstrictor can produce significant alteration in the cardiovascular system in compromised patients. The patient ends up showing other symptoms, such as tachycardia, sweating and agitation.16 In cases of hemorrhage, besides local measurements, the patient’s blood pressure must be measured to diagnose hypertension.

CONCLUSION Oral surgeries have a low rate of complications when performed under controlled conditions, with a detailed anamnesis, measurement of vital signs and surgical planning with monitoring by trained professionals. Continuous monitoring of the profile of oral surgery care and complications allows improvement of the service provided, with reduction of complications and establishment of preventive measures.

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De-Souza DCG, Batista CAC, Elizário AVC, Folha NLS, Goulart DR

References:

1. Moghadam HG, Caminiti MF. Life-threatening hemorrhage after extraction of third molars: case report and management protocol. J Can Dent Assoc. 2002;68(11):670-4. 2. Kraus CK, Katz KD. Extensive facial hematoma following third molar removal. Am J Emerg Med. 2014;32(9):1153.e5-6. 3. Rettore C, Ferreira CJ, Signori PH, Moraes JFD, Stobbe JC, Conto F. Infecções odontogênicas: análise de casos em ambiente hospitalar. J Braz Coll Oral Maxillofac Surg. 2016;2(2):23-30. 4. Krakowiak PA. Alveolar osteitis and oteomyelitis of the jaws. Oral Maxillofacial Surg Clin North Am. 2011;23(3):401-13. 5. Prasad TS, Sujatha G, Priya RS, Ramasamy M. Knowledge, attitude, and practice of senior dental students toward management of complications in exodontia. Indian J Dent Res. 2019;30(5):794-7 6. Tong DC, AI-Hassiny HH, Ain AB, Broadbent JM. Postoperative complications following dental extractions at the School of Dentistry, University of Otago. N Z Dent J. 2014 Jun;110(2):51-5. 7. Majid OW. Assessment of clinical ability in the removal of teeth among undergraduate dental students: a longitudinal comparative study. Br J Oral Maxillofac Surg. 2018 Nov;56(9):870-6.

8. Vasconcellos RJH, Ribeiro CMB, Marchiori ÉC, Fernandes TCA, Oliveira DM. Analgesia preemptiva em cirurgias de terceiros molares inferiores: estudo piloto /Preemptive analgesia in molar third surgery: a pilot study. Odonto (São Bernardo do Campo). 2006;14(27/28):84-93. 9. Sambrook PJ, Goss AN. Contemporary exodontia. Aust Dent J. 2018;63:(1Suppl):S11-S18 10. Lieberman BL, Kennedy MK, Lorenzo DR, Reed LJ, Adamo AK, Cardo VA, et al. Control of life-threatening head and neck hemorrhage after dental extractions: a case report. J Oral Maxillofac Surg. 2010;68(9):2311-9. 11. Gazal G. Management of an emergency tooth extraction in diabetic patients on the dental chair. The Saudi Dental Journal. 2020 Jan;32(1):1-6. 12. Vettori E, Costantinides F,Nicolin V, Rizzo B, Perinetti G, Maglione M, et al. Factors influencing the onset of intra-and postoperative complications following tooth exodontia: retrospective survey on 1701 patients. Antibiotics (Basel). 2019 Dec 13;8(4):264. 13. Dubey P, Kumar S, Bansal V, Kumar KVA, Mowar A, Khare G. Postextraction bleeding following a fever: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;115(1):e27-31.

14. Wasson M, Ghodke B, Dillon JK. Exsanguinating hemorrhage following third molar extraction: report of a case and discussion of materials and methods in selective embolization. J Oral Maxillofac Surg. 2012;70(10):2271-5. 15. Bouloux GF, Perciaccante VJ. Massive hemorrhage during oral and maxillofacial surgery: ligation of the external carotid artery or embolization? J Oral Maxillofac Surg. 2009;67(7):1547-51. 16. Gealh WC, Franco WPG. Atendimento odontológico ao paciente hipertenso protocolo baseado no VII JNC. J Bras Clínica Odontológica Integr e Saúde Bucal Coletiva. 2006;(Vii):01-9. 17. Ita M, Okafuji M, Maruoka Y, Shinozaki F. An unusual postextraction hemorrhage associated with KlippelTrenaunay-Weber syndrome. J Oral Maxillofac Surg. 2001;59(2):205-7.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):23-31

Original Article

Relevance of Oral and Maxillofacial Surgery dental records for trauma hospital WILLIAN MARTINS AZEREDO1 | GIULIANO TEIXEIRA PACHER1 | ANTONIO EUGÊNIO MAGNABOSCO-NETO1

ABSTRACT Objective: To propose a model of dental record for the area of Oral and Maxillofacial Surgery and Traumatology for use in hospital trauma services. Method: This is an experience report on the preparation of dental records, conducted from June to December 2019, during a Uniprofessional Residence of Oral and Maxillofacial Surgery and Traumatology in a public hospital in southern Brazil. Results: The clinical record was made based on the literature and divided into four sessions, which were organized between personal data, health history, trauma assessment, as well as intraoperative and postoperative information Conclusion: The preparation and correct completion of the dental record in the area of Oral and Maxillofacial Surgery and Traumatology are essential for the diagnosis, planning and correct treatment of each case. In addition, they favor epidemiological records and facilitate communication between multi-professional team of the hospital trauma service. Keywords: Patient care team. Dental staff, hospital. Trauma centers. Internship and residency.

How to cite: Azeredo WM, Pacher GT, Magnabosco-Neto AE. Relevance of Oral and Maxillofacial Surgery dental records for trauma hospital. J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):32-7. DOI: https://doi.org/10.14436/2358-2782.7.1.032-037.oar

Hospital Municipal São José, Serviço de Cirurgia e Traumatologia Buco-maxilo-facial (Joinville/SC, Brazil).

Submitted: January 19, 2020 - Revised and accepted: March 24, 2020 Contact address: Willian Martins Azeredo Rua Visconde de Mauá, 2268, bloco B, apartamento 402 Santo Antônio, Joinville/Santa Catarina CEP: 89.204-500 E-mail: willianazeredo@gmail.com

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

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):32-7

Azeredo WM, Pacher GT, Magnabosco-Neto AE

INTRODUCTION The dental record is considered a document of the patient that should be prepared and stored by the dental professional. Also, the dental professional should assure the access to medical records whenever necessary, since it is a legal document.1 Dental documentation is considered adequate when it includes all data and information provided by the patient, as well as information found on the physical examination and complementary exams.2 Records as certificates, declarations of attendance to the consultation and prescriptions should also be attached to the dental record, besides the clinical form.2,3 Oral and Maxillofacial Surgery and Traumatology (OMFST) is a surgical specialty in Dentistry that aims to offer treatments and care to patients with dentofacial deformities and trauma. In OMFST, the dental clinical record is essential, since data included will assist in the diagnosis and planning of each case. Thus, the use of a specific clinical form in the area, which includes personal, historical, extraoral and intraoral examinations, as well as relevant information on intraoperative and postoperative periods, is essential for planning, seeking to offer the best treatment and prognosis to individual in need of care.4 Also, the use of medical records facilitates the generation of knowledge among health team professionals, who need to identify the patient’s condition to perform interventions.5 To favor the standardization of information for epidemiological studies and facilitate the communication of the multidisciplinary hospital team, the present research aimed to propose a model of clinical dental records for the area of Oral and Maxillofacial Surgery and Traumatology to be used in hospital trauma services.

Preparation of the dental clinic record occurred from June to December 2019, based on the literature related to mandatory documents that must be included in the medical records of patients treated at OMFST services. RESULTS The clinical record was developed in four sessions, aiming at capturing different information from patients treated at the trauma service in a public hospital located in southern Brazil by a OMFST team. Due to regional standards, it was decided to make questions directed to the profile of individuals. The first section includes personal data of the patient, presence or absence of comorbidities, allergies and use of continuous medications. It aims to assess the general health status of the patient prior to trauma and to include legal information on the individuals, as well as to report the number of services in the hospital unit (Fig 1). The second section concerns the initial assessment performed during the care of traumatized patient in an emergency care unit, including information as the etiology of trauma, Glasgow scale, presence of soft tissue injuries, paresthesia on the face and presence or absence of visual, respiratory and occlusal complaints (Fig 2). In the third section of the clinical record there are sites for notes on the facial trauma presented. To improve the division and study of facial fractures, it was decided to divide the facial skeleton into fractures of the mandible, maxilla, frontal bone, orbital zygomatic complex and nasal bones, as well as a chart to fill in the preoperative laboratory exams (Fig 3). The fourth and last section of the clinical record addresses questions about the transoperative period, with topics related to type of intubation, procedure performed, fixation of fractures presented, intraoperative complications and information on the immediate postoperative period. At the end of the clinical record, there are sites for completing and signing by the professional responsible for data collection and physical examination. There are also spaces for signature by the patient or legal caretaker (which attest the information as true) and for the date of clinical examination (Fig 4).

METHODS This research is an experience report on the development of a clinical dental record, performed during Uniprofessional Residency in Oral and Maxillofacial Surgery and Traumatology in a public hospital in southern Brazil. The form was created due to the need to standardize data and information collected during anamnesis and physical examination of patients assisted at the service.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):32-7

Relevance of Oral and Maxillofacial Surgery dental records for trauma hospital

Figure 1: First section: legal and personal information of the patient.

Figure 2: Second section: information regarding the etiology of facial trauma.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):32-7

Azeredo WM, Pacher GT, Magnabosco-Neto AE

Figure 3: Third section: information regarding the facial trauma in relation to the affected bone structure.

Figure 4: Fourth section: trans- and postoperative information.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):32-7

Relevance of Oral and Maxillofacial Surgery dental records for trauma hospital

DISCUSSION The Federal Dental Council, in its code of ethics, Chapter VII, Article 17, exposes the obligation of dental professionals to prepare and perform proper maintenance of patient records, either digitally or in physical forms.6 Most dental professionals prefer the use of physical records, with printed questionnaires to collect data on the anamnesis and physical examination7. For a correct filling of the dental record, it is fundamental to achieve the patient’s signature after the information is collected.2 The current literature is scarce regarding the accomplishment and adequacy of dental records in the field of OMFST in the hospital environment. Most studies refer to the conduct of dental professionals in relation to medical records in non-hospital environments.1,3 One of the factors that cause damage in the collection and storage of data from patients’ clinical records is their inadequate filling.8 In a study by Angeletti and Abramowics9 evaluating dental records, it was observed that 93.2% of records were incomplete. One of the possible causes reported by Costa10 for this fact is the lack of specific predetermined fields to be filled, due to poor design of the clinical records. Due to this reason, during development making of this clinical record, it was decided to keep separate fields for each information to be inserted. Several failures, such as lack of general health information and facial trauma, are worsening when it is intended to perform a specific and detailed treatment plan for each patient, besides presenting insufficient data for epidemiological analyses.11 For this reason, this clinical record was proposed with four sections, to avoid losing essential information for diagnosis and treatment planning in OMFST. The first section of the questionnaire was composed of questions of legal and personal nature of the patient to be evaluated by the OMFST team. Approximately 55.5% of professionals qualified in health care believe that only the personal information of patients has mandatory filling.2 The approach should be performed in a systematic manner, which requires a specific approach during interview to collect information as the chief complaint, previous pathological history, allergies and use of medications.12 To present the proposal for a standardized clinical record, it was decided to follow a logical order to collect the patient information.

