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Volume 7, Number 3, 2021

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Journal of the Brazilian

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J Braz Coll Oral Maxillofac Surg. 2021 September-December;7(3):1-86

ISSN 2358-2782

Journal of the Brazilian

College of Oral and Maxillofacial Surgery JBCOMS

Since 2016

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

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

Quarterly ISSN 2358-2782

e Pesquisa Ltda. – Av. Dr. Luiz Teixeira Mendes, 2.712 – Zona 05 – ZIP code: 87.015-001 – Maringá/PR – Brazil.

All published articles are the exclusive responsibility of the authors. The opinions expressed do not necessarily correspond to the opinions of the Journal. Advertising services are the responsibility of advertisers. Subscription: dental@dentalpress.com.br or Tel./Fax: +55 44 3033-9818.

1. Cirurgia Bucomaxilofacial. I. Dental Press International.

CDD 21 ed. 617.605005 _______________________________________________________________________

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

EDITORIAL BOARD

Sylvio Luiz Costa de Moraes

Jonathan Ribeiro Belmiro Cavalcanti do Egito Vasconcelos

Gabriela Granja Porto

José Rodrigues Laureano Filho

Marcelo Marotta Araújo

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

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

Implants

Adrian Bencini

Clarice Maia Soares Alcântara

Darklilson Pereira Santos

Leonardo Perez Faverani

Rafaela Scariot de Moraes

Ricardo Augusto Conci

Rodrigo dos Santos Pereira

Trauma

Aira Bonfim Santos

Florian Thieringer

Leandro Eduardo Kluppel

Liogi Iwaki Filho

Márcio 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

Fábio Gamboa Ritto

Fernando Melhem Elias

Gabriela Mayrink

Joel Motta Júnior

José Laureano Filho

José Thiers Carneiro Júnior

José Nazareno Gil

Paul Maurette

Rafael Alcalde

Rafael Seabra Louro

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

TMJ Disorders Belmiro Cavalcanti do Egito Vasconcelos Carlos E. Xavier dos Santos R. da Silva

Chi Yang

Eduardo Hochuli Vieira

Eduardo Seixas Cardoso

João Carlos Birnfeld Wagner

Luis Raimundo Serra Rabelo

Patrícia Radaic Pastore

Sanjiv Nair

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

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

Pathologies and Reconstructions

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

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

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

Table of contents

4

Big challenges and great results Marcelo Marotta Araújo

6

Step-by-step scientific writing for young researchers Sylvio Luiz Costa de Moraes

11

Interview Lúcia Maria S. V. Costa Ramos

14

An interview with Valfrido Antonio Pereira Filho Valfrido Antonio Pereira Filho Original Articles

16

Epidemiological analysis of maxillofacial fractures in a referral hospital in Tocantins/Brazil

22

Smartphones use to study and professional development among maxillofacial surgeons and residents

30

Relationship between dimensional tissue changes in genioplasty: integrative review

Mariana Araújo dos Santos, Paula Vitória Bido Gellen, Hyara Luz Moreira, Marcos Phelipe Araújo Andrade Alves, Tássia Silvana Borges, José Afonso de Almeida

Luiz Felipe Rocha Vilaça, Lourrany Carmo Araujo, Lucas Teixeira Brito, Gustavo Campolina Barbosa Pereira, Robson Rodrigues Garcia, Douglas Rangel Goulart Jamille de Freitas Barolo, Renata Pittella Cancado

Technical note

38

Protocol for arthroscopic treatment of internal disorders of the temporomandibular joint: technical note Fábio Ricardo Loureiro Sato, Marcelo Marotta Araujo

Case reports

45

Bone-borne surgically-assisted rapid maxillary expansion: case report

52

Alloplastic reconstruction of the temporomandibular joint in patient with rheumatoid arthritis: case report

59

Surgical treatment of oro-sinusal fistula: Case report

64

Polymethylmethacrylate in aesthetic correction of anteroposterior maxillary hypoplasia: a series of 20 cases

71

Alternative technique with ductal preservation in sialolithiasis: case report

76

Lip Lift – an alternative for facial and smile harmonization: case report

82

Information for authors

Leonardo Augustus Peral Ferreira Pinto, Viviane Ferreira Ramos, Michelle Alonso Coutinho, Sabrina Morelli de-Oliveira Leandro Eduardo Kluppel, Caio Augusto Munuera Ueti

Vinícius Rodrigues Gomes, Josfran Ferreira Filho, Ricardo Franklin Gondim, Breno Souza Benevides Weber Céo Cavalcante, Paula Rizério D’Andréa Espinheira, Kátia Montanha Andrade, Leonardo Moraes Godói Figueiredo, Maria Cristina Cangussú, Roberto Almeida Azevedo Caio Cesar Santos Patron Luiz, Andressa Bolognesi Bachesk, Liogi Iwaki Filho Renato dos Santos

Letter from the President

Big challenges and great results

Dear members, The board of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology continues, strongly in line with its Mission and Institutional Vision, in the struggle for training in Oral and Maxillofacial Surgery only in the Residency modality, with workload of 8,640 hours, minimum duration of three years and exclusive dedication.

In these years, the board of CBCTBMF has reinforced the only and legitimate concern with the deficient training provided by specialization courses with the current workload approved by CFO (3,000 hours), consequently with the potential risk to the population when assisted by professionals with low qualifications.

The CFO was asked: » That the workload of Residency programs linked to the CFO is equivalent to the workload defined by MEC, i.e., 8,640 hours in three years of the program, as minimum workload. » That the specialization courses in CTBMF start to have the same workload as Residency programs (8,640 hours). » To re-establish the exam for registration of specialty, which should be mandatory for graduates from Residency programs as well as from specializations. » Or, that the Brazilian College of Oral and Maxillofacial Surgery and Traumatology may be responsible for implementing such measures.

How to cite: Araújo MM. Big challenges and great results. J Braz Coll Oral Maxillofac Surg. 2021 Sept-Dec;7(3):4-5.

DOI: https://doi.org/10.14436/2358-2782.7.3.004-005.crt

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Carta do Presidente

We are working to extend the benefits to members. In an unprecedented partnership with the Bionnovation company, the regular member has a new benefit: since September 2021, when paying the semestral fee, the member will have access to the same value in Bionnovation products and will also have a 20% discount when purchasing other products after using that credit.

Continuing Education courses, always with topics of great relevance and renowned professionals, are another benefit to members! The main objective is to continuously update the technical-scientific knowledge of the specialty for all regular members.

The CBCTBMF app has been updated and is available to members on iOS and Android platforms.

Hugs for all!

Marcelo Marotta Araújo President 2021/2022 Brazilian College of Oral and Maxillofacial Surgery and Traumatology

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Editorial

Step-by-step scientific writing for young researchers Where should I start drafting my research? This is a common question from the young researcher. The guidelines received can sometimes leave residual doubts that, to some extent, can cause difficulties in the organization and elaboration of scientific writing.

The first step is to select the journal to publish, since the work must follow its publication rules.

Not intending to teach how to write, here are some suggestions that may facilitate the sequence of text construction,1,2 since the “paper core” is composed of four parts, ordered in the text in a different manner: Material and Methods, Results, Discussion and Introduction.

Start with Material and Methods, elucidating, in the first paragraph, the study design and its steps. Population and sample: inclusion and/or exclusion criteria; approval by the institutional review board with report number. Description of specific sample subgroups or, when necessary to explain in more detail the procedures related to follow-up and eventual losses. Main and secondary methods: most important and least important variable or procedure. Study protocol: detail what was done and how it was done. Statistical analysis: descriptive and inferential methods, biostatistics application used and significance level.

All information aims at reproducibility.

In Results, report the findings, minimizing descriptions of what has already been done. Remember, here you present, you do not discuss. Use tables and figures. Prepare “one paragraph for each test” and, to make it easier, e.g., choose three colors to highlight the texts: in “green”, what was expected; in “yellow”, the unusual, which is also “part of the discussion”; and, in “red”, the so-called “unexpected”, which must also be discussed.

In Discussion, first address the main study question, hypothesis, or purpose. Discuss and compare results with previous

How to cite: Moraes SLC. Step-by-step scientific writing for young researchers. J Braz Coll Oral Maxillofac Surg. 2021 Sept-Dec;7(3):6-7. DOI: https://doi.org/10.14436/2358-2782.7.3.006-007.edt

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Editorial

publications. Explain what is new, with perspective and without exaggerating. Mention the scientific importance of findings.

Highlight weaknesses and strengths. Allocate one paragraph or two for “each color”, mentioned above, that “enhances the texts”. Start by what you highlighted in “green”; proceed with “yellow”; and, finally, allocate two to three paragraphs for what you marked in “red”. At this stage, the consultation to databases highlights the importance of these points.

With all data in hand, prepare the Introduction, which should be short, with approximately three paragraphs on one page. Leaving the Introduction to the end makes it easier, after the first three sections are complete. The first paragraph should provide a brief background in present tense, to establish the context, relevance or nature of the problem, issue or purpose (what is known). The second paragraph may include the importance of the problem and unclear issues (which is unknown).

The last paragraph should indicate the reasoning, hypothesis, main objective or purpose (why the study was done). Study data or conclusions do not belong in this section.

It should be noticed that the title is the first point that catches the interest of readers and should reflect the guiding question of the article. Be concise, since long titles discourage further reading.

Finally, before sending the text to English version, which is required by many journals, pay attention to some important points when you are not a native speaker.3 Go ahead! Success!

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

References:

1. Johnson TM. Tips on how to write a paper. J Am Acad Dermatol. 2008; 59(6):1064-9.

2. Araújo CGS. Detalhando a redação do artigo científico: 25 a 30 parágrafos. Arq Bras Cardiol. 2014;102(2):e21-e23.

3. Marlow MA. Writing scientific articles like a native English speaker: top ten tips for Portuguese speakers. Clinics 2014;69(3):153-7.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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11 a 13 de Agosto de 2022 . Maringá . PR . Brasil

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Carlos Alexandre Câmara

Daniel Machado

Fabiano Marson

Felipe Villa Verde

Luis Calicchio

Marcelo Giordani

Marcelo Kyrillos

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Marcos Pitta

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Interview

An interview with Lúcia Maria S. V. Costa Ramos

» »PhD in Information Sciences, School of Communications and Arts, University of São Paulo. » »Technical Director of the Dental Documentation Service, School of Dentistry, University of São Paulo. » »Coordinator of Rede BVS Odontologia Brasil, Researcher at the Center for Scientific Production Research and Technology of CNPq.

For a journal to be considered good level, it requires good papers. For a journal to receive good paper, it needs good indexing and prestige. What is your suggestion for a journal to survive and become a successful publication?

The scientific journal is formed by a structure that presents some extrinsic and intrinsic characteristics, constituting journal evaluation indicators, which are important factors for the survival and success of a publication.

Extrinsic characteristics are: explicit editorial practices; criteria and procedures for selecting and evaluating articles; explicit editorial policy;

SUBJECT: Steps that must be followed by a journal that intends to achieve positive notoriety in professional and academic environments The Brazilian College of Oral and Maxillofacial Surgery and Traumatology interviews, in this issue of the journal, Prof. Lúcia Maria SV Costa Ramos, Technical Head of the Dental Documentation Service, School of Dentistry, University of São Paulo (USP), Coordinator of the Rede BVS Odontologia Brasil, Researcher at the Center for Research and Technology in Scientific Production at CNPq and CiMetrias – Research Group in Science and Technology Metrics, Technical Evaluator for admission of journals in BBO and LILACS databases.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Interview

the identifier. It is a persistent, unique and published identifier that content managers link to physical or digital objects, which allows to offer services and ensure intellectual property, especially for digital objects available on the Internet.

The adoption of DOI by editors indicates a concern with quality and professionalism. For the authors, articles with DOI speed up the process of filling the Lattes Curriculum forms and improve the accuracy and precision of information, besides validating them, in the sense of collecting information provided by the editors on a reliable basis. This is possible because Crossref and other agencies maintain databases on the articles.

DOI acts in the identification and description of physical or abstract entities, real or virtual, digital or analog. The descriptive elements include location, intellectual property data and relationship with other objects, from which several services can be implemented.

instructions to authors; normalization; journal duration (tradition, continuity); regularity of publication; and indexing in national and international databases.

The intrinsic characteristics include: the Editorial Board, since the journal's reputation is checked by the excellence and representativeness of the editorial board; Peer Review System, for quality control of articles, since the judgment by peers is found in every social system that requires control; and the integration between author and reader, represented by the intention to maintain the reader's interest and the continuity of the journal's prestige and quality.

Some strategies can collaborate to increase the recognition of periodicals: from the simplest, such as the diffusion of journals in social networks, to having a geographically well-distributed editorial board.

The representativeness of the responsible editor and editorial board in the scientific community is an important point to be highlighted. When the editorial board of a journal is recognized and well-connected, it makes the journal recognized. The institutional and geographic distribution of this editorial board is also important: if team members are in different locations, they can promote the journal in their areas, increasing the journal's visibility in different institutions in the country and even abroad.

Another important factor is publication in more than one language – in English or Spanish, for example. This makes a difference. Thus, articles can also be cited and recognized outside the country. Another point to be highlighted for the success of a publication is the strict evaluation of articles, to ensure that journals publish quality studies that are read and used in other works, increasing the impact factor of the publication and the mean number of citations received by the journal articles in a given period.

Which path should be followed by a scientific publication, with regard to indexing? What should be the first indexing bases to look for?

What is the most sustainable path for this evolution?

As mentioned above, the Journal should have: explicit editorial practices; criteria and procedures for selecting and evaluating articles; explicit editorial policy; instructions to authors; normalization; journal duration (tradition, continuity); and regularity of publication.

The indexing of scientific journals depends on their suitability to the standardization criteria established by the indexers. Often, these criteria are presented as barriers for editors of scientific journals, mainly due to the large number of existing indexers and the variety of established criteria. JBCOMS, being a health sciences journal focused on dental sciences, may start requesting indexing in the BBO (Brazilian Bibliography of Dentistry) and LILACS (Latin American Literature in Health Sciences) databases. But this does not prevent you from also claiming indexing in other databases, such as SCOPUS and MEDLINE.

What is the importance of DOI today for scientific indexing?

DOI means Digital Object Identifier. It is a system that encompasses different subsystems for depositing metadata and resolving DOI names. Directly, it consists of a pair composed of identifier and metadata, or indexing, in which metadata can be retrieved from

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Ramos LMSVC, Ribeiro J

The "double-blind" review goes through questioning. What is your opinion about the scientific review? Should it be blind or not?

The main arguments in favor of double-blind review are the elimination of subjective judgments and authorship and affiliation biases, which would prevent less renowned institutions and authors from countries whose native language is not English from having the same opportunities to publish their articles. In addition, it encourages honest opinions and allows the reviewer to focus on the quality of the manuscript. Some researchers believe that it is not possible to remain anonymous at all times, since the theme, self-quotes or style end up giving strong indications of authorship. Others argue that knowing the author is important to better understand the paper content and helps detect plagiarism. The adoption of any procedure with regard to peer review must be discussed and decided with the Journal's Editorial Board.

