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

Exatidão no diagnóstico e planejamento, em fração de milímetros.

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J Braz Coll Oral Maxillofac Surg. 2021 May-August;7(2):1-84

ISSN 2358-2782

Journal of the Brazilian

College of Oral and Maxillofacial Surgery JBCOMS

Since 2016

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

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

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

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

EDITOR-IN-CHIEF Sylvio Luiz Costa de Moraes Jonathan Ribeiro Belmiro Cavalcanti do Egito Vasconcelos Gabriela Granja Porto José Rodrigues Laureano Filho Marcelo Marotta Araújo

Universidade Federal Fluminense - Niterói/RJ / Centro Universitário São José - São José/RJ - Brazil Centro Universitário Serra dos Órgãos - UNIFESO - Teresópolis/RJ - Brazil Centro Universitário Serra dos Órgãos - UNIFESO - Teresópolis/RJ - Brazil Universidade de Pernambuco - FOP/UPE - Camaragibe/PE - Brazil Universidade de Pernambuco - Recife/PE - Brazil Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba - Piracicaba/SP - Brazil Universidade Estadual Paulista, Instituto de Ciência e Tecnologia - São José dos Campos/SP - Brazil

Private practice - Mexico Universidade Federal do Amazonas - UFAM - Manaus/AM - Brazil Faculdade Ciodonto - Porto Velho/RO - 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

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

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 de Moraes Nicolas Homsi Otacílio Luiz Chagas Júnior Raphael Capelli Guerra 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 Metodista de São Paulo - São Bernardo do Campo/SP - Brazil Universidade de Pernambuco - FOP/UPE - Camaragibe/PE - Brazil

rthognathic Surgery and Deformities O Adriano Rocha Germano Fernando Melhem Elias Gabriela Granja Porto Gabriela Mayrink Joel Motta Júnior José Laureano Filho José Thiers Carneiro Júnior Paul Maurette Rafael Alcalde Rafael Seabra Louro

Universidade Federal do Rio Grande do Norte - Natal/RN - Brazil Universidade de São Paulo - Hospital Universitário - São Paulo/SP - Brazil Universidade de Pernambuco, Recife/PE - 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

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

TMJ Disorders Belmiro Cavalcanti do Egito Vasconcelos Universidade de Pernambuco - FOP/UPE - Camaragibe/PE - Brazil Carlos E. Xavier dos Santos R. da Silva Instituto Prevent Senior – São Paulo/SP - Brazil Chi Yang Shanghai Jiao Tong University - China Eduardo Hochuli Vieira Universidade Estadual Paulista Júlio de Mesquita Filho - FOAR/Unesp - Araraquara/SP - Brazil Eduardo Seixas Cardoso Universidade Federal Fluminense - UFF - Niterói/RJ - Brazil João Carlos Birnfeld Wagner Santa Casa de Misericórdia - Porto Alegre/RS - Brazil Luis Raimundo Serra Rabelo Universidade Federal do Maranhão - UFMA - São Luís/MA - Brazil Patrícia Radaic Pastore Hospital Sirio Libanes - Instituto de Ensino e Pesquisa - São Paulo/SP - Brazil Sanjiv Nair Bangalore Institute of Dental Sciences - India 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 Universidade Federal Fluminense - UFF - Nova Friburgo/RJ - Brazil

Table of contents

An eye on the future Sylvio Luiz Costa de Moraes

Word from the president Marcelo Marotta Araújo

Germano, elected president for the 2023/2024 term of the Brazilian College of Buco-MaxilloFacial Surgery and Traumatology, discloses the goals of his administration Adriano R. Germano

Interview Rogério Belle de Oliveira Original Articles

Prospective evolution of nutritional status in maxillofacial trauma patients

Microbiological and antimicrobial evaluation of Bio-Oss®: an in vitro study

Dental surgeons’ self-perception of medical urgencies and emergencies

Assessment of the prevalence and profile of impacted lower third molars, using panoramic radiographs

Camila Roberta Silva, Marcio Bruno Figueiredo Amaral, Alessandro Oliveira de-Jesus, Samuel Macedo Costa, Caroline San Severino Teixeira

Graziella Pelegrini, Lina Naomi Hashizume, Marcus Vinicius Reis Só, Angelo Menuci Neto, Fernando Branco Barletta Deyverton dos Santos Mendes, Renan Rangel Roveta, Jenifer Malingre de Oliveira, Stella Cristina Soares Araújo, Samara Reis Hilário, Renata Pittella Cançado

Ana Patrícia Magalhães Ramos, Alynne Vieira de Menezes Pimenta, Edson Luiz Cetira-Filho, Lúcio Mitsuo Kurita, Fábio Wilson Gurgel Costa

Case reports

Primary palatoplasty by Bardach technique

Joint and mandibular reconstruction with customized prosthesis

Surgical treatment of sialolith on submandibular gland duct

Cutaneous non-Hodgkin’s lymphoma in face, after tooth extraction

Firearm projectile removal from the maxillary sinus

Botryoid odontogenic cyst: case report, evolution of four years

Information for authors

Pedro Henrique da Hora Sales, Edson Luiz Cetira-Filho, Fábio Wildson Gurgel Costa, José Ferreira da Cunha-Filho, Jair Carneiro Leão Paulo Afonso Oliveira Junior, Danilo Dressano, Armando de Barros, Felipe Calile Franck, João Lisboa de Sousa Filho Paulo Matheus Honda Tavares, Letícia dos Santos Nascimento, Valber Barbosa Martins, Marcelo Vinicius Oliveira, Gustavo Cavalcanti de Albuquerque, Saulo Lôbo Chateaubriand do Nascimento, Rafael Saraiva Torres José Renato Linhares Fernandes, Marcia Maria de Gouveia, Paulo Sergio Martins Alcântara Paulo Matheus Honda Tavares, Shirlan Mady Marques, Gustavo Cavalcanti de Albuquerque, Valber Barbosa Martins, Marcelo Vinicius Oliveira, Saulo Lôbo Chateaubriand do Nascimento, Rafael Saraiva Torres Gleysson Matias de Assis, Francisco de Assis de Souza Junior, Matheus Dantas Tertulino, Calebe Lamonier de Oliveira Costa Paiva, Adriano Rocha Germano

Editorial

An eye on the future In order to continue building a successful publication, it is necessary to comply with the so-called inflexible requirements. In addition to the technical-scientific excellence of the Editorial Board and the quality control of manuscripts, in the peer review process, it is important that the reviewers, who constitute the quality standard of the journal, have full knowledge on the publication guidelines. The editorial team has been continuously working on adapting the guidelines and, for this reason, being up-to-date with its content is essential. Fulfilling and enforcing the guidelines to collaborators, when submitting manuscripts, must be one of the reviewers’ commitments. Once again, it should be highlighted that the National Commission on Research Ethics (CONEP) – in agreement with CNS Resolutions n. 466 of 2012 and n. 510 of April 7th, 2016 – guided the Institutional Review Boards (IRB) and researchers, by Circular Letter N. 166/2018-CONEP/SECNS/MS of June 12th, 2018, on the procedures for submission of Case Reports to the IRB, by Plataforma Brasil. In the same step, if the Letter to the Editor contains a clinical case, it must also be submitted to the IRB. Therefore, it is not just a matter of filling an informed consent form signed by the patient and the author(s) sending it to the journal.

How to cite: Moraes SLC. An eye on the future. J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):4-5. DOI: https://doi.org/10.14436/2358-2782.7.2.004-005.edt

J Braz Coll Oral Maxillofac Surg. Surg. 2021 May-Aug;7(2):4-5

Editorial

Another important factor is the speed in reviewing articles and sending them back to the journal. After this stage, corrections are directed to the authors, who need to make the proposed changes or clarify any questions raised by the reviewers and, after these changes, they must send them back to the journal. This step will lead to a new review, for the reviewers’ consent or not. Therefore, the faster the resubmission of manuscripts by the authors, the faster will be the review. This entire process of receiving, reviewing, correcting and resubmitting takes time. Delays cause more delays, which compromises the publication flow. Thus, speed in the review of manuscripts should also be one of the reviewers’ commitments. Herein we list smaller, surmountable obstacles that can be solved by our proactivity. After overcoming these minor obstacles, we will move towards indexing in BBO (Bibliografia Brasileira de Odontologia) e LILACS (Literatura Latino-Americana e do Caribe em Ciências da Saúde) databases. Let’s keep united and focused on the continuous growth of our thriving journal! Prof. Sylvio Luiz Costa de Moraes Editor-in-chief of JBCOMS Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. Surg. 2021 May-Aug;7(2):4-5

Letter from the President

Word from the president

Dear members, When we took over the board, in the midst of the Coronavirus pandemic, we were aware of the difficulties. We just could not imagine that there would be so many challenges. The first difficult decision was the postponement of COBRAC – Belém, which will be held in 2024. COBRAC 2022, in Florianópolis, is maintained and we shall monitor the situation until next year. The main objective is to protect everyone involved in these large events. In the same line, regional meetings will be held online. This will be a great challenge. COPAC, Ennec and Sul Brasileiro will be held together, in a big online event, between November 18th and 20th, 2021! We rely on the participation of all members to make this great meeting a historical moment! In virtual format, we will maintain the high scientific level of face-to-face events! It was also necessary to schedule the election for the next President. In 2021 it was performed for the first time in online format! Besides being unprecedented, this election allowed, for the first time, the effective and full members with up-to-date obligations, emeritus members (former presidents) and redeemed members to vote, from 8 am on June 23 rd until 5 pm on June 24th. Professor Dr. Adriano Rocha Germano was elected as future president – board 2023/2024. The Continuing Education Commission has prepared a schedule of online lessons distributed by Chapters during the years 2021-2022. Each coordinator will organize the Webinar, which will be free for all members!

How to cite: Araújo MM. Word from the president. J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):6-7. DOI: https://doi.org/10.14436/2358-2782.7.2.006-007.crt

J Braz Coll Oral Maxillofac Surg. Surg. 2021 May-Aug;7(2):6-7

Carta do Presidente

Until July 2021, two events had already been held with great success: on May 22nd, Chapter III, with the theme ‘Biosafety Protocols for infectious diseases with emphasis on the new COVID-19 at the outpatient and inpatient level’; and, on June 19 th, Chapter XV, with the theme ‘Surgical treatment of maxillomandibular tumors and cysts’. The Continuing Education Courses of Chapter XI, on July 24th, are already scheduled; of Chapter X, on August 21st; of Chapter VIII, on September 25th; and Chapter XIII, on October 23rd. Check the themes and other information on the website https:// www.bucomaxilo.org.br/ The Bioethics Committee is working on a compliance rules handout and the creation of an Institutional Review Board! Our concern in always striving for quality in teaching and training students in our specialty is one of the main objectives of this board. In this sense, we presented suggestions for unifying the residency format to the CFO. Several meetings have already been held aiming at adapting the College’s activities in this sad period of our history, and this will continue until the end of this administration! The Board is united and working hard! You can count on us! God bless you all! Marcelo Marotta Araújo President 2021/2022 Brazilian College of Oral and Maxillofacial Surgery and Traumatology

J Braz Coll Oral Maxillofac Surg. Surg. 2021 May-Aug;7(2):6-7

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CBCTBMF

Germano, elected president for the 2023/2024 term of the Brazilian College of BucoMaxillo-Facial Surgery and Traumatology, discloses the goals of his administration “I will be attentive to all discussions that may harm or improve our field of work, in an ethical and responsible manner, proposing ideals, action strategies and assisting in the execution”, says Adriano R. Germano. Regarding the training of specialists in Oral and Maxillofacial Surgery, Adriano Germano wants to strengthen the learning actions, with national and international partnerships, and work with the Ministries of Education, Health and CFO, by actions to strengthen the training of maxillofacial surgeons in the residency modality, as well as the incorporation of new technologies. He also intends to return the specialist exam by the Brazilian College of Oral and Maxillofacial Surgery and Traumatology. Benefits to partners will also be a priority in the 2023/2024 board, according to Dr. Adriano R. Germano. “We want to improve a wide benefits club and assure discounts for the purchase of virtual planning and clinical management softwares for all members”, says the future president. In addition, his board intends to create, within the institutional website, a differentiated space, following ethical rules and based on legislation, to allow the dissemination of its clinical practice and professional academic performance, in order to foster its service network. “We also want to offer theoretical-practical courses with the CBCTBMF brand, benefiting members”, concludes Adriano Germano.

Adriano Rocha Germano, who has just been elected president of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology, board 2023/2024, has been a partner since 1997 and full member of the CBCTBMF. He was Chapter coordinator twice and general secretary in the past administration. Specialist by CFO, Master and Doctor in CTBMF by Unicamp, he attended a postdoctoral study at Hospital 12 de Octubre/Madrid-Spain. He is currently a Full Professor in the field of CTBMF at UFRN, Coordinator of the CTBMF Residency Program at Onofre Lopes University Hospital/UFRN, Post-Graduate Professor at MSc and PhD programs/UFRN, oral and maxillofacial surgeon at Hospital Infantil Varela Santiago/RN and also works in private practice at the Centro de Reabilitação Maxilo-Facial/Natal/RN. According to Adriano Rocha Germano, his management will be marked by strengthening the actions of chapters with the CROs and the headquarters with the CFO, in defense of professional practice and professional development. With regard to professional development, it is necessary to have an updated fee table with health insurance companies and SUS. There will be no lack of efforts by the board to make the JBCOMS the greatest reference in the field in Latin America, besides strengthening relations with the various CBMF associations around the world. The aim will be to create a direct and transparent channel for dialogue with the ANS, regarding issues of the specialty, and to implement, within the national congress, a support group for the development of the category. Also, the future president intends to create a plan to promote the specialty and members in local and national media, as well as to encourage clinics and hospitals to establish partnerships with members of the CBCTBMF.

Prof. Adriano R. Germano President of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology (Board 2023/2024)

How to cite: Germano AR. Germano, elected president for the 2023/2024 term of the Brazilian College of Buco-Maxillo-Facial Surgery and Traumatology, discloses the goals of his administration. J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):11. DOI: https://doi.org/10.14436/2358-2782.7.2.011-011.col

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):11

Interview

Interview with Rogério Belle de Oliveira

» Scientific Director of CBCTBMF board 2021/2022.

What will be the Continuing Education (CE) project of the 2021/2022 board of CBCBTBMF? The Continuing Education (CE) the Brazilian College of Oral and Maxillofacial Surgery and Traumatology was an idea that emerged in the past board of directors. As soon as Dr. Marcelo Marotta Araujo was elected, the development of this project and its implementation as a continuous technical-scientific update structure for members of the College was initiated. Due to the COVID-19 pandemic, several changes were necessary and, finally, we reached this final project, with an online Continuing Education model via the Zoom platform. The initial idea was to hold events in each

state, with Chapters and themes defined by the Directors Board of the College; however, during the meetings of the Directors Board and Council of the College, the proposal for the online project was consolidated. From then onwards, a platform was sought that would meet the needs of integration between all Chapters and to which all members of the College could have access. Thus, the CE of CBCTBMF is scheduled to occur online by the Zoom platform, with themes already defined by the board and presented to all Chapter coordinators. Each month, a Chapter will be responsible for a national CE webinar.

How to cite: Oliveira RB, Ribeiro J. Interview with Rogério Belle de Oliveira. J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):12-3. DOI: https://doi.org/10.14436/2358-2782.7.2.012-013.ent Submitted: June 01, 2021 - Revised and accepted: June 15, 2021

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):12-3

Oliveira RB, Ribeiro J

Table 1 - Themes for the first Continuing Education events.

The Zoom platform opens up a new possibility for Chapter coordinators, since the Educational Meeting Events (EED), which are part of our statute and bylaws, can also be held online. Thus, Chapter coordinators will be able to perform several online activities with their Chapter members and even invite other Chapters to participate. Therefore, the project initially conceived is now an established reality. The Continuing Education of the College will be held online with the Zoom Webinar tool. These online CE events will have national scope, and for regular members registration for the Webinar is sufficient, at no additional cost. The Educational Meeting Events of each Chapter will be online using the Zoom Meeting tool. These EEDs will have regional coverage and, for regular members of the Chapter and others, registration for the Meeting is enough, without additional costs. Who can participate? Residents in oral and maxillofacial surgery too, for example? The proposal of the CE and EED of the College is to offer all members an online platform for webinars and meetings. All categories of College members will have access to CE and EED online events by registration and without participation costs. Colleagues who are not members of the College will have access upon registration at a cost of R$ 250.00 per online event. However, the goal is for more colleagues to join the College, since with the semester fee up to date, access to online events will be free of charge.

Chapter

22/05/2021

III

19/06/2021

24/07/2021

XII

21/08/2021

25/09/2021

VIII

23/10/2021

XIII

Theme Biosafety Protocols for infectious diseases with emphasis on the new COVID-19 at the outpatient and inpatient level Surgical treatment of maxillomandibular tumors and cysts Surgical treatment of impacted teeth / complex extractions. Drug therapy and adjutant therapies in the perioperative period of oral surgeries Anesthesiology and anxiety control in outpatient surgical patients Treatment of TMDs: - Clinical and imaging diagnosis; - Clinical and surgical treatment. Surgical approach for patients with systemic comorbidities

What will be the format and frequency? Online and monthly format for CE – Zoom Webinar platform. For EED, online format by Zoom Meeting platform – activities will be published by Chapter Coordinators over the months. This shall star on May 25th. When will it end? The Continuing Education proposal is permanent for members of the College. We have CE Webinars scheduled until December 2022. We are waiting for the online election of the next president of the College, so that we can start planning the themes and agenda for the period 2023-2024.

Besides the objective of expanding the training of oral and maxillofacial surgeons, in times of pandemic, how do you see the importance of this project? The main objective of the Directors Board of the College is, on an ongoing basis, to update the technical-scientific knowledge of the specialty for all regular members. It is also understood that it will be an excellent tool for integration between members of different Chapters and an approximation of conviviality and respect among colleagues in the exercise of the specialty.

Interviewer: Prof. Dr. Jonathan Ribeiro

Are the themes already defined? If yes, what are they? The themes for the first Continuing Education events are defined and are described in Table 1. A national Continuing Education event with participation of all academic leagues registered in the College is planned by the Zoom webinar for December 4th 2021 .

Date

- Associate Editor-in-Chief of JBCOMS Journal of the Brazilian College of Oral and Maxillofacial Surgery.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):12-3

Original Article

Prospective evolution of nutritional status in maxillofacial trauma patients CAMILA ROBERTA SILVA1 | MARCIO BRUNO FIGUEIREDO AMARAL2 | ALESSANDRO OLIVEIRA DE-JESUS3 | SAMUEL MACEDO COSTA4 | CAROLINE SAN SEVERINO TEIXEIRA5

ABSTRACT Introduction: Patients undergoing maxillofacial trauma are susceptible to malnutrition due to compromised oral and swallow function, and increased for nutrients demands for wound healing. Objective: This study aimed to demonstrate a prospective evolution of nutritional status in maxillofacial trauma victims. Methods: A cohort, prospective, descriptive and analytical study was performed, during June to December 2019, at two trauma hospitals in Belo Horizonte, Brazil. The nutritional status was measured in four nutritional assessment, being evaluated from the diet, weight, height, body mass index, arm circumference, weight loss and nutritional diagnosis. Results: Forty-five patients were included in this study, with a median age of 31 years (q1-q3: 23-47.5). Most patients were male (88.9%). Concerning the types of fractures, mandible fracture was predominated (n=25, 55.6%). Thirty-five patients (77.8%) underwent surgical treatment and 27 patients (60%) did not do intermaxillary fixation. Weight loss was significantly higher in the first 30 days after the trauma, and the most affected patients were those who presented fractures of more than one facial bone (1.4%), followed by those with isolated mandible fractures (1, 2%) (p=0.04). Conclusion: During treatment, victims of exclusive maxillofacial trauma showed impaired nutritional status. The first 30 days after the trauma was the most critical period for the nutritional condition, and it is recommended to initiate complementary nutritional therapy through oral or enteral supplementation at this time. Keywords: Nutritional status. Malnutrition. Mandibular Fractures. Maxillofacial injuries.

Nutritionist, Specialist in Emergency and Trauma, Hospital João XXIII/FHEMIG, Programa de Residência Multiprofissional em Nutrição (Belo Horizonte/MG, Brazil). PhD in Dentistry, Hospital João XXIII/FHEMIG, Programa de Residência em Cirurgia Buco-Maxilo-Facial (Belo Horizonte/MG, Brazil). 3 Master of Dentistry, Hospital João XXIII/FHEMIG, Programa de Residência em Cirurgia Buco-Maxilo-Facial (Belo Horizonte/MG, Brazil). 4 Bachelor of Dentistry, Hospital João XXIII/FHEMIG, Programa de Residência em Cirurgia Buco-Maxilo-Facial (Belo Horizonte/MG, Brazil). 5 Nutritionist, MSc in Women’s Health, Programa de Residência Multiprofissional em Nutrição (Belo Horizonte/MG, Brazil).