Due to the importance of initial evaluation by the OMFST team of patients with facial trauma,13 it was decided to define the information to be asked to the patient in the second section. The etiology of facial trauma is varied and is related to local, social and cultural aspects of individuals.14 For this reason, questions about the etiologies of injuries were included in this section. The facial bones, when compared to each other, have different characteristics. Fractures can be classified in different manners, such as: fractures of the mandible, zygomatic complex, maxillary bones, nasal bones15 and of the external plate of the frontal bone.16 They can also be classified as zygomatic, mandible, orbit, nasal, maxilla, frontal and naso-orbito-ethmoidal fractures.17 In the third section of the clinical record, aiming at facilitating the treatment and study of such lesions, it was decided to choose the first classification system, since the bone structures that make up the orbit region belong to previously mentioned structures, as well as the fact that nasal fractures can present in isolation, not associated with other structures. According to Carvalho et al.18, laboratory tests should be requested before surgical interventions for a better evaluation and treatment decision in each case, which demonstrates the importance of the third session of the designed dental clinical record. The same authors state that part of professionals request laboratory tests without knowledge of their indications and consequently of their interpretation, which affects the planning and surgical indication.18 The clinical record, when properly filled out, may encourage professionals to obtain such knowledge.19 During preparation of the clinical record of this study, it was decided to insert a table in which the professional can fill in the results of tests requested during the entire hospitalization period of the patient. One of the causes found by Silva and Tavares Neto20 for inadequate filling of the medical record was the lack of adequate space for recording information. On the fourth section of the clinical record, it was necessary to insert information regarding the transoperative period. The accomplishment of surgical procedures by the OMFST team sometimes requires interventions in different facial bones at the same surgical time and thus there are specific needs regarding the patient intubation.21 The procedure can be performed with orotracheal, nasotracheal or submental intubation or even tracheostomy.22

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):32-7

Azeredo WM, Pacher GT, Magnabosco-Neto AE

CONCLUSION The development and correct filling of the dental clinic file in the area of Oral and Maxillofacial Surgery and Traumatology are fundamental for the diagnosis, planning and correct treatment of each case. Also, they favor the epidemiological records and facilitate communication between the hospital trauma service team.

The treatment for facial fractures varies according to the injuries presented by the individuals and can be classified as conservative (without surgical intervention), closed reductions and extraoral accesses for rigid fixation with Miloro plates and screws.12 It is also necessary to monitor the patient in the postoperative period and make notes in the clinical record.4,12 For that reason, topics were also added to that section.

References:

1. Serra MC, Herrera LM, Fernandes CMS. Importância da correta confecção do prontuário odontológico para identificação humana. Relato de caso. Rev Assoc Paul Cir Dent. 2012; 66(2):100-4. 2. Benedicto EN, Lages LHR, Oliveira OF, Silva RHA, Paranhos LR. A importância da correta elaboração do prontuário odontológico. Odonto. 2010;18(36):41-50. 3. Amorim HPL, Marmol SLP, Cerqueria SNN, Silva MLCA, Silva UA. A importância do preenchimento adequado dos prontuários para evitar processos em Odontologia. Arq Odontol. 2016;52(1):32-7. 4. Carvalho MF, Herrero RKR, Moreira DR, Urbano ES, Reher P. Princípios de atendimento hospitalar em cirurgia buco-maxilo-facial. Rev Cir Traumatol Buco-Maxilo-Fac. 2010;10(4):79-84. 5. Franco JB, Jales SMCP, Zambon CE, Peres MPSM. A importância do prontuário odontológico em unidade de terapia intensiva: recomendações sobre a sua elaboração. Rev Fac Odontol UFBA, 2013;43(3):55-60. 6. Resolução CFO nº 118, de 11 de maio de 2012. Código de ética odontológico. Brasília, DF: CFO; 2012. 7. Ramos DIA. Prontuário odontológico: aspectos éticos e legais [dissertação].Piracicaba: Faculdade de Odontologia de Piracicaba, Universidade Estadual de Campinas; 2005. 8. Costa SM, Braga AL, Abreu MHNG, Bonan PRF. Questões éticas e legais no preenchimento das fichas clínicas odontológicas. RGO. 2009;57(2):211-6. 9. Angeletti P, Abramowics M. Subsídios para obtenção dos serviços da clínica odontológica da Faculdade de Odontologia da Universidade de São Paulo - aspectos éticos e legais. Rev Cons Odontol. 2001;4(1):13-36.

10. Costa DCB. Sugestão de prontuário eletrônico para a área de cirurgia e traumatologia buco-maxilo-facial [trabalho de conclusão de curso]. Natal: Universidade Federal do Rio Grande do Norte; 2016. 11. Soller ICS, Poletti NAA, Beccaria LM, Squizatto RH, Almeida DB, Matta PRA. Perfil epidemiológico de pacientes com traumatismos faciais atendidos em emergência hospitalar. REME Rev Min Enferm. 2016;20(1):01-08. 12. Miloro M, Ghali GE, Larsen PE, Waite PD. Princípios de Cirurgia Bucomaxilofacial de Peterson. 3a ed. São Paulo: Editora Santos Grupo Gen; 2016. 13. Aguiar ASW, Pereira APPV, Mendes DF, Gomes FIL, Branco YNC. Atendimento emergencial do paciente portador de traumatismo de face. Reb Bras Promoç Saúde. 2004;17(1):37-43. 14. Cardoso SO, Aragão-Neto AC, Passos KKM, Vieira FLT, Lobo J, Silva JJ. Levantamento epidemiológico de traumatismo maxilar em um hospital público do Recife. Odontol Clin Cient. 2016;15(2):97-102. 15. Zamboni RA, Wagner JCB, Volkweis MR, Gerhardt EL, Buchmann EM, Bavaresco CS. Levantamento epidemiológico das fraturas de face do Serviço de Cirurgia e Traumatologia Bucomaxilofacial da Santa Casa de Misericórdia de Porto Alegre - RS. Rev Col Bras Cir. 2017;44(5):491-7. 16. Singaram M, Vijayabala G S, Udhayakumar RK. Prevalence, pattern, etiology, and management of maxillofacial trauma in a developing country: a retrospective study. J Korean Assoc Oral Maxillofac Surg. 2016;42(4):174-81. 17. Deus DP, Pinho K, Teixeira SLA. Levantamento epidemiológico das fraturas faciais no hospital regional de urgência e emergência de Presidente Dutra - MA. Rev Cir Traumatol Buco-Maxilo-Fac. 2015;15(3):15-20.

18. Carvalho RWF, Pereira CU, Laureano Filho JR, Vasconcelos BCE. O paciente cirúrgico. Parte II. Rev Cir Traumatol Buco-Maxilo-Fac. 2011;11(1):37-46. 19. Mesquita AMO, Deslandes SF. A construção dos prontuários como expressão da prática dos profissionais de saúde. Saúde Soc. 2010;19(3):664-73. 20. Silva FG, Tavares Neto J. Avaliação dos prontuários médicos de hospitais de ensino do Brasil. Rev Bras Educ Méd. 2007;31(2):113-26. 21. Alcalde LFA, Ferreira PHSG, Reis ENRC, Capelari MM, Toledo Filho JL, Toledo GL. Intubação submento-orotraqueal - estudo retrospectivo de 02 anos. Rev Cir Traumatol Buco-Maxilo-Fac. 2015;15(4):25-30. 22. Rocha NS, Morais HHA, Fernandes AV, Caubi AF, Vasconcelos BCE. Intubação submentoniana para o manejo das vias aéreas em paciente politraumatizado de face: relato de caso e revisão de literatura. Rev Cir Traumatol Buco-Maxilo-Fac. 2006;6(3):47-52.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):32-7

Original Article

ABSTRACT Introduction: Suture threads are important substrates for microbial adhesion in oral surgeries. It was proposed to compare bacterial adhesion in silk and nylon sutures when impregnated or not with an antiseptic ointment based on iodoform and marigold. Methods: A prospective, randomized, double-blind, divided mouth trial was conducted. After extractions in one of the hemiarchs, a simple suture was performed with the nylon thread (group A) and another simple suture with the silk thread (group B) impregnated with the antiseptic ointment. At the same surgical moment, extractions were performed in the contralateral hemiarch and simple suture with nylon thread (group C) and silk thread (group D) without antiseptic ointment. The Student’s t-test compared the means of colony-forming units (CFUs), while the Friedman test analyzed the distribution of bacterial adhesion in each group. Results: The average of bacterial adhesion was higher in silk suture with antiseptic ointment (M = 5.7288log/CFU/mL) and lower in nylon suture without ointment (M = 4.0587log/CFU/mL). Conclusion: Despite the antiseptic composition of the ointment, it is noted that its impregnation, both with silk thread and nylon thread, did not reduce bacterial adhesion in the sutures. Keywords: Colony count. Microbial. Sutures. Surgery, oral.

How to cite: Alves L, Polo AB, Assis NMSP, Silva BN, Apolônio ACM, de-Carvalho MF. Bacterial adherence to silk and nylon sutures. J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):38-42. DOI: https://doi.org/10.14436/2358-2782.7.1.038-042.oar

Universidade Federal de Juiz de Fora, Departamento de Odontologia (Juiz de Fora/MG, Brazil).

Universidade Federal de Juiz de Fora, Departamento de Parasitologia, Microbiologia e Imunologia (Juiz de Fora/MG, Brazil).

Submitted: June 22, 2020 - Revised and accepted: September 22, 2020

Universidade Federal de Juiz de Fora, Departamento de Clínica Odontológica (Juiz de Fora/MG, Brazil).

» The authors report no commercial, proprietary or financial interest in the products or companies described in this article. Contact address: Matheus Furtado de-Carvalho Rua São Mateus, 270, apto. 601, bairro São Mateus CEP: 36.025-000 – Juiz de Fora/MG E-mail: matheus.furtado@ufjf.edu.br

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):38-42

Alves L, Polo AB, Assis NMSP, Silva BN, Apolônio ACM, de-Carvalho MF

INTRODUCTION Synthesis corresponds to the surgical maneuver that aims to tie the blood vessels and bring the tissues closer by sutures or adhesives. In oral surgery, the main objective is to reposition and maintain the stability of surgical flap, assisting in tissue repair. Also, it contributes to preservation of the clot in the dental socket and local hemostasis.1 Sutures are important substrates for microbial adhesion2 and can become a factor of tissue aggression when associated with foreign body reactions, and lead microorganisms into the wound, even causing bacteremia.3 Microbial adhesion depends directly on the material that constitutes the suture (silk, nylon, cotton, collagen) and has different capacities to absorb fluids and secretions from the oral environment. Microbial colonization is also related to the filamentary structure of sutures. Multifilament sutures, such as silk, are braided and more prone to microbial adhesion, while single-stranded sutures, such as nylon, hinder microbial colonization.4 In an attempt to minimize microbial adhesion and enhance tissue repair, some researchers advocate the use of antiseptic substances, such as tetracycline, chlorhexidine, propolis and marigold, on the surface of sutures.5-8 An ointment made of iodoform and calendula was effective in controlling aerobic and anaerobic microorganisms when applied inside dental implants, with satisfactory pharmacological stability to remain active in place between 1 and 5 years.9 Thus, the objective is to use the same aforementioned product and to compare bacterial adhesion on silk and nylon sutures, impregnated or not with iodoform and marigold oil antiseptic ointment.

tes, hypertension, anemia, malnutrition and with alveolar suppuration capable of interfering with tissue repair, patients allergic to the ointment components and patients with reports of use of antimicrobials in the last 15 days were excluded. The random sequence was generated by the Random Allocation Software 2.0 program, and randomization was organized by the strategy of random numbers on the Microsoft Excel software. Multiple extractions were performed in the same surgical procedure. In one of the hemiarches, a simple suture was performed with nylon (group A) and another suture with silk (group B), with spacing of 1 cm. The sutures were manually impregnated with 0.1 g of the antiseptic ointment on its free end (Fig 1). The ointment is composed of iodoform (12.85%) and marigold oil (4.1%), with excipients fatty acid esters, hydrocarbons, propylparaben and hydroxytoluene butylated (BHT). In the contralateral hemiarch there was no impregnation of ointment in nylon (group C) and silk (group D) sutures. For suture, silk and nylon sutures, black, 4-0 diameter manufactured by Ethicon (Johnson & Johnson, São Paulo, São Paulo, Brazil) were used, constituting an initial sample of 64 sutures. All participants performed a preoperative mouthwash using 15 ml of 0.12% chlorhexidine digluconate solution for 1 minute. Participants were medicated with analgesics and instructed about postoperative care, which included daily brushing of adjacent teeth and mouthwash with running water after 48 hours. Mouthwash with 0.12% chlorhexidine digluconate was not prescribed to avoid possible interference with the research results. The suture was removed on the seventh postoperative day, obtaining a 5mm fragment of the suture exposed to the oral mucosa. Each sample was transferred to a sterile Eppendorf centrifuge microtube, containing 1.5 ml of 0.85% saline solution, labeled and preserved on ice in a thermal container, for a maximum period of 2 hours, until processing in the Laboratory of the Department of Parasitology, Microbiology and Immunology. In the laboratory, each microtube was shaken in the Vortex Biomixer device (Biomol, Ribeirão Preto/ SP, Brazil) for a maximum of 12 rotations for 5 minutes and the suspension was diluted to 10-5 in 0.85% saline, i.e., 100 microliters for every 900 microliters of 0.85% saline, alternating with 10 minutes of stirring at each dilution (Fig 2).