Which scientific publications management softwares work well and are free for common use?

I am aware of the Sistema Eletrônico de Editoração de Revistas (SEER), a software developed for the construction and management of an electronic periodical publication. SEER is the result of technological prospection conducted by IBICT to identify applications that would enable the treatment and dissemination of Brazilian scientific production on the Web. This tool includes essential actions for the automation of scientific journal publishing activities.

Mendeley, EndNote and Zotero software are used to systematically search and organize the articles available in the literature.

Should the journal be registered with Publons?

Publons is the new environment where you can benefit from the improved ResearcherID, add your publications, track your citations, and manage your Editorial Board registration.

If you already have a ResearcherID account, log in with your usual credentials to view your ResearcherID profile on Publons.

Interviewer: Prof. Jonathan Ribeiro How to cite: Ramos LMSVC, Ribeiro J. Interview with Lúcia Maria S. V. Costa Ramos. J Braz Coll Oral Maxillofac Surg. 2021 Sept-Dec;7(3):11-3.

DOI: https://doi.org/10.14436/2358-2782.7.3.011-013.ent

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

Submitted: August 12, 2021 - Revised and accepted: August 27, 2021

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CBCTBMF

An interview with Valfrido Antonio Pereira Filho A survey of CBCTBMF members showed that there was an increase of approximately 17% in accidents with facial trauma in delivery riders throughout Brazil. In your opinion, what happened to this category during this period?

Unfortunately, motorcyclists/delivery riders/bikers are frequently affected by traffic accidents. Motorcycles are essential to provide greater speed in transport and delivery, especially in large centers. During the SARS-CoV-2 pandemic, there was a significant increase in delivery services, which allowed the country’s economy to function in the bars and restaurants sector.

We must remember that, during the pandemic, the number of unemployed exceeded 14% (IBGE, 2021).1 Thus, there was a greater demand for informal jobs. The motorcycle is the most used transportation means for this purpose, since it is fast and has lower financial cost when compared to cars. With the increase in the supply of people looking for financial alternatives, combined to the increase in the demand for tele-delivery, many saw this option as a work opportunity.

In 2019, Brazil was the fourth country in the world in number of deaths in traffic accidents. According to a report on Portal do Trânsito (2020),2 the country continues to record an average of 30,000 deaths/year in traffic. This means that, at every hour, three people die in our streets.

According to the newspaper Estadão,3 in the years 2019 to 2021, among motorcyclists who received fines, 43.7% were driving without a driver’s license; 73.4% had a license of a different category or suspended, and the number of fines by individuals who allowed the use of their motorcycle by someone else without a license or with a license of a different class nearly doubled. To make the scenario even more critical, there was an increase of 18.3% in fines for driving a motorcycle without wearing a helmet.

With Contran resolution 808 of December 15, 2020, RENAEST was created, which is a system for recording and statistics on road accidents in Brazil. In this tool (available at https://www.gov.br/infraestrutura/pt-br/assuntos/ transito/arquivos-denatran/docs/renaest), it is possible to verify that motorcycles are involved in 72.13% of all road

» » Graduate in Dentistry at the School of Dentistry of Araraquara-UNESP. » » Master and PhD Doctor in Oral and Maxillofacial Surgery and Traumatology by FOP-UNICAMP. » » Associate Professor, Discipline of Oral and Maxillofacial Surgery and Traumatology, School of Dentistry of Araraquara-UNESP. » »Postdoctoral Degree in Oral and Maxillofacial Surgery and Traumatology at FOP-UNICAMP.

In this issue of the Journal, the Brazilian College of Oral and Maxillofacial Surgery and Traumatology interviews Dr. Valfrido Antonio Pereira Filho, General Secretary of CBCBTMF, on the increase in accidents with facial trauma in the pandemic involving motorcycle delivery riders.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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CBCTBMF

they did not find differences in trauma severity between open helmets and not wearing helmets. That is, wearing open helmets or not wearing any helmets caused injuries with similar severity in the studied sample. Furthermore, the use of open helmets (or no helmet use) resulted in a higher incidence of cranial trauma.

Therefore, we can say that, as important as wearing a helmet, is wearing the correct helmet! This is the so-called “full face” helmet (a helmet that is closed on the chin), which is the only one really capable of fully protecting the rider’s face and skull. It must always be used with the restraint system locked. In fact, in Contran resolution 842/2021, electric bicycles were also included in the moped class and, according to Contran resolution 453/2013, their drivers are required to wear protective helmets. It should be noted, however, that non-motorized bicycles can also reach high speeds or cause significant falls, even at low speeds, resulting in severe trauma to the skull and face. However, the helmets normally used by bikers are open helmets of “coquinho” or “urban” type which, as already mentioned, do not protect the face and also allow a high rate of cranial trauma.

It is important to emphasize that the helmet must be accompanied by care in the traffic. And, as the advertisement says: “In traffic, your responsibility saves lives!”

accidents, since 2018, with a sad rate of 35.75% (25,524) of deaths in the national territory. The abuses and carelessness in traffic – both by drivers and motorcyclists – and the lack of effective punishment in most cases contribute a lot to this situation.

The CBCTBMF Chapter in Paraná participated in the campaign “Trampo Seguro” (Safe Job), by DETRAN-PR, which aimed to raise awareness and guide delivery riders. Is the College thinking of performing a campaign in this sense?

The Brazilian College of Oral and Maxillofacial Surgery and Traumatology has been working hard on this board, but also on past boards, in awareness campaigns for the population about the risks on several issues involving the scope of the specialty. These include facial trauma resulting from abuse, but also from the lack of protective equipment in traffic.

We’ve had appearances on national TV shows. In recent years, “Maio Amarelo” (Yellow May) activities have also been taking place in public environments, within the chapters. However, the SARS-CoV-2 pandemic precluded several face-to-face activities, such as those of “Trampo Seguro”, which should be resumed in 2022. In 2020 and 2021, the CTBMF has used its social networks to strengthen awareness , by society, of important themes, like the one in the question. Finally, the initiative of the project “Trampo Seguro”, by DETRAN-PR, was very important, since it aimed not only at technical teaching in defensive riding, but also at raising awareness about the correct use of helmets.

The CBCTBMF is very interested in supporting and seeking partnerships for events of this type across the country.

References: 1. Barros Al. Desemprego recua para 14,1% no 2º tri, mas ainda atinge 14,4 milhões de pessoas. Rio de Janeiro: Agência IBGE Notícias; 2021 [Acesso 28 set 2021]. Disponível em: https://agenciadenoticias.ibge.gov.br/agencia-noticias/2012-agencia-de-noticias/ noticias/31480-desemprego-recua-para-14-1-no-2-tri-mas-ainda-atinge-14-4-milhoes-depessoas.

2. Murialdo L. Em 2020, 80 pessoas morreram por dia em consequência de acidente de trânsito no país. Curitiba: Portal do trânsito e mobilidade; 2020 [Acesso 28 set 2021].

Disponível em: https://www.portaldotransito.com.br/noticias/em-2020-80-pessoasmorreram-por-dia-em-consequencia-de-acidente-de-transito-no-pais/.

3. Ramalho JA. O triste retrato da mortalidade de motociclistas no Brasil. São Paulo: Estadão; 2021 [Acesso 28 set 2021]. Disponível em: https://mobilidade.estadao.com.br/ meios-de-transporte/o-cenario-da-mortalidade-de-motociclistas-no-brasil/.

4. Lopes Albuquerque CE, Nogueira Arcanjo FP, Cristino-Filho G, Mont’alverne Lopes-Filho A, Cesar de Almeida P, Prado R, et al. How safe is your motorcycle helmet? J Oral Maxillofac Surg. 2014 Mar;72(3):542-9.

Data from the CBCTBMF show that the helmet reduces the risk and severity of injuries by 72% and reduces the probability of death by up to 39%, besides the costs of treatment associated with the collision. But not all types of helmets provide adequate protection. Could you please explain which are suitable for each type of delivery professional, i.e., motorcycle and bike riders?

A survey conducted by Brazilian researchers4 evaluated 253 motorcycle accident victims between June 2011 and June 2012. It was found that there were differences in the severity of facial trauma depending on the type of helmet used at the time of the accident. Among other results, the authors found significant differences in the type of trauma, when comparing the use of closed and open helmets; but

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

How to cite: Pereira Filho VA. Interview with Valfrido Antonio Pereira Filho. J Braz Coll Oral Maxillofac Surg. 2021 Sept-Dec;7(3):14-5.

DOI: https://doi.org/10.14436/2358-2782.7.3.014-015.col

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J Braz Coll Oral Maxillofac Surg. 2021 Sept-Dec;7(3):14-5

Original Article

Epidemiological analysis of maxillofacial fractures in a referral hospital in Tocantins/Brazil MARIANA ARAÚJO DOS SANTOS1 | PAULA VITÓRIA BIDO GELLEN1 | HYARA LUZ MOREIRA1 | MARCOS PHELIPE ARAÚJO ANDRADE ALVES1 | TÁSSIA SILVANA BORGES1 | JOSÉ AFONSO DE ALMEIDA1

ABSTRACT Introduction: Epidemiological studies on oral and maxillofacial trauma play an important role in public health, by directing actions for health promotion, prevention and diagnosis. Objective: The aim of this study was to identify the profile of traumatized patients, with an emphasis on oral and maxillofacial fractures treated in a referral hospital in the North region of Brazil. Methods: A retrospective analysis of the medical records of patients treated over a period of 7 years was performed, collecting the following variables: sex, age, diagnosis, etiology and anatomical site. A descriptive analysis of the data was performed, and some variables were assessed using the chi-square test. Results: 471 medical records were analyzed, most of them of male patients (73.5%; n = 346), aged 20 to 35 years (48.6%; n = 229). Regarding the etiological factors, 56.5% (n = 266) of the patients were victims of traffic accidents, being the most prevalent etiology. Physical aggressions corresponded to 24.8% (n = 117) of the treated cases. Based on this, the most affected oral and maxillofacial location was the mandibular bone (n = 121; 25.7%), followed by the nasal bone and zygomatic complex. Conclusion: The epidemiological profile of trauma in the studied hospital consisted of men, aged 20 to 35 years, mainly involved in traffic accidents, in which they had face trauma, with fracture of the mandibular bone.

Keywords: Epidemiology. Maxillofacial injuries. Health promotion.

How to cite: Santos MA, Gellen PVB, Moreira HL, Alves MPAA, Borges TS, Almeida JA. Epidemiological analysis of maxillofacial fractures in a referral hospital in Tocantins/Brazil. J Braz Coll Oral Maxillofac Surg. 2021 Sept-Dec;7(3):16-21.

DOI: https://doi.org/10.14436/2358-2782.7.3.016-021.oar Centro Universitário Luterano de Palmas, Departamento de Odontologia (Palmas/TO, Brazil).

1

Submitted: February 17, 2021 - Revised and accepted: July 31, 2021 Contact address: Mariana Araújo dos Santos E-mail: mariana13011997@gmail.com

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

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Santos MA, Gellen PVB, Moreira HL, Alves MPAA, Borges TS, Almeida JA

INTRODUCTION Maxillofacial trauma is considered a destabilization of the facial tissue integrity. Analysis of this type of trauma is recurrent in studies, considering the esthetic, functional and social importance of the face for the individual.1-4 The facial skeleton is the most prominent region of the human body4 and can be divided into three regions for classification of maxillofacial fractures: upper, middle and lower.9 Generally, such fractures can be associated with multiple traumas, thus requiring multidisciplinary care to avoid negligence and serious sequelae to the patient.2,5,10 With regard to the etiology of oral and maxillofacial trauma, it is clear that the constant population increase and the various types of relationships and daily interpersonal activities can directly interfere with the increased rate of bodily injuries, especially facial fractures. In this sense, urban violence and the high flow of cars in traffic are considered some of the main causes of trauma.2,5-9 From this perspective, victims may have serious problems regarding esthetics and quality of life, which can be altered by deficits in motor function. Also, the frequency of occurrence of traumas can generate a financial burden on the public service, since the treatment and rehabilitation of these patients require a network of professionals and significant material resources.6,7,11 In view of the severity of socioeconomic aspect and deleterious effects, epidemiological studies aim to analyze the current parameters of trauma in a given country, region, state or city, thus enabling the organization of prevention and health promotion strategies or maintenance and improvement of existing measures.3,4,6-8,12,13 Thus, this study conducted an epidemiological analysis of traumas involving oral and maxillofacial fractures in patients treated at the Department of Maxillofacial Traumatology of a reference hospital in Northern Brazil.

The study included medical records of patients assisted from January 2013 to September 2019, which were complete, readable and related to oral and maxillofacial fractures. The records referring only to fractures in other regions of the body were excluded, as well as those outside the pre-established period.

Data were collected using a form that included the following variables: age, sex, type of care (urgency or emergency), place where trauma occurred (street, home, work, other), type of trauma (isolated face, face associated with TBI, multiple trauma), trauma etiology (interpersonal violence, traffic accident, accidental accident, sports accident, occupational accident) and location of trauma (nasal [OPN], maxilla, mandible, alveolar bone, TMJ , zygomatic complex, orbit, craniofacial [Le Fort I, II, III], others). Data were collected and entered into a Microsoft Office Excel 2010 spreadsheet and later analyzed using SPSS version 20.0. A descriptive statistical analysis was performed, looking for simple and percentage frequency data, in addition to correlation.

The study was submitted and approved by the Institutional Review Board under report n. 3.141.579 and CAAE 02760518.7.0000.5516.

RESULTS A total of 701 medical records of patients treated at the hospital emergency department were evaluated. Of these, 471 were included in the study, being 346 (73.5%) males and 125 (26.5%) females. Regarding age group, there was prevalence of young adult patients aged between 20 and 35 years (n=229, 48.6%). Regarding the type of consultation, 331 cases (70.3%) were urgencies, and 140 cases were emergencies (29.7%).

Concerning the site of occurrence of trauma, most occurred on the street, with 243 cases (51.6%); followed by home, with 149 cases (31.6%). It is noteworthy that 29 cases had no such information. In the category of trauma, it was found that 369 cases (78.4%) affected only the face, being considered isolated facial trauma; 38 cases (8%) affected the face with traumatic brain injury, and there were 64 cases (13.6%) of multiple trauma.

Regarding the etiological factor, it was observed that accidents caused by circulation were responsible for the highest occurrence of trauma, with 266 cases (56.5%) (Table 1), with motorcycle accidents being the most prevalent classification in this category, with 197 cases (74%) (Table 2).

METHODS This is a retrospective study of a historical longitudinal cohort, conducted by the selection and analysis of medical records of patients diagnosed with oral and maxillofacial trauma at Hospital Geral de Palmas Dr. Francisco Ayres (Palmas/TO).

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Epidemiological analysis of maxillofacial fractures in a referral hospital in Tocantins/Brazil

demonstrating that males were the most affected, regardless of the etiological factor, with emphasis on traffic accidents (Table 4).