How to cite: Silva CR, Amaral MBF, De-Jesus AO, Costa SM, Teixeira CSS. Prospective evolution of nutritional status in maxillofacial trauma patients. J Braz Coll Oral Maxillofac Surg. 2021 MayAug;7(2):14-21. DOI: https://doi.org/10.14436/2358-2782.7.2.014-021.oar

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

Contact address: Camila Roberta Silva E-mail: camilas919@gmail.com

Submitted: April 06, 2020 - Revised and accepted: September 22, 2020

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):14-21

Silva CR, Amaral MBF, De-Jesus AO, Costa SM, Teixeira CSS

INTRODUCTION The prevalence of hospital malnutrition varies from 20% to 50% worldwide.1 Among malnourished patients, there is an increase in length of stay and hospital costs, greater chance of complications, such as increased risk of infections, due to reduced immunity and reduced wound healing, among other consequences.2 Patients who suffer maxillofacial trauma are at increased risk of malnutrition, because of changes in masticatory function and swallowing due to: compromised oral function by the fractures, fixation methods (stable or rigid), intermaxillary fixation (IMF) and postoperative edema, besides increased nutrient demands for wound healing.3-5 Patients with facial fractures commonly need a diet with modified consistency. Thus, a liquid or pasty diet is routinely recommended to avoid unnecessary mobility and stress at the fracture site.6 Also, some authors suggest that a liquid diet is necessary in patients submitted to intermaxillary fixation and that this diet should be maintained, preferably, until release of the IMF, which can vary from two to six weeks.4 This variation is established according to the type, location, number and severity of facial fractures, but also according to the patient’s age, previous health status and the method used to reduce and fixate the fractures.7-8 It is known that softer diets generally do not provide the nutrient requirements of traumatized patients, since they contain lower amounts of calories, proteins, vitamins and minerals.9 Additionally, these patients can also have lack of appetite, nausea and vomiting, which are related to worsening of their nutritional status and contribute to malnutrition.3 In this context and considering the scarcity of publications investigating nutritional impairment in victims of maxillofacial fractures, the present study aimed to monitor the evolution of nutritional status in patients with facial fractures that alter the masticatory function.

able to walk, who had no change in the consciousness level and had indication for liquid or pasty diet. The patients included in the study were diagnosed with fractures of the mandible, maxilla, zygomatic complex or an association of these fractures, treated at João XXIII/FHEMIG (Level 1 in trauma) and Maria Amélia Lins/FHEMIG hospitals, in the city of Belo Horizonte/MG, Brazil. Exclusion criteria comprised patients using enteral or parenteral nutrition, multiple trauma patients, pregnant women, non-compensated diabetics, patients with other associated systemic diseases, patients with facial fractures that do not change the masticatory function (frontal sinus, nasoorbitoethmoidal fractures and isolated orbit fractures) and individuals who did not return at least once for follow-up visits. Nutritional evaluation The nutritional status was assessed based on diet, body weight, height, body mass index (BMI), arm circumference (AC), percentage of weight loss and nutritional diagnosis. Patients included in the study were submitted to four assessments of nutritional status, namely: 1) first assessment: performed during hospitalization, as early as possible after patient admission; and 2) other assessments: performed in an outpatient setting, together with clinical reassessments by the Maxillofacial Surgery and Traumatology team. A minimum interval of seven days and a maximum of thirty days between outpatient evaluations was determined. Blood samples were collected twice during the study, with a minimum interval of one month between them, for analysis of serum albumin and total lymphocyte count (TLC). The use or not of IMF, fracture location and type of treatment were also analyzed. Body weight was obtained using a calibrated digital scale (Camry®). Height was measured using a stadiometer (Cescorf®), and arm circumference was achieved using an inelastic measuring tape, with 1-mm accuracy. The BMI was calculated and classified according to the cutoff points of the World Health Organization.10 The result obtained for arm circumference was compared to the values of the percentile table of Frisancho11 and classified as suggested by Blackburn and Thornton.12 Nutritional diagnosis was obtained by subjective global assessment, standardized by Detsky et al.,13 and biochemical parameters were interpreted according to Bottoni et al.14

METHODS Patients and study design This study was approved by the Institutional Review Board under number CAAE: 14198619.1.0000.5119 and all participants signed an Informed Consent Form. This was a cohort, prospective, descriptive-analytical study, conducted from June to December 2019. The sample was selected by convenience and included adult individuals, aged 18 to 65 years, of both sexes,

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):14-21

Prospective evolution of nutritional status in maxillofacial trauma patients

Results Forty-five patients were included, with median age of 31 years (q1-q3: 23-47.5), mostly males (88.9%). Regarding the types of fractures, there was predominance of isolated mandible fractures (n=25, 55.6%), followed by fractures of more than one facial bone (n=16, 35.6%) and isolated fractures of the zygomatic complex (n=4, 8.9%). No patient evaluated presented isolated maxillary fracture. Concerning the type of treatment, 35 patients (77.8%) underwent surgical treatment, and 10 patients (22.2%) underwent conservative treatment, with 27 (60%) of these patients not submitted to IMF. The main characteristics of the patients are shown in Table 1.

Statistical analysis All collected data were analyzed using SPSS Statistic® for Windows, version 20 (SPSS Inc., Chicago, IL, USA). For categorical variables, the absolute and relative frequency (%) was used. The median (Q1Q3) was used for continuous variables. The Shapiro-Wilk test was used to assess the distribution, according to the sample size (non-normal distribution). Parametric and/or non-parametric tests were used when appropriate. For comparative analyses, the chi-square test and the Mann-Whitney U test were used. Values of p < 0.05 were considered statistically significant.

Table 1: Sociodemographic characteristics and related to treatment. Age (years)

31 (23 – 47.5)

Sex Male Female Ethnicity White Admixed Black Fractures Mandible Maxilla Zygomatic complex Associated fractures Treatment Conservative Surgical Use of IMF No Yes

40 (88.9%) 5 (11.1%) 13 (28.9%) 12 (26.7%) 20 (44.4%) 25 (55.6%) 0 (0.0%) 4 (8.9%) 16 (35.6%) 10 (22.2%) 35 (77.8%) 27 (60.0%) 18 (40.0%)

The values are presented in number (%) or median (q1 – q3).

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):14-21

Silva CR, Amaral MBF, De-Jesus AO, Costa SM, Teixeira CSS

evaluations. The complete nutritional data presented by the patients included in the study are described in Tables 2 and 3. In the second nutritional assessment, weight loss was significantly higher among patients with fractures of more than one facial bone (1.4%), followed by isolated mandible fracture (1.2%) and isolated zygomatic complex (0%) (p=0.04). There was no significant difference in weight loss in the other nutritional reassessments, in relation to the type of fracture. The study also compared the association of weight loss, in the different assessments, with the types of treatments performed and the use or not of IMF; however, no statistical difference was found (Table 4). Considering the nutritional diagnosis in relation to the types of fractures, treatments and the use of IMF, there was no statistically significant difference.

Considering the nutritional assessment, 27 patients underwent the four proposed assessments. The mean of assessments performed per patient was 3.3 (±0.83) and the mean time interval between one assessment and another was 12 days (±1.47). Most patients were classified as “nourished” in the first nutritional assessment (62.2%) and as “suspected or moderate malnutrition” in the second (60.0%) and third assessments (60.0%). However, in the last assessment, most were again classified as “nourished” (66.7%). Considering all evaluations performed, none of the evaluated patients were classified as “severe malnutrition” (Fig 1). At the first evaluation, eight (17.7%) patients were using oral hypercaloric and high-protein nutritional supplement twice a day. However, the use of nutritional supplementation was not observed in subsequent

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Evaluation 1 Nourished

Evaluation 2

Evaluation 3

Evaluation 4

Suspected or moderate malnutrition

Figure 1: Nutritional diagnosis over time.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):14-21

Prospective evolution of nutritional status in maxillofacial trauma patients

Table 2: Nutritional parameters. n=45

Height (m)

1.71 (1.64 – 1.78)

Routine weight (kg)

65 (59.0 – 81.5)

Current weight (kg)

Evaluation 1

Evaluation 2

Evaluation 3

Evaluation 4

n=45

n=35

n=27

63.9 (59.3-78.5)

64 (56.5 – 78.9)

63.3 (55.7 – 79.9)

61.1 (52.9 – 79.8)

2.5 (0.0 – 4.8)*

1.1 (0.0 – 3.0)

0.9 (0.0 – 3.5)

0.2 (0.0 – 2.7)

Weight loss No

2 (4.4%)

Yes

43 (95.6%)

Weight loss (%) BMI (kg/m )

21.9 (20.5– 24.9) 22.0 (19.8 – 25.0) 21.0 (19.4 – 25.1)

21.6 (19.7 – 25.9)

BMI score Underweight II

1 (2.2%)

4 (8.9%)

2 (5.7%)

2 (7.4%)

Underweight I

2 (4.4%)

1 (2.2%)

3 (8.6%)

0 (0.0%)

Eutrophy

31 (68.9%)

28 (62.2%)

21 (60.0%)

16 (59.3%)

Overweight

9 (20.0%)

8 (17.8%)

8 (22.9%)

8 (29.6%)

Obesity I

2 (4.4%)

4 (8.9%)

1 (2.9%)

1 (3.7%)

Nourished

28 (62.2%)

18 (40.0%)

14 (40.0%)

18 (66.7%)

Suspected or moderate malnutrition

17 (37.8%)

27 (60.0%)

21 (60.0%)

9 (33.3%)

Severe malnutrition

0 (0.0%)

Nutritional diagnosis

Reduction of AC No

15 (33.3%)

Yes

30 (66.7%)

AC (cm)

28.0 (26.0– 31.0) 27.2 (25.5 – 30.6) 27.5 (24.8 – 30.5)

27.0 (24.1 – 31.0)

Classification of AC Severe malnutrition

0 (0.0%)

Moderate malnutrition

8 (17.8%)

9 (20.0%)

9 (25.7%)

8 (29.6%)

Mild malnutrition

12 (26.7%)

15 (33.3%)

10 (28.6%)

6 (22.2%)

Eutrophy

21 (46.7%)

17 (37.8%)

13 (37.1%)

12 (44.4%)

Overweight

3 (6.7%)

4 (8.9%)

3 (8.6%)

1 (3.7%)

Obesity

1 (2.2%)

0.0 (0.0%)

Completely liquid

8 (17.8%)

7 (15.6%)

5 (14.3%)

2 (7.4%)

Diet consistency Paste

16 (35.6%)

14 (31.1%)

8 (22.9%)

4 (14.8%)

Bland

6 (13.3%)

16 (35.6%)

11 (31.4%)

12 (44.4%)

Livre

15 (33.3%)

8 (17.8%)

11 (31.4%)

9 (33.3%)

The values are presented as number (%) or median (q1 – q3). *Weight loss in relation to habitual weight. AC: arm circumference. BMI: body mass index.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):14-21

Silva CR, Amaral MBF, De-Jesus AO, Costa SM, Teixeira CSS

Table 3: Biochemical parameters*.

Albumin** Normal Mild depletion Moderate depletion Severe depletion Total lymphocytes count *** Normal Mild depletion Moderate depletion Severe depletion

Dose 1 (n=36)

Dose 2 (n=26)

32 (89.9%) 4 (11.1%) 0 (0.0%) 0 (0.0%)

26 (100%) 0 (0.0%) 0 (0.0%) 0 (0.0%)

9 (21.4%) 22 (52.4%) 9 (21.4%) 2 (4.8%)

16 (57.1%) 12 (42.9%) 0 (0.0%) 0 (0.0%)

The values are presented in number (%). * Blood samples for biochemical analyses were collected in a mean time interval of 35 days (±7.12). ** Reference values employed for analysis of serum albumin: Normal: > 3.5 g/dl; Mild depletion: 3.0 – 3.5 g/dl; Moderate depletion: 2.4 – 2.9 g/dl; Severe depletion: < 2.4 g/dl. *** Reference values used for analysis of Total Lymphocyte Count: Mild depletion: 1200 – 2000/mm3; Moderate depletion: 800 – 1199/mm3; Severe depletion: < 800/mm3.

Table 4: Association of type of fracture, type of treatment and use of IMF with weight loss. Type of fracture

Weight loss 2

Weight loss 3

Weight loss 4

Mandible Associated fractures Zygomatic Mandible Associated fractures Zygomatic Mandible Associated fractures Zygomatic

Type of treatment

1.2 (0.0-2.6) 1.4 (0.7-4.1)

p=0.042

0.0 (0.0-0.3) 0.6 (0.0-3.3) 3.0 (0.0-4.6)

p=0.498

1.2 (1.2-1.2) 0.0 (0.0-3.9) 0.8 (0.0-3.4)

p=0.584

Conservative

0.9 (0.0-2.9)

Surgical

1.1 (0.0-3.2)

Conservative

1.2 (0.5-2.4)

Surgical

1.2 (0.0-4.1)

Conservative

0.0 (0.0-2.2)

Surgical

0.4 (0.0-3.5)

Use of IMF

p=0.819

p=0.848

p=0.377

0.7 (0.0-1.9)

Yes

2.3 (0.0-1.9)

0.5 (0.0-3.3)

Yes

3.0 (0.1-4.5)

0.2 (0.0-0.6)

Yes

2.2 (0.0-6.1)

p=0.125

p=0.055

p=0.074

0.4 (0.4-0.4)

The values are presented as median (q1 – q3).

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):14-21

Prospective evolution of nutritional status in maxillofacial trauma patients

Discussion In the present study, which evaluated the nutritional status of patients victims of maxillofacial trauma, almost all patients (95.6%) had some weight loss during follow-up (Table 2). The most expressive weight loss occurred in victims of fractures of more than one facial bone and isolated mandible fracture. The second nutritional assessment was performed up to 30 days after trauma, indicating that this may be the moment of greatest susceptibility of the patient victim of maxillofacial trauma to compromise the nutritional status, and the most important moment to establish the complementary nutritional therapy, by oral supplementation or enteral diet. Several authors also found a reduction in body weight in patients victims of maxillofacial trauma.15-17 Christensen et al.6 quantified the effects of mandibular fractures and their treatments on the body weight of 439 patients and found a loss of 4.9% in relation to the initial weight, after 49 days of surgery. They also observed a loss of 8.8% of body weight in patients hospitalized in Intensive Care Units, demonstrating greater impairment of nutritional status in patients with severe injury. It was observed that most patients did not correctly follow the liquid or pasty diet, despite its indication. This may explain the fact that there was no further reduction in body weight and more severe nutritional deficiencies. Also, it is important to emphasize that the consumption of foods with mild or normal consistency in patients after maxillofacial trauma could have increased the time required for fracture consolidation, pain, edema and infection due to unnecessary mobilization, stress at the fracture site and difficult cleaning of the oral cavity. When comparing the types of treatments with weight loss at the three moments (assessment 2, 3 and 4), no statistical difference was found. The same occurred when analyzing the use or not of IMF and weight loss. However, it should be noted that most patients underwent surgical treatment (n=35, 77.8%) without IMF (n=27, 60%), not correctly following the guidelines regarding the modification of diet consistency, which could explain the non-observation of an even greater body weight loss.

Cawood18 and Worrall19 also compared the nutritional status based on weight loss with the types of treatment instituted in patients with mandible fractures and found that patients who underwent surgery with stable internal fixation had a smaller reduction in body weight and fewer nutritional deficiencies. Jaworska et al.20 prospectively evaluated 83 patients who underwent maxillofacial surgery and observed a significant reduction in BMI in all patients 10 and 60 days after admission. However, they observed an increase in BMI between 60 and 180 days after admission and a mean time of 2.5 months for patients to return to their usual weight. This trend was similar to that found in this study, when the result of nutritional diagnosis was analyzed. In the second and third nutritional assessments, most patients were classified as “suspected or moderate malnutrition”, and in the fourth assessment as “nourished”, which showed nutritional recovery two months after the trauma. Regarding arm circumference, most patients (n=30, 66.7%) had a reduction in the measurement at some point during the study, although most were classified in the “eutrophy” category, according to the adequacy of the AC, in the four nutritional evaluations. The arm circumference represents the sum of areas constituted by bone, muscle and fat tissues of the arm, and its reduction is related to worsening of the nutritional status.11 Regarding the biochemical parameters and nutritional status, most patients were classified as “normal”, according to the serum albumin values in both doses, suggesting an adequate supply of caloric and protein substrate. Regarding the total lymphocyte count, in the first dose, most patients were classified as “mild depletion” and, in the second dose, as “normal”, as expected, since TLC is influenced by non-nutritional factors as trauma. It should be mentioned that this study had some limitations. Since four nutritional assessments were performed, some in an outpatient setting, some patients did not return for reassessments, causing losses in the study sample. Another important point is that several patients evolved their diet consistency without guidance by a professional, which may have caused clinical complications, which were not measured in this study.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):14-21

Silva CR, Amaral MBF, De-Jesus AO, Costa SM, Teixeira CSS

Conclusion From this study, it was observed that, during treatment, victims of exclusive maxillofacial trauma had impaired nutritional status, especially patients who suffered fractures of more than one facial bone and those affected by mandible fracture. The first 30 days after

fractures were the most critical from a nutritional standpoint, and it is recommended to establish complementary nutritional therapy, by oral or enteral supplementation, at this stage. Further studies should be performed to assess the evolution of nutritional status in patients with maxillofacial fractures.

References:

1. Norman K, Pichard C, Lochs H, Pirlich M. Prognostic impact of disease-related malnutrition. Clin Nutr. 2008;27(1):5-15. 2. Correia MI, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr. 2003;22(3): 235-9 3. Hughes P, Bradrick JP, Yowler CJ. Nutrition for the oral and maxillofacial surgery patient. In: Fonseca RJ, Walker RV, Barber HD, Powers MP, Frost DE, editors. Oral and maxillofacial trauma. 4th ed. St. Louis: Mosby; 2013. p. 30-47. 4. Giridhar VU. Role of nutrition in oral and maxillofacial surgery patients. Natl J Maxillofac Surg 2016;7(1):3-9 5. Jain S, Jain A, Palekar U, Shigli K, Pillai A, Pathak AD.Nutritional considerations for patients undergoing maxillofacial surgery: a literature review. Indian J Dent. 2014;5(Suppl):52-55. 6. Christensen BJ, Chapple AG, King BJ. How much weight loss can be expected after treating mandibular fractures? J Oral Maxillofac Surg.2019;77(4):777-82. 7. Yazdani J, Hajizadeh S, Ghavimi MA, Gargari BP, Nourizadeh A, Kananizadeh Y. Evaluation of changes in anthropometric indexes due to intermaxillary fixation following facial fractures. J Dent Res Dent Clin Dent Prospects. 2016;10(4):247-50.

8. Smith BM, Deshmukh AM, Barber HD, Fonseca RJ. Mandibular fractures. ln: Fonseca RJ, Walker RV, Barber HD, Powers MP, Frost DE, editors. Oral and maxillofacial trauma. 4th ed. St. Louis: Mosby; 2013. p. 717-805. 9. Bobamuratova DT, Boymuradov ShA, Rakhmonov SB, Olimjonov TA. Nutrition of patients with jaw fracture and after orthognatik surgery, review of the literature. J Dent Oral Disord Ther. 2018;6(2):1-7. 10. World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. Geneva: World Health Organization; 2000. (WHO - Technical Report Series, 894). 11. Frisancho AR. New norms of upper limb fat and muscle áreas for assessment of nutritional status. Am J Clin Nutr. 1981;34(11):2540-5. 12. Blackburn GL, Thornton PA. Nutritional assessment of the hospitalized patients. Med Clin North Am. 1979;63(5):1103-15. 13. Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson RA, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Nutr Enteral. 1987;11(1):8-13. 14. Bottoni A, Oliveira GPC, Ferrini MT, Waitzberg DL. Avaliação nutricional: exames laboratoriais. In: Waitzberg DL, editor. Nutrição oral, enteral e parenteral da prática clínica. Rio de Janeiro: Atheneu; 2000. p.279-94.

15. Kayani SG, Ahmed W, Farooq M, Rehman AU, Nafees Q, Baig AM. Weight loss due to maxillomandibular fixation in mandibular fractures. Pak Oral Dental J. 2015;35(3):374-6. 16. Ritzau M. Weight changes in patients with intermaxillary immobilization after jaw fractures. Int J Oral Surg. 1973;2(3):122-3. 17. Kuvat SV, Güven E, Hocaoqlu E, Bazaran K, Marzan G, Cura N, et al. Body fat composition and weight changes after double-jaw osteotomy. J Craniofac Surg. 2010;21(5):1516-8. 18. Cawood JI. Small plate osteosynthesis of mandibular fractures. Br J Oral Maxillofac Surg.1985;23(2):77-91. 19. Worrall SF. Changes in weight and body composition after orthognathic surgery and jaws fractures: a comparison of miniplates and intermaxillary fixation. Br J Oral Maxillofac Surg. 1994;32(5):289-92. 20. Jaworska E, Lewandowski Z, Samolczyk-wanyura D, Lawinski M, Pertkiewicz M. Method of nutrition of patients after major oral and craniofacial surgery and its effects on BMI changes during a half-year period of observation. Pol Przegl Chir. 2014;86(7):305-11.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):14-21

Original Article

Microbiological and antimicrobial evaluation of Bio-Oss®: an in vitro study GRAZIELLA PELEGRINI1 | LINA NAOMI HASHIZUME2 | MARCUS VINICIUS REIS SÓ2 | ANGELO MENUCI NETO3 | FERNANDO BRANCO BARLETTA1

ABSTRACT Introduction: Bone substitutes are materials designed to resemble and replace human bone. Objective: The objective of the study was to evaluate the contamination of the commercial product Bio-Oss® along the time after opening. Methods: Twelve vials of Bio-Oss® were tested at different time points: immediately after opening, 24 h, 48h, 72h, 7d, 14d and 21 days after. Suspensions of the commercial product were plated in culture media to evaluate yeasts, Streptococcus and total oral microorganisms growth. The plates were incubated at 37°C for 48 hours and the number of microorganisms was determined. Antimicrobial effect of the product was also verified by a disc-diffusion test. Results: No growth of total oral microorganisms, Streptococcus or yeasts was observed along the observed time (p>0.99). The product was not presented inhibition of total oral microorganisms in disc-diffusion test (p=0.1). Conclusion: It can be concluded that Bio-Oss® does not present microbial contamination in an interval of up to 21 days, when manipulated and stored aseptically. Keywords: Apicoectomy. Biological contamination. Bone regeneration. Microbiological techniques.