METHODS The study was approved by the Institutional Review Board of the Federal University of Juiz de Fora (CAAE 92790318.1.0000.5147), under report N. 2869833, in compliance with the Declaration of Helsinki. This is a prospective clinical trial, double blind, split-mouth, applied to 16 participants obtained from a convenience sample based on the search for patients in need of simple extraction. After that, patients of both sexes, aged over 18 years, who had multiple tooth extractions (minimum of two teeth) in both dental hemiarches were included. Patients with diabe-

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):38-42

Bacterial adherence to silk and nylon sutures

Figure 1: Impregnation of suture with the antiseptic ointment.

Figure 2: Laboratory step of serial dilution.

The samples were seeded (100 microliters) in Brain Heart Infusion (BHI) medium, from dilutions 10-3, 10-4 and 10-5, in duplicate, and incubated in microaerophilia at 37°C for 48 hours, for later counting of number of colony-forming units (CFU) of dilutions that grew 30 to 300 colonies (Fig. 3). The calculation to obtain the bacterial quantity present in each fragment of suture was obtained by the formula: CFU/mL = n (number of colonies counted)x10 (correction factor)x10x (inverse of dilution)/1.5 and expressed on a logarithmic scale (log CFU/mL). Data were analyzed using the SPSS version 21 software. The Shapiro-Wilk normality test was used to determine if the variables had normal distribution. The bacterial adhesion measured in log CFU/mL was the continuous quantitative dependent variable, and the types of sutures (nylon and silk) impregnated or not with antiseptic ointment were considered the independent variables. The paired Student’s t-test was used to compare the mean CFU in groups two by two, following the evaluations between the presence or not of ointment for the same type of suture (nylon: group A with group C; and silk) : group B with group D) and, later, by the type of suture impregnated with the antiseptic ointment (group A with group B). To analyze the distribution of bacterial adhesion, the Friedman test was used in each group. Values of p≤0.05 were considered significant.

Figure 3: Growth of CFUs in BHI medium, at 10-3 dilution.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):38-42

Alves L, Polo AB, Assis NMSP, Silva BN, Apolônio ACM, de-Carvalho MF

Table 1: Mean quantification of bacteria present in the different groups of sutures. Group

Mean number of bacteria (log CFU/mL)

Sample

Standard deviation

A) Nylon suture with ointment* B) Silk suture with ointment* C) Nylon suture without ointment* D) Silk suture without ointment*

4.8229 5.7288 4.0587 5.3250

14 16 15 16

1.01288 0.74399 1.01886 0.76319

* p≤0.05.

RESULTS Among the 16 study participants, 7 (43.75%) were females and 9 (56.25%) were males. The mean age of participants was 20 years. The study included a final sample of 61 sutures. There was a sample loss of 1 suture due to failure in microtube sealing and another 2 due to inadequate CFU growth. All patients returned for suture removal and showed no signs and symptoms of surgical complications. Among the four groups, the mean bacterial adhesion was higher in silk with ointment and lower in nylon without ointment. Also, it was noted that the mean bacterial adhesion on nylon impregnated with ointment was higher than when nylon was used without the ointment. A similar result was found in bacterial colonization of silk with the ointment, in which the mean bacterial adhesion was higher compared to silk without ointment (Table 1).

is consensus that nylon produces minimal acute inflammatory reaction in oral tissues, being an excellent option in periodontal and peri-implant esthetic surgery of anterior teeth, due to its composition with long chain aliphatic, which precludes bacterial adhesion.14 However, they may cause greater discomfort to the patient, due to their rigidity, inhibiting their use in surgeries close to the tongue and buccal mucosa. Conversely, it is known that silk suture has filaments of natural protein that allow softness and elasticity, providing greater security of the knot and distension along the swollen tissues. However, they have high capillarity as a disadvantage. Some authors believe that their impregnation with different compounds can minimize unwanted bacterial colonization.5-7 The present study adopted an antiseptic ointment based on iodoform and marigold. Iodoform is poorly soluble in water (1:1000) and its volatility in contact with organic liquids slowly releases iodine, which generates a smooth and persistent antiseptic action.15 Marigold oil, extracted from the herbal plant Calendula officinalis, has antimicrobial action.5 The mouthwash made of Calendula officinalis provided less bacterial adhesion on silk suture after third molars extraction when compared to the control group, and greater bacterial adhesion when compared to 0.12% chlorhexidine digluconate mouthwash.6 The microbial stability of a pharmacological product is related, among other factors, to the water absorption capacity. For this reason, some authors advocate the use of excipients in the ointment that do not absorb water.11 The excipients of the ointment used in the present study are anhydrous and form water-in-oil emulsions in the presence of water, which can be absorbed.

DISCUSSION According to Arteagoitia et al.,10 chlorhexidine has been the most used antiseptic solution for preoperative mouthwashes in tooth extractions and can be used in different concentrations, preventing bacteremia in 12% of cases. In the present study, mouthwash with 0.12% chlorhexidine was adopted. Larsen11 noticed a 60% reduction in the incidence of alveolitis using this same concentration in the preoperative removal of unerupted lower third molars. Ugwumba et al.12 recommend chlorhexidine at a concentration of 0.2%, aiming to reduce the risk of bacteremia. Mahesh et al.13 emphasize that the choice of suture in oral surgeries depends on the location, extent and area of exposure of the wound. In the present study, simple extractions of posterior teeth were performed, which allowed primary wound closure. There

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):38-42

Bacterial adherence to silk and nylon sutures

the dental biofilm, missing teeth and indication of extraction. All patients had unsatisfactory oral hygiene. Further studies are suggested to assess the correlation of other external factors, such as brushing habits and educational level, as well as to evaluate the bacterial colonization of sutures in patients with satisfactory oral hygiene that present indications for third molars extraction.

Rodanant et al.16 did not find significant differences in pain and quality of life of patients whose suture removal was performed on the third or seventh day after extraction of impacted lower third molars. In the present study, the suture was removed on the seventh postoperative day, since it is believed that this period allows a more favorable alveolar repair, avoiding wound dehiscence. Bacterial colonization in the suture may also be related to factors inherent to the patient, such as oral hygiene.17 In the present study, the oral hygiene of each patient was not analyzed in detail by the index of decayed, missing and filled teeth, being classified only as satisfactory and unsatisfactory, according to

CONCLUSION Despite the antiseptic composition of the ointment, it is noted that its association, both with silk and nylon sutures, did not reduce the bacterial adhesion on its surfaces.

References:

1. Silverstein LH, Kurtzman GM, Kurtzman D. Suturing for optimal soft tissue management. Gen Dent. 2007;55(2):95-100. 2. Asher R, Chacartchi T, Tandlich M, Shapira L, Polak D. Microbial accumulation on different suture materials following oral surgery: a randomized controlled study. Clin Oral Investig. 2019 Feb;23(2):559-65. 3. Otten JE, Wiedmann-Al-Ahmad M, Jahnke H, Pelz K. Bacterial colonization on different suture materials-a potential risk for intraoral dentoalveolar surgery. J Biomed Mater Res B Appl Biomater. 2005 Jul;74(1):627-35. 4. Dhom J, Bloes DA, Peschel A, Hofmann UK. Bacterial adhesion to suture material in a contaminated wound model: Comparison of monofilament, braided, and barbed sutures. J Orthop Res. 2017 Apr;35(4):925-33. 5. Faria RL, Cardoso LML, Akisue G, Pereira CA, Junqueira JC, Jorge AOC, et al. Antimicrobial activity of Calendula officinalis, Camellia sinensis and chlorhexidine against the adherence of microorganisms to sutures after extraction of unerupted third molars. J Appl Oral Sci. 2011 Oct;19(5):476-82. 6. Gupta SJ, Tevatia S, Khatri V, Dodwad V. Comparative evaluation of antiseptic pomade to prevent bacterial colonization after periodontal flap surgery — a clinical & microbiological study. J Dent Specialities. 2017;5(2):102-7.

7. Cruz F, Leite F, Cruz G. Sutures coated with antiseptic pomade to prevent bacterial colonization: a randomized clinical trial. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013 Aug; 116(2):e103-9. 8. Cruz M. Long-term assay of iodoform pomade in the bacterial control of the inner ambient of dental implants: a randomized clinical trial. Clin Int J Oral Science. 2002;15(1):1-13. 9. Cosola S, Giammarinaro E, Marconcini S, Lelli M, Lorenzi C, Genovesi AM. Prevention of bacterial colonization on suture threads after oral surgery: comparison between propolis- and chlorhexidinebased formulae. J Biol Regul Homeost Agents. 2019;33(4):1275-81. 10. Arteagoitia I, Andrés CR, Ramos E. Does chlorhexidine reduce bacteremia following tooth extraction? A systematic review and meta-analysis. PLoS One. 2018; 13(4): e0195592. 11. Larsen PE. The effect of a chlorhexidine rinse on the incidence of alveolar osteitis following the surgical removal of impacted mandibular third molars. J Oral Maxillofac Surg. 1991 Sep;49(9):932-7. 12. Ugwumba CU, Adeyemo WL, Odeniyi OM, Arotiba GT, Ogunsola FT. Preoperative administration of 0.2% chlorhexidine mouthrinse reduces the risk of bacteraemia associated with intra-alveolar tooth extraction. J Craniomaxillofac Surg. 2014 Dec;42(8):1783-8.