To perform the analysis of correlation between etiological factor and anatomical site, the three anatomical sites with the highest prevalence of fractures were highlighted, representing 265 cases (55.4%). Thus, it was observed that traffic accidents were the etiological factor that most caused fractures, presenting a higher frequency in all anatomical sites analyzed (Table 5).

Regarding the diagnosis, this study was based on facial fractures, with emphasis on trauma location. Therefore, all cases were fractures, differing only in anatomical site.

Thus, it was observed that the most fractured bones were the mandible (25.7%), nasal bone (17.4%) and zygomatic complex (13.2%) (Table 3).

Application of the chi-square test at a significance level of 5% revealed that there was an association between etiological factor and sex (p < 0.001), and between etiological factor and anatomical site (p < 0.05),

Table 1: Distribution of fracture cases according to etiological factor.

ETIOLOGICAL FACTOR

n

%

Circulation accidents Interpersonal violence Casual accident Work accident Sports accident Total

266 120 44 22 19 471

56.5% 25.4% 9.4% 4.7% 4% 100%

Table 2: Distribution of fracture cases by classification of etiological factors.

CIRCULATION ACCIDENTS Motorcycle Car Bike Running over Total INTERPERSONAL VIOLENCE Physical aggression Cold weapons Firearm Total CASUAL ACCIDENT Fall Fall from animal Kick from animal Total SPORTS ACCIDENT Contact Total WORK ACCIDENT Work accident Total

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

n

%

197 47 17 5 266

74% 17.7% 6.4% 1.9% 100%

91 13 16 120

75.8% 10.9% 13.3% 100%

28 12 4 44

63.6% 27.4% 9% 100%

19 19

100% 100%

22 22

100% 100%

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Santos MA, Gellen PVB, Moreira HL, Alves MPAA, Borges TS, Almeida JA

Table 3: Distribution of fracture cases according to anatomical location.

Fracture location

n

%

Mandible Nasal bone Zygomatic complex Orbit Alveolar Maxilla TMJ Le Fort I Le Fort II Le Fort III More than one type Total

121 82 62 42 14 27 12 24 26 18 43 471

25.7% 17.4% 13.2% 8.9% 3% 5.7% 2.6% 5% 5.5% 3.8% 9.2% 100%

Table 4: Distribution of fracture cases according to etiological factor and gender.

SEX

ETIOLOGICAL FACTOR

Circulation accident Interpersonal violence Casual accident Sports accident Work accident Total

Male

Female

201 95 23 11 15 345

65 25 21 8 7 126

Total

266 120 44 19 22 471

Table 5: Distribution of fracture cases according to the etiological factor and the most affected anatomical sites.

ETIOLOGICAL FACTOR

TRAUMATIZED ANATOMICAL SITE Mandible

Nasal bone

Zygomatic complex

62 37 11 6 5 121

47 13 10 7 5 82

20 19 6 6 11 62

Circulation accidents Interpersonal violence Casual accident Sports accident Occupational accident Total

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Total

129 69 27 19 21 265

J Braz Coll Oral Maxillofac Surg. 2021 Sept-Dec;7(3):16-21

Epidemiological analysis of maxillofacial fractures in a referral hospital in Tocantins/Brazil

DISCUSSION The epidemiological analysis of oral and maxillofacial trauma, from the perspective of incidence, prevalence and etiology, has varied results, depending on the population, geographic region, culture and socioeconomic factors.14,15 In this perspective, the epidemiological profile of patients who are frequently affected by facial trauma in the studied region was traced, most of whom were residents of Palmas/TO (54.4%), males (73.5%) and in the age group from 20 to 35 years (48.6%).

The most common etiology was traffic accidents (n=266, 56.5%), with emphasis on motorcycling (n=197, 74%). The most prevalent bone fracture was in the mandible (25.7%), followed by the nasal bone (17.4%) and zygomatic complex (13.2%).

The results presented agree with other evidence in the literature, which report that males are the most affected by facial trauma in all types of etiological factors analyzed, ranging from 55.3% to 91%.6,15 A possible explanation for this panorama is related to the fact that men are more active in their work and social activities, besides being frequently related to negligent driving of cars and motorcycles, and involved in sports and violence.6,15 The occurrence of facial trauma was more common in patients aged between 20 and 35 years (48.6%). Such data corroborate the results of a study conducted in Gonzaga/PB.13 The authors of this study claim that this finding is due to the fact that people in this age group are in full physical and professional activity, with lifestyles more exposed to risk factors.

Regarding the etiology of trauma, traffic accidents were the most prevalent, with 266 cases (56.5%), of which 74% were related to accidents involving motorcycles. Other studies6,13,14 have also reported motorcycle accidents as the main etiological agent of facial fractures. This is due to the fact that the motorcycle is a more affordable transportation for the population and because it has the ability to travel along narrow roads and bypass traffic jams.6,14 Also, the authors claim that the motorcycle is considered a transport that leaves the rider very exposed to external risks, in which the helmet is used as a safety device to reduce damage.6,14

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Concerning the location of oral and maxillofacial trauma, this study identified that the mandible was the most fractured bone (25.7%), followed by the nasal bone (17.4%) and the zygomatic complex (13.2%). Ramos et al.15 stated that the mandible is more vulnerable than the zygomatic-maxillary complex because it is the only mobile bone in the face, besides having a smaller supporting bone framework, making it more prone to receive impacts. As for the nasal bone, the explanation for its high prevalence may be related to the fact that it is located in a central and prominent position on the face, besides having a small bone thickness and little soft tissue coverage.13,15 These results corroborate other studies3,6,14 in which the mandible was also the most affected bone location, with 55%, 58.8% and 36.8% of cases analyzed, respectively. Conversely, other studies13,15 identified that the nasal bone was the most frequent location of trauma, with 41.8% and 38.2%, respectively.

Based on this analysis, studies13,15 emphasize that the occurrence of facial fractures can trigger physical, psychological and socioeconomic sequelae in the patient and in the health system. With this in mind, such sequelae could be avoided by programs that involve traffic education and the fight against domestic and social violence, besides punishing offenders by a stricter legislation.

CONCLUSION Oral and maxillofacial trauma victims treated at Hospital Geral de Palmas Dr. Francisco Ayres were predominantly men aged between 20 and 35 years, involved in motorcycle accidents and with injuries to the mandible. Thus, the studied sample showed that age, sex and trauma etiology determine the prevalence of maxillofacial fractures, besides the decision on the best treatment plan. Also, this study can contribute to the creation of appropriate policies in favor of disease prevention and health promotion, besides the organization of hospital management with regard to materials, procedures and professionals necessary for the care of traumatized patients in the geographic region studied.

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Santos MA, Gellen PVB, Moreira HL, Alves MPAA, Borges TS, Almeida JA

References:

1. Jin Z, Jiang X, Shang L. Analysis of 627 hospitalized maxillofacial-oral injuries in Xi’an, China. Dent Traumatol.

2014 Apr;30(2):147-53.

2. Mello Filho FV, Ricz H. Epidemiological modifications of facial trauma and its implications. Braz J Otorhinolaryngol.

2014 May-Jun;80(3):187-8.

3. Levi Duque F, Agudelo-Suarez A, Ardila CM. Etiology and Pattern of maxillofacial fractures in Medellín, Colombia: a retrospective analysis of 2680 patients. Int J Odontostomat. 2013;7(1):159-66.

4. d’Avila S, Barbosa KG, Bernardino Íde M, da Nóbrega LM, Bento PM, E Ferreira EF. Facial trauma among victims of terrestrial transport accidents. Braz J Otorhinolaryngol. 2016 May-Jun;82(3):314-20.

5. Latifi H. Prevalence of different kinds of maxillofacial fractures and their associated factors are surveyed in patients.

Glob J Health Sci. 2014 Sep 18;6(7 Spec No):66-73.

6. Samieirad S, Aboutorabzade MR, Tohidi E, Shaban B, Khalife H, Hashemipour MA, et al. Maxillofacial fracture epidemiology and treatment plans in the Northeast of Iran: a retrospective study. Med Oral Patol Oral Cir Bucal.

2017 Sep 1;22(5):e616-e24.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

7. Einy S, Abdel Rahman N, Siman-Tov M, Aizenbud D, Peleg K. Maxillofacial trauma following road accidents and falls. J Craniofac Surg. 2016 Jun;27(4):857-61.

8. Liang CC, Liu HT, Rau CS, Hsu SY, Hsieh HY, Hsieh CH. Motorcycle-related hospitalization of adolescents in a Level I trauma center in southern Taiwan: a crosssectional study. BMC Pediatr. 2015 Aug 28;15:105.

9. Martinez AY, Como JJ, Vacca M, Nowak MJ, Thomas CL, Claridge JA. Trends in maxillofacial trauma: a comparison of two cohorts of patients at a single institution 20 years apart. J Oral Maxillofac Surg. 2014 Apr;72(4):750-4.

10. Carvalho Filho MA, Saintrain MV, Dos Anjos RE, Pinheiro SS, Cardoso Lde C, Moizan JA, et al.

Prevalence of oral and maxillofacial trauma in elders admitted to a reference Hospital in Northeastern Brazil. PLoS One. 2015 Aug 19;10(8):e0135813.

11. Fama F, Cicciu M, Sindoni A, Nastro-Siniscalchi E, Falzea R, Cervino G, et al. Maxillofacial and concomitant serious injuries: an eight-year single center experience. Chin J Traumatol. 2017 Feb;20(1):4-8.

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12. Christian JM, Thomas RF, Scarbecz M. The incidence and pattern of maxillofacial injuries in helmeted versus non-helmeted motorcycle accident patients. J Oral Maxillofac Surg. 2014 Dec;72(12):2503-6.

13. Lucena AL, da Silva Filho GF, de Almeida Pinto Sarmento TC, de Carvalho SH, Fonseca FR, de Santana Sarmento DJ. Epidemiological profile of facial fractures and their relationship with clinical-epidemiological variables. J Craniofac Surg. 2016 Mar;27(2):345-9.

14. Barbosa APC, Matrone MA, Santos TI, Borba AM, Segundo AS. Análise epidemiológica das fraturas faciais no hospital e pronto socorro municipal de Cuiabá Brasil. Rev Faipe. 2019 Jul-Dez;9(2):29-35.

15. Ramos JC, Almeida MLD, Alencar YCG, Sousa Filho LF, Costa, CHM, Almeida MSC. Estudo epidemiológico do trauma bucomaxilofacial em um hospital de referência da Paraíba. Rev Col Bras Cir. 2018 Nov;45(6):27-34.

J Braz Coll Oral Maxillofac Surg. 2021 Sept-Dec;7(3):16-21

Original Article

Smartphones use to study and professional development among maxillofacial surgeons and residents LUIZ FELIPE ROCHA VILAÇA1 | LOURRANY CARMO ARAUJO1 | LUCAS TEIXEIRA BRITO1 | GUSTAVO CAMPOLINA BARBOSA PEREIRA2 | ROBSON RODRIGUES GARCIA1 | DOUGLAS RANGEL GOULART1

ABSTRACT Objective: The objective of this study was to evaluate the prevalence of the use of smartphones for the purpose of professional development in maxillofacial surgery. Methods: A cross-sectional study was carried out with residents and surgeons specializing in Oral and Maxillofacial Surgery and Traumatology (OMFS) from July 2020 to February 2021.

Data were collected through an electronic form designed specifically for this study and made available through a link and sent by email. Results: The study included 83 participants, of which 65.1% were OMFS specialists, while the percentage of residents was 34.9%. Among residents, the highest participation was among those in the first and third years, with 51.7% and 34.5% respectively. Of these professionals, 80.7% reported using some application on the smartphone for the purpose of continuing education in the area of maxillofacial surgery. The most used application for this purpose was the AO Manual Surgery, with an usage rate of 15.6% among specialists and residents. In addition, from the total of participants, 78.3% said they follow profiles on social networks, with professional and/or educational development purposes. The most used social media was Instagram, with 50.7% of users. Conclusion: Smartphones can offer a promising method of delivery and improving access to educational information for maxillofacial surgeons; for this, however, it is necessary to create new applications and quality control of the information provided.

Keywords: Mobile applications. Communication. Oral and maxillofacial surgeons. Social networking. Education, distance.

How to cite: Vilaça LFR, Araujo LC, Brito LT, Pereira GCB, Garcia RR, Goulart DR. Smartphones use to study and professional development among maxillofacial surgeons and residents. J Braz Coll Oral Maxillofac Surg. 2021 Sept-Dec;7(3):22-9.

DOI: https://doi.org/10.14436/2358-2782.7.3.022-029.oar

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

Faculdade de Medicina e Odontologia São Leopoldo Mandic, Departamento de Cirurgia e Traumatologia Bucomaxilofaciais (Campinas/SP, Brazil).

1 2

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

Submitted: May 31, 2021 - Revised and accepted: August 31, 2021 Contact address: Douglas Rangel Goulart E-mail: douglasrgoulart@gmail.com

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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J Braz Coll Oral Maxillofac Surg. 2021 Sept-Dec;7(3):22-9

Vilaça LFR, Araujo LC, Brito LT, Pereira GCB, Garcia RR, Goulart DR

INTRODUCTION In the last decades, mobile communication technologies, mainly by smartphones, have been widely used in many fields of human life. Thus, Dentistry has evolved with the development of apps that allow their use for education and professional development. This is because cell phones are no longer just a communication means and now integrate several functions of a computer. These advances in technology allowed greater accessibility to digital content, i.e., the ability to find what is needed, when needed. 1 It is observed that the number of smartphone users has increased rapidly, especially among health professionals. 2 In the professional environment, especially in Surgery, the use of mobile devices can complement or speed up the clinical activities, since they are good assistants for surgeons in their daily practices. Smartphones, by the combination of texts, photographs, videos, emails and instant messaging, allowed access to health information about care for the clinician and data transfer between team members and with the patient. 3 These advances in smartphone technology allowed the promotion of a tool that also acts in the continuing education of these professionals.

Apps for mobile devices have been mainly used for patient operative planning and also as sources of research and content access in specific and related areas, which act as a clinical guide, being considered a promising tool for information access by surgeons.3 The use of smartphones by oral and maxillofacial surgeons has been associated with an improvement in their capacity for differential diagnosis, treatment, follow-up and prevention of diseases, 4 which is an indisputable trend in the current communication dynamics.5 Thus, this study aimed to assess the prevalence of the use of smartphones for the purpose of professional development by surgeons and residents in Oral and Maxillofacial Surgery, to discuss how these devices are used and, consequently, may interfere with the continuing education process and clinical routine of these professionals.

METHODS A cross-sectional study was conducted on residents in Oral and Maxillofacial Surgery and Trau-

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

matology and oral and maxillofacial surgeons from July 2020 to February 2021. The study included professionals of both sexes, older than eighteen years old and living in Brazil. Data were collected by an electronic form specifically designed for this study, accessed by a link sent by email.