How to cite: Pelegrini G, Hashizume LN, Só MVR, Menuci Neto A, Barletta FB. Microbiological and antimicrobial evaluation of Bio-Oss®: an in vitro study. J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):22-8. DOI: https://doi.org/10.14436/2358-2782.7.2.022-028.oar

Universidade Luterana do Brasil, Endodontia (Canoas/RS, Brazil). Universidade Federal do Rio Grande do Sul, Endodontia (Porto Alegre/RS, Brazil). 3 Associação Brasileira de Odontologia Rio Grande do Sul, Cirurgia e Traumatologia Bucomaxilofacial (Porto Alegre/RS, Brazil). 1 2

Submitted: April 29, 2020 - Revised and accepted: October 07, 2020 Contact address: Graziella Pelegrini E-mail: graziella_pelegrini54@hotmail.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 May-Aug;7(2):22-8

Pelegrini G, Hashizume LN, Só MVR, Menuci Neto A, Barletta FB

METHODS Commercial product and experimental times The present study analyzed twelve flasks of BioOss, brand Geistlich, containing 1 g in each flasks, to verify the presence or absence of contamination at the time of opening and after twenty-four hours, forty-eight hours, seventy-two hours, seven days, fourteen days and twenty-one days. Bio-Oss® flasks were properly coded as A, B, C, D, E, F, G, H, I, J, K and L. The material was always handled aseptically inside a laminar flow chamber. Microbiological analysis To evaluate the degree of product contamination over time, the following microorganisms were selected for analysis: oral streptococci, total microorganisms and fungi/yeasts, according to Hashizume et al. 6 In the present study, the following culture media were used for selection and growth of selected microorganisms: Mitis Salivarius Agar (MS) (Difco, USA), for growth of oral streptococci; Brain Heart Infusion (BHI) Agar (Himedia, India) plus sheep blood for the growth of total microorganisms; and Sabouraud Agar with Chloramphenicol (SAB) (Himedia, India), for the growth of fungi/yeasts. The media were prepared according to the manufacturer’s instructions and sterilized in an autoclave for 15 minutes at 121 oC. For each experimental time, six plates were prepared for each culture medium. Suspensions were prepared with 0.1 g of the commercial product weighed on an analytical balance (Sartorius, Gottingen, Germany) (Fig 1). The product was collected using a sterile cement spatula (Duflex, Minas Gerais, Brazil) and added to properly coded sterile microtubes (Eppendorf, Hamburg, Germany). The vials were closed with the original lid and masking tape and underwent external disinfection with 70% alcohol and sterile gauze, being stored in the plastic envelope that accompanies the tube with biomaterial, also disinfected with 70% alcohol and sterile gauze, maintained at room temperature. Then, 1 mL of sterile saline solution was added to each flask, shaken for 20 seconds in a shaker (Phoenix, São Paulo, Brazil). A serial decimal dilution of the initial suspension was performed three times (Fig 2), and 25 µL of each dilution were seeded on plates containing the different culture media de-

INTRODUCTION Paraendodontic surgery is considered the last resource to preserve the tooth, being used when endodontic retreatment was not successful or when related to therapeutic risks. 1,2 Surgical intervention is indicated for the resolution of problems not solved by root canal treatment, such as persistent lesions in the apical region, inaccessible areas associated with the presence of intraradicular pins and unsatisfactory endodontic treatment, in which the risk of vertical or horizontal fracture is imminent. 3 In the presence of extensive bone lesions, bone regeneration does not occur completely (with areas of fibrous healing), and the defect heals by repairing fibrous connective tissue. 4 To prevent this, some authors recommend the use of biomaterials to aid bone regeneration in large lesions, in which bone regeneration will be faster compared to cases in which the technique was not used, including alveolar bone regeneration and periodontal ligament, as well as cementum repair.4,5 Bio-Oss® (Geistlich Pharma do Brasil, São Paulo/SP, Brazil) is the most commonly used bone replacement material in clinical practice. It is composed of cancellous bovine bone, without organic components, and presents a physical microstructure with a decisive role in controlling bone regeneration. Good biocompatibility and osteogenesis characteristics provide a good microenvironment for bone regeneration. The result of apical surgery is usually evaluated by clinical and radiographic follow-up one year after surgery. 3 According to ANVISA, Bio-Oss® must not be reprocessed (Resolution n. 2605 of August 11 th 2006) (Annex 1); however, its high cost can be a determining factor precluding its use on large scale. It is known that, legally, reprocessing of the product is not recommended by the manufacturer, yet scientifically there is no relevant literature or research demonstrating if the product is contaminated after it has been opened and reprocessed. Considering the importance of using Bio-Oss® to fill bone lesions due to apical periodontitis, this research aims to verify the degree of microbiological contamination of Bio-Oss® immediately after its opening and fractionation, to verify if there is product contamination. Also, it aims to verify the antimicrobial activity presented by the commercial product.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):22-8

Microbiological and antimicrobial evaluation of Bio-Oss®: an in vitro study

scribed above (Fig 3). All plates were incubated at 37oC for 48 hours. MS medium was incubated in microaerophilia, while SAB and BHI media were incubated in aerobiosis. After the incubation period, the colonies formed were counted using a stereomicroscope to determine the number of colony-forming units per milliliter (CFU/mL). Analysis of antimicrobial activity To verify the antimicrobial activity of the commercial product, the agar diffusion method was used as previously described by Moreira et al.7 Three flasks of Bio-Oss® containing 1 g each were used. A suspension was prepared by adding 0.1 g of the product in 300 µl of sterile saline solution. Total microorganisms from the saliva of a volunteer were seeded on plates containing Brain Heart Infusion agar medium (Himedia, India), in which three holes with 0.8 cm diameter and 1 cm depth were made. Then, 75 µL of each of the three solutions were added to each of the holes: suspension of the commercial product, saline solution (negative control) and 0.12% chlorhexidine solution (positive control). The plates were incubated in a bacteriological

oven (Fanem, São Paulo, Brazil) at 37oC for 24 hours (Fig 4). After the incubation period, the diameters of growth inhibition halos around the holes were observed and measured. RESULTS Statistical analysis To describe the rates of contamination events, the binomial distribution was used, with their respective 95% confidence intervals. To compare the proportions of contamination between the different dilutions and groups, the Fisher exact test was used. The significance level adopted was 5%. Results By microbiological analysis, in the predetermined periods and after 48 hours of incubation in a bacteriological oven at 37 oC, it was not possible to observe the growth of microorganisms in the different culture media, obtaining a contamination rate of 0.0% (95% CI: 0.0 to 26.5%) (p > 0.99) (Table 1). Regarding antimicrobial activity, Bio-Oss® did not show the formation of microbiological growth inhibition halos (p = 0.1) (Table 2).

Figure 1: Precision analytical scale.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):22-8

Pelegrini G, Hashizume LN, Só MVR, Menuci Neto A, Barletta FB

Figure 2: Decimal serial dilution of suspensions.

Figure 3: Commercial product plated on different culture media.

Figure 4: Bacteriological oven in which the culture media were incubated.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):22-8

Microbiological and antimicrobial evaluation of Bio-Oss®: an in vitro study

Table 1: Microbiological analysis. 0 hour

Flask A Contamination (BHI) Contamination (SAB) Contamination (MS) Flask B Contamination (BHI) Contamination (SAB) Contamination (MS) Flask C Contamination (BHI) Contamination (SAB) Contamination (MS) Flask D Contamination (BHI) Contamination (SAB) Contamination (MS) Flask E Contamination (BHI) Contamination (SAB) Contamination (MS) Flask F Contamination (BHI) Contamination (SAB) Contamination (MS) Flask G Contamination (BHI) Contamination (SAB) Contamination (MS) Flask H Contamination (BHI) Contamination (SAB) Contamination (MS) Flask I Contamination (BHI) Contamination (SAB) Contamination (MS) Flask J Contamination (BHI) Contamination (SAB) Contamination (MS) Flask K Contamination (BHI) Contamination (SAB) Contamination (MS) Flask L Contamination (BHI) Contamination (SAB) Contamination (MS)

Time (Hours/Days) 24 hours 48 hours

62 days

7 days

14 days

21 days

P > 0,99.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):22-8

Pelegrini G, Hashizume LN, Só MVR, Menuci Neto A, Barletta FB

Table 2: Antimicrobial analysis. Bio-Oss®

Saline solution

0.12% chlorhexidine

Flask A Flask B Flask C

P = 0,1.

DISCUSSION The importance of guided bone regeneration on the repair process in enucleated and extensive periapical bone lesions is unquestionable. However, when this repair occurs without the use of bone substitutes, the repair time is longer, with formation of fibrous connective tissue in the region. Thus, supported by research, the use of biomaterial is essential, providing adequate sealing, including regeneration of the alveolar bone and periodontal ligament, as well as cementum repair.3,6,7 Considering the relevance of Bio-Oss® and its excellent scientifically proven properties, it is pertinent to assess whether its reprocessing can cause contamination, compromising the consecutive treatment. Concerning the results obtained, despite the lack of contamination in any of the predetermined periods, one of the plausible explanations for this fact is that this in vitro laboratory study was performed in a controlled environment of microorganisms, which can influence the results. The authors of the present study agree with the considerations of other authors10,11 who demonstrated that guided bone regeneration can be affected by the presence of these microorganisms from the surgical environment, surgical materials, healthcare professionals and resistant bacteria from the patient. 8,9 Although there are no studies evaluating the contamination of Bio-Oss®, it is believed that this process is also due to the efficiency of the sterilization process by gamma radiation. This type of sterilization of materials for medical and surgical use, in the health area, allows to ensure, in the future, storage under sterile conditions, since it effectively eliminates almost all microorganisms, such as fungi, bacteria, viruses and sporulated forms. 10 It was observed that Bio-Oss® did not show formation of growth inhibition halos, demonstrating that it does

not have antimicrobial activity, and it did not show growth of microorganisms. However, the authors of this study agree with the manufacturer on the importance of not reprocessing Bio-Oss®, since in a controlled environment the risks of contamination are low, unlike the clinical practice, in which the environment is not controlled and the risk of exposure to microorganisms is greater. Conversely, it is necessary to emphasize the importance of using a substance that does not present contamination, for subsequent longitudinal control of the patient, not observing inoculation problems in the grafted environment. The methodology used was based on previous studies in the literature, proving to be a reliable and reproducible method, with scientific support. 11,12 Thus, the authors of this study support that, given the results obtained, even though no contamination was present, it is appropriate to consider that the method used was effective. Therefore, it is advised that, in a normal environment, the manufacturer’s recommendations should be followed. The technique used in this study to verify the antimicrobial activity of Bio-Oss® was the agar diffusion method, a methodology already tested and established for in vitro evaluations of antimicrobial potential.6,13 The present results demonstrate that the commercial product Bio-Oss® does not present antimicrobial activity, i.e., it did not present growth inhibition halos. It is important to emphasize that the use of chlorhexidine as positive control was due to its broad spectrum of action, acting on gram-positive and gram-negative bacteria, fungi and yeasts. It has excellent effectiveness in controlling plaque, being safely used in several clinical situations, and is considered superior to other substances in the qualitative and quantitative control of bacterial biofilm formation, due to its high substantivity.14,15

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):22-8

Microbiological and antimicrobial evaluation of Bio-Oss®: an in vitro study

grafted area. Even though this research was conducted in a controlled microorganism laboratory environment, the technique used followed the standard research model. Therefore, considering the manufacturer’s recommendation, the product should not be reprocessed, since there may be risk of contamination. However, more studies are needed, since in this condition there was no contamination.

In clinical practice, most microorganisms are airborne and can vary between environments. In this case, the material was collected following the strict biosafety standard, with a sterile field, but in a microbiologically controlled environment. Proper hand washing reduces the risk of exposure of the surgical field to microorganisms.9 If the dentist does not follow the proper biosafety measures, there may be greater contamination risk of the bone substitute. Storage can also interfere with product contamination. However, given the importance of association of Bio-Oss® with resorbable collagen membrane in extensive bone lesions, it can be stated that this is an excellent alternative, due to osseointegration of the

CONCLUSION According to the methodology used and based on the present results, it can be concluded that BioOss® does not present microbiological contamination in the predetermined periods and the commercial product does not present antimicrobial activity.

References:

1. Lee J, Byun H, Perikamana SKM, Lee S, Shin H. Current advances in immunomodulatory biomaterials for bone regeneration. Adv Healthc Mater. 2019;8(4):e1801106. 2. Artzi Z, Wasersprung N, Weinreb M, Steigmann M, Prasad HS, Tsesis I. Effect of guided tissue regeneration on newly formed bone and cementum in periapical tissue healing after endodontic surgery: an in vivo study in the cat. J Endod. 2012;38(2):163-169. 3. Bugno A, Buzzo AA, Nakamura CT, Pereira TC, Matos D, Pinto TJA. Avaliação da contaminação microbiana em drogas vegetais. Braz J Pharm Sci. 2005;41(4):4, 2005. 4. Alves PCS, Picosse LR, Deco CP, Fróis ÍM, Nicolau RA. Abordagem endocirúrgica de cisto periapical: caso clínico. J Braz Coll Oral Maxillofac Surg. 2017;3(3):61-6. 5. Van Strydonck DAC, Timmerman MF , Van der Velden U , Van der Weijden GA. Chlorhexidine mouth rinse in combination with an SLS- containing dentifrice and a dentifrice slurry. J Clin Periodontol. 2006;33(5):340-4. 6. Hashizume LN, Bastos LF, Cardozo DD, Hilgert JB, Hugo FN, Stein AT, et al. Impact of bariatric surgery on the saliva of patients with morbid obesity. Obes Surg. 2015;25(8):1550-5.

7. Moreira MJS, Ferreira MBC, Hashizume LN. Avaliação in vitro da atividade antimicrobiana dos componentes de um enxaguatório bucal contendo malva. Pesqui Bras Odontopediatria Clín Integr. 2012;12(4):505-9. 8. Gong J, Yang L, He Q, Jiao T. In vitro evaluation of the biological compatibility and antibacterial activity of a bone substitute material consisting of silver-doped hydroxyapatite and Bio-Oss®. Biomater J Biomed Mater Res B Appl. 2018;106(1):410-20. 9. Grieb TA, Forng R-Y, Stafford RE , Lin J, Almeida J, Bogdansky S, et al. Effective use of optimized, high-dose (50 kGy) gamma irradiation for pathogen inactivation of human bone allografts. Biomaterials. 2005;26(14):2033-42. 10. Von Dolinger EJO, Brito DVD, Souza GM, Melo GB, Gontijo Filho PP. Contaminação do ar em salas cirúrgicas durante cirurgias de artroplastias total de quadril e joelho, hemiartroplastias e osteossínteses no centro cirúrgico de um hospital brasileiro. Rev Soc Bras Med Trop. 2010;43(5):584-7. 11. Zilberman M, Elsner JJ. Antibiotic-eluting medical devices for various applications. J Control Release. 2008;130(3):202-15, 2008.

12. Merlini SP, Torres SA. Avaliação in vitro da atividade antimicrobiana de enxaguatórios bucais. Rev Bras Odontol. 2011;68(1):91-4. 13. Oliveira LS, Rossato LG, Bertol CD. Análise da contaminação microbiológica de diferentes dentifrícios. Rev Odontol UNESP. 2016;45(2):85-9. 14. Tsesis I, Rosen E, Tamse A, Taschieri S, Del Fabbro M. Effect of guided tissue regeneration on the outcome of surgical endodontic treatment: a systematic review and meta-analysis. J Endod. 2011;37(8): 1039-45. 15. Von Arx T, Alsaeed M. The use of regenerative techniques in apical surgery: a literature review. Saudi Dent J. 2011;23(3):113-27.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):22-8

Original Article

ABSTRACT Introduction: Medical urgencies and emergencies can occur before, during or after dental procedures, especially in patients with systemic impairment, so it is important that the dentist has the knowledge, drugs and basic equipment to conduct emergency care. Objectives: Thus, the aim of this study is to evaluate the self-perception that dentists in Vitória, Espírito Santo, Brazil, have when facing urgent and emergency medical situations inside the dental office. Methods: The sample consisted of 81 professionals and the data was collected using a self-administered questionnaire. Results: Most professionals were specialists (40.7%) and 50.6% of the individuals answered that they have attended medical emergencies classes during their university classes. Regarding urgent and emergency situations, 69.1% of interviewees thought they were qualified to diagnose them and 61.7% said they felt able to intervene. It was observed that 48.1% have already experienced such situations in the dental office, of which 87.2% have said that they felt confident to put into practice the treatment that they have chosen. The majority stated that they do not have equipment and drugs in their dental office (67.9%). Conclusions: The study has concluded that there is a need for better training of dental surgeons, both during their graduation and in post-graduation courses, in order to have greater knowledge and safety for the correct intervention in situations of medical urgencies and emergencies. Keywords: Emergencies. Dentistry. Self-assessment.

How to cite: Mendes DS, Roveta RR, Oliveira JM, Araújo SCS, Hilário SR, Cançado RP. Dental surgeons’ self-perception of medical urgencies and emergencies. J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):29-36. DOI: https://doi.org/10.14436/2358-2782.7.2.029-036.oar

Graduate student in Dentistry, Universidade Federal do Espírito Santo, Curso de Odontologia (Vitória/ES, Brazil). Dental surgeon, Faculdade Multivix, Curso de Odontologia (Vitória/ES, Brazil). 3 Dental surgeon, FAESA Centro Universitário, Curso de Odontologia (Vitória/ES, Brazil). 4 Resident in Oral and Maxillofacial Surgery and Traumatology, Hospital João XXIII - Fundação Hospitalar do Estado de Minas Gerais, Serviço de Residência em Cirurgia e Traumatologia Buco-maxilo-facial (Belo Horizonte/MG, Brazil). 5 PhD in Oral and Maxillofacial Surgery and Traumatology, Universidade Federal do Espírito Santo, Departamento de Clínica Odontológica do Curso de Curso de Odontologia (Vitória/ ES, Brazil). 1

Submitted: April 25, 2020 - Revised and accepted: September 22, 2020 Contact address: Deyverton dos Santos Mendes E-mail: deyvertonmendes@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 May-Aug;7(2):29-36

Dental surgeons’ self-perception of medical urgencies and emergencies

INTRODUCTION Medical urgencies and emergencies (MUE) can occur at any time in dental practice; thus, the dental professional (DDS) must be prepared to solve them. During dental appointments, some patients may have a certain degree of anxiety and trigger systemic changes, which may evolve into an unpredictable emergency. Also, considering the increasing number of systemically affected individuals, the chances of having MUE during dental treatment grow considerably, and these cases may occur during the procedure or in the waiting room.1,2,4 The DDS needs to differentiate situations in which, in an urgency, there is time for the professional to plan and remember the protocol for such event. However, in emergencies, there is no time for the professional to review the clinical protocol, since these appear suddenly and unexpectedly, requiring immediate intervention.3,4 With the advances in Medicine, people who previously did not have adequate systemic conditions can now receive dental treatment. Thus, currently, there is a greater presence of patients with diabetes, hypertension, heart disease and patients with liver and/ or kidney disorders in dental offices. Concomitantly, there is a gradual increase in the practice of more extensive procedures, which produces a greater chance of complications.8 Additionally, according to Malamed,11 stress and fear are the main causes of MUE in the dental office, accounting for 75% of cases. Emergency situations can be prevented by an adequate anamnesis, extra- and intraoral clinical examination, and the indispensable practice of monitoring vital signs, both before and after the consultation. Thus, assessment of the patient’s general health status and prevention, due to their limitations, increase the clinical safety in patient care.9,10 According to the legislation in force in our country, any citizen can provide aid by Basic Life Support (BLS), as long as he or she is enabled. According to article 135 of the penal code, “failing to provide aid to the victim of accidents or people in imminent danger, if able to do so, is a crime”, and the DDS is related to this law.6 Health professionals are expected to be able to handle such situations. However, the literature reports that DDSs are not skilled to intervene, becoming dependent on the medical presence to help their patients.7

The lack of recognition of MUE situations is related to the lack of preparation and training during graduation. This fact can be attributed to the lack of importance assigned to the topic by the student, the absence of a specific discipline addressing such situations, or disciplines with low workload. 10 Thus, this study aimed to evaluate the self-perception of DDSs in the city of Vitória/ES regarding the situations of MUEs in the dental office. METHODS This study was submitted and approved by the Institutional Review Board of the Health Sciences Center at the Federal University of Espírito Santo (CEP/CCS/UFES), under number 3.446.178, and was conducted according to guidelines CNS 466/12, respecting the principles of secrecy and confidentiality. This is a descriptive exploratory study, with cross-sectional design. The following inclusion criteria were used: DDSs with active registration in the Regional Dental Council in the State of Espírito Santo (CRO-ES); who worked in dental clinics in the city of Vitória/ES; and who voluntarily agreed to participate in the research, signing an Informed Consent Form. Data collection was performed using a self-administered questionnaire, created and validated by Haese et al. 4 and adapted by the authors, which assesses the self-perception of DDSs about the approach adopted in cases of MUE in dental clinics. Prior to collection, an official letter was sent to the president of CRO-ES requesting the sending of questionnaires by email to the DDSs. The questions aimed to characterize the professional profile, the occurrence of MUEs in the dental clinic, the situations witnessed and how they were managed, besides questions about pre-service evaluation, anxiety control methods and the use of medication and support equipment. The answers were entered into a proprietary spreadsheet created for this purpose on Microsoft Office Excel version 2016. A descriptive analysis of data was performed, using frequency graphs and tables, with number and percentage for each item of the survey instrument.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):29-36

Mendes DS, Roveta RR, Oliveira JM, Araújo SCS, Hilário SR, Cançado RP

RESULTS The sample consisted of 81 DDSs who responded to the questionnaire. Among them, 40.7% were specialists. Concerning the time since graduation, a higher percentage of DDSs with training time between 16 and 30 years (40.7%) was observed. When asked if the undergraduate course had a specific discipline of medical emergencies in its curriculum, 49.4% of professionals answered “no” and stated that this topic was addressed in other disciplines during graduation, such as the discipline of Maxillofacial Surgery (CBMF), mainly (52.5%). Regarding the clinical evaluation of the patient, 84% of individuals stated that they included anamnesis at this stage, and only 14.8% performed review of the systems. For anxiety control, it was observed that 77.8% perform conversation with the aim of distraction, 39.5% prescribe anxiolytics and no professional performs conscious sedation with nitrous oxide (Fig 1). Regarding the actions taken in MUEs situations, 69.1% of professionals believed they were able of diagnosing them and 61.7% stated they felt able to intervene. It was also observed that 48.1% of respondents have already experienced MUE in the dental office; among them, 87.2% stated they felt safe to put the adopted measure into practice. The participants were also asked if they had equipment and medication for emergencies in their clinic: 67.9% stated they did not. The answers of DDSs in relation to measures taken in MUEs situations in Dentistry are described in Figure 2. In the association between time since graduation of DDSs with questions related to clinical evaluation, it was observed that anamnesis was the most performed among all respondents, being more frequent by professionals with training time between 6 and 15 years (88.5%). However, the review of systems was the least performed by all professionals, and none with more than 31 years of graduation included the review of systems in the clinical evaluation. Relating the time since graduation with the MUEs situations, it was observed that most professionals in each group consider themselves capable and feel skilled to intervene. Concerning the experience of some situation, it was observed that professionals with graduation time between 16 and 30 years had most witnessed MUE situations (60.6%), and among them 85% felt safe during the intervention.

Educational level Graduation

14,8 12

Post graduation

14,8 12

Specialization MSc

9,9 8

PhD Not informed

40,7

33 13,6 11

6,2 5

Time since graduation 19,8 16

Up to 5 years 6-15 years

32,1

16-30 years 31 years or more

40,7

7,4 6

Did the Dentistry Course have a discipline addressing medical emergencies? Yes

51,9

48,1

If it did not, in which discipline was this issue addressed? Surgery

52,5

Pharmacology 12,5 Stomatology/Pathology

Specialization Extracurricular

6 10

Residency 2 Not informed

7,5

Clinical evaluation Anamnesis

Chief complaint

81,5

Medical history

Evaluation of vital signs

Physical examination

Systems review

45,7

14,8

Do you measure your patient’s blood pressure? Yes

61,7

38,3

Anxiety control Verbal statements

Talking to distract

Avoid unnecessary noise

Relaxing background music

Percent

77,8

48,1 52

Prescription of anxiolytics Conscious sedation with N2O

69,1

64,2

39,5

0 0

Number

Figure 1: Academic data of dental professionals participating in the study and responses concerning the clinical evaluation and anxiety control of the patients.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):29-36

Dental surgeons’ self-perception of medical urgencies and emergencies

The procedures most adopted among graduates and postgraduates for anxiety control are talking and music (70.8% for both). Among specialists, talking is the most used (78.8%). Finally, MScs and PhDs prefer to make verbal statements to control the patient anxiety (94.7%) (Table 2). It was observed that, in the clinical evaluation, anamnesis was the most performed among professionals who attended or not the discipline of Medical Emergencies during graduation (95.1% and 97.5% respectively); however, in both groups it was observed that the review of systems is not frequently included in the clinical evaluation. Regarding MUE situations, 78% and 70.7% of respondents who attended the course consider themselves capable and feel skilled to intervene, respectively, unlike professionals who did not take the discipline (60% and 52.5% ). The most adopted procedures for anxiety control, both by DDSs who attended the discipline and those who did not, was talking (75.6% and 82.5%), followed by verbal statements (68.3% and 75%) (Table 3). In addition, when data on time since graduation and having attended the discipline on MUE are associated, there was high percentage of DDSs with less time since graduation (up to 5 years) who attended the discipline on MUE at graduation (93.75%). Conversely, only 36.36% of DDSs with graduation time between 15 and 30 years reported to have attended the discipline at graduation.

Do you feel skilled to diagnose a medical emergency? Yes

30,9

69,1

Do you feel able to intervene, if there is an emergency? Yes

61,7

38,3

Have you experienced na emergency in your clinic? Yes

48,1 51,9

Do you feel safe to put the approach into practice? Yes

87,2

51,9

Are there emergency equipment and drugs in your clinic? Yes

28,4

67,9

3,7

Did not respond 3

Percent

Number

Figure 2: Responses of dental professionals concerning approaches adopted in MUE situations in Dentistry.