13. Mahesh L, Kumar VR, Jain A, Shukla S, Aragoneses JM, González JM, et al. Bacterial adherence around sutures of different material at grafted site: a microbiological analysis. Materials (Basel) 2019;12(18):1-8. 14. Koyuncuoglu CK, Yaman D, Kasnak G, Demirel K. Preference of suture specifications in a selected periodontal and implant surgeries in Turkey. Eur J Dent. 2019;13(1):108-13. 15. Silva Junior JA, Wassall T, Ramalho SA, Brito Junior RB. Evaluation of the tecidual reply to an iodoform folder applied in the internal chamber of ossentegration settings in vivo. RGO. 2006 Mar;54(1):21-6. 16. Rodanant P, Wattanajitseree K, Shrestha B, Wongsirichat N. Pain and quality of life related to suture removal after 3 or 7 days at the extraction sites of impacted lower third molars. J Dent Anesth Pain Med. 2016 Jun;16(2):131-6. 17. Bucci M, Borgonovo A, Bianchi A, Zanellato A, Re D. Microbiological analysis of bacterial plaque on three different threads in oral surgery. Minerva Stomatol. 2017 Feb;66(1):28-34.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):38-42

Case report

ABSTRACT Panfacial fractures are those that affect the upper, middle and lower face, making the treatment challenging. In some situations, the patients require multidisciplinary treatment because they have traumas in other regions of the body that preclude the treatment of all facial fractures. Cranioencephalic trauma, due to car accidents, often needs a neurosurgical approach. The use of biomaterials has been growing every day, like bioceramics, due to their characteristics, as an option for the reconstruction of bone defects. The objective of this article is to report a case of panfacial fracture treatment, with reconstruction, through a customized prosthesis (bioceramic), of a frontal region defect. The patient with multiple facial fractures was initially submitted to a surgical procedure to treat them. Later to correct a defect in the frontal region, it was installed a custom prosthesis. The patient has progressed well, with regression of complaints and correction of marked supraorbital defect. Thus, it can be concluded that panfacial fractures represent a complex challenge in the treatment of facial trauma. When they are accompanied with bone defects in the skull, the treatment through biomaterials and substances that can mimic the same characteristics of autogenous bone tissue has become an interesting option to be considered. Keywords: Multiple trauma. Bone substitutes. Biocompatible materials.

How to cite: Torres RS, Albuquerque GC, Motta Junior J, Martins VB, Oliveira MV, Tenório ISAC, Raid DE. Treatment of panfacial fracture and late reconstruction of frontal defect: Case report. J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):43-9. DOI: https://doi.org/10.14436/2358-2782.7.1.043-049.oar

Universidade do Estado do Amazonas, Programa de Residência em Cirurgia e Traumatologia Buco-maxilo-facial (Manaus/AM, Brazil).

Universidade Federal do Amazonas, Hospital Getúlio Vargas, Programa de Residência em Neurocirurgia (Manaus/AM, Brazil).

Submitted: November 09, 2018 - Revised and accepted: February 07, 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. 2021 Jan-Apr;7(1):43-9

Treatment of panfacial fracture and late reconstruction of frontal defect: Case report

INTRODUCTION Panfacial fractures are those in which all facial bones are affected. They constitute the most complex and destructive traumatic disorders of the facial skeleton, involving all its pillars and supporting rings. Usually they affect the maxilla, mandible, zygomatic and naso-orbit-ethmoidal complexes, besides the frontal bone. They represent the most challenging cases for the oral and maxillofacial surgeon.1 They are usually associated with severe soft tissue injuries and lead to important esthetic-functional deformities, with disruption of facial appearance and ocular and dental occlusion symptoms.1 In most large centers, the main etiological agents are car accidents and physical aggressions, and trauma often requires a neurosurgical approach for the treatment of brain injuries.2,3 The diagnosis of panfacial fractures is made by clinical and imaging tests. Among the imaging exams, the gold standard is computed tomography (CT), which reveals the exact degree of bone displacement of fractures, as well as their relationship with the adjacent structures.3 In case of full thickness bone loss of the cranial vault, cranioplasty has the main objective of protecting the brain and correcting an extremely apparent esthetic deformity. Among the autologous materials used for this purpose, autologous grafts of the external plate of the parietal bone, ribs and iliac crest are highlighted.2,3 However, the increase in operative time, surgical trauma and the possible complications inherent to the approach of the donor area do not always allow their use. The new biomaterials and substances that mimic the characteristics inherent to autogenous bone tissue have been a constant search for bioengineering.4 The alloplastic materials most used today include are bioceramics, mainly hydroxyapatite and beta tricalcium phosphate. Beta tricalcium phosphate has been widely used as a carrier or framework in tissue engineering.3,4 Bioceramics are osteoconductive and have the advantage of not being reabsorbed, such as autogenous bone grafts. They are considered inductive bone substitutes and thus favor the bone regeneration, promoting their new formation by osteoconduction, and have good biocompatibility.2,3 Thus, the objective of the present study is to report a case of surgical treatment of panfacial fracture and reconstruction of a defect in the frontal region, resulting from a car accident, using a customized prosthesis (bio-

ceramics), with good patient evolution. The entire treatment, from facial fractures to the planning and placement of prosthesis, is reported in detail. CASE REPORT Male patient, victim of a motorcycle accident, with 20 days of evolution, history of hospitalization due to serious injuries resulting from the accident, attended the service presenting a fracture in the anterior mandibular region (symphysis), left zygomatic maxillary complex, left naso-orbital-ethmoidal (NOE) fracture, besides depression in the left supraorbital region due to fracture of frontal bone after a motorcycle accident. Clinically, the patient was unable to lift the left eyelid, presented dystopia, diplopia, enophthalmos and loss of left malar projection (Fig 1A). Computed tomography revealed fracture in the mandibular symphysis, fracture in the zygomatic maxillary pillar, frontozygomatic, infraorbital ridge, nasal bones, left NOE fracture and of the frontal bone (both anterior and posterior wall) above the left orbital region (Fig 1B). Initially, the patient underwent a surgical procedure to reduce and fixate the facial fractures. Reduction and fixation were initially performed of fractures of the zygomatic maxillary complex, with fixation at three points, besides reduction of mandibular symphysis fracture with two plates (Fig 1C to 1F). The patient evolved well after the first surgery, with regression of preoperative complaints (Fig 2A to 2D). Transoperatively, there was no need to fixate the NOE fracture. Subsequently, to minimize the sequelae of facial trauma, it was proposed to manufacture a customized prosthesis (bioceramics) in the frontal region (Fig 2E and 2F). After making the prosthesis, the patient underwent a new surgical procedure, in partnership with the Neurosurgery team, due to loss of posterior frontal bone wall and direct communication with the dura mater. Bicoronal access and exposure of bone defect were performed and then the prosthesis was adapted and fixated with plates and screws of the 1.5 system (Fig 3A to 3D). The patient has been followed for 12 months after reduction and fixation of facial fractures, with the resolution of all complaints initially presented, and 60 days after placement of the customized prosthesis, with total resolution of the defect in the frontal region. No signs of infection were observed in the region where the prosthesis was placed (Fig 3E to 3H).

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):43-9

Torres RS, Albuquerque GC, Motta Junior J, Martins VB, Oliveira MV, Tenório ISAC, Raid DE

Figure 1: A) Clinical aspect on the first visit. B) Reconstruction using computed tomography, showing multiple fractures of the face and defect in the left supraorbital region. C) Fracture fixation of the zygomatic maxillary abutment. D) Frontozygomatic suture fixation. E) Orbital plate for reduction and fixation of the infraorbital rim. F) Reduction and fixation of the mandibular symphysis fracture.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):43-9

Treatment of panfacial fracture and late reconstruction of frontal defect: Case report

Figure 2: A) Clinical aspect after reduction of facial fractures. B) 3D reconstruction after reduction and fixation of facial fractures. C) Axial section after fixating the plate on the infraorbital rim. D) Coronal image showing the left orbital region after fixation of the orbital plate. E) Virtual planning for fabrication of customized prosthesis, in frontal view. F) Virtual planning for fabrication of customized prosthesis, in inferosuperior view.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):43-9

Torres RS, Albuquerque GC, Motta Junior J, Martins VB, Oliveira MV, Tenório ISAC, Raid DE

Figure 3: A) Axial section of computed tomography, showing fracture of the frontal bone affecting the anterior and posterior wall. B) Defect in the frontal region, on the left. C) Visualization of the defect after bicoronal access. D) Placement of customized prosthesis. E) Axial section after prosthesis placement. F) Defect in the corrected frontal region. G) 3D reconstruction after placing the custom prosthesis. H) Postoperative aspect at 60 days after prosthesis placement.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):43-9

Treatment of panfacial fracture and late reconstruction of frontal defect: Case report

DISCUSSION Panfacial fractures are those that simultaneously involve the upper, middle and lower facial thirds. They constitute the most complex and destructive traumatic disorders of the facial skeleton, involving all its pillars and supporting rings. 5 The concept of delayed treatment of panfacial fractures after full clinical recovery of the patient often results in severe secondary facial deformities. Treatment options for secondary deformities are never ideal, and the long-term result is poor. Thus, treatment should be performed as soon as possible, as long as it can be conducted safely. 1 He et al.6 state that, if the treatment is not performed soon after trauma, the facial bones remain poorly united, the soft tissues shrink and contract and fibrosis occur, and all these factors hinder the later treatment. Surgical treatment of facial fractures reported in the present clinical case was performed approximately 25 days after trauma, since the patient suffered severe injuries to other organs and was only released for surgery after the mentioned period. Kelly et al.7 advocated bone reconstruction of the facial skeleton as soon as possible, to minimize the retraction of soft tissues and non-anatomical consolidations of fractures. Regarding the surgical aspects, the fractures were already in the process of non-anatomical consolidation and formation of bone callus. Transoperatively there was a need for refracture, both in the mandibular symphysis region and in the zygomatic maxillary complex, for subsequent reduction and fixation in ideal position. Fracture fixation of the zygomatic maxillary complex was performed at three points (zygomatic maxillary abutment, frontozygomatic abutment and infraorbital ridge), with 1.5 system plates; and reduction of the mandibular symphysis fracture was performed with 1.5 and 2.0 system plates. There was no need for surgical treatment of the NOE fracture. Cranioplasties can be performed with autologous bone, allogeneic (bone bank) or alloplastic material (bioceramics, titanium and polymethylmethacrylate). One advantage of using synthetic materials is to avoid the collection of other autogenic materials for grafting, such as bones, muscles and fat, which reduces the total time required for surgery.8 Considering the biomaterials used for prosthesis manufacturing, acrylic

resin appears as a widely advantageous possibility for the professional and the patient.5 Since treatment onset, reconstruction of the frontal region defect by alloplastic material was planned. At first, it was decided to make a polymethylmethacrylate (PMMA) prosthesis, due to its low cost and easy accomplishment. However, Cakarer et al.9 state that, although PMMA is being used in surgical practice, due to its high stability, it must be considered that the exothermic reaction can cause tissue necrosis, and that the presence of residual monomers causes inflammatory reactions, contributing to tissue destruction. Due to the direct proximity to the dura mater and considering the low control of formation of residual monomers and high risk of infection, the option to make a PMMA prosthesis was discarded. Several authors describe that calcium phosphates and their derivatives, including beta tricalcium phosphate, act more directly on osteoblasts and have been extensively studied as bone substitutes.2,4,8 Considering the cited advantages, a prosthesis was requested from the company Eincobio®, customized by prototyping and made of porous ceramics (composed mainly of hydroxyapatite (HA) and beta-tricalcium-phosphate (B-TCP), in addition to other minerals). The presence of pores of various sizes is important for migration of both fibrous and bone tissue inside the prosthesis.8 Maricevich et al.8 state that a customized prosthesis has greater thickness than the titanium prosthesis, reducing the dead space between the prosthesis and the dura mater. It offers a perfect contour, but there is risk of infection, possibility of prosthesis exposure in case of low coverage of soft tissues, besides the cost, which can be an impediment to its use.10 There were no signs of infection, exposure of prosthesis or any other changes to date. FINAL CONSIDERATIONS The surgical treatment of panfacial fractures is considered complex and requires maximum anatomical knowledge and surgical techniques by the oral and maxillofacial surgeon. The correction of bone defects resulting from trauma and other different etiologies is a challenge for modern medicine. The use of biomaterials for facial reconstruction instead of autogenic materials is an increasingly frequent reality. Bioceramics, considering their characteristics, have become an interesting choice.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):43-9

Torres RS, Albuquerque GC, Motta Junior J, Martins VB, Oliveira MV, Tenório ISAC, Raid DE

References:

1. Gilvani AOC, Ono MC, Junior IM. Fraturas panfaciais: experiência do ano 2011. Rev Bras Cir Craniomaxilofac. 2012;15(2):79-82. 2. Zabeu JLA, Mercadante MT. Substitutos ósseos comparados ao enxerto ósseo autólogo em cirurgia ortopédica: revisão sistemática da literatura. Rev Bras Ortop. 2008;43(3):59-68. 3. Hara T, Santos CA, Farias AF, Costa MJM, Cruz RJL. Cranioplastia: parietal versus prótese customizada. Rev Bras Cir Plást. 2011;26(1):32-6. 4. Souza DFM, Correa L, Sendyk DI, Burim RA, Naclério MG, Deboni MCZ. Efeito adverso do beta fosfato tricálcico com controle de potencial zeta no reparo de defeitos críticos em calvária de ratos. Rev Bras Ortop. 2016;51(3):346-52.