The form collected sociodemographic information, such as sex, age, state of residence and availability/type of internet access, and questions about the use of apps and social networks for professional improvement. Forms that were incompletely filled or completed by people who did not identify themselves as residency students in Oral and Maxillofacial Surgery or as dental surgeons specializing in this field were excluded.

The collected data were grouped in a table and submitted to descriptive and comparative analysis using the SPSS Statistics for Windows, version 18.0 (SPSS Inc., Chicago, Illinois, USA) program. The chisquare test was used to compare the variables, and the results were considered statistically significant for values ​​of p < 0.05.

RESULTS Eighty-three participants were included in this research, among which 69.9% were males and 30.1% were females. The minimum age among respondents was 21 years and the maximum was 63 years.

The study sample consisted mainly of specialists in Oral and Maxillofacial Surgery and Traumatology (65.1%), followed by the participation of residents (34.9%). Among residents, the greatest participation was composed of residents of the first and third years, with 51.7% and 34.5%, respectively. Figure 1 shows the sample distribution. As for the place of origin, the highest number of responses was obtained from professionals living in the Federal District, with a rate of 16.9%, followed by Gosia and Piauí, with a rate of 13.3%, as shown in Table 1.

All participants reported that they owned a smartphone. The iOS® system was the most used (79.5%), followed by the Android® system (Open Handset Alliance), with 20.5%. Most of these participants reported that they accessed the internet from multiple locations. About 42.2% reported using the internet from the college/hospital, from their homes or student homes and private internet (3G or 4G); followed by those that use only the private internet

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Total dental professionals (n = 83. 100%)

Smartphones use to study and professional development among maxillofacial surgeons and residents

Specialist in Oral and Maxillofacial Surgery and Traumatology (n = 54, 65.1%) Residents in Oral and Maxillofacial Surgery and Traumatology (n = 29, 34.9%)

First year of residency (n = 15, 51.7%) Second year of residency (n = 3, 10.3%) Third year of residency (n = 10, 34.5%) Fourth year of residency (n = 1, 3.4%) Figure 1: List of specialists and residents in Oral and Maxillofacial Surgery and Traumatology.

Table 1: Distribution of absolute and relative frequencies of specialists and residents in Oral and Maxillofacial Surgery and Traumatology by State/Federation Unit.

State

Absolute frequency (n)

Relative frequency (%)

Distrito-Federal/DF Goiás/GO Piauí/PI Mato Grosso/MT Paraná/PR Minas Gerais/MG Bahia/BA Rio Grande do Sul/RS São Paulo/SP Ceará/CE Rio de Janeiro/RJ Alagoas/AL Amazonas/AM Espírito Santo/ES Paraíba/PB Pernambuco/PE Santa Catarina/SC Tocantins/TO TOTAL

14 11 11 9 8 6 4 4 4 2 2 1 1 1 1 1 1 1 83

16.9 13.3 13.3 10.8 9.6 7.2 4.8 4.8 4.8 2.4 2.4 1.2 1.2 1.2 1.2 1.2 1.2 1.2 100

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Vilaça LFR, Araujo LC, Brito LT, Pereira GCB, Garcia RR, Goulart DR

was also observed that residents use the apps for this purpose more frequently (89%) than specialist surgeons (77%); however, there was no statistically significant difference (X²=1.79; p = 0.18). Figure 2 shows the number of apps used. The most used app for this purpose was AO Manual Surgery, with a rate of use of 15.6% among specialists and residents. Table 3 presents the apps used.

service (3G or 4G) and from their homes or student homes, not using it in the work or study place (22.9%). Table 2 shows the distribution of participants in relation to where they use the internet.

Concerning the mode of use of smartphones, nearly 80.7% of professionals reported using at least one app for continuing education in the field of ​​Oral and Maxillofacial Surgery. Within these results, it

Table 2: Distribution of absolute and relative frequencies of internet access sites by specialists and residents in Oral and Maxillofacial Surgery and Traumatology.

Sites of internet access

Absolute frequency (n)

Relative frequency (%)

College or hospital. home or student home. and private (3G or 4G) Home or student home. and private (3G or 4G) Only mobile private internet (3G or 4G) Others TOTAL

35 19 18 11 83

42.2 22.9 21.7 13.2 100

Table 3: Distribution of absolute and relative frequencies of apps most used by specialists and residents in Oral and Maxillofacial Surgery and Traumatology.

Apps

Absolute frequency (n)

Relative frequency (%)

Others AO Manual Surgery ICD-10 Whitebook* PSUS TUSS Medphone SUS My ATLS Total apps cited

56 17 8 7 6 6 5 2 2 109

51.3 15.6 7.3 6.4 5.5 5.5 4.6 1.8 1.8 10

*Created by PEBmed, presenting information and tools to support the clinical decision in Medicine.

Do not use (n = 16. 19.3%)

Yes. they use (n = 67. 80.7%)

1 apps (n = 15, 18.1%)

2 apps (n = 9, 10.8%)

3 apps (n = 15, 18.1%)

4 apps (n = 8, 9.6%)

5 apps (n = 6, 7.2%)

More of 5 apps (n = 5. 6.0%)

Non specified (n = 25, 30.1%)

Figure 2: Quantitative list of apps used by specialists and residents in Oral and Maxillofacial Surgery and Traumatology.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Smartphones use to study and professional development among maxillofacial surgeons and residents

(86.2%) believe that the apps help in their professional training, without statistically significant difference between groups (X 2 = 0.11; p = 0.73 ).

The use of social media platforms, such as Instagram, Facebook, Twitter and YouTube, was also analyzed for the purpose of study and professional development. Most participants (78.3%) stated they follow profiles on social networks, with the purpose of professional and/or educational development. Among these participants, 13.4% reported they follow more than 10 profiles. Figure 3 shows the distribution of participants according to the number of profiles followed. However, CTBMF residents follow profiles on social networks more frequently (93%) than surgeons (74%), with statistically significant difference (X2 = 4.39; p = 0.03). The most used social media was Instagram, with 50.7% of users. Table 5 shows the distribution of participants according to the social media followed.

Concerning the acquisition means of these apps for educational purposes, 39.7% of participants reported having learned about them by referral from a colleague, followed by internet searches (16.9%).

Table 4 shows how the participants had information about the app. Among the residents, 14 participants (48.3% of residents) indicated that the professors or preceptors use some app to aid the teaching method, and, in this case, the apps used were AO Manual Surgery and ICD-10.

The level of reliability of apps was evaluated by users, with 84.3% considering the app information to be reliable and believing that the apps help in their professional performance or in their training.

Within this aspect, the level of reliability of residents (89%) is higher than that of surgeons (81.4%), yet without statistically significant difference (X² = 0.95; p = 0.32). Most surgeons (83.3%) and residents

Table 4: Distribution of absolute and relative frequencies on the means of acquisition of apps by specialists and residents in Oral and Maxillofacial Surgery and Traumatology.

Means of acquisition

Absolute frequency (n)

Relative frequency (%)

Indication of colleagues Internet search Indication from professor/preceptor Search in App Store or Play Store Others Search in App Store or Play Store and indication of colleagues Indication from professor/preceptor; indication of colleagues; internet search; search in App Store or Play Store Non specified TOTAL

33 14 10 9 3 1 1

39.7 16.9 12.0 10.8 3.6 1.2 1.2

12 83

14.4 100

Table 5: Distribution of absolute and relative frequencies of social networks most used by specialists and residents in Oral and Maxillofacial Surgery and Traumatology for the purpose of learning or professional development.

Social networks

Absolute frequency (n)

Relative frequency (%)

Instagram Instagram and YouTube Instagram and Facebook Instagram, Facebook and YouTube Non specified Facebook Instagram, Facebook, YouTube and Twitter Instagram, Facebook and Twitter TOTAL

34 11 5 9 3 2 2 1 67

50.7 16.4 7.5 13.4 4.8 3.0 3.0 1.5 100

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Vilaça LFR, Araujo LC, Brito LT, Pereira GCB, Garcia RR, Goulart DR

Yes. How many profiles? (n = 67, 78.3%)

1 profile (n = 1, 1.5%)

2 profiles (n = 3, 4.5%)

3 profiles (n = 8, 11.9%)

4 profiles (n = 1, 1.5%)

Do not follow (n = 16, 19.3%)

5 profiles (n = 13, 19.4%)

10 profiles (n = 12, 17.9%)

+10 profiles (n = 9, 13.4%)

Did not reply (n = 20, 29.8%)

Figure 3: Quantitative list of specialists and residents in Oral and Maxillofacial Surgery and Traumatology who follow some profile on a social network with the purpose of learning or professional development.

DISCUSSION This research revealed that a significant number of surgeons and residents in Oral and Maxillofacial Surgery use their smartphones for professional development, and among these, 80.7% reported using at least one app for continuing education in the field of Oral and Maxillofacial Surgery. Among the most used apps, the AO Manual Surgery stands out, which is consistent with the need for quick and practical access to information regarding the most demanded procedures in the clinical environment, such as the diagnosis and treatment of facial fractures. In addition, other apps, such as those on Pharmacology and consultations to the International Classification of Diseases (ICD), are also used very frequently.

Modernization of the clinical environment using the smartphone, especially in the field of ​​Oral and Maxillofacial Surgery, has provided promising methods for improving the access to health information, which are recognized in several countries. In China, apps have been associated with a positive impact on clinical practice, education and patient care by relevant medical information.6 In Saudi Arabia, a study showed that smartphones allow both professionals and residents to access important content and resources efficiently during clinical care, which help in decision-making.7 Similarly, in Iran, a study showed that this agility in decision-making provided by the use of smartphones is also essential to minimize the time lost in emergency situations.8 In Turkey, a retrospective study stated that the use of apps as WhatsApp has increased the efficiency of communication within the Oral and Maxillofacial Surgery

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

team. 9 Similar to this study, a survey conducted in Canada indicates that smartphones, besides facilitating the communication between professionals, also facilitate communication between professionals and patients. 10 The apps have been applied to teaching surgical residents in many countries and have shown positive results with regard to: communication between team members, mainly in the exchange of information related to the patient; consultations with medical references, i.e., content aimed at facilitating decision-making regarding a clinical procedure; and photographic documentation. 11 In this study, it was observed that the popularity of these apps is mainly due to the exchange of information between professionals. An interesting fact is that a professional, whether specialist or a resident surgeon, has a greater chance of getting to know an app based on the recommendation of a colleague. Among those interviewed, 39.7% claimed to have had this type of knowledge. This low percentage referring to apps acquired by indication of the preceptor/professor, when compared to other acquisition methods, is consistent with the statement that only 14 residents stated that their preceptors use some app to assist in the teaching process.

In this study, social media such as Instagram were also evaluated. This platform has been used as a tool for professional and/or educational use based on posts or profiles that aim to disseminate content aimed at Oral and Maxillofacial Surgery. In this survey, 50.7% of respondents reported using only Instagram. However, there are others who use Instagram

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Smartphones use to study and professional development among maxillofacial surgeons and residents

ing. Thus, it is noteworthy that there are not only advantages related to the use of these platforms by surgeons and residents, but there are also disadvantages, such as the possibility of violating the rules of the Dental Code of Ethics, regarding the exposure of procedures and patient confidentiality, device cost, risk of professional distraction at work, risk of contamination of the surgical environment by the device itself and possibility of false information and lack of scientific basis for the information provided.

The study proposes a reflection on the limitations of these resources, such as the level of credibility and the scientific relevance of the posted content.

There is also lack of national apps used for academic purposes and for professional development by these professionals, which represents a potential area of ​​development. This paper has limitations related to the restricted sample size and its concentration in some Brazilian states. This reflects the difficulty in voluntary participation of surgeons in this type of research using an electronic questionnaire. Future studies on this topic may elucidate gaps in this research.

in combination with other social media such as YouTube, Facebook and Twitter. However, for these cases, professionals prefer to use more the association between Instagram and YouTube (16.4%); therefore, there is a tendency of lower use of Facebook. Thus, Instagram is currently the social media that most favors a flexible learning environment and professional use, contrasting with some older literature, such as that proposed by Alshiekhly et al., 12 who considered Facebook as the social network capable of promoting a unique learning environment.

Twitter, in turn, is the social network that seems to be used as last resort, since it was the least mentioned among respondents. This is not surprising, since when compared to other social networks, Twitter allows short messages (144 characters), and this can cause a lack of interest in the user, even though video sharing or status updates are allowed. Thus, Twitter, despite being a tool with educational potential, shows a slow trend of popularity, as defended by Junco et al.,13 or it may be an underexplored environment, as mentioned by Dunlap et al.14 and addressed by Diug et al.15 In general, social media, besides text messages, allow users to send images, videos and audios, and this favors a new manner of providing and sharing new information. These platforms are able to overcome physical barriers, since they make the learning process more flexible and encourage interactivity.

An important question is the nature of information provided by these apps. A significant number of professionals (84.3%) consider the information from apps to be trustworthy and believe that the apps aid in their professional performance or in their train-

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

CONCLUSION Smartphones are widely used by surgeons and residents for professional development in the field of ​​Oral and Maxillofacial Surgery. Apps for mobile devices and social media can be valuable tools for transmitting knowledge and facilitating the acquisition of skills, since they are more attractive tools for new generations of professionals, who are increasingly familiar with the digital technology. The lack of national apps in this field is an invitation to their development by professionals and institutions.

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Vilaça LFR, Araujo LC, Brito LT, Pereira GCB, Garcia RR, Goulart DR

References:

1. Ruiz JG, Mintzer MJ, Leipzig RM. The impact of E-learning in medical education. Acad Med. 2006 Mar;81(3):207-12.

2. Mosa AS, Yoo I, Sheets L. A systematic review of healthcare applications for smartphones. BMC Med Inform Decis Mak. 2012 Jul 10;12:67.

3. Carey E, Payne KF, Ahmed N, Goodson A. The benefit of the smartphone in oral and maxillofacial surgery: smartphone use among maxillofacial surgery trainees and iphone apps for the maxillofacial surgeon. J Maxillofac Oral Surg. 2015 Jun;14(2):131-7.

4. Dhuvad JM, Dhuvad MM, Kshirsagar RA. Have smartphones contributed in the clinical progress of oral and maxillofacial surgery? J Clin Diagn Res. 2015 Sep;9(9):ZC22-4.

5. Ozdalga E, Ozdalga A, Ahuja N. The smartphone in medicine: a review of current and potential use among physicians and students. J Med Internet Res. 2012 Sep 27;14(5):e128.

6. Zhang C, Fan L, Chai Z, Yu C, Song J. Smartphone and medical application use among dentists in China. BMC Med Inform Decis Mak. 2020 Sep 7;20(1):213.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

7. Jamal A, Temsah MH, Khan SA, Al-Eyadhy A, Koppel C, Chiang MF. Mobile phone use among medical residents: a cross-sectional multicenter survey in Saudi Arabia. JMIR Mhealth Uhealth. 2016 May 19;4(2):e61.

8. Jahanshir A, Karimialavijeh E, Motahar Vahedi HS, Momeni M. Smartphones and medical applications in the emergency department daily practice. Arch Acad Emerg Med. 2019 Aug;7(1):1-5.