DISCUSSION In this study, there was prevalence of DDSs who stated to have attended a discipline on Medical Emergencies in graduation (50.6%). However, the number of professionals who stated that at the time there was no specific discipline in the course curriculum was high (49.4%). At graduation, the discipline of emergencies is not mandatory,10 and the topic is usually addressed in other disciplines. Among them, the most prevalent in this study was the CBMF discipline (52.5%). It is worth emphasizing the importance of the specific discipline of medical emergencies with a broad approach to the subject and specific training. It is known that, with this knowledge, most MUEs in the dental clinic can be avoided, besides reducing morbidity, avoiding future complications and even saving the patient’s life.6

Among the procedures adopted for anxiety control, talking was the most adopted measure among professionals with 6 to 15 years and 0 to 5 years of graduation, respectively (92.3% and 81.25%). Conversely, DDSs with 16 to 30 years of graduation prefer verbal statements (69.7%), and those with 31 years or more choose to use music (83.3%) to calm down the patient (Table 1). In situations of MUEs, most professionals said they felt capable and skilled to intervene. However, among them, specialists had a lower percentage (57.6% and 51.5%, respectively).

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):29-36

Mendes DS, Roveta RR, Oliveira JM, Araújo SCS, Hilário SR, Cançado RP

Table 1: Relationship between graduation time, clinical evaluation before attendance, MUE situation and procedures adopted for anxiety control of assisted patients. Characteristics

0 – 5 years n = 16 %

Anamnesis Chief complaint Medical history Vital signals Physical examination Reviews systems Checks blood pressure

14 14 14 8 7 1 9

87.5 87.5 87.5 50.0 43.7 6.2 56.2

Considers skilled Feels apt Has experienced Felt reassured Owns equipment

10 9 4 3 6

62.5 56.2 25 75.0 37.5

Verbal statements Talking Avoiding noises Music Anxiolytics N2O sedation

11 13 8 10 7 0

68.7 81.2 50.0 62.5 43.7 0.0

6 – 15 years n = 26 %

16 – 30 years n = 33 %

Clinical evaluation 23 88.5 22 84.6 23 88.5 11 42.3 15 57.7 4 15.4 17 65.4 MUE situation 19 73.1 19 73.1 12 46.2 11 91.7 6 23.1 ANXIETY CONTROL 21 80.8 24 92.3 14 53.8 19 73.1 10 38.5 0 0.0

31 years or more n=6 %

27 27 24 10 14 7 20

81.8 81.8 72.7 30.3 42.4 21.2 60.6

4 3 3 1 1 0 4

66.7 50.0 50.0 16.7 16.7 0.0 66.7

24 19 20 17 10

72.7 57.6 60.6 85.0 30.3

3 3 3 3 1

50.0 50.0 50.0 100.0 16.7

23 22 15 18 13 0

69.7 66.7 45.5 54.5 39.4 0.0

1 4 2 5 2 0

16.7 66.7 33.3 83.3 33.3 0.0

Table 2: Relationship between educational level, clinical evaluation before attendance, MUE situation and procedures adopted for anxiety control in assisted patients. Characteristics

Graduation and postgraduation n = 24 %

Anamnesis Chief complaint Medical history Vital signals Physical examination Reviews systems Checks blood pressure

18 18 18 6 9 2 15

Considers skilled Feels apt Has experienced Felt reassured Owns equipment

17 18 6 5 8

Verbal statements Talking Avoiding noises Music Anxiolytics N2O sedation

15 17 12 17 11 0

Specialization n = 33 %

Clinical evaluation 75.0 75.0 75.0 25.0 37.5 8.3 62.5 MUE situation 70.8 75.0 25.0 83.3 33.3 Anxiety control 62.5 70.8 50.0 70.8 45.8 0.0

MSc and PhD n = 19 %

27 25 24 11 14 4 21

81.8 75.8 72.7 33.3 42.4 12.1 63.6

18 18 17 11 14 6 11

94.7 94.7 89.5 57.9 73.7 31.6 57.9

19 17 21 17 8

57.6 51.5 63.6 81.0 24.2

15 11 9 9 6

78.9 57.9 47.4 100.0 31.6

21 26 12 18 9 0

63.6 78.8 36.4 54.5 27.3 0.0

18 15 11 13 10 0

94.7 78.9 57.9 68.4 52.6 0.0

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Dental surgeons’ self-perception of medical urgencies and emergencies

Table 3: Relationship between attending a discipline of Medical Emergencies, clinical evaluation before attendance, MUE situation and procedures adopted for anxiety control in assisted patients. Characteristics

Attended discipline n = 42

Anamnesis Chief complaint Medical history Vital signals Physical examination Reviews systems Checks blood pressure

39 30 30 15 17 3 26

Considers skilled Feels apt Has experienced Felt reassured Owns equipment

32 29 14 13 16

Verbal statements Talking Avoiding noises Music Anxiolytics N2O sedation

28 31 20 23 17 0

Clinical evaluation 92.9 71.4 71.4 35.7 40.5 7.1 61.9 MUE situation 76.2 69.0 33.3 31.0 38.1 Anxiety control 66.7 73.8 47.6 54.8 40.5 0.0

Since 2001, by Resolution CFO 22/2001 of the Federal Dental Council (CFO), the discipline of Medical Emergency has been included in the related area of all specialization courses, with a minimum workload of 15 hours (Resolution CFO 25/2002),6 which can be lectured by a physician or DDS, necessarily a specialist in Maxillofacial Surgery and Traumatology. This explains the fact that, among professionals who did not have the specific discipline in the course (49.4%), 15% of them had the content covered in the specialization. It is important to highlight that the knowledge about the patient’s health status during the initial assessment aids to prevent MUEs.12 It was observed that 86% of DDSs stated that they did not include the review of systems in their evaluations. Data indicate that professionals are not contributing to clinical safety during the performance of procedures, thus increasing the chances of MUE.1,2,4 The assessment

Did not attend discipline n = 39 %

39 37 35 16 19 8 24

100.0 94.9 89.7 41.0 48.7 20.5 61.5

24 21 25 21 7

61.5 53.8 64.1 53.8 17.9

30 33 20 27 19 0

76.9 84.6 51.3 69.2 48.7 0.0

of vital signs at all sessions also helps to recognize risk situations and avoid possible MUEs in the office and, considering that the rate of hypertension is high in the Brazilian population, the study individualized the analysis of blood pressure (BP) measurement in the questionnaire, to evidence the information in this study, thus noting that BP was measured by 61.7% of respondents before the procedure. Most professionals thought they were able of diagnosing MUEs (69.1%), corroborating the results of Fiuza,2 in which 60% of answers reported that DDSs felt able to make the diagnosis. However, the study by Arsati et al.13 reported that more than half (50.2%) of DDSs did not consider themselves able of diagnosing a MUE. A point observed in this study is that 87.2% of respondents who have already experienced a MUE episode said they felt safe during the intervention, corroborating the study by Haese,4 in which 61%

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Mendes DS, Roveta RR, Oliveira JM, Araújo SCS, Hilário SR, Cançado RP

also observed that, for anxiety control, most uses talking with the patients to calm them down, and no one performs nitrous oxide sedation (Tables 2 and 3). Finally, the academic degree seemed to influence the situations of MUEs. Specialists had a lower percentage when they stated they felt capable and skilled to intervene (57.6% and 51.5%, respectively), i.e., most specialists do not feel able and skilled to intervene in MUE situations. The graduates/postgraduates group had the highest percentage (75%) when they stated they felt able to intervene in situations of MUEs as compared to specialists and MScs/PhDs (51.5% and 57.9%, respectively). However, in relation to self-perception, it is believed that individuals with higher educational level tend to question their competence and skills when not prepared, unlike individuals with a lower educational level. Pelham and Swann 16 stated that, as the doubt associated with important skills increases, the self-esteem about these skills decreases. Thus, this may be related to the fact that MScs and PhDs had a lower percentage in relation to the aptitude for intervention. Regarding attending the discipline of Medical Emergencies in graduation, 78% and 70.7% of DDSs who attended the discipline considered themselves capable and felt skilled to intervene, respectively, different from professionals who did not attend the discipline (60% and 52.5%), highlighting its importance in professional training.17 Regarding the association of data on time since graduation and whether or not they attended the discipline on MUE, there was high percentage of DDSs with less time since graduation (up to 5 years) who attended the discipline on MUE at undergraduate level (93, 75%); conversely, only 36.36% of DDSs with graduation time between 15-30 years said they had attended the discipline at graduation. This shows that the initiative to include the discipline in the course curriculum seems to be recent and thus it is necessary to evaluate the result of this initiative in the long term, since this change in the curriculum can lead to a new future perspective of professional positioning. Thus, it is believed that DDSs in the city of Vitória/ES are not fully prepared to perform MUEs in the dental office, which can be assigned to a failure in the training of these professionals, both at undergraduate and graduate levels.

of respondents claimed to have experienced a MUE and, from this percentage, 86.2% felt prepared to intervene. However, data must be carefully evaluated, since in this study the main MUEs experienced were faintness, syncope and hypotension, which are relatively easy to manage. Thus, the statements regarding the safety of intervention can be related to the low degree of complexity and high resolvability of the main events mentioned. Anxiety control procedures are essential for the prevention of MUEs and should be emphasized in systemically compromised patients. According to Malamed,11 75% of cases of MUE in a dental clinic are caused by stress and fear. In this study, it was observed that the main procedure adopted is talking, which is a non-pharmacological method widely used and of proven efficacy. Alike the study of Haese et al.,4 none of the respondents performed conscious sedation with nitrous oxide. When asked if they had equipment and medication for emergencies in their clinic, it was observed that most DDSs did not have them available for such situations, reflecting an unpreparedness to deal with MUEs. In 2002, the American Dental Association determined that all dental clinics should have at least the recommended drugs and basic emergency equipment. They suggested that at least the following drugs should be included in the kit: Adrenaline/ Epinephrine 1:1000 (injectable); Diphenhydramine hydrochloride (antihistamine – injectable); E-size oxygen cylinder; Nitroglycerin (sublingual tablet or spray); Salbutamol (bronchodilator, spray); Glucose (orange juice, soft drinks or sugar tablets) and acetylsalicylic acid (tablets). 14 According to Malamed, 15 the equipment that must be available in dental clinics are: automated external defibrillator, face masks (pediatrics and for adults), syringes (2 ml), needles (20 gauge) and spacer for inhalation of bronchodilators. However, even if offices that have these resources, it does not exclude the need for professional preparation on the occurrence of MUEs. It should be remembered that, in this study, regardless of the time since graduation, academic degree and whether or not the discipline was attended, most professionals performed anamnesis. However, few perform systems review (Table 2 and 3). It was

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Dental surgeons’ self-perception of medical urgencies and emergencies

CONCLUSION The results obtained in this study allow to conclude that MUEs are not rare situations in clinical practice in dental offices. Most DDSs said they felt able to diagnose MUE situations and, when they witnessed any case, they felt safe to intervene. However, such data cannot be considered sufficient, since it may have been related to the low degree of complexity and high resolvability of the events witnessed. In addition, most do not have medication and equipment in their clinic for such situations, showing the lack of preparation of professionals.

Coping with MUE situations can be influenced by inadequate preparation during graduation and by the lack of training during professional exercise. There is a failure in the training of DDSs, requiring investment in the training of undergraduate and graduate students in the area of emergency, requiring a more comprehensive approach to the various MUEs, including practical classes, to be able to implement an adequate training program, providing greater knowledge and security for a correct intervention.

References:

1. Hanna LMO, Alacantara HSC, Damasceno JM, Santos MTBR. Conhecimento dos cirurgiões dentistas diante urgência/ emergência médica. Rev Cir Traumatol Buco-Maxilo-Fac. 2014;14(2):79-80. 2. Fiuza MK, Balsan ST, Pretto JLB, Cenci RA, Conto F. Avaliação da prevalência e do grau de conhecimento do cirurgião-dentista em relação às emergências médicas. RFO UPF. 2013;18(3):295-301. 3. Andrade ED, Ranali J, Neisser MP. Emergências médicas em odontologia. 3a ed. São Paulo: Artes Médicas; 2011. 4. Haese RP, Cancado MRP. Urgências e emergências médicas em odontologia: avaliação da capacitação e estrutura dos consultórios de cirurgiões-dentistas. Rev Cir Traumatol Buco-Maxilo-Fac. 2016;16(3):31-3. 5. Andrade ED, Ranali J. Emergências médicas em odontologia. 2a ed. São Paulo: Artes Médicas; 2004. 6. Caputo IGC, Bazzo GJ, Silva RHA, Daruge JE. Vidas em risco: emergências médicas em consultório odontológico. Rev Cir Traumatol Buco-Maxilo-Fac. 2010;10(3):51-8.

7. Gonzaga HFS, Buso L, Jorge MA, Gonzaga LHS, Chaves MD, Almeida OP. Evaluation of knowledge and experience of dentists of São Paulo satate, Brazil about cardiopulmonary resuscitation. Braz Dent J. 2003;14(3):220-2. 8. Queiroga TB, Gomes RC, Novaes MM, Marques JLS, Santos KSA, Grempel RG. Situações de emergências médicas em consultório odontológico. Avaliação das tomadas de decisões. Rev Cir Traumatol Buco-MaxiloFac. 2012;12(1):115-22. 9. Santos JC, Rumel D. Emergência médica na prática odontológica no Estado de Santa Catarina: ocorrência, equipamentos e drogas, conhecimento e treinamento dos cirurgiões-dentistas. Cienc Saúde Coletiva 2006;11(1):183-90. 10. Silva GDG, Diniz DN, Marques CMB, Figueiredo, RLQ. Emergências médicas em odontologia: avaliação do conhecimento dos acadêmicos. RSC. 2018;7(1):6575. 11. Malamed, SF. Sedation and safety: 36 years of perspective. Alpha Omegan. 2006; 99(2):70-4.

12. Haas DA. Preparing dental office staff members for emergencies. Developing a basic action plan. J Am Dent Assoc. 2010;141(Supl 1):8S-13S. 13. Arsati F, Montalli VA, Flório FM, Ramacciato JC, Cunha FL, Cecanho R et al. Brazilian dentists’ attitudes about medical emergencies during dental treatment. J Dent Educ. 2010;74(6):661-6. 14. American Dental Association. Office emergencies and emergency kits. J Am Dent Assoc. 2002;133(3):364-5. 15. Malamed SF. Emergency medicine in pediatric dentistry: preparation and management. J Calif Dent Assoc. 2003;31(10):749-55. 16. Pelham BW, Swann WB. From self-conceptions to self worth: On the sources and structure of global selfesteem. J Pers Soc Psychol. 1989; 57(4):672-80. 17. Mutz VSA, Cançado RP. Training study of undergraduate dentistry students in a public institution of Espírito Santo face to medical urgencies/emergencies. Rev Odonto Cienc. 2017;32(1):35-40.

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Original Article

Assessment of the prevalence and profile of impacted lower third molars, using panoramic radiographs ANA PATRÍCIA MAGALHÃES RAMOS1 | ALYNNE VIEIRA DE MENEZES PIMENTA1 | EDSON LUIZ CETIRA-FILHO1 | LÚCIO MITSUO KURITA1 | FÁBIO WILSON GURGEL COSTA1

ABSTRACT Introduction: The lower third molar (LTM) has the highest index of cases of impaction, being frequently associated with pericoronaritis, periodontitis, neoplasia and root resorption, making its surgical removal one of the most frequent procedures in dentistry. Objective: the objective of this study was to assess the prevalence and profile of LTM using panoramic radiographs (PR), since PR allow to classify the LTM and establish a surgical plan. Material and Methods: To carry out a survey of the prevalence of sex and age, position variability and pathological changes associated with the impacted LTM, 678 PRs of both sexes were selected, with at least one impacted LTM, whose adjacent second molars were present, since their presence is necessary to classify the impaction level of LTM. Each RP was analyzed by a previously calibrated examiner (Kappa = 0.852). Results: There was a higher prevalence of females and of the mesioangular and horizontal positions and Class II / positions A and B. Regarding the incidence of pathological changes, the values obtained were not high, but there was a higher incidence of caries. Conclusion: Thus, the knowledge of dentists about the positions and classifications of LTM in the PR, and consequent associated pathological changes is essential to establish the correct diagnosis and clinical management. Keywords: Molar, third. Radiography, panoramic. Diagnosis. Surgery, oral.

How to cite: Ramos APM, Pimenta AVM, Cetira-Filho EL, Kurita LM, Costa FWG. Assessment of the prevalence and profile of impacted lower third molars, using panoramic radiographs. J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):37-43. DOI: https://doi.org/10.14436/2358-2782.7.2.037-043.oar

Universidade Federal do Ceará, Disciplina de Radiologia, Departamento de Clínica Odontológica, Curso de Odontologia (Fortaleza/CE, Brazil).

Submitted: November 19, 2019 - Revised and accepted: September 22, 2020 Contact address: Ana Patrícia Magalhães Ramos E-mail: patriciaramosamr@outlook.com

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

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Assessment of the prevalence and profile of impacted lower third molars, using panoramic radiographs

INTRODUCTION Impacted teeth are those that do not appear in the oral cavity within the normal eruption chronology.¹ Among them, the third molars present the highest rate of impaction, due to lack of space, since they are the last teeth to complete their formation and undergo the eruption process.² Also, they may be associated with other factors, such as an obstacle posed by the adjacent tooth, excessive resistance from the bone tissue or fibromucosa, extended permanence or premature loss of deciduous teeth.³ The lower third molars are frequently associated with pericoronitis, periodontitis, cystic lesion, neoplasia and root resorption.4 Resorption of the distal surface and marginal bone loss from the distal root of the second molar, as well as enlargement of the periodontal space or cyst around the third molar crown, are complications commonly observed in lower third molars. These pathological changes can be asymptomatic and, in the absence of clinical symptoms, can be analyzed by radiographic images.5 The surgical removal of lower third molars is one of the most frequent procedures in Dentistry, being extracted during adolescence and adulthood.6 However, there may be some postoperative complications, such as sensory nerve damage, pain, swelling, trismus, infection and bleeding. Besides the surgery-related factors, the position and angulation of third molars are strongly associated with the number and degree of postoperative morbidities.7 In this context, panoramic radiography is considered the technique of choice to evaluate the impaction of third molars – in terms of impaction angle, impaction level and amount of bone coverage8 – besides providing information about the tooth, adjacent teeth and related anatomical structures. The parameters that must be evaluated include the impaction status; root development; tooth angulation; number of roots; and root morphology.9 Aiming at contributing to surgical planning, Winter,10 Pell and Gregory11 established classifications for the third molars, which are very popular due to their simplicity, thus facilitating the communication between professionals, being advantageous for clinical case reports, degree of complexity of cases and prognosis.12 In this context, the dentist should know these classifications, aiming at diagnosing the impacted third molar, in relation to its position and angulation.13,14

Thus, the present study surveyed the prevalence in terms of sex and age, variability of positions and pathological changes associated with impacted lower third molars, by the analysis of panoramic radiographs performed at the Dental Radiology Clinic of the Dentistry course of Pharmacy, Dentistry and Nursing School, Federal University of Ceará. METHODS This study was approved by the Institutional Review Board of the Federal University of Ceará, under report n. 3.416.079, in accordance with the resolution of the National Health Council (CNS) n. 466 of December 2012. This retrospective and cross-sectional observational study was conducted on 678 panoramic radiographs obtained from January 2017 to December 2018 at the Dental Radiology Clinic of the Dentistry course of the Federal University of Ceará. The sample was selected by analysis of inclusion and exclusion criteria applied to the files of 3,314 panoramic radiographs, including panoramic radiographs of patients of both genders, with at least one impacted lower third molar, with present lower second molars, thus enabling their classification. As exclusion criteria, panoramic radiographs were excluded as shown in Figure 1. For the classification of Winter,10 the following were considered: vertical position = when the long axis of the unerupted tooth follows the same direction as the long axis of the second molar; horizontal position = when the long axis is perpendicular to the long axis of the second molar; mesioangular position = when the crown is inclined towards the second molar; distoangular position = when the long axis of the third molar is distally or posteriorly angled in relation to the second molar; transalveolar position = second and third molars buccally or lingually positioned; inverted position = crown facing the mandibular base and root facing the occlusal surface. For the classification of Pell and Gregory,11 the following were considered: Class I = sufficient amount of space to accommodate the mesiodistal diameter of the third molar crown; Class II = space between the ramus and the distal side of the second molar is smaller than the mesiodistal diameter of the third molar; Class III = all or most of the third molar is located within the mandibular ramus; position A = the highest part of the tooth is at or above the occlusal line; position B = the highest part of the tooth is below the occlusal plane,

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Ramos APM, Pimenta AVM, Cetira-Filho EL, Kurita LM, Costa FWG

860 with erupted third molar

3314 orthopantomograms performed

68 without lower second molar

638 from partially edentulous individuals

152 from individuals in the mixed dentition

368 without the lower third molar

20 from individuals with syndromes

166 from totally edentulous individuals

48 with artifacts/errors

260 repeated orthopantomograms

56 non-classifiable

678 selected panoramic radiographs

Figure 1: Flowchart of exclusion criteria in the present study. Table 1: Criteria for diagnosis of radiographic lesions around impacted lower third molars. Diagnosis

Criterion

Caries

A radiographically clear carious lesion on the impacted lower third molar or adjacent lower second molar.

Pericoronal radiolucent area

Completely radiolucent area affecting the crown of the fully unerupted impacted lower third molar.

Periapical radiolucent area*

Completely radiolucent area connected to the apical root third of the impacted third molar. It may extend to reach the root side, yet not above the cementoenamel junction.

Odontoma

Radiopaque mass lesions, with similar radiographic density as the dental tissues, shaped as multiple calcified structures or a uniform opaque mass, surrounded by a radiotransparent margin located mesially, coronally, distally or apically to the impacted lower third molar.

External root resorption

Clear loss of root structure on the root of the adjacent lower second molar, due to direct contract between it and the impacted lower third molar.

Source: Al-Khateeb and Bataineh.15

yet above the cervical line of the second molar; position C = the occlusal surface of the unerupted tooth is below the cervical line of the second molar. To calculate the intraexaminer error, 68 panoramic radiographs were randomly selected (10% of the sample), which were again analyzed by a single examiner two weeks after the first analysis. The intra-examiner agreement assessed was substantial (Kappa=0.852). Since then, the previously calibrated examiner analyzed 678 panoramic radiographs, observing the age and sex of patients, as well as the classification of each third molar, analyzing its angulation according to the classification of Winter10 and

its position according to Pell and Gregory.11 Regarding injuries associated with third molars, the criteria for diagnosing radiographic injuries (Table 1) of the study by Al-Khateeb and Bataineh15 were used. Data were collected and tabulated in a Microsoft Excel 2016 spreadsheet, and a descriptive analysis was performed based on the collected data: age, sex and pathological changes, as well as variations in position and angulation of the lower third molars. After completing the survey, data were expressed as absolute and percentage frequency, analyzed by Pearson’s chi-square test or Fisher’s exact test (p<0.05), using the SPSS version 19.0 program (SPSS® Inc., Chicago , USA).