5. Souza RRL, Menezes LP, Silva Júnior EZ, Alencar MGM, Vasconcelos BCE, Laureano Filho JR. Reconstrução de sequela facial por prótese interna acrílica. Rev Cir Traumatol Buco-Maxilo-Fac. 2017;17(3):29-32. 6. He D, Zhang Y, Ellis 3rd E. Panfacial fractures: analysis of 33 cases treated late. J Oral Maxillofac Surg. 2007;65(12):2459-65. 7. Kelly KJ, Manson PN, Vander Kolk CA, Markowitz BL, Dunham CM, Rumley TO, et al. Sequencing LeFort fracture treatment (Organization of treatment for a panfacial fracture). J Craniofac Surg. 1990;1(4):168-78. 8. Maricevich P, Mansur A, Peixoto A, Amando J, Pantoja E, Braune A, et al. Cranioplastias: estratégias cirúrgicas de reconstrução. Rev Bras Cir Plást. 2016;31(1):32-42.

9. Caraker S, Selvi F, Isler C, Olgac V, Keskin C. Complication of polymethylmethacrylate bone cement in the mandible. J Craniofac Surg. 2010;21(4):1196-8. 10. Maia M, Klein ES, Monje TV, Pagliosa C. Reconstrução da estrutura facial por biomateriais: revisão de literatura. Rev Bras Cir Plást. 2010; 25(3):566-72.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):43-9

Case Report

Osteoid osteoma in the mandible: Case report

ABSTRACT Osteoid osteoma is a benign tumor characterized by limited growth. It is more common in long bones and extremely rare in gnatic bones. It is typically presented as an injury that causes pain mainly at night, which can be alleviated with the use of non-steroidal anti-inflammatory drugs. Radiographically is a radiopaque lesion delimited by a radiolucent region. It usually does not exceed 20 mm in diameter. The treatment of choice is usually surgical removal, and recurrence is very rare. The purpose of this study is to report a case of a rare osteoid osteoma in the posterior mandible region, near the mandibular canal. Radiographically, is presented as a sclerotic lesion, well delimited, surrounded by a radiolucent halo. Clinically, it caused recurrent discomfort to the patient. Surgical removal was performed in an outpatient setting under local anesthesia. After the lesion was excised, the patient presented resolution of the symptoms. Keywords: Osteoma, osteoid. Bone neoplasms. Tomography.

Universidade do Estado do Amazonas, Programa de Residência em Cirurgia e Traumatologia Buco-maxilo-facial (Manaus/AM, Brazil).

How to cite: Torres RS, Nascimento SLC, Tavares PMH, Martins VB, Motta Junior J, Albuquerque GC, Oliveira MV. Osteoid osteoma in the mandible: Case report. J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):50-4. DOI: https://doi.org/10.14436/2358-2782.7.1.050-054.oar

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

Submitted: October 22, 2018 - Revised and accepted: February 07, 2019

» 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. 2021 Jan-Apr;7(1):50-4

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

INTRODUCTION The osteoid osteoma is characterized as a tumor of benign origin, with the first reports by Heine; histology by Bergstrand; and, in 1953, Jaffe described and classified it as a clinical and pathological entity. This allowed to differentiate it from other tumors.1 It is a benign primary tumor whose niche is composed of hypervascular immature osteoid tissue surrounded by reactive sclerotic bone. It has low growth potential and usually has diameter smaller than 15mm.1 The osteoid osteoma can develop in multiple locations, yet it is most often seen in the long bones of the lower limbs, i.e., the femur, tibia and fibula, with less than 1% occurring in the jaws. The male-to-female ratio is about 4:1 and it predominates in children and young adults from the first to the third decade of life. The most common symptom is localized bone pain, which can be relieved with the use of non-steroidal anti-inflammatory drugs (NSAIDs).1,2 In the oral and maxillofacial complex, this type of lesion is commonly described, mainly in the mandible, in the molar region; however, few cases have been reported.3 Radiographically, it is characterized by the presence of a radiolucent area, with small diameters, rarely exceeding 20 mm, almost always surrounded by reactive sclerotic bone.2 Its occurrence in the mandible usually mimics most common odontogenic lesions, such as cementoblastoma and osteoblastoma. Imaging exams can often favor a better characterization of the niche; these include magnetic resonance imaging and computed tomography. Bone scintigraphy can also show intense niche activity and low activity in the region of surrounding reactive zone; however, anatomopathological examination is responsible for the final diagnosis.4,5 Macroscopically, the niche is wine-colored and almost always well defined. In most cases, it does not exceed 2 cm in diameter. Microscopically, it is composed of mature bone trabeculae and an osteoid matrix with abundant vascularization. In some cases, it presents central calcification zones. It is believed that its etiology may be related to continuous muscle traction and osteogenic reactions, hamartomatous events, inflammatory processes or even healing of trauma in the final stage.6 The main treatment option for these tumors has been classic surgery for a long time. Thus, the options are curettage, en bloc resection and wide resection (with graft). Complete removal of the lesion assures the absence of relapse. If the osteoid osteoma is located deeply,

the surgical procedure will be difficult. The success rate of classic surgery ranges from 88% to 100%. However, the main point of concern is the occurrence of complications such as necrosis and fractures.7 According to Cantwell et al.9, complications occur in 20-45% of procedures. Besides these complications, the surgical time is longer, and tissue damage, healing and morbidity are greater compared to minimally invasive therapies. Although osteoid osteoma is considered a latent lesion, it also requires a strategic approach, so that surgery has minimal invasion, but allows complete lesion removal.9 CASE REPORT Female patient, Caucasoid, aged 23 years, was referred to the Oral and Maxillofacial Surgery and Traumatology service at the State University of Amazonas, complaining of discomfort in the region of tooth 37, with repercussion on the left ear, besides episodes of recurrent paresthesia, with one year of evolution. The patient did not report history of trauma or infection in the dental region, only reporting that she had undergone extraction of tooth 38 exactly three years ago, due to orthodontic indication. Extraoral examination did not reveal facial asymmetry or bone alteration during palpation, as well as on the intraoral examination, which showed normality at the region of pain complaint. Imaging examination revealed a radiopaque image, with well-defined margins, in the region of tooth 38. In the parasagittal section, the lesion was 7.80 mm high and 6.60 mm wide. The suggestive diagnosis at first was complex odontoma (Fig 1). Surgical removal of the lesion under local anesthesia was planned in the outpatient clinic. Access to the mandible was achieved by intraoral approach, with a flap extending up to the mesial aspect of tooth 37, with full mucoperiosteal detachment, followed by osteotomy for lesion exposure and removal (Fig 2). After complete removal, the specimen obtained was submitted to histopathological examination, which showed mineralized material with prominent reverse lines and sheets of irregular trabeculae, evidencing a lesion of osteoid osteoma type (Fig 2). At seven days postoperatively the patient had no complications, only discomfort in that region. At 12 months after surgical removal the patient did not have any complaint, thus presenting an excellent prognosis (Fig 3).

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):50-4

Osteoid osteoma in the mandible: Case report

Figure 1: Computed tomography presenting, on panoramic and parasagittal sections, a radiopaque image with well-defined margins, in the region of tooth 38.

Figure 2: Transoperative aspect: A) Flap extending to the mesial surface of tooth 37 (similar to the access for third molar removal). B) Osteotomy for lesion exposure and removal. C) Macroscopic aspect. D) Histopathological aspect, showing mineralized material with prominent reverse lines and irregular trabeculae.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):50-4

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

Figure 3: Computed tomography at 12 months postoperatively, showing new bone formation and lesion resolution.

DISCUSSION Osteoid osteoma is a benign lesion that consists of a small, rounded nest. It accounts for 3% of all primary bone tumors and about 10% of benign bone tumors. About 80% of osteoid osteomas occur in long bones, while less than 1% occur in the jaws. Mild pain and discomfort are the main symptoms, as in the present case.10 Analysis of reports in the literature reveals that most osteoid osteomas of the jaws occur in the second and third decades of life, and the majority of cases were reported in the mandible, not the maxilla.1,3,5,6 This is because the posterior mandibular body, especially the molar region, is more prone to development of this lesion, which coincides with the present case report. The actual prevalence of osteoid osteoma is unknown. It is more frequently observed in men than women, at a ratio of approximately 4:1,1,2,10 contrasting with the present study, which reports a case in a female patient.

The exact etiology and pathogenesis of osteoid osteoma is unknown. Neoplastic and reactive causes have been suggested as possible etiological factors. It is believed that its etiology may be related to continuous muscle traction and osteogenic reactions, hamartomatous events, inflammatory processes or even final healing stage of trauma.8 However, in the present case, we only have information about extraction of tooth 38 approximately three years before, which may be a possible cause. Histologically, osteoid osteomas consist of compact bone, which are interconnected and are sometimes separated by small medullary spaces as reported in this case. Radiographically, osteomas show a well-circumscribed, densely sclerotic and radiopaque mass. They are usually identified in routine radiographic examination and treated by local excision,9 data that coincide with the present case.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):50-4

Osteoid osteoma in the mandible: Case report

unknown origin. Imaging methods are used in the evaluation of osteoid osteoma, such as computed tomography, which play a fundamental role in identifying the lesion. Surgery remains the standard treatment in cases where the histology of the lesion is doubtful. The present case is similar to cases reported in most national and international literature, demonstrating that the evolution, diagnosis, treatment and prognosis do not differ in different regions.

Recurrence after surgical excision is extremely rare.1,2,5,8,9 The present case had a good prognostic evolution, without relapse of neoplasia. Removal was performed effectively, thus showing no harmful signs and symptoms postoperatively. FINAL CONSIDERATIONS Osteoid osteoma of the mandible is a benign neoplasm that is increasingly frequent, even though it is of

References:

1. Karandikar S, Thakur G, Tijare M, Shreenivas K, Agrawal K. Osteoid osteoma of mandible. BMJ Case Reports. 2011;1(1):1-4. 2. El-Naggar AK, Chan JKC, Grandis JR, Takata T, Slootweg PJ. WHO classification of head and neck tumours - WHO/IARC classification of tumours. 4th ed. Lyon: International Agency for Research on Cancer; 2017. v. 9. 3. Nijland H, Gerbers JG, Bulstra SK, Overbosch J, Stevens M, Jutte PC. Evaluation of accuracy and precision of CT- guidance in Radiofrequency Ablation for osteoid osteoma in 86 patients. PLoS One. 2017;12(4):e0169171. 4. Singh A, Solomon MC. Osteoid osteoma of the mandible: a case report with review of the literature. J Dent Sci. 2017;12(2):185-9.