9. Koparal M, Ünsal HY, Alan H, Üçkardeş F, Gülsün B. WhatsApp messaging improves communication in an oral and maxillofacial surgery team. Int J Med Inform. 2019 Dec;132:103987.

10. Lo V, Wu RC, Morra D, Lee L, Reeves S. The use of smartphones in general and internal medicine units: a boon or a bane to the promotion of interprofessional collaboration?

J Interprof Care. 2012 Jul;26(4):276-82.

11. Kameda-Smith MM, Iorio-Morin C, Winkler-Schwartz A, Ahmed US, Bergeron D, Bigder M, et al. Smartphone usage patterns by canadian neurosurgery residents: a National Cross-Sectional Survey. World Neurosurg. 2018 Mar;111:e465-e70.

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12. Alshiekhly U, Arrar R, Barngkgei I, Dashash M. Facebook as a learning environment for teaching medical emergencies in dental practice. Educ Health (Abingdon). 2015 Sep-Dec;28(3):176-80.

13, Junco R, Heiberger G, Loken E. The effect of Twitter on college student engagement and grades. J Comput Assist Learn 2011;27:119‑32.

14. Dunlap J, Lowenthal P. Tweeting the night away: Using Twitter to enhance social presence. J Inf Syst Educ 2009;20:129‑35.

15. Diug B, Kendal E, Ilic D. Evaluating the use of twitter as a tool to increase engagement in medical education. Educ Health (Abingdon). 2016 Sep-Dec;29(3):223-30.

J Braz Coll Oral Maxillofac Surg. 2021 Sept-Dec;7(3):22-9

Original Article

Relationship between dimensional tissue changes in genioplasty: integrative review JAMILLE DE FREITAS BAROLO1 | RENATA PITTELLA CANÇADO1

ABSTRACT Introduction: Genioplasty is a surgical procedure that allows three-dimensional changes in position and contour of the chin, resulting in significant improvements in facial esthetics. Objective: Determine the relationship between soft tissues and bone movements in the genioplasty procedure, by means of a integrative literature review, using the following points: pogonium (Pg), soft tissue pogonium (Pg’), menton (Me), soft tissue menton (Me’), mentolabial sulcus (Si), and Point B. Methods: An integrative literature review was carried out using three databases, with the descriptors “Mentoplasty and soft tissue” and “Genioplasty and soft tissue”. Results: From the established criteria, articles were selected to compose the sample, among them: a systematic review, prospective and retrospective studies. In the forward and backward movements, the averages obtained were respectively 0.91:1 and 0.65:1 in Pg’:Pg horizontally; 1.05:1 and 0,9:1 in Si:Point B horizontally; 0.82:1 and 0.88:1 in Me’:Me vertically. Vertical reduction showed the ratio of 0.88:1 in Pg’:Pg horizontally; 0.79:1 in Pg’:Pg vertically, 0.89:1 in Si:Point B horizontally and a mean of 0.4:1 in Me’:Me vertically. Conclusion: It can be observed that apparently, in movements of advancement and inferior replacement, a closer relation between soft and hard tissue was obtain, the same not being true in backward and vertical reductions.

Keywords: Genioplasty. Tissues. Vertical dimension.

How to cite: Barolo JF, Cançado RP. Relationship between dimensional tissue changes in genioplasty: integrative review. J Braz Coll Oral Maxillofac Surg. 2021 Sept-Dec;7(3):30-7.

DOI: https://doi.org/10.14436/2358-2782.7.3.030-037.oar

Universidade Federal do Espírito Santo, Departamento de Clínica Odontológica, Disciplina de Cirurgia Bucomaxilofacial I (Vitória/ES, Brazil).

1

Submitted: June 29, 2020 - Revised and accepted: November 02, 2020

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

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Contact address: Jamille de Freitas Barolo E-mail: jamillebarolo@hotmail.com

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Barolo JF, Cançado RP

INTRODUCTION Facial asymmetry represents an imbalance in the proportions of homologous bone structures of the face, when compared to each other. This asymmetrical growth affects a large portion of the population.

However, this asymmetry is considered a problem only when noticeable by the patient.¹ Genioplasty is a surgical procedure that allows three-dimensional changes in chin position and contour, resulting in significant improvements in facial esthetics.2 According to Seifeldin et al.,3 besides allowing profile improvements, functional genioplasty allows the achievement of muscle balance in the labiomental region and even in the nasolabial region of the face, and may also be used in association with maxillomandibular advancement, for the treatment of obstructive sleep apnea.

Genioplasty can be performed in a single step or in combination with other surgical procedures of the maxilla and/or mandible. Among all possible directions for chin repositioning, advancement genioplasty, to correct the recessed chin, is probably the most common procedure.4 When chin osteotomy is performed or a bone graft is fixed, the soft tissue will somehow follow the bone tissue. Therefore, it is important to be aware of the relationship between bone and soft tissue movement, providing better predictions and results when using the facial profile for planning. However, according to a systematic review conducted by Moragas et al.,5 this relationship between soft tissue and hard tissue movement in this procedure is not well established.

Therefore, the aim of the present study was to determine, by an integrative literature review, the relationship between dimensional changes in soft tissue and bone movements in the genioplasty procedure, using the following points: pogonion (Pg), tissue pogonion mole (Pg’), chin (Me), chin of soft tissue (Me’), mentolabial sulcus (Si) and point B.

2) Definition of criteria for inclusion and exclusion of studies: the following inclusion criteria were used to select the articles: a) only academic publications in humans; b) only articles with evidence level from I to IV, according to the Oxford Center for Evidence-based Medicine;6 c) number of patients should be mentioned in the articles; d) articles that addressed the surgical procedure of genioplasty; e) the hard and soft tissue relationships should be cited in the articles or, at least, could be calculated with the quantitative data available in the article; f) if all patients in an article had undergone additional osteotomies performed in conjunction with chin osteotomy, there should be an independent group assessment of data referring to the chin; g) articles that were available in Portuguese, English, Spanish or German; and h) articles available in full. Exclusion criteria were: a) articles in which patients underwent grafts using prostheses; b) articles that addressed clinical studies on anatomical specimens; c) articles that analyzed the soft tissue position in relation to tooth inclination; d) articles that presented patients with history of pathologies in the chin or mandibular region; e) articles in which the patients had a history of congenital deformities, clefts, syndromes or other systemic diseases; f) articles that addressed the predictability of software.

3) Literature review: a search of scientific papers was performed in journals indexed in the electronic databases PubMed, Bireme and SciELO, using the descriptors “mentoplasty and soft tissue” and “genioplasty and soft tissue”.

4) Determination of information to be extracted from the selected studies: all selected articles were referenced and classified according to the evidence level, based on the type of research design, adapting the criteria established by the Oxford Center for Evidence-based Medicine.6 Relevant information was extracted to answer the guiding question, such as the genioplasty technique used, additional surgical procedures, fixation methods and the quantitative relationship between soft and hard tissues – which were described using a table.

5) Interpretation of results: after data analysis, the mean relationship between soft and hard tissues was calculated at each analyzed point (Fig 1), in genioplasty procedures involving forward or backward movement, vertical reduction and lower repositioning.

METHODS An integrative literature review was performed to identify the relationship between changes in soft tissue and bone movements in genioplasty.

1) Topic identification: GUIDING QUESTION: “What scientific evidence is available assessing the relationship between soft tissue changes and bone movements in genioplasty?”

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Relationship between dimensional tissue changes in genioplasty: integrative review

6) Composition of knowledge: summary of available evidence and preparation of the text describing the review.

The selected articles were critically analyzed in relation to the criteria of authenticity, methodological quality, importance of information and representativeness. After collecting data from articles found in the literature, they were divided into categories based on the level of scientific evidence, analyzed and included in the objectives of this research.

RESULTS The search strategy presented in the flowchart (Fig 2) resulted in 485 articles, and the number of articles selected for full reading was 37.

Twenty-one articles were obtained for the integrative review, classified by levels of scientific evidence according to the Oxford Center for Evidence-based Medicine,6 whose information is described in Table 1.

B Pg

Si Pg’

Me Me’ Figure 1: Cephalometric points used in this study: Pogonion (Pg), soft tissue pogonion (Pg’), chin (Me), soft tissue chin (Me’), mentolabial sulcus (Si) and Point B.

Titles excluded (303): - grafts using prostheses (22) - predictability of softwares (53) - tooth positioning (11) - patients with clefts (18) - patients with syndromes (25) - patients with congenital deformities (15) - other procedures* (159)

Articles (485) Bireme (157) PubMed (327) SciELO (1)

Articles selected by title (182)

Total articles excluded by: - duplicity (76) - abstracts (62) - language (2) - unavailability in full (6) Total articles read (37)

Figure 2: Flowchart showing the method of paper selection for integrative review. *Other procedures: analysis of patients’ quality of life, stability, facial harmonization, use of toxins, mandibular distraction, complications in genioplasty, comparisons and descriptions of surgical techniques, periodontal complications in orthognathic surgery.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Total articles excluded by: - not relating the hard and soft tissues (10) - not separating the groups submitted to genioplasty (3) - addressing the planning predictability (1) - treating stability (1) - using prosthesis (1)

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Articles eligible for integrative review (21)

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Barolo JF, Cançado RP

1,05:1 0,91:1 0,82:1

0,95:1

A

B

0,9:1

0,89:1 0,79:1 0,88:1

0,65:1 0,88:1

0,4:1

C

D

Figure 3: A) Mean ratios obtained for advancement. B) Mean ratios obtained for lower repositioning. C) Mean ratios obtained for setback. D) Mean ratios obtained for vertical reduction.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Relationship between dimensional tissue changes in genioplasty: integrative review

Table 1: Selected papers.

AUTHOR

YEAR

TYPE

SEL

GENIOPLASTY TECHNIQUE

Bell et al.7

1981

Retro.

2C

Setback genioplasty (HO)

Gallagher et al.8

1984

Retro.

2C

Park et al.9

1989

Retro.

2C

Krekmanov e Kahnberg10

1992

Prosp.

2C

Advancement genioplasty (HO) Advancement genioplasty (horizontal sliding osteotomy of the symphysis) Sliding advancement genioplasty Sliding setback genioplasty

Ewing e Ross11

1992

Retro.

2C

Dolce et al.12

2001

Prosp.

2C

Talebzadeh e Pogrel13

2001

Retro.

2C

Dolce et al.

2C

Advancement genioplasty (HO)

Shaughnessy et al.15

2006

Retro.

2C

Advancement genioplasty (HO)

Kim e Kim16

2009

Retro.

2C

Kim et al.17

2010

Retro.

2C

Vertical reduction

Reddy et al.18 Erbe et al.19

2011 2011

Prosp.

Retro.

2C 2C

Advancement genioplasty (HO) Advancement genioplasty

Ho et al.20

2012

Retro.

4

Oh et al.21

2013

Retro.

2C

Park et al.22

2013

Retro.

2C

2014

Prosp.

4

Seifeldin et al.

2014

Prosp.

2C

Kumar et al.2

2015

Prosp.

2C

3

NR

NP

FR/Wire

SBSO for mandibular advancement SBSO for mandibular Advancement genioplasty (HO) advancement Genioplasty or associatAdvancement genioplasty ed with SBSO for mandibular advancement

Prosp.

As’adi et al.23

NP

Advancement genioplasty

2003

14

ADDITIONAL PROCEFIXATION DURES Mandibular advancement; NR Le Fort I Le Fort I FR

SBSO for mandibular advancement

FR/Wire FR/Wire FR

FR/Wire

NP FR/Wire Genioplasty or associatAdvancement and setback geed with ramus SBSO or FR nioplasty (transverse osteotomy) associated with Le Fort I Ramus SBSO

NP NP Ramus SBSO for manVertical reduction genioplasty dibular setback Bimaxillary surgery (Le Advancement genioplasty Fort I, ramus SBSO) Genioplasty or associated with bimaxillary Setback genioplasty surgery (Le Fort I, ramus SBSO) Advancement genioplasty (HO) NP Sliding advancement genioNP plasty Advancement genioplasty with NP or without vertical reduction

Moragas et al.5

2015

RS

1A

- Advancement genioplasty - Setback genioplasty - Inferior repositioning genioplasty - Vertical reduction genioplasty

Budharapu et al.4

2018

Prosp.

2C

Advancement genioplasty by oblique sagittal sliding

NR FR FR/Wire NR

RELATIONSHIP BETWEEN HARD AND SOFT TISSUES Pog’:Pog = 0,58:1 Pog’:Pog = 0,87:1 Pog’:Pog = 0,97:1 In FR - Pog’:Pog = 092:1 In BR - Pog’:Pog = 0.53:1 In FRS - Pog’:Pog = 1.38:1 Pog’:Pog = 0,9:1 Si:Ponto B = 1:1 Pog’:Pog = 1:1 Si:Point B = 1:1 Pog’:Pog = 0,75:1 Si:Point B = 1,2:1 com FR Si:Point B = 1:1 with Wire Pog’:Pog = 1:1 with FR Pog’:Pog = 0,8:1 com fio Pog’:Pog = 0,92:1 Pog’:Pog = 0,9:1 Me’:Me = 0,66:1 Pog’:Pog = 0,88:1 Si:Point B = 0,89:1 Pog’:Pog = 0,89:1 Pog’:Pog = 0,99:1 Pog’:Pog = 0,79:1 Me’:Me = 0,36:1

FR

Pog’:Pog = 0,9:1

NR

Pog’:Pog = 0,7:1 Si:Point B = 0,9:1 Me’:Me = 1,1:1

FR

Pog’:Pog = 0,8:1

FR

Pog’:Pog = 0,83:1

NR

Pog’:Pog = 0,61:1

Several

FR/Wire

In FR - Pog’:Pog = 0.9:1 In BR - Pog’:Pog = – 0.52:1 In inferior repositioning: Me’:Me = 0.95:1 In vertical reduction: Me’:Me = – 0.43:1

NP

FR

Pog’:Pog = 0,9:1

Abbreviations: SEL (Level of Scientific Evidence), Retro (Retrospective), Prosp (Prospective), RS (Systematic Review), OH (Horizontal Osteotomy), RF (Rigid Fixation), NR (Not Reported), SBSO (Split Bilateral Sagittal Osteotomy ), NP (No Additional Procedure), Pog (Pogonion), Pog’ (Soft Tissue Pogonion), Me (Mento), Me’ (Soft Tissue Mento), Si (Mentolabial Furrow), FR (Forward Repositioning), BR (Backward repositioning), ASR (Anterosuperior repositioning).

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DISCUSSION The relationships between soft tissue and hard tissue after genioplasty can be more complex, since they depend on some factors such as morphology, thickness, posture and muscle tone – which vary among patients;3,21 type of surgical technique used; type of incision; fixation method;12 accuracy and reproducibility of planning, including the difficulty in identifying some reference points; amount of mucoperiosteal detachment;4 amount of advancement; presence of other maxillomandibular surgeries; bone remodeling process; and use of bone grafts.5 In addition, the occurrence of scars12,3 and postoperative edema can also influence the soft tissue changes. Thus, it is necessary to analyze the soft tissues at least six months after the surgical procedure.21 When analyzing the changes and relationships between soft and hard tissues in chin advancement, it was observed that there was variation in the soft pogonion to pogonion ratio (Pg’:Pg) between 1:112,14 with the use of rigid fixation and 0.8:114 using steel wire. Conversely, Kumar et al.2 found a ratio of 0.61:1.