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Assessment of the prevalence and profile of impacted lower third molars, using panoramic radiographs

RESULTS Overall, 905 impacted lower third molars were analyzed on a total of 678 panoramic radiographs, being 449 on the left side and 456 on the right side. Most of the population was female, 394 (58.1%), with 284 (43.9%) males. It was also observed that, in this study, there was higher prevalence of impacted lower third molars among patients aged 19 to 30 years old, adding up to 502 panoramic radiographs (74%), as shown in Table 2. According to the classification of Winter,10 the most prevalent position was mesioangular, followed by the horizontal position. Subsequently, the vertical position appears as the third most prevalent position, while the distoangular, buccolingual positions were

less prevalent. No teeth were found in inverted position (Table 3). According to the classification of Pell and Grego11 ry, regarding the depth of impaction, the most prevalent positions in the sample were positions A and B, while position C had lower prevalence. Regarding the mandibular ramus, Class II was the most prevalent in this study, followed by Class I and Class III, as shown in Table 4. Following the criteria for diagnosing radiographic lesions expressed in Table 2, there was higher prevalence of caries in adjacent second molars and third molars, followed by a radiolucent pericoronal area and external root resorption. The presence of periapical radiolucent area and odontoma was not observed (Table 5).

Table 2: Prevalence of impacted lower third molars according to sex and age range.

sex Female Male Age (years) Up to 18 19-30 >30

394 284

58.1 41.9

99 502 77

14.6 74.0 11.4

Data expressed as absolute and percent frequency, analyzed by the Pearson chi-square test or Fisher exact test (p < 0.05).

Table 3: Positions of third molars, according to the classification of Winter.10 left

right

Horizontal position

174

38.8

175

38.5

Mesioangular position

205

45.7

212

46.6

Vertical position

13.6

13.0

Distoangular position

0.7

0.4

Buccolingual position

1.3

1.5

0.982

Data expressed as absolute and percent frequencies, analyzed by the Pearson chi-square or Fisher exact test (p < 0.05).

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Ramos APM, Pimenta AVM, Cetira-Filho EL, Kurita LM, Costa FWG

Table 4:Third molar positions according to the classification of Pell and Gregory.11 Left

Pell and Gregory (Class) Class I Class II Class III Pell e Gregory (Posição) Position A Position B Position C

Right

55 365 26

12.3 81.8 5.8

55 370 30

12.1 81.3 6.6

0.891

203 200 43

45.4 44.7 9.6

203 213 39

44.6 46.8 8.6

0.773

Data expressed as absolute and percent frequencies, analyzed by the Pearson chi-square or Fisher exact test (p < 0.05).

Table 5: Prevalence of radiographically detected pathological lesions associated with impacted third molars, according to Al-Khateeb and Bataineh.15 Left

Lesions Caries on third molar Caries on adjacent second molar Pericoronal radiolucent area External root resorption

Right

4 8 6 3

19.0 38.1 28.6 14.3

3 10 7 1

14.3 47.6 33.3 4.8

0.700

Data expressed as absolute and percent frequencies, analyzed by the Pearson chi-square or Fisher exact test (p &lt; 0.05).

DISCUSSION Classification systems for impacted third molars were developed for communication between professionals and for the surgical predictability of each extraction.12 These classification systems assist in surgical planning, and, to some extent, they also determine the complexity of each case.16 The lower third molars are usually deeply impacted and more difficult to extract, due to the coronal bone strength, proximity of the inferior alveolar canal and risk of mandibular fracture due to deep impaction.17 Thus, panoramic radiography is a useful tool to classify third molars, following the classifications of Winter and Pell and Gregory.16 Regarding the classification of Winter, corroborating the results of Gomes et al.3 and Matzen et al.,18 it was observed that there was higher prevalence of lower third molars impacted in mesioangular and hor-

izontal positions, on both sides analyzed. This is an unfavorable position for third molar eruption and is directly related to the complexity of surgery.14,16,19 In this context, the removal of these teeth is considered a great challenge, especially in horizontal position, due to the great bone strength, as well as the risk of injury to the inferior alveolar nerve. They can also be located below the cervical lines of the lower second molars, with risk of trauma to adjacent teeth.17 Considering the classification of Pell and Gregory, there was higher prevalence of positions A and B, besides higher prevalence of Class II, corroborating the results of Fonseca et al.,14 in which position A was the most prevalent, followed by position B. The results of the present study also corroborate the findings of Trento et al.,20 in which a higher prevalence of Class II was observed, followed by Class I. Thus, it is important to emphasize that the deeper the impac-

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Assessment of the prevalence and profile of impacted lower third molars, using panoramic radiographs

resorption of the adjacent second molar, with greater indication for prophylactic removal of these teeth. According to Matzen et al.,9 panoramic radiography is the first method of choice for the evaluation and removal of lower third molars. Also, it is a relatively low radiation dose test that provides an image of all four third molars in one exposure. Some cases of proximity between the lower third molar and the lower alveolar nerve suggest the need of cone beam computed tomography (CBCT); however, in most cases, when compared to PR, some authors emphasize that the request for CBCT does not change the surgical planning. Thus, by panoramic radiographs, conditions related to the position of impacted third molars can be studied, with horizontal or mesioangular teeth showing greater relationship with most pathological conditions. In the presence of such situations, it is essential to correctly assess the position of these teeth by panoramic radiographic exams.16 Dentists should be aware of their limitations and characteristics, since it remains a valid examination method for the diagnosis and clinical management of third molars.14

tion in the mandibular ramus, the more complex is the surgery; therefore, the dentist should use these positions to perform a more careful surgical planning, preventing complications in the trans- and postoperative period.3,19 Regarding the age group, it was observed that there was higher prevalence between 19 and 30 years of age, corresponding to 74% of analyzed panoramic radiographs, corroborating the results of Trento et al.,20 in which there was higher prevalence for the age group 21 to 25 years, and by Fonseca et al.,14 with a higher prevalence of patients aged 21 to 40 years. This high prevalence can be explained by the eruption chronology of third molars around 21 years of age and by the higher prevalence of pericoronitis between 21 and 25 years, which leads to the search for diagnosis.6 Regarding the incidence of pathological alterations observed in the present study, it is considered that, even though their identification values were not high, there was higher incidence of caries in adjacent second molars and third molars. According to previous studies, the high frequency of dental caries in partially erupted lower third molars or associated second molars is related to the relative inaccessibility of these teeth for routine oral hygiene, which allows biofilm accumulation and food entrapment, resulting in caries.15 Concerning the incidence of pericoronal radiolucent area and external root resorption, the results agree with previously published studies, which revealed a low frequency of root resorption.15 In this context, Matzen et al.5 also concluded that the mesioangular and horizontal angulations of the lower third molar are risk factors for marginal bone loss and

CONCLUSION Therefore, there was higher prevalence of impacted lower third molars in females and, in relation to age group, there was higher prevalence between 19 and 30 years. As for the position variability, there was higher frequency of Winter’s mesioangular and horizontal positions, along with a higher prevalence of A and B positions and Pell and Gregory’s Class II. Despite the low values found, there was also a higher prevalence of caries in adjacent second molars and third molars.

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References:

1. Seguro D, Oliveira RV. Complicações pós-cirúrgicas na remoção de terceiros molares inclusos. Uningá Review. 2018;20(1):30-4. 2. Pinto DG, Mockdeci HR, Almeida LE, Assis NMSP, Vilela EM. Análise da prevalência e correlações por gênero, faixa etária, raça e classificação dos terceiros molares. HU Rev. 2015;41(3/4):155-62. 3. Gomes JPF, Freire JCP, Barreto JO, Santos JA, Araujo JCWP, Dias-Ribeiro E. Prevalência das posições de terceiros molares retidos em radiografias panorâmicas: estudo retrospectivo no sertão nordestino. Arch Health Invest. 2017;6(7):328-31. 4. Singh N, Chaudhari S, Chaudhari R, Nagare S, Kulkarni A, Parkarwar, P. A radiographic survey of agenesis of the third molar: a panoramic study. J ForensicDent Sci. 2017;9(3):130-4. 5. Matzen LH, Schropp L, Spin-Neto R, Wenzel A. Radiographic signs of pathology determining removal of an impacted mandibular third molar assessed in a panoramic image or CBCT. Dentomaxillofac Radiol. 2017;46(1):20160330. 6. Ventä I, Vehkalahti MM, Suominen AL. What kind of third molars are disease-free in a population aged 30 to 93 years? ClinOral investig. 2019;23(3):101522. 7. Ryalat S, AlRyalat SA, Kassob Z, Hassona Y, AlShayyab MH, Sawair, F. Impaction of lower third molars and their association with age: radiological perspectives. BMC Oral Health. 2018;18(1):58.

8. Jain S, Debbarma S, Prasad SV. Prevalence of impacted third molars among orthodontic patients in different malocclusions. Indian J Dent Res. 2019;30(2):238-42. 9. Matzen LH, Wenzel A. Efficacy of CBCT for assessment of impacted mandibular third molars: a review-based on a hierarchical model of evidence. Dentomaxillofac Radiol. 2014;44(1):20140189. 10. Winter GB. Principles of exodontia as applied to the impacted mandibular third molar: a complete treatise on the operative technic with clinical diagnoses and radiographic interpretations. St. Louis: American Medical Book Company; 1926. 11. Pell GJ, Gregory GT. Impacted mandibular third molars: classification and modified techniques for removal. Dent Dig. 1933;39:330-8. 12. Matos A, Vieira L, Barros L. Terceiros molares inclusos: revisão de literatura. PsicolSaúde Debate. 2017;3(1):34-49. 13. Mayrink G, Nicolai B, Aboumrad Júnior JP. Comparative study of dipyrone and paracetamol pain control after third molar extraction. J Braz Coll Oral Maxillofac Surg. 2018;4(2):32-7. 14. Fonseca ALFB, Marques FL, Brasileiro CB, Milagres C, Moreira R, Amaral TMP. Estudo da frequência e da variabilidade de posições dos terceiros molares nas radiografias panorâmicas no serviço de radiologia da Faculdade de Odontologia da Universidade Federal de Minas Gerais. Arq Odontol. 2018;54:e01.

15. Al-Khateeb TH, Bataineh AB. Pathology associated with impacted mandibular third molars in a group of Jordanians. J Oral MaxillofacSurg. 2006;64(11):1598-602. 16. Xavier CRG, Dias-Ribeiro E, Ferreira-Rocha J, Duarte BG, Ferreira-Júnior O, Sant’Ana, E, et al. Avaliação das posições dos terceiros molares impactados de acordo com as classificações de Winter e Pell & Gregory em radiografias panorâmicas. RevCirTraumatol Buco-Maxilo-Fac. 2010;10(2):83-90 17. Ye ZX, Yang C. Mesiolingual root rotation for horizontal mandibular third molar extraction: position classification and surgical simulation. SciRep. 2017;7:14405. 18. Matzen LH, Schropp L, Spin-Neto R, Wenzel A. Use of cone beam computed tomography to assess significant imaging findings related to mandibular third molar impaction. Oral Surg Oral Med Oral Pathol Oral Radiol. 2017;124(5):506-16. 19. Juodzbalys G, Daugela P. Mandibular third molar impaction: review of literature and a proposal of a classification. J Oral Maxillofac Res. 2013;4(2):e1. 20. Trento CL, Zini MM, Moreschi E, Zamponi M, Gottardo DV, Cariani JP. Localização e classificação de terceiros molares: análise radiográfica. Interbio. 2009; 3(2):18-26.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):37-43

Case Report

Primary palatoplasty by Bardach technique PEDRO HENRIQUE DA HORA SALES1,2 | EDSON LUIZ CETIRA-FILHO3 | FÁBIO WILDSON GURGEL COSTA4 | JOSÉ FERREIRA DA CUNHA-FILHO5,6 | JAIR CARNEIRO LEÃO7

ABSTRACT The cleft lip and palate are congenital malformations that can affect the lip, palate or both, and are due to errors in the fusion of the embryonic facial processes by changes in the normal development of the primary or secondary palate. Patients with such fissures present complex anatomical changes, being a challenge to the surgeons regarding rehabilitation. The objective of the present article is to present a patient with cleft palate submitted to a surgical procedure of palatoplasty using the Bardach technique under general anesthesia. Slit margin incisions were made, as well as lateral relaxing incisions accompanied by incisions in the anterior pedicles. Total mucoperiosteal detachment was performed. The musculature of the soft palate was deinserted and dissected, in order to be positioned in the proper position. Sutures were performed in the nasal, muscular and oral planes, and the lateral relaxing incisions healed by second intention. After three months of postoperative follow-up, the patient showed no signs of fistulas and presents good mobility of the soft palate musculature. The Bardach technique presents as an excellent option for primary palatoplasties, offering high success rates and few associated complications. Keywords: Cleft palate. Oral surgical procedures. Congenital abnormalities.

Universidade Federal de Pernambuco, Departamento de Prótese e Cirurgia Buco-Facial. Doutorando em Odontologia (Recife/PE, Brazil). Santa Casa de Misericórdia de São Miguel dos Campos, Departamento de Cirurgia Bucomaxilofacial (São Miguel dos Campos/AL, Brazil). 3 Universidade Federal do Ceará, Departamento de Clínica Odontológica. Doutorando em Clínicas Odontológicas (Fortaleza/CE, Brazil). 4 Universidade Federal do Ceará, Departamento de Clínica Odontológica. Professor Adjunto do curso de Odontologia (Fortaleza/CE, Brazil). 5 Hospital Infantil Albert Sabin, Setor de Cirurgia Bucomaxilofacial (Fortaleza/CE, Brazil). 6 Hospital Batista Memorial de Fortaleza, Preceptor da Residência em Cirurgia e Traumatologia Bucomaxilofacial (Fortaleza/CE, Brazil). 7 Universidade Federal de Pernambuco, Departamento de Clínica e Odontologia Preventiva. Professor Titular e Coordenador do programa de Pós Graduação em Odontologia da UFPE (Recife/PE, Brazil). 1

» 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.

How to cite: Sales PHH, Cetira-Filho EL, Costa FWG, Cunha-Filho JF, Leão JC. Primary palatoplasty by Bardach technique. J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):44-9. DOI: https://doi.org/10.14436/2358-2782.7.2.044-049.oar Submitted: March 25, 2019 - Revised and accepted: March 17, 2020 Contact address: Pedro Henrique da Hora-Sales E-mail: salespedro@gmail.com

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):44-9

Sales PHH, Cetira-Filho EL, Costa FWG, Cunha-Filho JF, Leão JC

INTRODUCTION Cleft lip and palate is the most common congenital craniofacial defect in children, with consequences on facial growth, hearing, speech and psychosocial well-being.1 In Brazil, it is considered the most common craniofacial malformation, with an incidence of approximately one in every 650 newborns.2 The classification of types of cleft most used worldwide was proposed by Spina,3 who suggested a classification based on anatomy and considering the incisive foramen as reference, which is the dividing landmark between the primary and secondary palate. Thus, clefts are divided into four groups: pre-foramen, in which the primary palate is involved; trans-foramen, which reaches the primary and secondary palates; post-foramen, which affects only the secondary palate; and rare facial clefts, which can be complete or incomplete.3 The management of patients with clefts is complex and requires a multidisciplinary team, which includes maxillofacial surgeons, plastic surgeons, orthodontists, otolaryngologists, speech therapists and pediatricians, among others. Surgical repair of cleft palate typically occurs after 9-10 months of age, which is associated with excellent results regarding speech.4 For the success of this surgery, it is fundamental to reestablish the anatomy of the palate, promot-

ing adequate velopharyngeal function and improving breathing, speech, chewing and esthetics, as well as preserving the potential for normal growth of the affected area.1,5 Several palatoplasty techniques have been described in the literature, and the choice is based on several criteria, such as type of cleft, cleft extent, surgeon’s preference and technical skill.6,7,8 Thus, the aim of this study is to report the clinical case of a patient with cleft palate who underwent primary palatoplasty surgery using the Bardach technique. CASE REPORT A 15-month-old female patient attended a reference hospital for the treatment of cleft lip and palate with her mother, with complaint that the “roof of the mouth was open”. After evaluation by the maxillofacial surgery team, it was observed that the patient had complete left unilateral trans-foramen cleft lip and palate, with the lip already operated, but requiring palatoplasty. It was decided to perform palatoplasty using the Bardach technique. It was performed under general anesthesia with orotracheal intubation (Fig 1). Lateral releasing incisions, combined with incisions at the cleft margin and total mucoperiosteal detachment of the entire bilateral palatal mucosa, were carefully

Figure 1: Preoperative clinical image of the cleft.

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Primary palatoplasty by Bardach technique

and sutured in the midline, using a 4-0 resorbable suture, and a “U” suture was performed. Thus, there was contact between the raw tissues, allowing good healing. Lateral releasing incisions healed by second intention (Fig 6). After a period of 45 days, the patient had complete healing of the operated region, without the presence of an oronasal fistula, being monitored by a multidisciplinary team. At the moment, she has two years of postoperative follow-up, presenting an excellent functional result (Fig 7).

performed, to avoid injury to the larger palatine vascular nerve bundles, which would nourish the palate posteriorly (Figs 2 and 3). Then, the soft palate musculature, which is vertically inserted at the posterior edge of the cleft palate, was detached and suture was initiated. A transverse reorientation of the soft palate musculature was performed, so that speech could be normally performed later (Fig 4). The anterior pedicles were then repositioned, and at that moment, passivity and elongation of the palatine mucosa were observed (Fig 5). The nasal and oral planes were aligned

Figure 2: Incisions performed with detached anterior pedicles.

Figure 3: Raised flap, showing preservation of the greater palatine vascular-nerve bundles.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):44-9

Sales PHH, Cetira-Filho EL, Costa FWG, Cunha-Filho JF, Leão JC

Figure 4: Transverse reorientation of soft palate muscles.

Figure 5: Reorientation of the anterior pedicle, showing elongation of the palatal mucosa.

Figure 6: Final aspect after suturing the oral and nasal mucosa.

Figure 7: Aspect of the region after two-year follow-up.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):44-9

Primary palatoplasty by Bardach technique

DISCUSSION Correct closure of the primary palate is fundamental when treating a patient with cleft lip and palate. Due to the complexity of surgery and anatomical limitations, such as lack of tissue in the region and limited vascularization, this type of procedure can cause sequelae that are difficult to resolve if surgery is not correctly performed, the main sequelae being oronasal fistulas, velopharyngeal dysfunctions and speech problems.9 The Bardach technique allows for good elongation of the soft palate, which is particularly advantageous in case of shorter palates, with an oronasal fistula formation rate around 5% of cases.9 However, it is extremely important to perform the surgical technique correctly, requiring aggressive posterior repositioning of the soft palate levator muscle, as well as careful attention to closure, with all tissue layers being sutured correctly. Undoubtedly, inadequate closure and inadequate soft tissue manipulation are frequent causes of relapse.5 In a recent systematic review that compared several techniques for closing the primary palate, it was observed that the Von Langenbeck technique had a higher rate of fistula formation than the Veu technique. The latter also proved to be more effective in relation to the Bardach technique, with regard to the velopharyngeal function.6 In their surgical routine, the authors of the present study observed good results in velopharyngeal function when the Bardach technique was used, being extremely important to carefully dissect and realign the soft palate muscles to obtain this result. Another important aspect regarding the choice of technique is the cleft palate width. While smaller clefts present good closure and minor complications with the Von Langenbeck or Furlow techniques, wider

clefts require greater tissue detachment to reduce tension in the suture area. It is highly recommended that clefts wider than 8 mm be treated with techniques such as Bardach, enabling a more passive tissue accommodation, as in the present case.7 Although the current literature agrees that primary palate closure must occur before one year of age,4 in Brazil, many cases are operated outside the ideal age, as in the present case – which may imply future problems, especially in relation to speech. The reasons for such delay in surgical treatments still need to be studied; however, it is believed that the socioeconomic condition of the patients, difficulties in accessing specialized care, as well as the lack of adequate training by specialists contribute to this situation. The effective participation of maxillofacial surgeons in the treatment of cleft lip and palate, as well as the encouragement of training in residency programs, should be strongly encouraged. In some services, lip and palate primary surgeries may correspond to approximately 70% of surgical procedures performed,10 and it is important to emphasize that the treatment of congenital malformations in the craniofacial region – thus including cleft lip and palate – is part of the scope of the specialty, and the specialist must be able to fully perform the treatment. FINAL CONSIDERATIONS The management of cleft palate is complex and must be performed by a multidisciplinary team with specific training. Several surgical techniques are described for primary closure of cleft palate. However, it is observed that the Bardach technique presents low rates of oronasal fistulas, low morbidity and good stretching of palate muscles, thus being an excellent option for primary palatoplasties, especially in wide clefts.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):44-9

Sales PHH, Cetira-Filho EL, Costa FWG, Cunha-Filho JF, Leão JC

References:

1. Crockett DJ, Goudy SL. Cleft lip and palate. Facial Plast Surg Clin North Am. 2014; 22(4):573-86. 2. Valente AMSL, Espinosa MM, Silva AN, De Luccia G. Characteristics of patients who underwent primary correction of the cleft-lip and palate. Rev HCPA. 2013; 33(1):32-9. 3. Spina V. A proposed modification for the classification of cleft lip and cleft palate. Cleft Palate J. 1973;10:2512. 4. Mahoney MH, Swan MC, Fisher DM. Prospective analysis of presurgical risk factors for outcomes in primary palatoplasty. Plast Reconstr Surg. 2013;132(1): 165-71.

5. Losken HW, Van Aalst JA, Teotida SS, Dean SB, Hultman S, Uhrick KS. Achieving low cleft palate fistula rates: surgical results and techniques. Cleft Palate Craniofac J. 2011; 48(3):312-20. 6. Stein MJ, Zhang Z, Fell M, Mercer N, Malic C. Determining post-operative outcomes after cleft palate repair: a systematic review and meta analysis. J Plast Reconstr Aesthet Surg.2019;72(1):85-91. 7. Losken HW, Van Aalst JA, Teotia SS, Dean SB, Hultman S, Uhrich KS. Achieving low cleft palate fistula rates: surgical results an techniques. Cleft Palate Craniofac J. 2011;48(3):312-20.

8. Ribeiro AF, Silva ML, Sato FRL, Marchiori EC, Moreira RWF. Avaliação de duas técnicas de palatoplastia em pacientes portadores de fissuras palatinas. J Braz Coll Oral Maxillofac Surg. 2017;3(1):20-4. 9. Aslam M, Ishaq I, Malik S, Faryyaz GQ. Frequency of oronasal fistulae in complete cleft palate repair. J Coll Physicians Surg Pak. 2015;25(1):46-9. 10. Gaião L, Souza TBP, Mendes RV, Macêdo PF. Cleft lip and palate surgies: Report of 7-year experience in Centrinho Imperatriz/MA (Brazil). J Braz Coll Oral Maxillofac Surg. 2018;4(3):37-41.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):44-9

Case Report

Joint and mandibular reconstruction with customized prosthesis PAULO AFONSO OLIVEIRA JUNIOR1 | DANILO DRESSANO1 | ARMANDO DE BARROS1 | FELIPE CALILE FRANCK1 | JOÃO LISBOA DE SOUSA FILHO1

ABSTRACT The objective of the present work is to present a 18-years follow-up of a patient diagnosed with an extensive odontogenic mixoma that affected the right side of the mandible. In the first surgery, a mandibulectomy was performed, followed by a free fibula flap reconstruction. Fourteen years after the surgery, the patient returned and a fracture of the grafts proximal segment was noted. This complication was solved with the installation of a customized prosthesis to reconstruct the right temporomandibular joint (TMJ) and half part of the mandible. Four years after the prosthesis installation, the patient has a satisfactory occlusion, no pain, oral aperture of 47 mm and an excellent facial contour. The importance of this case is based on the few reports with this kind of reconstruction in the literature. In conclusion, the TMJ customized prosthesis is an excellent option for selected cases in which the articular and mandibular reconstruction are required.