5. Liu PT, Kujak JL, Roberts CC, Chadarevian JP. The vascular groove sign: a new CT finding associated with osteoid osteomas. AJR Am J Roentgenol. 2011;196(1):168-73. 6. Motamedi D, Learch TJ, Ishimitsu DN, Motamedi K, Katz MD, Brien EW. Thermal ablation of osteoid osteoma: overview and step-by-step guide. Radiographics. 2009;29(7):2127-41. 7. Caubi AF, Moura RQ, Borba PM, Costa DFN, Bispo LMM . Osteoma em mandíbula: quando tratá-lo cirurgicamente. Rev Cir Traumatol Buco-Maxilo-Fac. 2013;13(1):53-8.

8. Richardson S, Khandeparker RV, Sharma K. A large osteoid osteoma of the mandibular condyle causing conductive hearing loss: A case report and review of literature. J Korean Assoc Oral Maxillofac Surg. 2017;43(1):106-14. 9. Cantwell CP, Obyrne J, Eustace S. Current trends in treatment of osteoid osteoma with an emphasis on radiofrequency ablation. Eur Radiol. 2004;14(4):607-17. 10. Carmargo OP. Abordagem atual das lesões ósseas benignas. Rev Bras Ortop. 2000;35(7):227-30.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):50-4

Case Report

Well-differentiated lipossarcoma of soft palate: case report and literature review JULIO CLAUDIO SOUSA1 | ROGERIO COSTA TIVERON1 | RENATO QUEIROZ RAMOS1 |RENATA MARGARIDA ETCHEBEHERE1

ABSTRACT Liposarcoma is a malignant mesenchymal tumor originating in adipose tissue cells. It occurs mainly in the extremities and retroperitoneum, but is rarely found in the head and neck region, including the oropharanyx. Thus, the objective of the present article is to presented the case report of a 27-year-old woman with a bulge in the soft palate for three years. Imaging exams showed tissue with a density compatible with fatty tissue. The lesion was removed, and the histopathology exam suggested lipoma of the soft palate. The patient missed her check-ups, and the lesion recurred three years after being removed. She again underwent surgery, and histopathology revealed a well-differentiated liposarcoma of the soft palate. Since then, the patient has maintained outpatient follow-up without evidence of recurrence. It can be concluded that, although rare in the head and neck region, liposarcoma should be considered as a possibility for lesions with a lipomatous component. Keywords: Palate, soft. Liposarcoma. Lipoma.

How to cite: Sousa JC, Tiveron RC, Ramos RQ, Etchebehere RM. Well-differentiated lipossarcoma of soft palate: case report and literature review. J Braz Coll Oral Maxillofac Surg. 2021 JanApr;7(1):55-60. DOI: https://doi.org/10.14436/2358-2782.7.1.055-060.oar

Universidade Federal do Triângulo Mineiro, Departamento de Cirurgia, Disciplina de Otorrinolaringologia (Uberaba/MG, Brazil).

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

Submitted: July 18, 2018 - Revised and accepted: March 06, 2019

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

Contact address: Julio Claudio Sousa E-mail: jcotorrino@gmail.com

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):55-60

Well-differentiated lipossarcoma of soft palate: case report and literature review

INTRODUCTION The liposarcoma, described by Virchow in 1857, is a malignant mesenchymal tumor originating from fat tissue cells. It represents approximately 17 to 30% of all soft tissue sarcomas.1 These tumors occur predominantly in the limbs and retroperitoneum and in middle-aged adults, being rare in the head and neck region, especially in the oropharynx.2 In general, sarcomas represent only 1% of primary head and neck tumors.3 A comprehensive literature review demonstrated that soft palate liposarcoma is extremely rare, limited to occasional reports. The objectives of the present case report were to present the occurrence of this rare well-differentiated soft palate liposarcoma and present a literature review, regarding the diagnosis, treatment and prognosis of this pathology.

pansive lesion, measuring 6 x 5.5 x 3.5 cm, located close to the posterior and left lateral walls of the oropharynx, grossly ovoid, with well-defined limits, similar signal as fat tissue in all study sequences, without significant post-contrast enhancement (Fig 3). Based on the clinical characteristics of the lesion and imaging findings, a clinical hypothesis of soft palate lipoma was made, and the patient underwent general anesthesia with transoral excision of the lesion from a paramedian incision on the soft palate. The lesion was enucleated without difficulty, measuring 7 x 5 x 3 cm. The postoperative period was uneventful. The patient was discharged one day after surgery with good velopharyngeal function. The histopathological result revealed lipoma of the soft palate. The patient missed the outpatient follow-up consultations, returning in June 2013, complaining of a new bulging in the soft palate for one year, with rapid evolution in the last four months. At the time, she complained of intense dysphagia and weight loss. Otolaryngological examination evidenced a large bulging of the soft palate. The patient underwent a new transoral excision of the lesion. Again, surgery was uneventful, and the lesion measured 7 x 5.5 x 3.5 cm. The histopathology of this second approach revealed a well-differentiated liposarcoma, with surgical margins coinciding with the pseudocapsule (Fig 4). Despite this coincidence, it was decided not to perform adjuvant radiotherapy.

CASE REPORT Female patient aged 27 years, Caucasoid, without clinical history, attended the Otolaryngology service in July 2009 due to a complaint of bulging in the soft palate for approximately three years, associated with nasal obstruction and dysphagia for liquid and solid foods. The general physical examination did not show abnormalities. During otolaryngological examination, a volumetric increase in the soft palate was observed, predominantly to the left, with soft consistency, undefined limits, painless on palpation and lined by mucosa with normal aspect (Fig 1). The cervical tomography in coronal section, showed a grossly ovoid expansive lesion with well-defined limits and fat density, dimensions of 5x5 cm, with epicenter located on the left lateral wall of the oropharynx (Fig 2). Cervical resonance showed an ex-

RESULTS Since reoperation, i.e., 5 years ago, the patient has maintained the outpatient follow-up, without evidence of new relapse (Fig 5).

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):55-60

Sousa JC, Tiveron RC, Ramos RQ, Etchebehere RM

Figure 1: Volumetric increase of the soft palate.

Figure 2: 2D computed tomography (coronal section) showing an expansive well-defined lesion with fat density, located on the soft palate.

Figure 3: T1-weighted coronal plane MRI showing expansive ovoid lesion, defined limits at the transition between naso- and oropharynx, with homogeneous hypersignal and fine interspersed trabeculae.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):55-60

Well-differentiated lipossarcoma of soft palate: case report and literature review

Figure 4: Mesenchymal neoplasm composed of mature adipocytes permeated by rare lipoblasts (hematoxylin-eosin, 400X).

Figure 5: T1-weighted MRI, coronal plane, showing soft palate with no changes in the late postoperative period.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):55-60

Sousa JC, Tiveron RC, Ramos RQ, Etchebehere RM

DISCUSSION Liposarcomas of the head and neck are rare, representing 5 to 9% of all liposarcomas.2 Specifically concerning the topography of the oropharynx, the incidence of liposarcomas is extremely rare, being limited to isolated case reports. During the present literature review in the PubMed database, using the keywords liposarcoma, oropharynx and soft palate, only four cases were found reported in the last ten years. The histological classification of liposarcomas has changed over the decades. The need for universal standardization gave rise to the classification of the World Health Organization in 2002. Advances in genetic and molecular research revealed that liposarcoma corresponds to a heterogeneous group of tumors, consisting of five histological types: well-differentiated, myxoid, round cells, pleomorphic and undifferentiated.4 Well-differentiated and myxoid tumors are considered low-grade lesions, with less aggressive behavior and characterized by usually local relapse with rare metastases. However, pleomorphic, round cell and undifferentiated types are considered high-grade lesions and thus exhibit more aggressive behavior. The well-differentiated subtype represents the most frequent liposarcoma, accounting for about 40 to 45% of all liposarcomas.5 The outstanding histological characteristics that allow the diagnosis of well-differentiated liposarcoma are: variation in adipocyte size, adipocytes with atypical, enlarged and hyperchromatic nucleus and bizarre stromal cells, frequent in fibrous septa, between adipocytes and also in vessel walls. The histological evaluation of head and neck tumors with a lipomatous component requires differential diagnosis with fatty necrosis, silicone granuloma and benign tumors with an adipocytic component.2 In many cases, the differentiation between a benign adipocytic tumor and a well-differentiated liposarcoma can be extremely difficult. Thus, cytogenetic evaluation can have a valuable contribution, since well-differentiated liposarcoma has peculiar chromosomal changes that differentiate it from lipoma.6 Liposarcomas usually manifest as a slow-growing, painless tumor. Subsequent signs and symptoms result from the affected region and possibility of involvement of neurovascular structures. Less frequently, these lesions present with rapid, aggressive growth, invading locally and originating metastases to the lung, brain, liver, kidney and spine.3,7 In the present case, the patient had oropharyngeal dysphagia and nasal obstruction.

During imaging examination, the identification of fatty tissue inside the lesion represents the critical point in the suspicion of a lipomatous tumor. The careful evaluation of images, besides raising the hypothesis of lipomatous tumor, allows accuracy as to the lesion location, local extent and relationship with adjacent structures. Large and heterogeneous lesions, in deep location and rapidly growing are usually associated with an increased risk of malignancy. Tomography and magnetic resonance imaging are highlighted in the investigation of expansive lesions in the head and neck region. The distinction between liposarcoma and lipoma is often a diagnostic dilemma, especially in small lesions. In magnetic resonance imaging, the most relevant findings to differentiate liposarcoma from lipoma are: presence of septa with thickening greater than 2 mm, nodular or globular areas of non-adipocytic tissue inside or adjacent to the lesion, and amount of non-adipocytic tissue greater than 25% of the lesion.8 In the present case, lipoma was the initial clinical diagnosis, considering the duration, surface and consistency of the lesion. Imaging findings also did not suggest liposarcoma. The most effective treatment for liposarcoma is complete surgical excision, with free margins. However, in the head and neck region, the extent of resection must consider the possibility of functional losses and the proximity to important neurovascular structures. Since incomplete resection increases the possibility of relapse, postoperative radiotherapy may be necessary for selected cases, especially those in which total excision was not possible.3,4,9 For liposarcomas of the head and neck, factors as more superficial lesions, smaller dimensions and myxoid and well-differentiated histological subtypes indicate good prognosis. Also, when compared to other anatomical sites, liposarcomas of the head and neck show less aggressive behavior and thus have a better prognosis.3,9 FINAL CONSIDERATIONS Though rare in the head and neck region, liposarcoma should be considered as a differential diagnosis of lesions with lipomatous component. Complete surgical excision with an adequate margin represents the treatment of choice, and postoperative radiotherapy is an alternative for selected cases. Due to the possibility of relapse, extended postoperative follow-up is necessary.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):55-60

Well-differentiated lipossarcoma of soft palate: case report and literature review

References:

1. Kim YB, Leem DH, Baek JA, Ko SO. Atypical lipomatous tumor/well-differentiated liposarcoma of the gingiva: a case report and review of literature. J Oral Maxillofac Surg. 2014;72(2):431-9. 2. Nascimento AF, McMenamin ME, Fletcher CDM. Liposarcoma/atypical limomatous tumors of the oral cavity: a clinicopathologic study of 23 cases. Ann Diagn Pathol. 2002;6(2):83-93. 3. Gritli S, Khamassi K, Lachkhem A, Touati S, Chorfa A, Makhlouf TB, et al. Head and neck liposarcomas a 32 years experience. Auris Nasus Larynx. 2010;37(3):347-51. 4. Cheng J, Wang Y, Cheng A, Wang L, Tian Z, Yu H, et al. Primary liposarcoma in oral and maxillofacial region. J Craniofac Surg. 2011;22(5):1765-71.