This difference in results may have occurred because Kumar et al.,2 after a follow-up of more than 2 years, reported a 24% rate of relapse of surgical advancement, due to the remodeling process that occurs in the surgical site; while Dolce et al.12,14 performed, respectively, 2 years and 5 years of post-surgical follow-up and observed that, at 2 years, the pogonion was 6 mm to 7 mm more anteriorly in the groups that used rigid fixation and associated steel wire to genioplasty. At 6 months, the Pg’:Pg change was 85%, remaining 86% at 5-year follow-up.

In addition, Dolce et al.12 reported the use of rigid fixation and steel wire, with a difference in the relationship between fixation means; while Kumar et al.2 did not specify which fixation was used. Thus, Dolce et al.12,14 concluded that the percentage of soft tissue changes for a given advance in hard tissue depended both on the fixation method chosen for treatment and on time.

The relationship between the mentolabial sulcus (Si) and Point B in the same study by Dolce et al.12,14 and in the study by Ewing and Ross11 varied in the proportion of 1:1. Dolce et al.14 justify this result due to the use of steel wire for fixation; when using rigid fixation in genioplasty in this study, this variation became 1.2:1.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Also, in the advancement genioplasty procedure, the chin (Me’:Me) presented a ratio of 0.66:1.16 This measure was reported only in this study, and it is not possible to compare it with other findings.

In the inferior replacement genioplasty, the value of Me’:Me = 0.95:16 was obtained. Only Moragas et al.5 reported this variable, and it is not possible to compare it with other literature.

According to Moragas et al.,5 the Pg’:Pg ratio in setback genioplasty ranged from –0.27:1 to -0.70:1, with an average of -0.52:1. However, in that study, it was concluded that these results are not predictable and vary greatly because test correlation analysis was not performed in all studies, or because some articles used a small number of patients in the sample.

Kim and Kim16 found a mean of 0.9:1, and the mean regression of Pg’ was 39.8%, being considered high.

Thus, a mean of 0.65:1 for the Pg’:Pg ratio is found in this procedure.

In the study by Park et al.,22 the Si:Point B ratio in setback genioplasty was 0.9:1. Only these authors addressed this relationship and, from an esthetic standpoint, concluded that, for patients with chin protrusion, setback genioplasty provides a satisfactory overall esthetic improvement in the lower facial third.

Also, in the setback genioplasty procedure, Park et al.22 observed that the Me’:Me ratio was 1.1:1 when only setback genioplasty was performed. When this was performed in association with bilateral mandibular ramus osteotomy, this ratio was 1:1. However, setback genioplasties are usually not performed alone, for several reasons, such as the fact that indications are limited, and most cases of protruded chin accompany mandibular prognathism - and genioplasty alone does not provide better esthetic results, even under correct indications. Kim and Kim16 found a mean ratio of 0.66:1 for the chin.

In vertical reduction genioplasty, Ho et al.20 found a Pg’:Pg ratio of 0.79:1 vertically. They reported an increase in soft tissue thickness, which may be due to the increase in soft tissue volume associated with vertical bone movement and relaxation of muscles in the mental region. Also, they reported that there was no change in pogonion horizontally after the surgical procedure, while Kim et al.17 found a 0.88:1 ratio horizontally. The difference between values ​​found may be due to the length of follow-up of patients, since Ho et al.20 performed data collection before surgery and

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Relationship between dimensional tissue changes in genioplasty: integrative review

CONCLUSION By the methodology used, it can be concluded that, in forward and backward movements, the means obtained were, respectively: 0.91:1 and 0.65:1 in Pg’:Pg horizontally; 1.05:1 and 0.9:1 in Si:Point B horizontally; 0.82:1 and 0.88:1 in Me’:Me vertically (Fig 3A, 3C). The vertical reduction showed a ratio of 0.88:1 in Pg’:Pg horizontally; 0.79:1 in Pg’:Pg vertically; 0.89:1 at Si:Point B horizontally and an average of 0.4:1 at Me’:Me vertically (Fig 3D). It can be observed that, apparently, the lower advancement and repositioning movements obtain a closer relationship between soft tissue and hard tissue, yet this is not observed for setback and vertical reductions. More studies on these relationships are needed, addressing factors that may interfere with the results, such as sex, age, quantity and quality of soft tissue, osteotomy technique used, and magnitude of movements performed.

immediately after the procedure, while Kim et al.17 performed a six-month follow-up. The Si:Point B ratio in this same procedure was 0.89:1,17 and only these authors addressed this ratio.

Also in the vertical reduction procedure, after reviewing six studies, Moragas et al.5 found a mean of -0.43:1 for Me’:Me, ranging between -0.22:1 and -0.80:1; while Ho et al.20 found the ratio of 0.36:1, highlighting that the accumulation of soft tissue is evident when the bone tissue is reduced.

There are no articles relating the change of soft tissues after bone movements performed in genioplasty using the horizontal expansion or narrowing technique of the chin.

Based on this study, it was possible to observe that, in advancement genioplasty procedures and in inferior replacement, better ratios between soft and hard tissues were obtained, when compared to setback and vertical reduction procedures. This fact may be related to the individual characteristics of each patient – such as morphology, thickness, posture, muscle and skin tone, amount of fat tissue in the chin and age – and may influence the response of soft tissue to hard tissue, especially in setback and vertical reductions, when, in some cases, post-surgical soft tissue sagging can be observed.

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References:

1. Wagner JCB, Volkweis MR, Zamboni RA, Lepper TW, Zaffari L, Brandalise JRK. Assimetria facial corrigida por cirurgia ortognática. J Braz Coll Oral Maxillofac Surg.

2018 Sept-Dec;4(3):48-52.

2. Kumar BL, Raju GK, Kumar ND, Reddy GV, Naik BR, Achary CR. Long term stability following genioplasty: a cephalometric study. J Int Oral Health. 2015 Apr;7(4):44-50.

3. Seifeldin SA, Shawky M, Hicham Nouman SM. Soft tissue response after chin advancement using two different genioplasty techniques: a preliminary technical comparative study. J Craniofac Surg. 2014 Jul;25(4):1383-8.

4. Budharapu A, Sinha R, Tauro DP, Tiwari PK. Musculoskeletal changes as a sequel to advancement genioplasty: a long-term cephalometric prospective study. J Maxillofac Oral Surg. 2018 Jun;17(2):233-41.

5. San Miguel Moragas J, Oth O, Büttner M, Mommaerts MY. A systematic review on soft-to-hard tissue ratios in orthognathic surgery part II: Chin procedures.

J Craniomaxillofac Surg. 2015 Oct;43(8):1530-40.

6. Howick J, Chalmers I, Glaszio P, Greenhalgh T, Heneghan C, Liberati A, et al. Oxford Centre for evidence-based medicine. Oxford: OCEBM Levels of Evidence Working Group; 2011.

7. Bell WH, Brammer JA, McBride KL, Finn RA. Reduction genioplasty: surgical techniques and soft-tissue changes. Oral Surg Oral Med Oral Pathol. 1981 May;51(5):471-7.

8. Gallagher DM, Bell WH, Storum KA. Soft tissue changes associated with advancement genioplasty performed concomitantly with superior repositioning of the maxilla.

J Oral Maxillofac Surg. 1984 Apr;42(4):238-42.

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9. Park HS, Ellis E 3rd, Fonseca RJ, Reynolds ST, Mayo KH. A retrospective study of advancement genioplasty. Oral Surg Oral Med Oral Pathol. 1989 May;67(5):481-9.

10. Krekmanov L, Kahnberg KE. Soft tissue response to genioplasty procedures. Br J Oral Maxillofac Surg.

1992 Apr;30(2):87-91.

11. Ewing M, Ross RB. Soft tissue response to mandibular advancement and genioplasty. Am J Orthod Dentofacial Orthop. 1992 Jun;101(6):550-5.

12. Dolce C, Johnson PD, Van Sickels JE, Bays RA, Rugh JD. Maintenance of soft tissue changes after rigid versus wire fixation for mandibular advancement, with and without genioplasty. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001 Aug;92(2):142-9.

13. Talebzadeh N, Pogrel MA. Long-term hard and soft tissue relapse rate after genioplasty. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001 Feb;91(2):153-6.

14. Dolce C, Hatch JP, Van Sickels JE, Rugh JD. Fiveyear outcome and predictability of soft tissue profiles when wire or rigid fixation is used in mandibular advancement surgery. Am J Orthod Dentofacial Orthop. 2003 Sep;124(3):249-56; quiz 340.

15. Shaughnessy S, Mobarak KA, Høgevold HE, Espeland L. Long-term skeletal and soft-tissue responses after advancement genioplasty. Am J Orthod Dentofacial Orthop. 2006 Jul;130(1):8-17.

16. Kim SK, Kim SG. Analysis of soft tissue changes after genioplasty in skeletal Class III dentofacial deformity. Yonsei Med J. 2009 Dec 31;50(6):814-7.

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17. Kim M, Lee DY, Lim YK, Baek SH. Three-dimensional evaluation of soft tissue changes after mandibular setback surgery in Class III malocclusion patients according to extent of mandibular setback, vertical skeletal pattern, and genioplasty. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 May;109(5):e20-32.

18. Reddy PS, Kashyap B, Hallur N, Sikkerimath BC. Advancement genioplasty--cephalometric analysis of osseous and soft tissue changes. J Maxillofac Oral Surg. 2011 Dec;10(4):288-95.

19. Erbe C, Mulié RM, Ruf S. Advancement genioplasty in Class I patients: predictability and stability of facial profile changes. Int J Oral Maxillofac Surg. 2011 Nov;40(11):1258-62.

20. Ho CT, Huang CS, Lo LJ. Improvement of chin profile after mandibular setback and reduction genioplasty for correction of prognathism and long chin. Aesthetic Plast Surg. 2012 Oct;36(5):1198-206.

21. Oh KM, Seo SK, Park JE, Sim HS, Cevidanes LH, Kim YJ, et al. Post-operative soft tissue changes in patients with mandibular prognathism after bimaxillary surgery. J Craniomaxillofac Surg. 2013 Apr;41(3):204-11.

22. Park JY, Kim MJ, Hwang SJ. Soft tissue profile changes after setback genioplasty in orthognathic surgery patients. J Craniomaxillofac Surg. 2013 Oct;41(7):657-64.

23. As’adi K, Salehi SH, Shoar S, Guyuron B. Soft-tissue response rate to chin skeletal advancement in patients with lower facial burn scar. Plast Reconstr Surg. 2014 May;133(5):669e-674e.

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Technical Note

Protocol for arthroscopic treatment of internal disorders of the temporomandibular joint: technical note FÁBIO RICARDO LOUREIRO SATO1 | MARCELO MAROTTA ARAUJO1

ABSTRACT Introduction: Temporomandibular joint (TMJ) arthroscopy is considered a minimally invasive treatment for the TMJ, and the use for the treatment of internal joint disorder has increased in the last years. As it is a relatively new treatment, specialists still have many doubts on how to systematize this procedure. Objective: The objective of this article was to present the systematized and hierarchical steps of the protocol adopted for TMJ arthroscopy, describing the procedures performed in each of these steps.

Keywords: Temporomandibular joint disorders. Temporomandibular joint dysfunction syndrome. Arthroscopy.

How to cite: Sato FRL, Araujo MM. Protocol for arthroscopic treatment of internal disorders of the temporomandibular joint: technical note. J Braz Coll Oral Maxillofac Surg. 2021 Sept-Dec;7(3):38-44.

DOI: https://doi.org/10.14436/2358-2782.7.3.038-044.oar

Universidade Estadual Paulista, Disciplina de Cirurgia e Traumatologia Bucomaxilofacial (São José dos Campos/SP, Brazil).

1

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

Submitted: April 04, 2020 - Revised and accepted: June 03, 2021

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

Contact address: Fábio Ricardo Loureiro Sato E-mail: frlsato@uol.com.br

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INTRODUCTION The internal derangement of the temporomandibular joint (TMJ) can be defined as a change in the internal aspects of the TMJ in which the disc leaves its normal relationship between the condyle and the articular portion of the temporal bone.5 Usually, patients who present with intra-articular internal derangement are treated conservatively, including physical therapy and the use of occlusal splints. Most of these patients with disc displacement end up improving spontaneously or when treated by a conservative approach. When the patient remained symptomatic even after conservative treatment, in the past, open surgery for disc repositioning was indicated. Although a significant number of these patients show improvement after the procedure, it presents risks, especially involving a possible injury to the facial nerve branches.

Recently, especially in Brazil, arthroscopy has gained popularity, since it is a minimally invasive surgery with lower risk of accidents and complications, when correctly performed, and shorter hospital stay.

Among the numerous advantages of arthroscopy, there is the possibility, in the same procedure, of diagnosing and treating intra-articular changes, by visualization and direct manipulation of joint structures, improving pain and the mouth opening limitation in these patients.10,16 According to McCain,12 TMJ arthroscopy can be divided into three levels: Level 1 – lysis and lavage arthroscopy or diagnostic arthroscopy; Level 2 – operative arthroscopy; and Level 3 - video-assisted discopexy.

Since this procedure is not widespread in the country, there are still many doubts regarding the sequence in which it should be performed. Thus, the objective of this study was to describe a protocol of TMJ arthroscopy in a systematic manner, focusing on Levels 1 and 2, according to McCain.12

Publication dates were between 1980 and 2021, and all types of articles (originals and reviews) published in English or Portuguese were included in the research. After searching the selected terms on the search platforms, 776 articles were located, using 18 as the main ones, describing protocols for this surgical technique.

RESULTS Demarcation of points TMJ arthroscopy should always be performed under general anesthesia and with nasotracheal intubation. It is not recommended on an outpatient basis under local anesthesia, since it is very uncomfortable for the patient, besides the risk of possible bleeding, which may originate in the superficial temporal arteries or even the maxillary artery, which would be difficult to control if the patient is not under general anesthesia.4 Orotracheal intubation is not ideal for TMJ arthroscopy, since mandibular manipulation is required during surgery, which is impaired in this type of intubation.

To perform arthroscopy, three access points are needed, with the following purposes: first point – insertion of arthroscope; second point – placement of a drainage needle into the irrigation fluid; and third point – introduction of the working portal, through which the instruments are inserted into the joint for surgery.

The demarcation of points can be performed in two manners: using anatomical or numerical references. The numerical reference considers the line from the tragus to the outer corner of the eye,9 in which three points are marked, 10 mm apart, as follows: the first point 2 mm below the line, the second point 7 mm below, and the third point 10 mm below, as shown in Figure 1.15 The other possibility of demarcating the points is using anatomical references, as follows: the first point marked in the uppermost portion of the articular fossa, the second point in the region in front of the articular eminence, and the third point 10 mm in front of the second point , on an imaginary line passing through the first and second points (Fig 2).