Keywords: Joint diseases. Mandibular prosthesis. Joint prosthesis.

How to cite: Oliveira Junior PA, Dressano D, Barros A, Franck FC, Sousa Filho JL. Joint and mandibular reconstruction with customized prosthesis. J Braz Coll Oral Maxillofac Surg. 2021 MayAug;7(2):50-5. DOI: https://doi.org/10.14436/2358-2782.7.2.050-055.oar

Irmandade Santa Casa e Piracicaba, Departamento de Cirurgia e Traumatologia Bucomaxilofacial (Piracicaba/SP, Brazil).

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

Submitted: November 15, 2018 - Revised and accepted: March 06, 2019

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

Contact address: Paulo Afonso Oliveira Junior E-mail: pauloafj@terra.com.br

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):50-5

Oliveira Junior PA, Dressano D, Barros A, Franck FC, Sousa Filho JL

INTRODUCTION Mandibular reconstructions are indicated in several traumatic pathologies and defects that involve the only mobile bone in the skull. Free fibula grafts gained popularity in mandibular reconstructions due to studies by Hidalgo,1,2 Lee et al.,3 Peled et al.4 and Tarsitano et al.5 Although other donor areas are also used, such as iliac bone, scapula, radius etc., Toroni et al.6 state that there is a clear trend towards the use of microvascular grafts and, among them, more frequently the fibula.7 Autogenous grafts are still the gold standard for mandibular reconstructions, since they enable the esthetic-functional rehabilitation of the stomatognathic system.4,5 However, no matter how well indicated and performed, they are subject to complications and complications. Mandibular reconstructions involving the joint region are more difficult, mainly because they need to reconstruct a complex structure as the TMJ, thus being subject to several alterations, such as bone resorption or ankylosis. Mercury8 describes that mandibular and joint reconstructions with prostheses have advantages over microvascular and free grafts, due to their reduced morbidity, excellent biomechanical function and stability, being mainly indicated for reconstructions involving the joints or in complex defects. The application of customized prostheses has currently been reported for some complex mandibular reconstructions, especially in cases involving the TMJ and/or part of the mandible, according to Rodrigues et al.9 These customizations allow the correction of defects in a personalized manner, aiming to meet the specific needs of the case,8 which is a current trend concerning alloplastic reconstructions.

three fragments to adapt to the mandibular contour, a technique considered adequate for the time, since until then procedures as microvascular grafts were not widespread, since they required specialized teams. In the immediate postoperative period, the patient presented infection of the graft, which was solved with systemic use of antibiotics and local irrigation. Fourteen years passed and the patient had good functional and esthetic characteristics. After this period of clinical stability, the patient returned with history of pain and edema, after reporting a strong click in the region of the right mandibular ascending ramus. Conventional imaging exams were not elucidative and a CT scan with 3D reconstruction was requested, in which it was possible to observe the fracture of the upper graft segment and its migration to the medial space, with consequent rotation of the reconstruction plate to the temporal region of the zygomatic arch, which caused pain and mandibular hypomobility (Fig 2). The therapeutic proposals were thoroughly discussed with the patient and family. For this decision, all risks, advantages and disadvantages of the proposed technique were considered. We decided to use a customized prosthesis, since the defect mainly included the right TMJ. Surgery was performed after all preliminary stages of planning and making the customized prosthesis, emphasizing the importance of participation of the surgeon in prosthesis planning and design, considering the surgical possibilities that some of the screws placed in the first surgery were osseointegrated, precluding their removal during surgery, which could interfere with the placement of the current prosthesis (Fig 3). Thus, in the final design of the prosthesis, these perforations cannot be used. After designing and waxing the prosthesis, the images were sent to the surgeon for verification and approval (Fig 4). Pre-auricular and submandibular accesses, all extraoral, were used. After careful extra- and intraoral antisepsis, the mandibular reconstruction plate was carefully removed by a submandibular access, noting that one of the screws fractured during removal. To remove the plate, it was also necessary to perform osteotomy in the upper part of the temporal bone region, for total release. These areas were previously demarcated in the prototype with the necessary wear areas. The specific biomodel of the region was also sent for intraoperative guidance, aiming at proper placement of the prosthetic fossa.

CASE REPORT A 25-year-old female patient with a histopathological diagnosis of odontogenic myxoma extending in the mandible from the parasymphyseal region up to close the mandibular head was operated at the Maxillofacial Surgery and Traumatology Service of Santa Casa de Misericórdia de Piracicaba (São Paulo), where hemimandibulectomy was performed (Fig 1), by intra- and extraoral access, and immediate reconstruction with a free graft from the fibula and a 2.7-mm locking system mandibular reconstruction plate. The graft was segmented into

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):50-5

Joint and mandibular reconstruction with customized prosthesis

Figure 1: Mandible reconstructed with autogenous free fibula graft, immediately after tumor removal (surgery performed 18 years earlier).

Figure 2: Tomography showing graft fracture with medial migration, contact and onset of ankylosis formation between the reconstruction plate and the temporal bone.

Figure 3: Stereolithographic model with drawing of prosthesis perforations, in blue.

Figure 4: Final wax-up of the prosthesis.

To place the mandibular component, a Hegar uterine dilator with slightly larger diameter than that the prosthesis was used (Fig 5). This method proved to be effective for stability of the mandibular component (Fig 6) and prosthesis cavity, without the need for condyle fixation using wires in the polyethylene portion of the cavity, a technique often used in this type of prosthesis (Fig 7). The mandibular component was stabilized in the mandible and in the remaining segment of the graft, using 2.0-mm cortical screws (Figs 6 and 9).

Another highlighted procedure is the use of autogenous fat graft around the joint portion of the prosthesis (Fig 8), since according to Wolford et al.10 the fat graft prevents ankylosis and joint hypomobility, besides improving quality of life and reducing pain. The patient had a good postoperative period, with transient neuropraxia in the frontal and zygomatic branches of the facial nerve on the right side. After a four-year follow-up, the patient presents an oral opening of 47 mm (Fig 13), without functional or esthetic complaints or facial asymmetries (Figs 11 and 12).

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):50-5

Oliveira Junior PA, Dressano D, Barros A, Franck FC, Sousa Filho JL

Figure 5: Hegar dilator promoting space for positioning the mandibular component of the prosthesis.

Figure 6: Overview of the prosthesis before placement.

Figure 7: Prosthesis placed, fossa in position.

Figure 8: Placement of autogenous fat in the joint region of the prosthesis.

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Joint and mandibular reconstruction with customized prosthesis

Figure 9: End of prosthesis placement.

Figure 11: Frontal view with 4 years of prosthesis.

Figure 10: Current panoramic radiograph, 4-year prosthesis control.

Figure 12: Profile view, 4-year control.

DISCUSSION The customized prosthesis was indicated, mainly because the patient had already undergone a fibular graft 14 years earlier, and also because there is a possibility that these grafts undergo remodeling, causing bone resorption or ankylosis, besides presenting superior stability and biomechanical function. The most likely cause of failure of the first surgery is due to these processes, mainly influenced

Patients undergoing reconstructive surgery with prostheses should receive careful periodic clinical follow-up, as well as yearly radiographs (Fig 10) or CT scans. Dental monitoring is also very important, since it allows prevention of infectious conditions and tooth loss that compromise the occlusal function, besides the control of parafunctional habits, which is also essential to prevent problems with these prostheses.

Figure 13: 47-mm mouth opening, 4 years after prosthesis placement.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):50-5

Oliveira Junior PA, Dressano D, Barros A, Franck FC, Sousa Filho JL

FINAL CONSIDERATIONS The use of customized prostheses for mandibular reconstruction was indicated in this case because the lost bone graft segment involved structures of the mandibular body, ramus and condylar process, thus being a suitable replacement, with excellent biomechanical quality, besides providing reinforcement to the structure of the remaining bone graft. Wolford et al.,11 in a 20-year follow-up of 111 patients with this type of prosthesis in isolated joint reconstructions, achieved excellent function, such as ability to ingest solid foods, absence of pain and satisfactory joint functioning, with very low complication rates.8,10,11 In the light of current knowledge, it appears to be a promising technique, with more predictable prognosis compared to free or microvascular grafts, and with less morbidity. However, it must be mentioned that more studies like this are still needed to confirm the efficiency of the technique.

by the infectious condition that occurred in the postoperative period immediately following the first surgery. The use of Hegar dilators (instruments for dilation of natural spaces) for expansion of the muscle belt to adjust the prosthesis diameter to the previously placed graft bed proved to be an adequate technique, facilitating and promoting correct adaptation of the prosthesis and providing joint stability provided by the preexisting muscle strap that involved the graft segment (Fig 5), proving to be effective in stabilizing the prosthesis. The use of customized prostheses in complex mandibular reconstructions is well indicated, due to their excellent biomechanical characteristics, better stability and lower morbidity.8-11 However, it still represents a costly treatment, involving technology and high-cost tests that are not yet accessible to the entire population. Retrospective clinical studies are still scarce in the literature, yet they are necessary to reliably assess if the technique has good long-term results.8 In the present report, the technique proved to be effective, with a fouryear follow-up, with very satisfactory results.

References:

1. Hidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg.1989;84(1):71-9. 2. Hidalgo DA. Fibula free flap mandibular reconstruction. Clin Plastic Surg.1994;21(1):25-35. 3. Lee JH, Kim MJ, Kim JW. Mandibular reconstruction with free vascularized fibular flap. J Craniomaxillofac Surg.1995;23(1):20-6. 4. Peled M, El-Naaj IA, Lipin Y, Ardekian L. The use of free fibular flap for functional mandibular reconstruction. J Oral Maxillofac Surg.2005;63(2):220-4. 5. Tarsitano A, Ciocca L, Cipriani R, Scotti R, Marchetti C. Mandibular reconstruction using fibula free flap harvested using a customized cutting guide: how we do it. Acta Otorhinolaryngol Ital. 2015;35(3):198-201.

6. Torroni A, Marianetti TM, Romandini M, Gasparini G, Cervelii D, Pelo S. Mandibular reconstruction with different techniques. J Craniofac Surg. 2015; 26(3):885-90. 7. Wu J, Sun J, Shen SG, et al. Computer-assisted navigation: Its role intraoperatively accurate mandibular reconstruction. Oral Surg Oral Med Oral Pathol Oral Radiol. 2016; 122(2):42. 8. Mercuri LG. Mandibular replacement utilizing TMJ TJR devices In: Temporomandibular joint replacement -TMJ TJR, part III. Swizterland: Springer Internacional Publishing; 2016.p. 165-186. 9. Rodrigues DB,Wolford LM, Pietry M,Campos PSF. Concomitant of treatment of mandibular ameloblastoma and bilateral temporomandibular joint osteoarthritis with bone grafts and total joint prostheses. J Oral Maxillofac Surg. 2015;73(1):63-74.

10. Wolford L, Movahed R, Teschke M, Fimmers R, Havard D., Schneiderman E. Temporomandibular joint ankilosis can be successfully treated with TMJ concepts patients-fitted total joint prosthesis and autogenous fat grafts. J Oral Maxillofac Surg. 2016:74(6):1215-27. 11. Wolford LM, Mercuri LG, Schneiderman E, Movahed R, Allen W. Twenty-year follow-up on a patient-fitted temporomandibular joint prosthesis: the Techmedica /TMJ concepts devices. J Oral Maxillofac Surg. 2015;73(5):952-60.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):50-5

Case Report

Surgical treatment of sialolith on submandibular gland duct

ABSTRACT Sialoliths are calcified structures that develop in the salivary glands or in their ducts, causing its obstruction and producing inflammation or infection of region. Diagnostic methods include inspection, palpation, radiographic examination, computed tomography and a detailed anamnesis. A 31-year-old male with no systemic alterations presented with complaints of increased volume and discomfort in the oral floor during meals. On clinical examination, a volume increase was observed in the right-side buccal floor, and on palpation, a nodule of hardened and mobile consistency was observed. A cone beam computed tomography scan was performed, in which the presence of a hyperdense and cylindrical mass, suggestive of salivary calculus in the region corresponding to the duct of the submandibular gland on the right side, was evidenced. The proposed treatment was surgical removal, through intraoral access under local anesthesia and installation of a plastic device to avoid the collapse of the duct. In the postoperative period, the patient had no complaints of pain or discomfort, and the physiological functions were preserved. It was concluded that a quality image examination and evaluation by the dental surgeon are fundamental for definition of the diagnosis and planning of the surgical procedure to be performed. Keywords: Submandibular gland. Salivary gland calculi. Salivary duct calculi.

Universidade do Estado do Amazonas, Programa de Residência em Cirurgia e Traumatologia Bucomaxilofacial (Manaus/AM, Brazil). Universidade do Estado do Amazonas, Curso de Graduação em Odontologia (Manaus/AM, Brazil).

How to cite: Tavares PMH, Nascimento LS, Martins VB, Oliveira MV, Albuquerque GC, Nascimento SLC, Torres RS. Surgical treatment of sialolith on submandibular gland duct. J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):56-62. DOI: https://doi.org/10.14436/2358-2782.7.2.056-062.oar

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

Submitted: November 09, 2018 - Revised and accepted: March 21, 2019

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

Contact address: Paulo Matheus Honda Tavares E-mail: matheus_apj@yahoo.com.br

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):56-62

Tavares PMH, Nascimento LS, Martins VB, Oliveira MV, Albuquerque GC, Nascimento SLC, Torres RS

INTRODUCTION Sialolithiasis is the most common pathology of the main major salivary glands and is characterized by obstruction of the gland or salivary duct due to formation of a calculus called sialolith, causing infection or painful inflammation in the involved region. The calculus has hard consistency, yellowish color, can be ovoid, cylindrical or round, and its length varies from a few millimeters to a few centimeters, normally not exceeding 10 mm. Sialoliths larger than 15 mm in any dimension are considered to be giant and rare. It most often affects males in any age group, being more common in young and middle-aged adults. The submandibular gland is most commonly affected (83%), followed by the parotid (10%) and, to a lesser extent, by the minor salivary and sublingual glands (7%).1-4 Although the pathophysiology of salivary calculi is still uncertain, it is believed that they are formed from the deposition of calcium salts around a niche of organic material. These organic debris can include thick mucus, bacteria, duct epithelial cells, or foreign bodies. Alkalinity and increased calcium concentration in saliva are also considered causal factors, besides inflammation, infection or trauma to the gland or salivary duct. 2,5 The diagnosis is determined based on anamnesis and careful extraoral and intraoral clinical examination, associated with imaging tests such as ultrasonography, sialography, computed tomography, panoramic radiographs and magnetic resonance imaging. Clinically, there is increased volume of the involved gland, pain, infection of the affected area and dilation of the salivary duct; it is common to report pain, swelling of the mouth floor and discomfort in the gland after meals or when there is salivary stimulus. Radiographically, it presents as a radiopaque mass, which is not always visible on conventional radiographs, due to the degree of calcification of some lesions.2,5 The appropriate treatment depends on aspects such as the affected gland, size and location of the stone. The surgical technique consists of removing the sialolith in a conservative manner or with total removal of the involved gland. 2 Conservative and minimally invasive methods are recommended for smaller sialoliths, such as sialoendoscopy and lith-

otripsy by intra- or extracorporeal shock waves, in order to break the calculus into smaller fragments, which will be expelled, as well as conservative surgical removal and instruction on diet with citrus liquids associated with periodical massages, aiming at stimulating salivation, resulting in spontaneous exit of the calculus. For larger salivary calculi located in the gland parenchyma, more invasive techniques are indicated, such as surgical removal.6,7 Thus, this article aims to report a clinical case of a large sialolith located in the submandibular gland duct (Wharton’s duct), addressing its clinical and radiographic aspects and conservative surgical treatment with duct repair. CASE REPORT A 31-year-old male patient without systemic changes attended the service complaining of swelling and discomfort in the mouth floor during meals. On clinical examination, there was increased volume in the right mouth floor, extending from the canine to the molars, without changes in color and texture of the mucosa and on palpation; besides a circumscribed, mobile, hard and painless nodule. Cone beam computed tomography exam was requested, which showed the presence of a hyperdense and cylindrical mass, measuring approximately 2.8 x 0.7 x 0.6 cm, suggestive of sialolith in the region corresponding to the right submandibular gland duct (Fig 1). Based on clinical and imaging findings, the proposed treatment was surgical removal by intraoral access under local anesthesia. The patient was normosystemic and able to undergo surgery. The informed consent form was read and filled by the patient, and the procedure was clearly explained. The sialolith was located in a superficial and anterior position of the duct, making the access easier to perform in an outpatient setting. The sialolith was located by palpation and clamped with the fingers, to keep it fixed in a single position; a small incision was then made in the mouth floor over the calculus, which was immediately visualized in the superficial portion of the incision. The duct was located and dissected by blunt divulsion, for greater exposure and visualization of the sialolith, which moved in a passive and expulsive

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Surgical treatment of sialolith on submandibular gland duct

At 10 days postoperatively, the suture and plastic device were removed, and the anatomy and function of the submandibular gland duct were preserved. Sixty days after surgery, the patient had no complaints of pain or discomfort in the mouth floor region (Fig 3).

manner, facilitating its complete excision. Careful suture was performed, and a plastic device (Jelco n. 20 flexible intravenous catheter) was placed, aiming at maintaining the continuity of the glandular duct to the oral mucosa, thus preventing its collapse and maintaining its function (Fig 2) .

Figure 1: Preoperative aspect. A) Increased volume on the right mouth floor region. B) Axial section of preoperative computed tomography, showing the presence of salivary calculus in the region of Wharton’s duct. C) Parasagittal computed tomography sections, showing the presence of calculus in the premolar region.

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Tavares PMH, Nascimento LS, Martins VB, Oliveira MV, Albuquerque GC, Nascimento SLC, Torres RS

Figure 2: Transoperative aspect. A) Surgical technique: incision over the calculus in the mouth floor. B) Duct dissection using the divulsion technique. C) Removal of sialolith. D) Suture and placement of flexible device (Jelco n. 20).

Figure 3: Postoperative aspect. A) Sialolith removed. B) 45-day follow-up, with maintenance of physiological functions.

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Surgical treatment of sialolith on submandibular gland duct

DISCUSSION Salivary gland sialolithiasis is characterized by inflammation of the gland or its excretory duct from the obstruction resulting from a sialolith, which presents as a yellowish calcified mass, with cylindrical, ovoid or rounded shape, and this aspect may indicate its location. Stones inside the gland have a rounded shape and, when located in the duct, they have a more cylindrical shape. They most frequently affect the submandibular gland (80.4%), with size ranging from 10 to 35 mm, and calculi in the Wharton’s duct, which commonly have a cylindrical and elongated shape.2,4,8 The reported case corroborates the current literature in which the calculus was located in the anterior region of the submandibular gland duct, with a cylindrical and elongated shape. In all literature reviewed, the highest incidence of salivary calculi formation was in the submandibular gland. Males were the most affected, with adults over 30 years of age being the most affected. 1,2,4,9,10 Sialoliths most frequently affect the submandibular gland, due to factors as the path of salivary flow against gravity, long and tortuous duct anatomy, and the composition of saliva produced by this gland, which has higher calcium concentration and alkalinity. Stones grow by deposition and have a slow evolution, with a 1.0 to 1.5-mm rate of increase per year. Its size ranges from less than 1 mm to a few centimeters; when they exceed 15 mm, they are considered giant calculi, as in the present case, in which the salivary calculus had dimensions of 2.8 x 0.7 x 0.6 cm, this measurement being characteristic of a large sialolite. 1,3,5,9 It is important to associate anamnesis and careful clinical examination with imaging exams, to provide a correct diagnosis and treatment plan for the clinical case. On intraoral examination, the most common and characteristic aspect is the increased volume in regions that have salivary glands, with no change in mucosa color and texture;7,9,10 as well as in the clinical aspect of the presented case, in which the mucosa had normal color, without changes in texture and shape, with only a slight increase in volume. Palpation is an important diagnostic maneuver, in which it is expected to find a hardened nodule, with some degree of mobility. Conventional radiographic examination is the simplest and most used method, in which panoramic radiography and transoral oc-

clusal imaging provide better images for identifying salivary calculus. Other more specific imaging tests help in a more accurate diagnosis, such as sialography and computed tomography. Sialography helps in the diagnosis, since it identifies the entire course of the duct; however, it is contraindicated in cases of sialadenitis, since it can spread the infection.7,9 In the present case, due to the more superficial position of the sialolith in the duct, it was possible to locate it by bidigital palpation, which evidenced the hardened consistency and mobility of the stone. Computed tomography was requested to complement the initial panoramic radiography exam, guiding with greater accuracy the size and exact location of the sialolith in the right submandibular gland duct, aiding the best choice of treatment, corroborating the literature, which suggests, for sialoliths of larger proportions, the use of computed tomography to analyze the three-dimensional extent, mineralization degree and exact location of the calculus.1,5,9,10 The literature mentions that, since it is asymptomatic and slow-growing, the sialolith is usually randomly detected, as a radiographic finding in routine imaging exams. However, there are also reports in the literature of cases in which salivary calculi were found after investigation of pain complaints, discomfort and swelling in the mouth floor mentioned by patients during anamnesis. 1,2,5,9,10 In this study, the patient reported discomfort and increased volume in the mouth floor during meals, which led to the investigation of salivary glands and consequently to the diagnosis. There are several methods for treating sialolithiasis in the submandibular gland duct, from conservative management to surgery. The choice of treatment technique varies according to the size of sialolith, location into the duct and the likelihood of complications, considering the patient’s specific condition and symptoms. In cases of small sialoliths, conservative treatment is chosen, such as stimulating the patient’s salivation by a diet with citrus foods and prescription of sialogogues associated with massage of the salivary gland, which leads to spontaneous exit of the calculus. Lithotripsy with intra- and extraoral shock waves, sialendoscopy and intervention with radiological machines are also considered less aggressive techniques.6,7,9 In the case of sialoliths located in the anterior third of the duct,

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Tavares PMH, Nascimento LS, Martins VB, Oliveira MV, Albuquerque GC, Nascimento SLC, Torres RS

small incision was made over the calculus for removal. However, the blunt dissection technique was used for greater exposure, so that the sialolith moved passively, facilitating its complete excision. Some authors, after removal of the sialolith, recommend only a non-occlusive suture in the mucosa for synthesis, avoiding interruption of salivary drainage. Others make use of plastic devices introduced into the duct and sutured to the mucosa, to assist in the continuity of the duct to the mucosa. The literature reports possible surgical complications, such as injury to the lingual nerve and ductal stenosis. 1,6,7,9 In the present case, the use of a device was recommended to obtain a ductal repair, maintaining its continuity and function. At 45 days postoperatively, it was observed that the physiological functions were preserved, with complete healing of the mouth floor and salivation with normal flow. Thus, the treatment proposed to the patient was effective for resolution of the presented clinical case.

the surgical incision is made where the stone is located, for exposure followed by removal; in the case of sialoliths located in the posterior region of the duct or inside the gland, the approach is surgical and may be associated with total removal of the gland. 2,9 The treatment chosen in the reported case, due to its size and location, was surgical approach with an incision in the calculus region for exposure, considering its location in the Wharton’s duct, followed by divulsion and excision, which is in accordance with the literature consulted. The surgical approach is performed with intraoral access, most often under local anesthesia, and involves removal of the stone or affected gland. Other authors, considering the stone size, recommend extraoral access when it is necessary to remove the gland together with the sialolith.5,6,7,9 In the presented case, surgery was performed under local anesthesia in an outpatient clinic, since the calculus was in an easily accessible location. The technique consists of a longitudinal axis incision on the floor, followed by blunt dissection for direct access. The use of a repair stitch by an incision in the area posterior to the sialolith prevents stone movement during surgical manipulation, preventing it from moving into the gland. 6,7,9 Unlike the use of an incision with a repair stitch, in the reported case, bidigital clamping of the sialolith was performed to keep it fixed, preventing its displacement to the posterior duct region, and a

FINAL CONSIDERATIONS Sialolithiasis is a common pathology, of uncertain pathogenesis, in which clinical and radiographic findings are crucial for the correct diagnosis. The treatment is varied, and the most used approach is surgical removal by intraoral access. Large sialoliths are rare and, due to their shape, the treatment of choice is surgical removal, with excellent prognosis.