5. Bree E, Karatzanis A, Hunt JL, Strojan P, Rinaldo A, Takes RP, et al. Lipomatous tumours of the head and neck: a spectrum of biological behaviour. Eur Arch Otorhinolaryngol. 2015;272(5):1061-77. 6. Nishio J. Contributions of cytogenetics and molecular cytogenetics to the diagnosis of adipocytic tumors. J Biomed Biotechnol. 2011;2011:524067. 7. Fusetti M, Silvagni L, Eibenstein A, Chiti-Batelli S, Hueck S, Fusetti M. Myxoid liposarcoma of the oral cavity: case report and review of the literature. Acta Otolaryngol. 2001;121(6):759-62. 8. Kransdorf MJ, Bancroft LW, Peterson JJ, Murphey MD, Foster WC, Temple HT. Imaging of fatty tumors: distinction of lipoma and well-differentiated liposarcoma. Radiology. 2002;224(1):99-104.

9. Gerry D, Fox NF, Spruill LS, Lentsch EJ. Liposarcoma of the head and neck: analysis of 318 cases with comparison to non-head and neck sites. Head Neck. 2014;36(3):393-400.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):55-60

Case Report

Low-intensity LED therapy in facial paralysis: Case report MARCELLO DE SOUZA SILVA1 | RENATA AMADEI NICOLAU1 | MATHEUS AUGUSTO PEREIRA1 | CARLOS EDUARDO DIAS COLOMBO2

ABSTRACT Peripheral facial palsy (PFP) is characterized by the interruption of the neuronal stimulus of the branches of the VII cranial pair due to several etiological factors that acutely affect the total or partial motor information of the facial muscles. PFP may be related to infectious, traumatic, neoplastic, autoimmune, metabolic and iatrogenic processes. The objective of this article is to present the case report of a 41-year-old, Caucasian, male patient, PFP compatible with Ramsay Hunt Syndrome type II, treated with pharmacological approach associated with low intensity LED therapy (640 ± 20 nm), applied all the nerve path, for 30 seconds, with energy density of 1.7 J/cm², energy of 3 J and power of 100 mW. After the first session, there was an expressive improvement in the clinical picture, promoting increased muscle tone and greater contracture of the facial mimic, such as frowning, beak, smile and completely closing the eye. For 15 days, five applications were performed, resulting in the absence of any signal or symptom referring to paralysis. It was concluded that low intensity LED therapy was effective in the treatment of PFP, with the protocol tested. Keywords: Facial paralysis. Low-level light therapy. Facial nerve.

Universidade do Vale do Paraíba, Departamento de Cirurgia e Traumatologia Buco-Maxilo-Facial (São José dos Campos/SP, Brazil).

How to cite: Silva MS, Nicolau RA, Pereira MA, Colombo CED. Low-intensity LED therapy in facial paralysis: Case report. J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):61-7. DOI: https://doi.org/10.14436/2358-2782.7.1.061-067.oar

Universidade do Vale do Paraíba, Departamento de Patologia Bucal (São José dos Campos/SP, 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. Submitted: August 08, 2018 - Revised and accepted: February 07, 2019 Contact address: Renata Amadei Nicolau E-mail: renatanicolau@hotmail.com

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):61-7

Low-intensity LED therapy in facial paralysis: Case report

INTRODUCTION Facial paralysis (FP) is characterized by the interruption of neuronal stimulation of branches of cranial nerve VII due to several etiological factors that acutely affect the total or partial motor information of the facial musculature, either unilaterally or bilaterally.1 Facial paralysis can present as an idiopathic form, according to reports in the literature; however, it is possible to identify the presence of infectious, traumatic, neoplastic, autoimmune, metabolic and/or iatrogenic disorders. Pregnancy, diabetes mellitus and severe systemic hypertension are also considered risk factors. Among the etiological factors described, Bell’s palsy is the most common, with an estimated incidence of 20 to 30 cases per 100,000 inhabitants, with prevalence in the third and eighth decades of life, being rare before ten years old, affecting both genders, even though some authors cite higher prevalence in women.2 Due to its high incidence, trauma is the second most frequent cause of FP and is relevant due to the long intracranial path of the facial nerve, increasing the risk of injuries that affect its functions, partially or totally. The main traumas include fracture of the temporal bone (most frequent), fracture of facial bones, firearm injuries, blunt injuries of the face, birth trauma and iatrogenic. The nerve is rarely completely sectioned, and longitudinal involvement of the temporal bone presents higher incidence and better prognosis in relation to transverse fractures.3 Viral infection by herpes simplex or other pathogens has been discussed as the main pathophysiological agent. It is believed that its reactivation occurs in the geniculate ganglion, due to climatic factors, fever, stress and trauma in oral surgeries. According to Lazarini et al.4, a clinical study found DNA of herpes simplex virus type 1 (HSV-1) in 11 cases of 38 patients evaluated, presenting a significant result, suggesting that viral reactivation may be the etiology of disease, not interfering with the prognosis. The Ramsay Hunt syndrome, also known as herpes zoster oticus, is one of the etiological factors associated with FP, due to reactivation of varicella zoster virus in the geniculate ganglion. It is prevalent between the second and third decades of life but can occur at any age. Clinically, vascular lesions are observed in the pinna and ipsilateral otalgia, which can cause vertigo, vomiting and nausea.5

Another triggering factor for FP is anesthesia of the inferior alveolar nerve, cited by Viegas et al.6 in their clinical cases, in which the movements were normalized after drug therapy, laser therapy, physiotherapy and waiting for three hours, respectively. Less prevalent factors are also cited in the literature, such as acute and chronic otitis media, malignant external otitis, Melkersson Rosenthal syndrome, Lyme disease, congenital anomalies and association between facial paralysis and intracranial hypertension. Several treatments have been described, aimed at the recovery of nerve fibers, elimination of possible sequelae and mainly normalization of facial movements. Although facial paralysis has an unknown etiology in most cases, the indicated treatments have been effective in the improvement of patients who did not have spontaneous recovery of symptoms. Physiotherapy is an important treatment method for cases of FP, for the recovery of muscle tone, with associations with other types of therapies. The main guideline is the implementation of measures that avoid one of the worst complications, such as corneal ulcer, due to lack of complete eye closure. It is recommended to lubricate the eyes with artificial tears, applied at every 60 minutes during the day, and the use of sunglasses to protect against foreign bodies. Corticosteroids, according to Viegas et al.6, have a potent anti-inflammatory action, which can minimize the damage of nerve fibers and improve the prognosis of patients with this condition. A clinical study conducted by Ferraria et al.7 demonstrated the association of antiviral and corticosteroids, evaluating 180 cases of Bell’s palsy, in which the main therapy used was the combination of corticosteroids and antivirals, in 67.2% of cases. The total recovery rate using this combination was 65.5% (57 out of 87 patients) versus 72.4% (21 out of 29 patients) with isolated corticosteroid therapy. The combination did not present difference in the recovery rate compared to corticosteroid therapy alone. Surgical intervention, according to Paraguassú et al.2, aims to decompress the facial nerve; however, many risks are involved, including seizures, deafness, leakage of cerebrospinal fluid and facial nerve damage. Thus, surgery is not widely used in the treatment of FP. A new treatment method has been used in FP, the low-level LED therapy, due to its beneficial characteristics to biological tissues, such as increased microcirculation, genesis of new blood capillaries, stimulating

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):61-7

Silva MS, Nicolau RA, Pereira MA, Colombo CED

8/8h for 7 days), prednisolone 20 mg (1 tablet orally 24/24h for 7 days), injection solution containing 100 mg of thiamine hydrochloride (vitamin B1), 100 mg of pyridoxine hydrochloride (vitamin B6) and 5000 mcg of cyanocobalamin (vitamin B12), intramuscularly at every 72 hours for 16 days, besides continuous use of lubricating eye drops (2 drops 8/8h). Serological tests were negative for antibodies against herpes simplex virus (HSV-1 and HSV-2) and positive for IgG against varicella zoster virus (VZV). The patient reported chickenpox in childhood. The condition was diagnosed as neuritis affecting the facial nerve, compatible with Ramsay Hunt type II syndrome. This syndrome is caused by reactivation of VZV, previously latent in the sensory ganglion of the facial nerve, which, by acute inflammatory reaction of the facial nerve and vestibulocochlear nerve, can cause vesicular eruptions in the pinna, which may extend through the neck, as well as vertigo, fever, dry eyes, changes in taste, severe earache and facial paralysis. Eleven days after FP, the patient attended the Polyclinic of the Dentistry course at the University of Vale do Paraíba to treat the condition. After anamnesis and physical examination, it was clinically observed that the right side of the face showed asymmetry and the musculature was deficient, with difficulty in contracting the forehead, pouting, smiling and completely closing the eye on that side of the face. The patient also reported feeling of heaviness on the right eye. The selected treatment was low-level LED therapy, applied throughout the path of the facial nerve and its branches, at equidistant points of 1 cm, wavelength of 640±20 nm (GaAlAs diode, red region of the electromagnetic spectrum), for 30 seconds, with energy density of 1.7 J/cm², energy of 3 J and power of 100 mW. This therapy was performed in five applications for fifteen days, with one application per session. The severity of facial paralysis was classified as grade IV according to the House-Brackmann classification table. To check the improvement of signs and symptoms of the disease, analyses were performed by photogrammetry comparatively between sessions. The measurements were obtained by calibrating the Image J program, considering the anatomical references of the software itself, so that the minimum measurement error could be incorporated into the analyses (Fig 1).

growth and cell regeneration, besides anti-inflammatory and analgesic effects.8 The basic principle of low-level LED therapy is the absorption of light in irradiated tissues. This light is only a visible part of the electromagnetic spectrum composed of oscillatory and vibrating energies, in which the different types differ according to the frequency of oscillation. According to Bispo,9 these reactions occur by the capture of light by photoreceptors called chromophores, present in the crest of cytoplasmic organelle, called mitochondria, in which the captured energy is stored as adenosine triphosphate (ATP) and transformed into adenosine diphosphate (ADP). When released, this alters the Krebs cycle, stimulating oxidative phosphorylation with the purpose of promoting greater cellular energy and, consequently, increasing its metabolic functions, such as: collagen production, analgesia, reduction of enzymes that degrade the skin, reduction of edema and erythema, stimulation of the immune system, production of hormones, better oxygenation of tissues and normalization of pH, accelerating the tissue repair process and minimizing the use of drugs. Scientific studies involving low-level LED therapy in FP are scarce, justifying research in this field, so that this innovative, non-invasive, effective and relatively lowcost method can be widely disseminated in the dental field. Thus, the aim of the present study is to present and discuss a clinical case of FP treated with low-level LED. CASE REPORT This case report was approved by the Institutional Review Board of the University of Vale do Paraíba, under report N. 2529129. A 41-year-old male Caucasoid patient initially presented with a painful whiteopaque vesicle of approximately 2 mm on the lateral tongue edge on the right side, evolving within a few days to inflammation in the right ear, with the presence of vesicles in the pinna, which was swollen. Two days after the diagnosis of otitis, the condition evolved to facial paralysis on the right side. The patient also had tinnitus in the right ear and vertigo. In the emergency room, the patient underwent computed tomography of the skull, which showed a normal aspect, discarding the hypothesis of etiology in the central nervous system, suggesting facial paralysis resulting from peripheral nerve impairment. With the hypothesis of viral infection, the patient was medicated with fanciclovir 500 mg (1 tablet orally

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):61-7

Low-intensity LED therapy in facial paralysis: Case report

It can be observed in this analysis that, soon after the first session, there was proximity of measurements of the affected side in relation to the contralateral side. In the second session, the distance between the contraction of commissures normalized to 3.6 cm in reference to the contralateral side and there was complete eyelid occlusion. The midline/pupil/commissure angulation was normalized, according to the reference (28 degrees), in the third session. In the fourth session, the distance of commissural distension reached the standard of 6.3 cm. Finally, in the fifth and last session, the values of dental exposure area were normalized, with 6.3 cm2, and the eyebrow/nose tip distance, with 6.7 cm. Only the eyebrow/pupil distance (2.7 cm) showed a small discrepancy from the final value (2.9 cm). The final values presented were considered as reference of the patient’s face. The treatment resulted in absence of any signs or symptoms related to the paralysis.