METHODS Methodology Initially, an extensive search for papers was performed in Bireme’s search engines, using the following databases: Lilacs, Medline and BBO. The terms used in this search were: (arthroscopy or artroscopia) AND (TMJ or ATM).

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Protocol for arthroscopic treatment of internal disorders of the temporomandibular joint: technical note

Figure 1: Numerical reference marking.

Figure 2: Anatomical reference marking.

Infiltration After defining the points for the arthroscopic approach, the procedure begins by intra-articular infiltration in the first port for expansion of the joint capsule. This initial infiltration is, at most, around 3 to 4 ml, depending on the joint size.13 Regarding the substance to be initially infiltrated, the ideal would be an anesthetic without vasoconstrictor, so that vasoconstriction does not occur, which could impair the visualization of intra-articular synovitis. At home, this is mainly for levels 1 and 2 arthroscopy. When level 3 arthroscopy is needed (arthroscopic discopexy), the preference is to perform anesthetic infiltration with vasoconstrictor, to help control hemostasis.

At this point, to make sure that infiltration is being done inside the joint (and not outside the joint),

the mandible must perform a protrusion movement, and the operator feels resistance in relation to the plunger movement.

After this initial infiltration, arthrocentesis is performed with Ringer Lactate with a volume of approximately 100 ml, to achieve an even greater expansion of the joint capsule and break some adhesions that may be present inside the joint.

Arthroscopy for lysis and lavage Every arthroscopy procedure starts with the lysis and lavage procedure, also called diagnostic arthroscopy. At this point a scan of the entire joint is performed systematically, to detect all pathological alterations present and subsequently treat them in the following stages of arthroscopy.

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Operative arthroscopy Level 1 arthroscopy (lysis and lavage) starts in the posterior recess of the joint, passes through the intermediate zone and ends up in the anterior recess.

Then, stage 2 of operative arthroscopy is initiated exactly in the anterior recess.

For this step, the triangulation is initially inserted, which initially consists of identifying the working portal, which is inserted in the third portal inside the joint.

After triangulation, the treatment of intra-articular changes found during the diagnostic arthroscopy procedure is initiated. The first change that must be treated is always the elimination of intra-articular adhesions. These adhesions are responsible for disc hypomobility; therefore, it is not possible to restore mobility to the disc, even less reposition it, with the presence of adhesions.18 After removing the adhesions, since we are in the region of the anterior recess, a capsulotomy and myotomy are started in the region from the medial-anterior to the lateral-anterior corners. This capsulotomy/ myotomy can be performed using different instruments, such as electrocautery, laser, or radiofrequency, which is the most recommended.2 Myotomy must always be superficial, never deeper than 2 to 3 mm, since the risk of bleeding is high.

After capsulotomy/myotomy, the disc is pulled with

As a rule, we follow the seven regions described

by González-García et al.,8 which must be mandatorily evaluated in the upper joint space (Fig 3): 1. Middle synovial fold.

2. Shadow of the pterygoid muscle.

3. Retrodiscal tissue: a) oblique protuberance; b) retrodiscal tissue attached to the posterior glenoid process; c) lateral recess of the retrodiscal tissue.

4. Posterior portion of the articular eminence and glenoid fossa.

5. Articular disc.

6. Intermediate zone.

7. Anterior recess: a) synovial crest of the disc; b) intermediate strength; c) medial-anterior corner; d) anterior-lateral corner.

It is always important to remember the need to place a drainage port throughout the arthroscopy procedure, and usually a 40 x 1.2 mm needle is used for this purpose.

All pathological changes found must be noted by an assistant, in a specific form for this purpose, for later consultation. When this diagnostic stage is completed, the operative stage of treatment is initiated.

6

1 2

4 7 3

5

Figure 3: Regions to be evaluated in arthroscopy lysis and lavage: 1) middle synovial fold; 2) oblique prominence; 3) retrodiscal tissue; 4) posterior aspect of articular eminence; 5) articular disc; 6) shadow of the pterygoid muscle; and 7) anterior recess.

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Protocol for arthroscopic treatment of internal disorders of the temporomandibular joint: technical note

et al.,11 Goizueta-Adame and Muñoz-Guerra7 and Yang et al.17 The technique by McCain et al.,11 which is technically simpler, is used in cases of more restricted joint spaces, since there is not much need for intra-articular instrumentation. For cases in which the upper joint space is wider, the technique by Yang et al.17 is used, since it is technically more complex; however, it has advantages as allowing a double pass and suturing the disc close to the conduct cartilage, which is more stable than suture performed close to the subcutaneous tissue. Another widely used technique was described by Goizueta-Adame and Muñoz-Guerra,7 which presents a double suture through the disc, unlike the technique of McCain et al.;11 however, it is stabilized in the subcutaneous tissue (Fig 6).

Another possibility of arthroscopic disc fixation, especially in cases where greater stability is desired, is the use of anchors arthroscopically.14 This technique, despite being more complex, allows for great disc stability, since it is fixed to the mandible head by two anchors placed arthroscopically.

Intra-articular infiltration The last step of arthroscopy involves intra-articular infiltration, the most used being viscosupplementation with hyaluronic acid or the infiltration of growth factors, such as the use of Platelet Rich Plasma (PRP) or Platelet Rich Fibrin (PRF).

the help of an angled palpator to a more posterior position and checked before performing discopexy.

After the disc is taken into place, there will be tissue leftover in the retrodiscal region, where usually there is also synovitis. This tissue fold and the synovitis region is treated by cauterization (Fig 4) and infiltration of some sclerosing substance (Ethamolin).

It is also quite common to find synovitis in the medial wall region; however, since this is a risky region (thin area which, if injured, may leak fluid to the medial region), the use of cautery in this region is not recommended. Therefore, it is preferred to perform intrasynovial corticosteroid infiltration (methylprednisolone) (Fig 5).

Other possibilities for operative arthroscopy include the removal of free bodies (chondromatosis), calcium pyrophosphate crystals (chondrocalcinosis) and the use of shavers in advanced cases of chondromalacia.

Arthroscopic discopexy After performing the diagnostic and operative parts of arthroscopy, the final part is initiated, namely arthroscopic discopexy. It is important to emphasize that this step should only be performed after being sure about the correct disc placement. Currently, there are several techniques described in the literature that can be used for this purpose. The suture techniques most used by our team are the techniques by McCain

A

B

Figure 4: Cauterization of synovitis in the retrodiscal region: A) use of electrocautery; B) use of radio frequency.

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A

B

Figure 5: Corticoid infiltration in the medial wall region: A) needle being prepared for infiltration; B) infiltration in the medial wall region.

A

B

Figure 6: Disc suture: A) internal image of suture; B) external image of suture.

nous biological product, derived from blood centrifugation, which allows the concentration of platelets and growth factors, which have beneficial effects, mainly in favoring tissue repair of degenerative joint changes.3

Viscosupplementation is the intra-articular infiltration technique considered as gold standard, since it has the largest number of studies showing its advantages.6 Intra-articular hyaluronic acid infiltration has anti-inflammatory and analgesic effects, which help repair joint fibrocartilage and normalize the endogenous synthesis of endogenous hyaluronic acid by synovial cells, reducing friction on joint surfaces.1 Recently, several studies in the literature have demonstrated the advantages of using growth factors, especially Platelet Rich Plasma (PRP). PRP is an autoge-

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

DISCUSSION When the creation of a protocol for a given procedure is discussed, it is based on the so-called best practices described in the literature. However, it is certainly possible to also find other behaviors that can be divergent.

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Protocol for arthroscopic treatment of internal disorders of the temporomandibular joint: technical note

monopolar or bipolar electrocautery, in addition to laser, as found in the literature.2 At the end of arthroscopy, the protocol still uses viscosupplementation as a standard, although some authors also perform infiltration with medications as corticosteroids or growth factors, such as PRP or PRF.3

The first divergence that can be found concerns the type of anesthesia. Although most authors propose the procedure under general anesthesia, others propose its accomplishment under local anesthesia.17 Regarding the entry points, although we recommend the so-called anatomical references, some authors advocate the so-called numerical markings, which are indicated for those who are initiating in the arthroscopic technique.15 Another divergence concerns the initial infiltration: we recommend the use of lidocaine with vasoconstrictor, while many authors recommend the use of anesthetic without vasoconstrictor, to avoid bias on the diagnosis of synovitis.13 Regarding operative arthroscopy, radiofrequency should be preferred, despite the possibility of using

CONCLUSION Arthroscopy of the temporomandibular joint presents positive results when properly indicated and performed. To be successful, this type of surgery must be performed following a logical sequence of hierarchical procedures, according to the protocol presented in this study, which is used by the team for the video treatment of intra-articular TMJ changes.

References:

1. Altman R, Bedi A, Manjoo A, Niazi F, Shaw P, Mease P. Anti-inflammatory effects of intra-articular hyaluronic acid: a systematic review. Cartilage. 2019 Jan;10(1):43-52.

2. Chen MJ, Yang C, Zhang SY, Cai XY. Use of Coblation in arthroscopic surgery of the temporomandibular joint. J Oral Maxillofac Surg. 2010 Sep;68(9):2085-91.

3. Chung PY, Lin MT, Chang HP. Effectiveness of plateletrich plasma injection in patients with temporomandibular joint osteoarthritis: a systematic review and metaanalysis of randomized controlled trials. Oral Surg Oral Med Oral Pathol Oral Radiol. 2019 Feb;127(2):106-16.

4. Tsuyama M, Kondoh T, Seto K, Fukuda J. Complications of temporomandibular joint arthroscopy: a retrospective analysis of 301 lysis and lavage procedures performed using the triangulation technique.

J Oral Maxillofac Surg. 2000 May;58(5):500-5; discussion 505-6.

5. Dolwick MF, Katzberg RW, Helms CA. Internal derangements of the temporomandibular joint: fact or fiction? J Prosthet Dent. 1983 Mar;49(3):415-8.

6. Ferreira N, Masterson D, Lopes de Lima R, de Souza Moura B, Oliveira AT, Kelly da Silva Fidalgo T, et al.

Efficacy of viscosupplementation with hyaluronic acid in temporomandibular disorders: a systematic review.

J Craniomaxillofac Surg. 2018 Nov;46(11):1943-52.

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7. Goizueta Adame CC, Muñoz-Guerra MF. The posterior double pass suture in repositioning of the temporomandibular disc during arthroscopic surgery: a report of 16 cases. J Craniomaxillofac Surg. 2012 Jan;40(1):86-91.

8. González-García R, Gil-Díez Usandizaga JL, Rodríguez-Campo FJ. Arthroscopic anatomy and lysis and lavage of the temporomandibular joint.

Atlas Oral Maxillofac Surg Clin North Am. 2011 Sep;19(2):131-44.

9. Holmlund A, Hellsing G. Arthroscopic surgery of the temporomandibular joint. Internal derangement with persistent closed lock. Oral Surg, Oral Med, Oral Pathol. 1986 Oct;62(4):361-71.

10. Israel HA. Part I: the use of arthroscopic surgery for treatment of temporomandibular joint disorders.

J Oral Maxillofac Surg. 1999 May;57(5):579-82.

11. McCain JP, Podrasky AE, Zabiegalski NA. Arthroscopic disc repositioning and suturing: a preliminary report. J Oral Maxillofac Surg. 1992 Jun;50(6):568-79.

12. McCain JP. Arthroscopy of the human temporomandibular joint. J Oral Maxillofac Surg. 1988 Aug;46(8):648-55.

13. Murakami K, Ono T. Temporomandibular joint arthroscopy by inferolateral approach. Int J Oral Maxillofac Surg. 1986 Aug;15(4):410-7.

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14. Loureiro Sato FR, Tralli G. Arthroscopic discopexy technique with anchors for treatment of temporomandibular joint internal derangement: Clinical and magnetic resonance imaging evaluation. J Craniomaxillofac Surg. 2020 May;48(5):501-7.

15. Tarro AW. Arthroscopic diagnosis and surgery of the temporomandibular joint. J Oral Maxillofac Surg. 1988 Apr;46(4):282-9.

16. White RD. Arthroscopy of the temporomandibular joint: technique and operative images. Atlas Oral Maxillofac Surg Clin North Am. 2003 Sep;11(2):129-44.

17. Yang C, Cai XY, Chen MJ, Zhang SY. New arthroscopic disc repositioning and suturing technique for treating an anteriorly displaced disc of the temporomandibular joint: part I--technique introduction. Int J Oral Maxillofac Surg. 2012 Sep;41(9):1058-63.

18. Zhang S, Huang D, Liu X, Yang C, Undt G, Haddad SM, et al. Arthroscopic treatment for intra-articular adhesions of the temporomandibular joint. J Oral Maxillofac Surg. 2011 Aug;69(8):2120-7.

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Case Report

Bone-borne surgically-assisted rapid maxillary expansion: case report LEONARDO AUGUSTUS PERAL FERREIRA PINTO1 | VIVIANE FERREIRA RAMOS2 | MICHELLE ALONSO COUTINHO3 | SABRINA MORELLI DE-OLIVEIRA4

ABSTRACT Surgically-assisted rapid maxillary expansion is a surgical-orthodontic procedure performed in patients with bone maturity and unilateral or bilateral transverse discrepancies, whether or not associated with other facial deformities. The aim of this study is to present a case report of a surgical-orthodontic treatment performed by surgically-assisted rapid maxillary expansion with bone-borne appliance. The patient was a 33-years-old male, with maxillary transverse discrepancy of 9 mm, anterior and posterior crossbite, dental crowding, dental Class III and Pattern III facial growth, with vertical excess of the lower facial third. After surgical-orthodontic treatment, a cone-beam computed tomography of the final zoocal models was performed, for documentation, verification of operative stability of bone structures and gain of transverse maxillary distance. The patient presented bone stability of the values achieved in the surgical expansion. In patients with severe transverse deficiency, bilateral crossbite, uprighted maxillary alveolar ridges, periodontal deficiencies in the teeth supporting the tooth-borne appliance, systemic diseases that compromise the tooth enamel and bone maturation, the best treatment is surgically-assisted rapid maxillary expansion with bone-borne appliance.

Keywords: Osteogenesis, distraction. Palatal expansion technique. Surgery, oral.

Centro de Tratamento da Face, Cirurgia Bucomaxilofacial (Rio de Janeiro/RJ, Brazil).

Centro de Tratamento da Face, Ortodontia (Rio de Janeiro/RJ, Brazil).

Hospital São José, Cirurgia Bucomaxilofacial (Rio de Janeiro/RJ, Brazil).

4 S&S Odontologia, Cirurgia Bucomaxilofacial (Rio de Janeiro/RJ, Brazil).

1 2 3

How to cite: Pinto LAPF, Ramos VF, Coutinho MA, De-Oliveira SM. Bone-borne surgically-assisted rapid maxillary expansion: case report. J Braz Coll Oral Maxillofac Surg. 2021 Sept-Dec;7(3):45-51.