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Surgical treatment of sialolith on submandibular gland duct

References:

1. Oliveira TP, Oliveira INF, Pinheiro ECP, Gomes RCF, Mainenti P. Giant sialolith of submandibular gland duct treated by excision and ductal repair: a case report. Braz J Otorhinolaryngol. 2016;82(1):112-5. 2. Lima AN, Milani BA, Massaine LF, Souza AMM, Jorge WA. Sialolitíase em glândula submandibular: relato de caso clínico. Rev Cir Traumatol Buco-Maxilo-Fac. 2013;13(1): 23-8. 3. Rodrigues GHC, Carvalho VJG, Alves FA, Domaneschi C. Giant submandibular sialolith conservatively treated. Autops Case Rep. 2017;7(1):9-11. 4. Manzi FR, Silva AIV, Dias FG, Ferreira EF. Sialolito na glândula submandibular: Relato de caso clínico. ROBRAC. 2010;19(50): 270-4. 5. Iwai T, Izumi T, Ohya T, Oguri S, Tohnai I. Giant sialolith of the submandibular gland. J Clin Diagn Res. 2017;11(8):ZJ03-4.

6. Seong-Ho C, Ji-Deuk H, Jung-Han K, Shi-Hyun L, JiBong J, Chul-Hoon K, et al. Removal of submandibular calculi by surgical method and hydraulic power with curved needle: a case report. J Korean Assoc Oral Maxillofac Surg. 2017;43(3):182-5. 7. Goes PEM, Lima VN, Carvalho FSR, Queiroz SBF, Camargo IB. Sialolito gigante em ducto de Wharton: Um caso distinto e revisão de literatura. Rev Cir Traumatol Buco-Maxilo-Fac. 2013;13(4):71-8. 8. Sigismund PE, Zenk J, Koch M, Schapher M, Rudes M, Iro H. Nearly 3.000 salivary stones: Some clinical and epidemiologic aspects. Laringoscope. 2015;125(8):1879-82. 9. Jaeger F, Andrade R, López Alvarenga R,Galizes BF, Amaral MBF . Sialolito gigante no ducto da glândula submandibular. Rev Port Estomatol Med Dent Cir Maxilofac. 2013;54(1):33-6.

10. Guimarães MAA, Pinto LAPF, Carvalho SB, Soares HA, Costa C. Sialolito gigante de glândula submandibular: achados na tomografia computadorizada. J Health Sci Inst. 2010;28(1):84-6.

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Case Report

Cutaneous non-Hodgkin’s lymphoma in face, after tooth extraction JOSÉ RENATO LINHARES FERNANDES1 | MARCIA MARIA DE GOUVEIA2 | PAULO SERGIO MARTINS ALCÂNTARA3

ABSTRACT B-cell primary cutaneous lymphomas are part of the non-Hodgkin-type B lymphocyte origin malignancies. Primary cutaneous lymphomas often have different clinical and prognostic behavior than systemic lymphomas of similar histological subtype. According to the World Health Organization and Cutaneous Lymphoma Study Group of the European Organization for Research and Treatment of Cancer (WHO-EORTC), cutaneous centrofollicular lymphoma is an indolent lymphoma. The diagnosis is obtained by histopathological and immunohistochemical studies. Radiotherapy is the treatment of primary choice, with or without adjuvant surgical therapy. The present study aims to report a case of central follicular primary cutaneous lymphoma in a 42-year-old man, exploring its clinical aspects and the need for early diagnosis, in an attempt to improve the life expectancy of patients. The patient did not present recurrences after 21 months of lesion excision and 16 months of six cycles of chemotherapy. Despite the repetitive reference to the appearance of B-cell NHL after exodontia, including the present report, there is no evidence to demonstrate its relation in the onset of the neoplastic process. Therefore, studies are needed in this area. Keywords: Lymphoma. Mouth neoplasms. Lymphoma, non-Hodgkin.

Hospital Universitário da Universidade de São Paulo, Programa de Residência em Cirurgia e Traumatologia Bucomaxilofacial (São Paulo/SP, Brazil). Hospital Universitário da Universidade de São Paulo, Serviço de Cirurgia e Traumatologia Bucomaxilofacial (São Paulo/SP, Brazil). 3 Hospital Universitário da Universidade de São Paulo, Divisão de Clínica Cirúrgica (São Paulo/ SP, Brazil). 1

How to cite: Fernandes JRL, Gouveia MM, Alcântara PSM. Cutaneous non-Hodgkin’s lymphoma in face, after tooth extraction. J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):63-9. DOI: https://doi.org/10.14436/2358-2782.7.2.063-069.oar

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

Submitted: January 28, 2019 - Revised and accepted: April 18, 2019

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

Contact address: José Renato Linhares Fernandes E-mail: renatoodontofip@hotmail.com

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):63-9

Cutaneous non-Hodgkin’s lymphoma in face, after tooth extraction

INTRODUCTION Lymphomas can be simply defined as malignant neoplasms of lymphocytes and their precursor cells. Currently, they are divided into two groups: Hodgkin lymphomas (HL) and non-Hodgkin lymphomas (NHL), according to their histological characteristics and behavior patterns.1 HL is determined by the presence of multinucleated giant cells called Reed-Sternberg cells. The other neoplasms of the lymphoid system are called NHL.2 The etiology of lymphomas is uncertain, yet several factors are cited, such as exposure to pesticides and radiation, prolonged immunosuppression, autoimmune diseases, viral and bacterial infections.3 The incidence of lymphomas is higher in individuals with immunodeficiencies, such as congenital (Bloom’s syndrome, Wiskott-Aldrich syndrome, common variable immunodeficiency, etc.), and acquired disorders (AIDS, autoimmune diseases as Sjogren’s syndrome, systemic lupus erythematosus, rheumatoid arthritis).3 Primary cutaneous B-cell lymphomas (PCBCL) PCBCL are part of the group of malignant neoplasms originating in B lymphocytes, NHL. They often have a different clinical behavior and prognosis from systemic lymphomas of similar histological subtype. About 30% of NHL affect extranodal tissues, the skin being the second most involved organ, after the gastrointestinal tract, accounting for approximately 18% of these lymphomas.2 According to the new classification of the World Health Organization and Cutaneous Lymphoma Study Group of the European Organization for Research and Treatment of Cancer (WHO-EORTC), PCBCL are divided into three main types: primary cutaneous centrofollicular lymphoma (CfPCL), marginal zone primary cutaneous lymphoma (MZPCL) and diffuse primary cutaneous large B-cell lymphoma of the leg (DPCLBCLL).4 CfPCL is relatively common, characterized by neoplastic proliferation of centrocytes and centroblasts confined in the skin.5 Since the lesions slowly increase in size over the years and dissemination to extracutaneous sites is uncommon, this type is indolent.4 CfPCL lesions range from plaques to tumors, from violaceous to erythematous in color. They can be multiple or solitary, disseminated or grouped in one location of the body, and rarely present ulceration or necrosis.6 The diagnosis of NHL is histopathological and can present in various forms, depending on the degree of cell differentiation. Thus, the histological variations of this tumor are grouped into three categories: low, intermediate

and high, due to the reduction in cell differentiation with the increase in grade.7 Once the diagnosis has been defined, tumor staging must be performed to choose the therapy and assess the prognosis.1 The treatment of a patient with NHL is based on multiple factors, including the degree of lymphoma, stage, systemic general status and the patient’s past medical history.3 The purpose of this study is to present a clinical case of CfPCL in a 42-year-old man, exploring its clinical importance and the need for early diagnosis to improve the life expectancy of affected patients. CASE REPORT A 42-year-old male black patient attended the CTBMF outpatient clinic of the University Hospital (HU) of University of São Paulo (São Paulo/SP) for the first time on November 25th 2016, reporting a progressive growth of the face on the right side, with two months of evolution, coinciding with extraction of the upper right second premolar (tooth n. 15). He did not report associated pain. He reported antibiotic therapy (clindamycin 1800 mg/d) and warm compresses on the face for several weeks, without regression of volume increase. Physical examination revealed severe facial asymmetry to the right, due to the increased volume in the zygomatic region. The cutaneous tissues overlying the lesion had more intense melanin pigmentation (Fig 1). On intraoral examination, an increase in volume was observed in the region of the right maxillary vestibule, without morphological changes in the buccal mucosa (Fig 2). Computed tomography (CT) of the face revealed an expansive lesion in the subcutaneous plane of the right genian region, measuring 4.9 x 4.5 x 2.9 cm, causing significant facial bulging, solid-homogeneous in appearance, with minimal uniform impregnation, regular contours, without signs of bone invasion or remodeling of the anterior wall of the maxillary sinus. It is worthy to note the comparative enlargement of the infraorbital foramen on the affected side, possibly related to neural infiltration. Two incisional biopsies were performed by intraoral access and the report was inconclusive in both. In the second sample, there was presence of exuberant lymphohistoplasmacytic infiltrate, with lymphoid aggregates, in fibroadipose tissue. Immunohistochemical examination of the surgical specimen was positive for ACL markers, KI67/SP-6, CD20 (PAN B) / L26, CD3 POLYCLONAL, CD5 / SP19, CD 23 / 1B12 and BCL-2 / 124.

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Fernandes JRL, Gouveia MM, Alcântara PSM

ture not compromised by the tumor. The loss of integumentary thickness was partially compensated by an adipose flap from the ipsilateral jugal and infratemporal region, accommodated and sutured to the adjacent musculature (Fig 3). Histopathological study of the specimen defined the diagnosis of CfPCL (Fig 4). The patient was referred to the Oncology team for complementary therapy, which consisted of six cycles of combination of the chemotherapy drugs Rituximab, Cyclophosphamide, Doxorubicin (Hydroxydaunomycin), Vincristine (Oncovin) and Prednisone (R-CHOP), at every 21 days.

After tomographic staging, without evidence of lymphadenomegaly in the studied areas (cervical and thoracic), it was decided to perform surgical resection of the tumor. However, the patient suffered a cerebrovascular accident (CVA), with transient sequelae in the right limbs. A new CT of the face was performed in the week before surgery, one month after the stroke, showing expansion of the lesion (6.2 x 4.3 x 5.5 cm) six months after the aforementioned extraction. Tumor resection was performed using a full-thickness Weber-Fergunson approach, preserving skin and bone struc-

Figure 1: Frontal (A) and axial (B) views.

Figure 2: Intraoral aspect.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):63-9

Cutaneous non-Hodgkin’s lymphoma in face, after tooth extraction

Figure 3: A) Demarcation of the Weber-Ferguson incision. B) Lesion exposure. C) Aspect after lesion removal. D) Two-day postoperative period.

Figure 4: Immunohistochemical examination.

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Fernandes JRL, Gouveia MM, Alcântara PSM

RESULTS To date, 21 months after surgical excision and 16 months after chemotherapy, the patient has not relapsed (Fig 5). The patient agreed to participate in the case report by signing the free informed consent form.

Figure 5: A) Frontal view, showing skin depigmentation in the area of lesion removal, since the patient was wearing a gauze dressing for his own choice (21 months postoperatively). B) Profile view. C) Intraoral aspect.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):63-9

Cutaneous non-Hodgkin’s lymphoma in face, after tooth extraction

DISCUSSION PCBCL represent 25% of cutaneous lymphomas and, among its classification, the centrofollicular form is relatively common, characterized by neoplastic proliferation of centrocytes and centroblasts confined in the skin.4 Multifocal skin lesions are rare and not associated with a poorer prognosis. The color can range from erythematous to violaceous and usually has a smooth, shiny surface. Statistically, there is predilection for the head (scalp and frontal region) and trunk. 1 In the present case, there was a single tumor lesion located on the face, involving the zygomatic-maxillary region on the right side, with intense melanin pigmentation in the area in relation to the adjacent normal skin, accompanied by punctual tissue ischemia. Studies show that, if left untreated, the lesion continues to progress slowly, although there are reports of rare cases of spontaneous regression. 1 In the present case, growth was progressive and slow in the first two months of evolution, although it reached the tumoral form in this phase, with aggressive behavior from the third to the sixth month. There are several reports on the appearance of B-cell NHL after tooth extraction.8 However, so far, the triggering mechanisms of these injuries are not known and thus the associations have not been defined, and it is not known whether they are stimulated by surgical trauma or by the altered environment in the alveolodental region. Parrington and Punnia-Moorthy 8 showed considerable evidence that lymphomas, in certain environments, are preceded by local inflammation. It is speculated that the increased rate of lymphocyte cell division in the inflammatory process would increase the risk of malignant ‘clone’ cell division. In the present report, the patient reported appearance of the lesion immediately after extraction of tooth n. 15. Histopathologically, CfPCL shows variations in cytomorphological characteristics and in its architecture, which can be follicular, diffuse or mixed. The follicular growth pattern shows a neoplastic infiltrate of centrocytes with some small reactive lymphocytes mixed together, involving the dermis and preserving the epidermis. 1 The diffuse growth pattern lacks follicular (nodular) morphology and thus it may be more difficult to immediately recog-

nize as follicular lymphoma, although it is the most common pattern found in the skin.4 In this pattern, there are layers of large centrocytes with a smaller number of centroblasts or mixed immunoblasts, extending across the entire dermis thickness.1 Other growth patterns and morphological variables that have been reported include a mixed growth pattern with diffuse follicular areas. The mixed growth pattern was thought to be a large diffuse B-cell lymphoma, but it is now recognized as a rare morphological variant of CfPCL which, despite its alarming appearance, behaves similarly to conventional variants. 1 In the present report, follicular (70%) and diffuse (30%) growth patterns were observed, with more than 15 centroblasts per high-magnification field. Studies demonstrate a high positivity rate for CD20, BCL-6, CD10, KI-67 and rarely for MUM-1, BLC-2, FOx-P1, IgM and P63 in the immunohistochemical analysis for determination of CfPCL.5 In the immunohistochemical study reported, there was positivity for CD20, BCL-6, CD10, BCL-2, MUM-1 and KI-67 antibodies. The treatment of CfPCL is variable and multifactorial-dependent, depending on the number of lesions, spaces involved and the patient’s response to the therapies used. 5 Studies demonstrate that radiotherapy is the treatment of choice for cases of CfPCL, and in general there is no consensus regarding the duration of treatment, which varies depending on the size and number of lesions. 4 In cases of single lesions or those limited to an anatomical region, radiotherapy and/or surgical excision are therapeutic options, being radiotherapy the primary option that can be accompanied by surgical excision. However, there are studies that demonstrate the efficiency of surgery as a single therapy. 1 For very extensive skin lesions and extracutaneous diseases, chemotherapy is the indicated treatment, with R-CHOP being indicated as the preferred chemotherapy association. 9 Comparative studies have shown that the association of Rituximab, a chimeric murine-human antibody to the CD20 antigen, to the CHOP regimen increased the therapeutic efficiency, promoting a 60% reduction in the risk of failure and an increase

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Fernandes JRL, Gouveia MM, Alcântara PSM

FINAL CONSIDERATIONS The current classification of PCBCL allows a more reliable differentiation between painless and aggressive forms, facilitating the therapeutic choice. In the clinical suspicion of LCPCB, histological and immunohistochemical studies are required for diagnostic confirmation. Despite the repeated reference to the emergence of B-cell NHL after tooth extraction, including the present report, there is no evidence to demonstrate its relationship in triggering the neoplastic process. Therefore, studies in this area are needed. Although radiotherapy is the primary treatment for CfPCL lesions, the chosen therapy must evaluate all aspects involved in the condition, aiming at ensuring quality of life, safety and improved life expectancy of the patient with the lesion.

in the time to failure. Additionally, the rate of lesion recurrence or progression after successful initial therapy was significantly lower in patients treated with R-CHOP, resulting in longer duration of treatment response. 10 In the present report, due to the patient’s low self-esteem and depression related to the esthetic aspect, and because it was a single lesion with well-defined tumor margins, surgical excision was chosen for diagnostic definition and restoration of patient comfort. The patient was referred for complementary therapy to the Oncology Service to undergo six cycles of R-CHOP at every 21 days and, so far, has had no relapses.

References:

1. Hope CB, Pincus LB. Primary cutaneous B-cell lymphomas. Clin Lab Med. 2017;37(3):547-74. 2. Moricz CZM, ShancesJr JA. Processo linfoproliferativos da pele. Parte 1- Linfomas cutâneos de células B. An Bras Dermatol. 2005;80(5): 461-71. 3. Neville B. Patologia oral e maxillofacial. 3ª ed. Rio de Janeiro: Elsevier; 2009. 4. Camargo CMS, Bomm L, Abraham LS, Daher R, Scotelano MFG, Abulafia LA. Primary cutaneous centro follicular lymphoma with a good response to radiotherapy. An Bras Dermatol. 2013; 88 (6 Suppl 1):136-8. 5. Senff NJ, Noordijk EM, Kim YH, Bagot M, Berti E, Cerroni L, et al. European Organization for Research and Treatment of Cancer and International Society for Cutaneous Lymphoma consensus recommendations for the management of cutaneous B-cell lymphomas. Blood. 2008;112(5):1600-9.

6. Grange F, Bekkenk MW, Wechsler J, Meijer CJ, Cerroni L, Bernengo M, et al. Prognostic factors in primary cutaneous large B-cell lymphomas: a European multi center study. J Clin Oncol. 2001;19(16):3602-10. 7. Jayapalan CS, Pynadath MK, Mangalath U, George A, Aslam S, Hafiz A. Clinical diagnostic dilemma in an uncharacteristicrapidly enlarging swelling of the anterior maxilla: extranodal diffuse large B cell lymphoma. BMJ Case Rep.2016;2016:bcr2015213141. 8. Parrington SJ, Punnia-Moorthy A. Primary non-Hodgkin’s lymphoma of the mandible presenting following tooth extraction. Br Dent J. 1999;187(9): 468-70. 9. Schulz H, Bohlius J, Skoetz N, Trelle S, Kober T, Reiser M, et al. Chemotherapy plus Rituximab versus chemotherapy alone for B-cell non Hodgkin’s lymphoma. Cochrane Database Syst Rev. 2007;(4):CD003805.

10. Hiddemann W, Kneba M, Dreyling M, Schmitz N, Lengfelder E, Schmits R, et al. Frontline therapy with rituximab added to the combination of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) significantly improves the outcome for patients with advanced-stage follicular lymphoma compared with therapy with CHOP alone: results of a prospective randomized study of the German Low-Grade Lymphoma Study Group. Blood 2005;106(12):3725-32.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):63-9

Case Report

ABSTRACT Gunshot injuries cause serious problems to the maxillofacial complex, especially when extensive injuries, comminuted fractures and retention of projectiles are involved. The maxillary sinus is the largest of the paranasal sinuses and the most affected by injuries. Foreign bodies inside are unusual occurrences, usually caused by penetrating trauma or iatrogenic conditions. Caldwell-Luc approach to the maxillary sinus is largely suggested and used, because it is a simple technique and provides good visualization and good inspection. Patient injured by firearm, with entrance hole in right hemiface near the wing of the nose, with no exit hole; presented in the computed tomography a retained bullet in the left maxillary sinus. Caldwell-Luc approach was used for exploration of the maxillary sinus, projectile removal and copious washing of the sinus. Surgical removal was satisfactory and conservative. The patient progressed without complications caused by the injury or the treatment performed. It is essential that the choice by the removal or not of the foreign body, using a surgical or conservative approach, take into account clinical, surgical and anatomical criteria, to bring resolution to the case with patient safety.

Keywords: Maxillary sinus. Wounds. Gunshot. Foreign bodies. Surgery, oral.