The evaluated points were eyelid occlusion, elevation of the eyebrow in relation to the pupillary center, angulation of the midline/lip commissure and area of dental exposure and distance between lip commissures (Fig 2). After the patient started the treatment, in the second session it was observed that after the first application there was significant improvement in the clinical status, promoting an increase in muscle tone and greater contraction of mimic muscles, such as frowning, smiling and closing the eye. The patient also reported greater sensation of lightness on the right eye. From the third to the fifth session, there was progression in the improvement of contraction of the facial musculature. Comparisons of measurements were made between points on the affected side and the normal side of the patient’s face at completion of each session (Tab. 1 and Fig 3).

Figure 1: Measurement between commissures and calibration of the digital image analysis system.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):61-7

Silva MS, Nicolau RA, Pereira MA, Colombo CED

Figure 2: Points analyzed to assess the clinical status: A) eyelid occlusion; B) eyebrow elevation; C) midline/commissure angulation and dental exposure area; and D) commissural distance.

Table 1: Progression and comparison of measurements during treatment on the affected side, in relation to the contralateral side.

Affected side

Contralateral side

Sessions

Eyelid occlusion

Eyebrow/pupil distance (cm)

Eyebrow/nose tip distance (cm)

Distance of commissure distention (cm)

Distance of contraction between commissures (cm)

1st

1.7

5.9

5.7

4.7

Yes

2.3

6.4

5.9

3.6

Yes

2.3

6.6

3.6

Yes

2.6

6.6

6.3

3.6

Yes

2.7

6.7

6.3

3.6

Yes

2.9

6.7

6.3

3.6

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):61-7

Low-intensity LED therapy in facial paralysis: Case report

Figure 3: Example of the clinical status in the first (A) and fifth (B) session of low-level LED therapy.

DISCUSSION Several types of treatments have been described in the literature, aiming to recover the nerve fibers, eliminating possible sequelae and mainly normalizing the facial movements. Such treatments include drug therapy with the use of corticosteroids and antivirals, physiotherapy, acupuncture, surgery, laser therapy and, more recently, LED therapy. According to Barros, Barros and Nascimento,10 acupuncture aims to treat diseases by stimulating the so-called acupoints on the skin, with several beneficial effects in the treatment of facial paralysis. These authors reported a clinical case of FP treated

with drug therapy and acupuncture, which at treatment completion presented mild weakness, small asymmetry of the mouth during movement, persistence of tearing, greater control in keeping food in the mouth and small activity of the mentalis muscle. The use of corticosteroids and antivirals has been the treatment most accepted and described in the literature.6 A clinical study by Ferraria et al.7 demonstrated the effectiveness of the combination of antiviral and corticosteroids in patients with Bell’s palsy. The use of isolated corticosteroids showed inferior results in relation to the association. Accordingly, Magalhaes et al.5, in a clinical case of facial

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):61-7

Silva MS, Nicolau RA, Pereira MA, Colombo CED

of low level. Regardless of the etiology of FP, treatments have been used to normalize the facial movements; however, complete cure is not always possible. LED therapy has been shown to be efficient in promoting greater cellular energy and, consequently, increasing its metabolic functions, such as stimulation of microcirculation, collagen production, analgesia, reduction of edema and erythema, stimulation of the local immune system, better tissue oxygenation and normalization of pH, accelerating the tissue repair process and minimizing the use of medications.8,9 Facial paralysis evolves differently according to the proposed treatments; therefore, the combination of drug therapy, physiotherapy, acupuncture, and various treatments described is essential, none of which should be replaced by light therapy. However, low-level LED therapy has been very useful, due to the decrease in drug prescription and rapid recovery of nerve fibers and facial muscle movements in a short period of time. The present clinical case corroborates data in the literature regarding the effectiveness of treatment, which is non-invasive, fast and painless.

paralysis compatible with Ramsay Hunt Syndrome, indicated treatment with acyclovir, leading to disappearance of lesions in the pinna and partial improvement of facial paralysis after 30 days of monitoring. In the present study, the patient was medicated with a combination of antiviral and corticoids, aiming to control the process of neurodegeneration, pain and inflammation. Low-level laser therapy in FP has been used in recent decades to control pain and inflammation in the acute phase and aid in the process of neuronal recovery and muscle motility.1 Viegas et al.6 presented a clinical case of FP treated with physiotherapy and corticosteroids, in which the paralysis was not solved by drug and physiotherapeutic treatment, with difficulty in moving the mouth and hypotonicity on the affected side. Thus, laser therapy was performed, and the movements of facial mimic muscles normalized in 40 days. LED therapy has recently been incorporated into the dental, physiotherapy, speech pathology and medical clinic. The difference between laser therapy and LED therapy is the lack of light coherence when LED equipment is used. However, the therapeutic wavelengths employed for both therapies are similar. Thus, the effects promoted by LEDs have been similar to those obtained by laser. LEDs have lower cost and less equipment wear over time, thus being advantageous in relation to lasers, in the case

FINAL CONSIDERATIONS It was concluded that low-level LED therapy, in the tested protocol, was effective in the treatment of acute FP, associated with Ramsay Hunt syndrome type II.

References:

1. Januário PO, Cruz AT, Garcez AG, Júnior ARP, Nicolau RA, Lima MO. Efeitos terapêuticos do biofeedback e do laser de baixa intensidade na função física e social em pacientes com paralisia facial periférica. Rev Ter Man. 2012;10(47):34-9. 2. Paraguassú GM, Souza JAC, Ferraz EG. Abordagem clínica e terapêutica da paralisia facial de Bell: uma revisão de literatura. Clipe Odonto - UNITAU. 2011; 3(1):45-9. 3. Jorge JS, Borges GC, Pialarissi PR, Júnior JJJ. Paralisia facial periférica traumática: avaliação clínica e cirúrgica. Rev Fac Ciênc Med Sorocaba. 2013;15(3):68-72. 4. Lazarini PR, Vianna MF, Alcântara MPA, Scalia RA, Filho HHC. Pesquisa do vírus herpes simples na saliva de pacientes com paralisia facial periférica de Bell. Rev Bras Otorrinolaringol. 2006;72(1):7-11.

5. Magalhães MJS, Cardoso MS, Gontijo IL. Ramsay Hunt syndrome - case report. Rev Bras Neurol Psiquiatr. 2014;18(3):247-52. 6. Viegas VN, Kreisner PE, Mariani C, Pagnoncelli RN. Laserterapia associada ao tratamento da Paralisia Facial de Bell. Rev Port Estomatol Cir Maxilofac. 2006; 47(1):43-8. 7. Ferraria LAM, Silva MIAP, Rosa MHC, Antunes LACJ. Tipo de terapêutica e fatores de prognóstico na paralisia de Bell: estudo retrospectivo de cinco anos em um hospital português. Sci Med. 2016: 26(1):21384. 8. Cavalcanti PM, Catão MHCV, Lins RDAU, Almeida-Barros RQ, Feitosa APA. Conhecimento das propriedades físicas e da interação do laser com os tecidos biológicos na odontologia. An Bras Dermatol. 2011;86(5):955-60.

9. Bispo LB. A nova tecnologia do laser terapêutico no controle da dor. Rev Bras Odontol. 2009;66(1):107-11. 10. Barros HC, Barros ALS, Nascimento MPR. Uso da acupuntura no tratamento da paralisia facial periférica estudo de caso. Rev Neurociênc. 2012;20(2):246-53.

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Information Information for authorsfor authors

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

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

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

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):68-72

Information for authors

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

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

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

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

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

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

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

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

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

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

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):68-72

Information for authors

REFERENCES - All papers cited in the text should be included in the reference list. - All references should be cited in the text. - To enhance reading, the references should be cited in the text indicating only their numbers. - The references should be indicated in the text by superscript Arabic numbers in order of appearance. - The abbreviations of journal titles should be formatted according to the publications “Index Medicus” and “Index to Dental Literature”. - The authors are responsible for the accuracy of references, which should contain all data necessary for their identification. - The references should be presented at the end of the text completion, following the Vancouver guidelines (http://www.nlm.nih.gov/bsd/uniform_requirements. html). - Use the examples below:

Book chapter Baker SB. Orthognathic surgery. In: Grabb and Smith’s Plastic Surgery. 6th ed. Baltimore: Lippincott Williams & Wilkins. 2007. Chap. 27, p. 256-67. Book chapter with editor Breedlove GK, Schorfheide AM. Adolescent pregnancy. 2nd ed. Wieczorek RR, editor. White Plains (NY): March of Dimes Education Services; 2001. Dissertation, thesis and monograph Ryckman MS. Three-dimensional assessment of soft tissue changes following maxillomandibular advancement surgery using cone beam computed tomography [Thesis]. Saint Louis: Saint Louis University; 2008. Electronic publication Sant´Ana E. Ortodontia e Cirurgia Ortognática – do planejamento à finalização. Rev Dental Press Ortod Ortop Facial. 2003 maio-jun;8(3):119-29 [Acesso 12 ago 2003]. Disponível em: http://www.dentalpress.com.br/ artigos/pdf/36.pdf.

Paper with up to six authors Espinar-Escalona E, Ruiz-Navarro MB, Barrera-Mora JM, Llamas-Carreras JM, Puigdollers-Pérez A, Ayala-Puente. True vertical validation in facial orthognathic surgery planning. Clin Exp Dent. 2013 Dec 1;5(5):e2318. Paper with more than six authors Pagnoni M, Amodeo G, Fadda MT, Brauner E, Guarino G, Virciglio P, et al. Juvenile idiopathic/rheumatoid arthritis and orthognatic surgery without mandibular osteotomies in the remittent phase. J Craniofac Surg. 2013 Nov;24(6):1940-5.

J Braz Coll Oral Maxillofac Surg. 2021 Jan-Apr;7(1):68-72

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.

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Notice to Authors and Consultants - Registration of Clinical Trials

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

WHO proposes that as a minimum requirement the following information be registered for each trial. A unique identification number, date of trial registration, secondary identities, sources of funding and material support, the main sponsor, other sponsors, contact for public queries, contact for scientific queries, public title of the study, scientific title, countries of recruitment, health problems studied, interventions, inclusion and exclusion criteria, study type, date of the first volunteer recruitment, sample size goal, recruitment status and primary and secondary result measurements. Currently, the Network of Collaborating Registers is organized in three categories: » Primary Registers: Comply with the minimum requirements and contribute to the portal; » Partner Registers: Comply with the minimum requirements but forward their data to the Portal only through a partnership with one of the Primary Registers; » Potential Registers: Currently under validation by the Portal’s Secretariat; do not as yet contribute to the Portal. 3. Journal of the Brazilian College of Oral and Maxillofacial Surgery Dental Journal of the Brazilian College of Oral and Maxillofacial Surgery endorses the policies for clinical trial registration enforced by the World Health Organization - WHO (http://www.who.int/ictrp/en/) and the International Committee of Medical Journal Ed-

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

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Revista JBCOMS - Vol. 7, Número 1, 2021

Articles inside

Information for authors

Low-intensity LED therapy in facial paralysis: Case report

Well-differentiated lipossarcoma of soft palate: case report and literature review

Osteoid osteoma in the mandible: Case report

Case reports

Bacterial adherence to silk and nylon sutures

Systematic review on firearm injuries in the face: state of the art and existing gaps

Relevance of Oral and Maxillofacial Surgery dental records for trauma hospital

Tribute

Interview

New CBCTBMF 2021/2022 board

New CBCTBMF board and the formation of the oral and maxillofacial surgeon

New Qualis periodics