How to cite: Tavares PMH, Marques SM, Albuquerque GC, Martins VB, Oliveira MV, Nascimento SLC, Torres RS. Firearm projectile removal from the maxillary sinus. J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):70-5. DOI: https://doi.org/10.14436/2358-2782.7.2.070-075.oar

Universidade do Estado do Amazonas, Residência em Cirurgia e Traumatologia Bucomaxilofacial (Manaus/AM, Brazil). 2 Universidade do Estado do Amazonas, Curso de Odontologia (Manaus/AM, Brazil). 1

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

Submitted: February 06, 2019 - Revised and accepted: June 26, 2019

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

Contact address: Paulo Matheus Honda Tavares E-mail: matheus_apj@yahoo.com.br

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):70-5

Tavares PMH, Marques SM, Albuquerque GC, Martins VB, Oliveira MV, Nascimento SLC, Torres RS

INTRODUCTION The maxillary sinuses are spaces filled with air that occupy the maxilla bilaterally. They are the first of the paranasal sinuses to develop embryologically, starting in the third month of fetal development as invaginations or bags originating from the mucosa of the ethmoid infundibulum.1 These sinuses, named after the bones in which they are inserted, are eight: four on the right side and four on the left. The structural functions assigned to the paranasal sinuses are to reduce the skull weight, protect the intraorbital and intracranial structures, absorbing part of the impact in the event of trauma, and also participating in facial growth. Concerning the functional aspect, the sinuses form resonance boxes of voice, act in conditioning the inspired air, warming and moistening it, contribute to the secretion of mucus, promote thermal isolation of the brain, balance the pressure in the nasal cavity during barometric variations (sneezing and sudden changes in altitude) and are coadjutants in smell.2 The maxillary sinus is the largest of the paranasal sinuses and the most affected by injuries. It is also known as the antrum, or Highmore antrum. The word antrum is derived from Greek and means cave, and Highmore (Nathaniel Highmore) was a 17th century English physician who described a sinus infection associated with a maxillary tooth and had his name associated with the sinus nomenclature ever since. The maxillary sinus is described as a four-sided pyramid, with the base fixed vertically to the medial surface and forming the lateral nasal wall. Its apex extends laterally towards the maxillary zygomatic process. The upper wall (or roof) of the sinus is also the orbit floor. The posterior wall extends the entire length of the maxilla, dipping into the tuberosity. The sinus extends anteriorly and laterally to the first premolar or canine region. The sinus floor forms the basis of the alveolar process. The average length of an adult maxillary sinus is 34 mm in anteroposterior direction, 33 mm in height, and 23 mm in width. The sinus volume varies approximately between 15 and 20 mL. The sinuses are primarily lined with respiratory epithelium, which is mucus-secreting, pseudostratified, ciliated, and columnar. The cilia and mucus are needed for sinus drainage, as the sinus opening is at two-thirds the way above the medial wall and drains into the nasal cavity.1

The displacement of foreign bodies into the maxillary sinus is a relatively rare occurrence, resulting from penetrating injuries, such as high kinetic energy trauma, in which objects (firearm projectiles, pieces of glass, stones, wood) can be thrown into the sinus and also during dental procedures when teeth, tooth roots, endodontic cement or gutta-percha cones can also be inadvertently thrown into it.3 A new pattern of facial injuries emerged in the th 13 century, with the introduction of Chinese gunpowder in Europe and the consequent development of firearms. Since they are more exposed to risks and predisposing factors, men are usually more affected, and the third decade of life is the most prevalent age group. Basically, there are two types of firearm injuries: low and high energy. The wound extent depends on the type, size and shape of the projectile, distance from the shot to the target and anatomical structure affected. Firearm projectile (FAP) wounds can also be classified as: penetrating, when perforating objects, such as projectiles and shrapnel, after breaking the skin barriers, suffer braking by higher density tissues and dissipate their energy, lodging at varying depths; non-penetrating, when the projectile does not enter the tissues; perforating, when the projectile has an entry and exit path; and avulsion, when there is tissue avulsion, regardless of the final location of the FAP. In addition to penetration into the body, the projectile can generate permanent cavitation (where there is tissue rupture in the path, with formation of dead space), temporary cavitation (there is tissue damage and necrosis, but only with stretching of structures) and fragmentation (when reaching hard tissues like bone). Knowing when and how to remove fragments is essential for successful treatment; removal is not always the best option. In these cases, imaging exams are greatly important, since they provide valuable additional information.4 The imaging tests used for diagnosis of foreign bodies in the maxillary sinus and surgical planning include the incidence of Waters, the face profile, orthopantomography (panoramic), which is the most used method, and computed tomography, which offers advantages such as three-dimensional vision and better precision. Once diagnosed, whenever possible, the foreign body should be removed to prevent complications such as acute or chronic maxillary sinusitis. Commonly, the Caldwell-Luc technique is used to ac-

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):70-5

Firearm projectile removal from the maxillary sinus

presence of a foreign body, which was lodged in the patient’s left maxillary sinus (Fig 1). By clinical and tomographic examination, it was possible to observe the path of the FAP, which had its entry hole in the anterior wall of the right maxillary sinus; however, it was lodged in the left maxillary sinus, more precisely in the second molar region. Surgical removal of the bullet was planned in an outpatient clinic and the Caldwell-Luc access was chosen for exploration of the maxillary sinus. The patient and his guardian were clearly informed about the surgical procedure and an informed consent form was read and filled by both. The procedure started with anesthesia of the posterior superior alveolar, middle superior alveolar and greater palatine nerves. The flap was raised observing the location of the maxillary pillars, mucoperiosteal detachment and exposure of the anterior wall of the maxillary sinus. Then, osteotomy was performed with a round carbide bur at low speed and constant irrigation. The maxillary sinus was explored, and the FAP was located just above tooth 27, then clamped and removed (Fig 2). After cavity cleaning and copious irrigation, a continuous scalloped suture was performed with 4.0 nylon. The patient and guardian were instructed about the postoperative care. The removed bullet was handed over to the surgical clinic management and sent to the hospital director for appropriate action. After 10 days, the suture was removed, and 15 days after surgery there was regularity of intraoral tissues, maintenance of the patient’s physiological function and absence of complications resulting from both the surgical approach and the initial wound (Fig 3).

cess the maxillary sinus, due to its easy use and because it allows inspection and treatment of diseases that affect it. The technique was developed in 1890 by George Caldwell, in the United States, and perfected by Henri Luc in France.5 This approach is used for the treatment of irreversible chronic maxillary sinusitis, removal of tooth roots and foreign bodies, excision of antrochoanal polyps, pyoceles, tumors and odontogenic cysts, and in the repair of oroantral fistulas. The technique consists of ostectomy of part of the anterior wall of the maxillary sinus, in the canine to molar region, above the root apices, through which foreign bodies are removed and the infected sinus mucosa is cured.3 Therefore, this article aims to report a clinical case of removal of a firearm bullet, under local anesthesia, housed in the maxillary sinus of a young patient, addressing clinical and imaging aspects used for localization, diagnosis and surgical planning, as well as the chosen technique for treatment. CASE REPORT A 15-year-old male patient attended the Residency Service in Oral and Maxillofacial Surgery and Traumatology of the State University of Amazonas (UEA, Manaus/AM), accompanied by his guardian, reporting that he had suffered a firearm injury (FAF) at the face three days ago. In the anamnesis, the patient was in good general condition, without any physiological and systemic changes. On clinical examination, the FAP entry orifice was observed in the right hemiface, close to the nasal ala and without an exit orifice. A computed tomography exam was requested, which showed the

Figure 1: A) Sagittal section of cone beam computed tomography (CBCT), showing the presence of projectile inside the maxilla. B) Axial CBCT section showing the trajectory of the projectile, with entry into the right maxilla and retention in the left maxillary sinus. C) Coronal section of CBCT, showing the location of the projectile above the molar roots.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):70-5

Tavares PMH, Marques SM, Albuquerque GC, Martins VB, Oliveira MV, Nascimento SLC, Torres RS

Figure 2: A) Initial transoperative aspect. B) Mucoperiosteal flap performed and exposure of the anterior wall of the maxillary sinus. C) Ostectomy for access to the maxillary sinus, with a round drill in a straight handpiece. D) Location of the projectile in the posterior region of the maxillary sinus. E) Removal of the projectile. F) Continuous scalloped suture.

Figure 3: A) Extraoral aspect, showing the entry site of the firearm projectile. B) Projectile removed.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):70-5

Firearm projectile removal from the maxillary sinus

DISCUSSION As the first to appear, from an embryonic standpoint, the maxillary sinus, or antrum, is considered the largest and most affected by injuries among all paranasal sinuses, presenting as a pneumatic space of large volume, located bilaterally inside the jaw bone. Its lining is constituted by pseudostratified columnar ciliated mucus-secreting epithelium, containing goblet cells.5,6 Foreign bodies in the paranasal sinuses are uncommon, being mostly the result of penetrating injuries after traumatic accidents or iatrogenic events. 6 Foreign bodies in the middle facial third (maxillary sinus and nasal cavity) can be classified as: iatrogenic foreign bodies (tooth, dental drills, instruments used in the root canal, among others) or traumatic foreign bodies (compressed air pistol bullet, object fragments, shrapnel, firearm projectile, among others). 6,7 In the present case, the foreign body that was lodged in the patient’s maxillary sinus, victim of penetrating injury, was classified as traumatic, since it was a firearm projectile. Concerning the epidemiology, data are consensual in stating that men are more affected than women and that the third decade of life is more affected; the male/female ratio reaches 4:1 and 60% of cases occur between the ages of 20 and 30 years,4-8 partly corroborating the reported case, in which the patient, victim of a firearm injury, was male and 15 years old. Although the projectile and shrapnel can become inert, the consequences of retention of these artifacts are many. Factors as the type of metallic surface, characteristic of the adjacent tissue, location, characteristics of the wound, degree of contamination and the individual’s immune system can be determinant in the behavior of these objects. As complications, there can be sensory disturbances, migration of objects, foreign body reaction, chemical reactions due to intoxication depending on the raw material used, obstructions, secondary infections and even mechanical impediments to muscle functions. Particularly in the maxillary sinus, recurrent infections, edema and excess production of secretions can occur.4,6,8 Whenever possible, the foreign body should be removed. In the present case, there was no chronic inflammatory process, only a slight increase in the production of secretions, since surgery to remove the bullet was performed shortly after trauma. Concerning compli-

cations, there were no sensory disturbances, nor mechanical impediments to muscle functions that could be caused by the trajectory of the bullet or by the surgical approach performed to remove it. Except in emergency cases, removal of the FAP can be postponed, and the indication for the approach must consider factors such as the quantity and size of the object, depth, possibility of access and anatomical proximity of the foreign body with noble structures.4 In the present case, the FAP was located in a favorable location for surgical removal, inside the left maxillary sinus, close to the apex of tooth 27 and far from noble structures; the patient was in good general condition and without systemic changes. Thus, there was no contraindication for bullet removal. The methods used for foreign body removal differ according to their size and location. The removal of foreign bodies from the maxillary sinus can be performed using minimally invasive methods, assisted by endoscopy, or surgically using the Caldwell-Luc access. Endoscopic access has the advantage of promoting less tissue damage and, consequently, less postoperative inflammation; however, it may fail to allow object removal, mainly due to its size and shape. In this context, the Caldwell-Luc access is widely used and advocated. The technique is constantly used to gain access to the maxillary sinus, with the advantages of being a comfortable procedure for the patient, which can be performed under local anesthesia and allows good visualization of the operative field. There is also the alveolar approach, which is reserved for cases of dental roots displaced into the maxillary sinus. This technique is effective in cases of displacement of the alveolus to the lower part of the maxillary sinus. The literature concludes that most foreign bodies in the maxillary sinus are removed surgically.4,8,9 In the present case, we opted for surgical removal under local anesthesia, by the Caldwell-Luc approach, which allowed adequate exploration of the maxillary sinus, removal of the retained projectile and copious irrigation, with minimal morbidity for the patient. Conventional radiographs are useful to locate metallic objects, such as Waters, lateral face and orthopantomography views. Orthopantomography is the most used in initial exams; these conventional two-dimensional radiographs, due to their low cost and easy access, are generally requested initially and may be useful in identifying the foreign body. How-

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):70-5

Tavares PMH, Marques SM, Albuquerque GC, Martins VB, Oliveira MV, Nascimento SLC, Torres RS

FINAL CONSIDERATIONS The retention of foreign bodies can cause additional late complications after firearm injury. Foreign bodies in the maxillary sinus can cause local and systemic changes; their removal is recommended whenever possible, provided it can be performed safely and with minimal risk of morbidity to the patient. For the diagnosis and surgical planning of these situations, it is essential to combine clinical examination and good imaging. For that purpose, computed tomography is the most recommended for a thorough approach. When indicated for surgical removal, the Caldwell-Luc access is an excellent treatment option, allowing a safe approach with good visibility to the maxillary sinus.

ever, computed tomography allows precise location of the foreign body, assessment of the extent of damage, trajectory of the projectile, as well as visualization of soft tissue and assistance in 3D planning to remove the foreign body,4-9 corroborating the reported case , in which the patient had a FAP entry orifice, yet no exit orifice. The requested tomographic exam was essential for precise location of the FAP; also, it provided a detailed study of the path, proximity to noble structures and detailed surgical planning.

References:

1. Peterson LJ, Ellis E, Hupp JR, Tucker MR. Cirurgia oral e maxilofacial contemporânea. 4a ed.Rio de Janeiro: Guanabara Koogan; 2005. 2. Batista PS, Rosário Junior AF, Wichnieski C. Contribuição para o estudo do seio maxilar. Rev Port Estomatol Med Dent Cir Maxilofac. 2011;52(4):235-9. 3. Cruz MN, Porto DE, Pereira SM, Lima FJ, Godoy GP. Corpo estranho em seio maxilar: remoção pela técnica de Caldwell-Luc. Rev Cir Traumatol Buco-Maxilo-Fac. 2014;14(1):55-8. 4. Suassuna TM, Silva Júnior AJ, Lima EPA, Landim FS, Valente RHO. Retenção de projéteis de arma de fogo na face - relato de casos. Rev Cir Traumatol BucoMaxilo-Fac, 2017;17(1):46-50.

5. Cerqueira LS, Almeida AS, Rebouças DS, Sodré JS, Marchionni AMT. Remoção de corpo estranho em seio maxilar: relato de caso. Rev Cir Traumatol Buco-MaxiloFac. 2016;16(2):44-7. 6. Lee DH, Lim SC. Maxillary fungus ball caused by retained foreign bodies for 25 years. J Craniofac Surg. 2012;23(3):e176-7. 7. Datarkar AN, Dhawad M, Deshpande A. Unusual foreign body in mid face. J Maxillofac Oral Surg. 2015;14(Suppl 1):96-9. 8. Hara Y, Shiratsuchi H, Tamagawa T, Koshi R, Miya C, Nagasaki M, et al. A large-scale study of treatment methods for foreign bodies in the maxillary sinus. J Oral Sci. 2018;60(3):321-8.

9. Kumar A, Srivastava RK, Saxena A, Khanna R, Ali I. Removal of Infected Maxillary Third Molar from the Infra-temporal Fossa by Caldwell Luc Procedure - Rare Case Report with Literature Review. J Clin Diagn Res. 2016;10(12): ZD01-3.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):70-5

Case Report

Botryoid odontogenic cyst: case report, evolution of four years GLEYSSON MATIAS DE ASSIS1 | FRANCISCO DE ASSIS DE SOUZA JUNIOR1 | MATHEUS DANTAS TERTULINO2 | CALEBE LAMONIER DE OLIVEIRA COSTA PAIVA3 | ADRIANO ROCHA GERMANO4

ABSTRACT Introduction: The botrioid odontogenic cyst (COB) is a rare variant of the lateral periodontal cyst, corresponding to 0.5% of odontogenic cystic lesions, with the anterior maxilla being affected in only 4% of cases. Malassez remains and reduced enamel epithelium are possible histogenic sources. Most reported cases have shown to present multilocular radiolucency. Methods: This study will present the case report of a COB in the anterior maxilla, presenting unilocular radiographic aspect, and surgically treated by curettage-associated enucleation, with 4-year follow-up. Results: The patient presented with 4 years of postoperative without clinical symptoms and no signs of lesion recurrence. Conclusions: The COB may be confused with other cystic modifications. Therefore, biopsy for diagnostic confirmation is essential, and may be associated with definitive treatment through enucleation and curettage. Keywords: Odontogenic cysts. Periodontal cyst. Oral surgical procedures.

How to cite: Assis GM, Souza Junior FA, Tertulino MD, Paiva CLOC, Germano AR. Botryoid odontogenic cyst: case report, evolution of four years. J Braz Coll Oral Maxillofac Surg. 2021 MayAug;7(2):76-9. DOI: https://doi.org/10.14436/2358-2782.7.2.076-079.oar

Universidade Federal do Rio Grande do Norte, Doutorado em Ciências Odontológicas (Natal/ RN, Brazil). Universidade Federal do Rio Grande do Norte, Departamento de Odontologia (Natal/RN, Brazil). 3 Universidade Federal do Ceará, Residência em Cirurgia e Traumatologia Buco-maxilo-facial (Fortaleza/CE, Brazil). 4 Universidade Federal do Rio Grande do Norte, Área de Cirurgia e Traumatologia Buco-maxilo-facial (Natal/RN, Brazil). 1

Submitted: August 20, 2019 - Revised and accepted: April 24, 2020 Contact address: Calebe Lamonier de Oliveira Costa Paiva E-mail: calebelamonier@hotmail.com

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):76-9

Assis GM, Souza Junior FA, Tertulino MD, Paiva CLOC, Germano AR

INTRODUCTION The botryoid odontogenic cyst (BOC) is a rare variant of lateral periodontal cyst (LPC), whose histogenesis remains uncertain, with Malassez remnants and reduced enamel epithelium as possible sources.1 LPC corresponds to only 1.2% of odontogenic cystic lesions, 2 with its variant BOC representing only 0.5% and preferably affecting the region of premolars and canines of the mandible and maxilla, with 68% and 15%, respectively. The anterior region of the maxilla is affected only in 4% of cases.3 It is considered an odontogenic cyst with intraosseous development, mainly found in adults between the fifth and seventh decades of life, being very rare in people under 30 years of age, besides not presenting sex predilection. 4 Although most reported cases of BOC have been shown as multilocular radiolucency, some authors demonstrate that the lesion often presents as a unilocular radiographic image, which can be confused with some odontogenic cysts and even neoplasms. 5,6 The aim of this paper is to report a clinical case of BOC in the anterior maxillary region, with unilocular radiographic appearance, surgically treated and followed for a period of four years.

do Norte (UFRN) complaining of discomfort in the region of teeth 11, 12 and 13. Endodontic treatment of the central incisor had already been performed two years earlier, and the other teeth responded positively to the pulp vitality tests. On extraoral physical examination there was no apparent asymmetry. However, on intraoral examination, tooth 11 was buccally tipped, associated with an increase in buccal and palatal volume. Radiographically, a well-delimited, radiolucent unilocular lesion was observed in the periapical region of teeth 11, 12 and 13, suggesting a root cyst (Fig 1). Before performing the proposed procedures, the patient was informed about the treatment and signed an informed consent form. The surgical procedure for collection of material and histopathological evaluation was performed by an Ochsenbein-Luebke incision, which allowed enucleation and curettage of the lesion. Histological features showed a cystic lesion of odontogenic origin, characterized by the presence of multiple cystic cavities lined with stratified squamous epithelium, predominantly consisting of three layers of cells, although it presented focal areas of nodular thickening, exhibiting clear cells, besides an intense inflammatory infiltrate in the connective tissue capsule, thus being classified as a botryoid odontogenic cyst (Fig 2D). Currently, the patient has been followed for four years after surgery, without clinical symptoms or signs of lesion relapse (Fig 3).

CASE REPORT A 34-year-old black patient attended the Oral and Maxillofacial Surgery and Traumatology outpatient clinic of the Federal University of Rio Grande

Figure 1: Panoramic radiograph identifying the lesion location and extent.

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Botryoid odontogenic cyst: case report, evolution of four years

Figure 2: A) Surgical access to the lesion. B) Enucleation and curettage. C) Aspect of the surgical wound after complete lesion removal. D) Photomicrograph of the lesion (thin epithelial lining and nodular thickening, swirl appearance of cells³).

Figure 3: Control panoramic radiograph after four years. New bone formation is observed at the site that comprised the lesion.

J Braz Coll Oral Maxillofac Surg. 2021 May-Aug;7(2):76-9

Assis GM, Souza Junior FA, Tertulino MD, Paiva CLOC, Germano AR

DISCUSSION The botryoid odontogenic cyst (BOC) is an uncommon pathological condition and, by definition, represents a variant of the non-keratinized lateral periodontal cyst (LPC) that develops in the alveolar bone along the lateral surface of a tooth that may be vital.7,8 Histologically, LPC is characterized by a thin layer of non-keratinized lining epithelium and a thick cell layer, which resembles the reduced enamel epithelium, usually without inflammatory infiltrate, and the walls consist of fibrous collagen tissue. The histological distinction between LPC and BOC is due to the multiple pathological cavities found in its botryoid variant, which promotes a polycystic aspect to the BOC.3 A clinical pathological study on BOC showed that 80% of cases affected the mandible and 20% the maxilla, with the male sex being more affected, with 70%.4 The present clinical case affected the anterior maxillary region in a female patient, associated with a non-vital endodontically treated tooth, constituting a minority in the literature, yet not a rarity. Due to the unilocular radiographic characteristic of the lesion, unlike most cases reported in the literature,5,6 endodontic treatment was performed, with suspicion of root lesion. Since the lesion did not resolve after endodontic treatment, an excisional biopsy was performed for diagnostic elucidation and represented the definitive treatment.

Postoperative relapse of this type of pathology is related to the multilocular nature of the lesion, which complicates the enucleation of the entire lesion.3-6,9,10 In these cases, performing surface treatment associated with lesion enucleation reduces the risk of postoperative relapse. The multiple loculations and their relationship with the dental roots make access difficult and may hide remnants of the lesion, and tooth extraction is not uncommon, especially in cases of multiple relapses. However, since this is a unilocular lesion, this difficulty was not observed. Enucleation followed by curettage of the surgical wound and root of the involved tooth was possible and was probably decisive for the non-relapse of the lesion in the follow-up period. FINAL CONSIDERATIONS BOC represents an expansive lesion, with uni or multilocular characteristics, which can be confused with other cystic alterations. As a result, performing biopsy for diagnostic confirmation, which may be associated with definitive treatment, by enucleation and curettage in unilocular cases, and enucleation with surface treatment (wear drills or sclerosing substances) in multilocular cases, decreases the chances of postoperative relapse.

References:

1. Magraw CBL. Mandel L. The botryoid cyst: case report. N Y State Dent. J. 2014 Jan;80(1):42-44. 2. Souza LB, Gordón-Núñez MA, Nonaka CFW, Medeiros MC, Torres TF, Emiliano GBG. Odontogenic cysts: Demographic profile in a Brazilian population over a 38-year period. Med Oral Patol Oral Cir Bucal. 2010 Jul;15(4):e583-90. 3. Neville BW, Damm DD, Allen CM, Bouquot JE. Patologia Oral e Maxilofacial. 3ed. Rio de Janeiro: Elsevier Brasil, 2009. 4. Santos PPA, Freitas VS, Freitas RA, Pinto LP, Souza LB. Botryoid odontogenic cyst: A clinicopathologic study of 10 cases. Ann Diagn Pathol. 2011 Aug;15(4):221-4.

5. Üçok Ö, Yaman Z, Günhan Ö, Üçok C, Dogan N, Baykul T. Botryoid odontogenic cyst: report of a case with extensive epithelial proliferation. Int J Oral Maxillofac Surg. 2005 Sep;34(6):693-5. 6. Chbicheb S, Bennani A, Taleb B, Wady WE. Botryoid odontogenic cyst. Rev Stomatol Chir Maxillofac. 2008 Apr;109(2):114-6. 7. Méndez P, Junquera L, Gallego L, Baladrón J. Botryoid odontogenic cyst: clinical and pathological analysis in relation to recurrence. Med Oral Patol Oral Cir Bucal 2007 Dec;12(8):E594-8.

8. Jadu F, Tremblay S, Pharoah MJ, Bradley G, Psutka D. Hybrid botryoid odontogenic cyst-glandular odontogenic cyst of the mandible. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;105(4):e52-3. 9. Miloro M, Ghali GE, Larsen PE, Waite PD. Princípios de cirurgia bucomaxilofacial de Peterson. 3ed. São Paulo: Editora Santos, 2016. 10. Liu C, Samani M, Kwok J, Sproat C. Conservative management of botryoid odontogenic cysts using Carnoy’s solution. Br J Oral Maxillofac Surg. 2020 Feb;58(2):245-247.

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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.

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Information for authors

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

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

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

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

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

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

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

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

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

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

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Information for authors

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

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

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

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Notice to Authors and Consultants Registration of Clinical Trials

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

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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