DOI: https://doi.org/10.14436/2358-2782.7.3.045-051.oar

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

Submitted: February 05, 2020 - Revised and accepted: May 17, 2020

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

Contact address: Michelle Alonso Coutinho E-mail: michellectbmf@yahoo.com.br

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Bone-borne surgically-assisted rapid maxillary expansion: case report

INTRODUCTION The correction of transverse maxillary discrepancies appeared in 1860, with Angell, who described an augmentation of the upper arch, opening the palatal suture.

Since then, rapid maxillary expansion (RME) has been performed in a variety of malocclusions in children and young people.1,2,3 Surgically assisted rapid maxillary expansion (SARME) is a technique that corrects transverse maxillary bone deficiency in adult patients4 with discrepancies equal to or greater than 5 mm. In adults, the prognosis of RME is unfavorable, due to the increased thickness of bone structures, reduced elasticity and consequent increase in interdigitation of the midpalatal suture, which occurs with the skeletal maturity of this suture.1,2,5,6 For a better determination of bone maturation, the use of hand and wrist radiography is indicated,5 although there is discussion in the literature regarding the age of skeletal maturity of patients to define treatment with RME or SARME.1,5 The growth of transverse dimension precedes the anteroposterior and vertical growth, which can generate maxillary atresia, vertical hypoplasia with anteroposterior discrepancy and skeletal Class III, leading to a second surgery to correct vertical and anteroposterior defects.

This defect can generate unilateral or bilateral posterior crossbite, anterior maxilla crowding, dark buccal corridors when smiling, upper respiratory alterations, inadequate tongue position, altered swallowing pattern and mouth breathing.1,7,8 In the literature, there is no consensus on SARME regarding the surgical technique, the type of device (palatal bone distractor [PBD] or dentoskeletal distractor [DSD]),9 the existence, cause and quantity of relapse. Also, there are discussions regarding overcorrection,6 activation protocol, use of retainer and what is indicated.5,6 In DSD, mechanical stresses are applied and dissipated in teeth, periodontal ligament and bone structures, making it difficult to avoid recurrences in bone segments during the consolidation period.4 The first PBD was used to provide the expansion force directly into the maxillary bone.4

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Thus, the aim of the present study is to present a clinical case of orthodontic-surgical treatment performed using SARME with PBD for the correction of the patient’s transverse problem.

CASE REPORT A 33-year-old male patient presented with a 9-mm transverse maxillary discrepancy, anterior and posterior crossbite, dental crowding, dental Class III and Pattern III facial growth, with vertical lower third excesso (Fig 1).

The initial superior and inferior trimmed models were used to measure the transverse discrepancy, by cone beam computed tomography (CBCT) (Fig 2), allowing the choice of transpalatal distractor, with a 33-mm cursor and maximum aperture of 65 mm, achieving up to 32 mm of bone expansion.

During surgery, the distractor was placed between premolars and molars, and a Le Fort I osteotomy was performed, releasing the pterygopalatine pillars. The distractor was fully activated with the 7-mm key to check for possible bone interference and then deactivated. A minimum activation of 1 mm was maintained, seen by the diastema between maxillary central incisors (Fig 3); 48h after surgery, the distractor was activated. The distractor has three expansion levels, represented by numbers 1, 2 and 3, which are marked on its body. The desired expansion occurred after 1 month of surgery; then, the system was locked using the locking screw and maintained for 6 months as a transpalatal bar.

Healing of the midpalatal suture was followed by periodic total maxillary occlusal radiographs and, after completion, the distractor was removed in the office (Fig 4).

After the orthodontic-surgical treatment was completed, after performing the combined orthognathic surgery, a CBCT of a new model was performed for documentation, assessment of operative stability of bone structures and gain in maxillary transversal distance (Fig 5). The patient reported improved respiratory function, greater satisfaction with dental esthetics and darker buccal corridors when smiling, improved speech due to better tongue positioning between the upper incisors across the palate, and better swallowing pattern during feeding.

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Figure 1: Initial patient records: photographs of the face and occlusion, and panoramic radiography.

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Figure 2: Transverse discrepancy measured by cone beam computed tomography of initial trimmed models.

Figure 3: Distractor in place.

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Figure 4: Occlusal radiograph with the distractor positioned and locked, with bone healing in the maxillary midline, and photograph of the palate one week after distractor removal.

Figure 5: Transverse discrepancy measured by cone beam computed tomography of the final trimmed models.

DISCUSSION As described in the literature,1,7 the patient had the characteristics associated with severe maxillary atresia of 9 mm, anterior and posterior crossbite, anteroposterior maxillary deficiency, Angle Class III pattern and vertical excess of the lower facial third. These characteristics, associated with the patient’s skeletal maturity1,2,5 and the transverse maxillary discrepancy greater than 5-7 mm,6,8,10 are imperative for the accomplishment of SARME. Besides the transverse problem, the patient presented Angle Class III, which generates complaints related to masticatory function, dental esthetics and smile, corroborating an epidemiology analysis conducted in Southeast Brazil.8

Some studies report a “V”-shaped distraction related to positioning of the PBD close to the upper premolars or the use of DSD, and the non-release of pterygoid pillars.4 This differs from the technique performed in the case described, in which the PBD was positioned between the upper premolars and molars, and the release of pterygoid sutures was performed after Le Fort I osteotomy. These procedures distribute the distraction stress evenly across the craniofacial skeleton and, with the posterior location of distraction force, there is a more parallel expansion.2,3,4,6,9,10 If the patient does not have healthy teeth, excellent periodontal health and/or several fixed prostheses, PBD is the most indicated. In addition, there are advantag-

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Bone-borne surgically-assisted rapid maxillary expansion: case report

es such as absence of buccal inclination of teeth, dental extrusion, root resorption, bone fenestration, gingival retraction and mobilization of anchorage teeth.

These advantages make the use of PBD a more favorable choice even for patients who have teeth.2-7 All these items, which could be undesirable if they occurred and which are common to the use of DSD, were not observed during the activation period or distraction latency in the present clinical case, confirming the advantages of PBD compared to DSD. Some of these advantages, not reported in the literature, are: marking of different sides of the device’s cylinder, which changes according to the activation turn, confirming that the device has been expanded, not contracted – being easy to monitor by a professional or even by the patient; the larger size of the activation key, which prevents swallowing accidents, as sometimes occurs in DSD; and the lower risk of fracture of its parts, as observed in DSD welds.

Although DSD is less invasive, its bands are cemented to the teeth, with risk of loosening during the activation period, generating asymmetric expansion or relapse. It must be placed before surgery and removed, without difficulty, in the office. The PBD can be placed during surgery and must be removed in a second surgical moment in the office, under local anesthesia, becoming a disadvantage.9 There are no studies that demonstrate clinical significance and a differentiated degree of adherence by patients due to this disadvantage.

The PBD used in the present clinical case had a thread that firmly locks the device, preventing it from performing an expansion or contraction movement, maintaining the transverse gain obtained by distraction, serving as an active device and retainer during the consolidation period. Therefore, there is only one moment of intervention in the office with the PBD, to remove the distractor, in contrast to the DSD, which would need four moments: distractor placement and removal, and transpalatal bar placement and removal, increasing the chances of unstable and irregular distraction.

The main disadvantages of PBD are the high cost, greater technical difficulty in placement (particularly on a very high palate) and a smaller number of distraction vectors, because there is only one support point in each hemimaxilla, unlike the distractor device installed in the described case, with two vectors in each hemimaxilla.9,10 The latency period is rarely reported in the literature but it is described as 5-7 days after surgery.5

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Screw activation varies according to the authors and the brand of distractor used.5 The device used in this patient has a default of 0.33 mm of distraction for every third of a turn, totaling 0.66 mm of distraction per day, since activation occurs at every 12/12h. Expansion without overcorrection is effective in cases of PBD, due to its stability, reducing the total treatment time, as the activation period becomes shorter.

The period of bone healing was followed by upper occlusal radiographs until a bone callus was observed, at around three months. The PBD was removed after six months, as a guarantee of total stability for the onset of orthodontic treatment,6 since, in clinical practice, there are reports of strong asymmetries three months post-expansion with the PBD.10 The activation protocol, device used for retention and the surgical technique may differ between studies.5 SARME biases are overlooked, including: type of distraction; existence, cause and amount of relapse; need for overcorrection; latency period; need for retention;6 comparison between stability and possible problems associated with DSD and PBD during the activation period, such as loss of the device, swallowing of activation keys and asymmetric distraction – which are not mentioned in the literature – as well as the risk of hemorrhage during separation of the pterygomaxillary suture, since the area to be sectioned is very close to the internal maxillary artery, which is also not mentioned in the literature describing the accomplishment of SARME.2 FINAL CONSIDERATIONS In patients with severe transverse deficiency, bilateral crossbites, vertically positioned upper alveolar ridges, periodontal deficiencies in the supporting teeth of DSD and systemic diseases that compromise tooth enamel and bone maturation, SARME with PBD is the best treatment. It should be noted that, in cases of maxillary atresia greater than 7 mm and with other facial deformities, such as Angle Class III in the present case, orthognathic surgery in the second surgical stage becomes necessary, depending on the degree of postoperative stability of SARME and analysis of the patient’s dental casts.

The great clinical significance of this deformity and the wide divergence in the literature regarding treatment, activation period and latency suggest that further studies should be conducted to create more consistent protocols.

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References:

1. Giannini L, Maspero C, Galbiati G, Feresini M, Farronato G. Comparison of the palatal expansion obtained via the use of the rapid maxillary expander compared with surgically assisted rapid maxillary expansion. Minerva Stomatol. 2016 Apr;65(2):72-80.

2. Singaraju GS, Chembeti D, Mandava P, Reddy VK, Shetty SK, George SA. A comparative study of three types of rapid maxillary expansion devices in surgically assisted maxillary expansion: a finite element study. J Int Oral Health. 2015 Sep;7(9):40-6.

3. Dalband M, Kashani J, Hashemzehi H. Three-dimensional finite element analysis of stress distribution and displacement of the maxilla following surgically assisted rapid maxillary expansion with tooth- and bone-borne devices. J Dent (Tehran). 2015 Apr;12(4):298-306.

4. Verstraaten J, Kuijpers-Jagtman AM, Mommaerts MY, Bergé SJ, Nada RM, Schols JG, et al.

A systematic review of the effects of bone-borne surgical assisted rapid maxillary expansion. J Craniomaxillofac Surg. 2010 Apr;38(3):166-74.

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5. Vilani GN, Mattos CT, de Oliveira Ruellas AC, Maia LC. Long-term dental and skeletal changes in patients submitted to surgically assisted rapid maxillary expansion: a meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012 Dec;114(6):689-97.

6. Starch-Jensen T, Blæhr TL. Transverse expansion and stability after segmental le fort i osteotomy versus surgically assisted rapid maxillary expansion: a systematic review. J Oral Maxillofac Res. 2016 Dec 28;7(4):e1.

7. Lin L, Ahn HW, Kim SJ, Moon SC, Kim SH, Nelson G. Tooth-borne vs bone-borne rapid maxillary expanders in late adolescence. Angle Orthod. 2015 Mar;85(2):253-62.

8. Araújo RZ, Pinto Júnior AAC, Lehman LFC, Campos FEB, Cunha JF, Castro WH. Análise epidemiológica de 132 casos de cirurgia ortognática. J Braz Coll Oral Maxillofac Surg. 2015 Maio-Ago;1(2):30-5.

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9. Zandi M, Miresmaeili A, Heidari A. Short-term skeletal and dental changes following bone-borne versus tooth-borne surgically assisted rapid maxillary expansion: a randomized clinical trial study. J Craniomaxillofac Surg. 2014 Oct;42(7):1190-5.

10. Laudemann K, Petruchin O, Nafzger M, Ballon A, Kopp S, Sader RA, et al. Long-term 3D cast model study: bone-borne vs. tooth-borne surgically assisted rapid maxillary expansion due to secondary variables. Oral Maxillofac Surg. 2010 Jun;14(2):105-14.

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Case Report

Alloplastic reconstruction of the temporomandibular joint in patient with rheumatoid arthritis: case report LEANDRO EDUARDO KLUPPEL1 | CAIO AUGUSTO MUNUERA UETI1

ABSTRACT The inflammatory arthritis of the temporomandibular joint (TMJ) is uncommon, but when it occurs it can become debilitating. Early diagnosis and treatment by a maxillofacial surgeon can prevent joint collapse. The most prevalent form of inflammatory arthritis, the rheumatoid arthritis, when affects the TMJ, causes destruction of the mandibular condyle, with consequent retrusion of the chin, shortening of the mandible branch, and anterior open bite. Due to the reduction of the anteroposterior and posterior vertical dimensions of the mandible, there is a reduction in the upper airway space; and, in severe cases, it implies the development of obstructive sleep apnea syndrome. The aim of this study is to present a clinical case of advanced degenerative disease secondary to rheumatoid arthritis, with involvement of the temporomandibular joints, in association with mandibular and mental retrusion, and obstructive sleep apnea syndrome. The proposed treatment plan was orthognathic surgery associated with temporomandibular joint reconstruction with custom prostheses. The articular problem was resolved, facial harmony and aesthetics improved, and upper airway enlarged. The alloplastic reconstruction offers an effective treatment of patients with temporomandibular joint autoimmune disease, avoids donor site morbidity and allows correction of facial deformity in a single procedure.

Keywords: Temporomandibular joint. Arthritis, rheumatoid. Sleep apnea syndrome.

How to cite: Kluppel LE, Ueti CAM. Alloplastic reconstruction of the temporomandibular joint in patient with rheumatoid arthritis: case report. J Braz Coll Oral Maxillofac Surg. 2021 Sept-Dec;7(3):52-8.

DOI: https://doi.org/10.14436/2358-2782.7.3.052-058.oar

Universidade Federal do Paraná, Cirurgia e Traumatologia Bucomaxilofacial (Curitiba/PR, Brazil).

1

Submitted: September 03, 2019 - Revised and accepted: December 13, 2019

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

Contact address: Caio Augusto Munuera Ueti E-mail: caiouetimunuera@gmail.com

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

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INTRODUCTION Inflammatory arthritis of the TMJ is uncommon; however, when it occurs it can become debilitating.

The most common inflammatory arthritis conditions include: rheumatoid arthritis, arthritis associated with psoriasis, or psoriatic arthritis, and ankylosing spondylitis. Rheumatoid arthritis has the highest prevalence, followed by psoriatic arthritis. The incidence of temporomandibular joint involvement in patients with rheumatoid arthritis varies widely, from 5 to 86%. However, the temporomandibular joint tends to be more affected in patients who have the most severe disease and the longest duration.1 Diagnosis and treatment by the oral and maxillofacial surgeon can prevent possible ankylosis and joint collapse. An advanced-stage disease can be treated with open joint surgery or prosthetic replacement.2 Treatment of the joint affected by rheumatoid diseases is more successful with alloplastic reconstruction, because autogenous reconstruction involves the risk of disease relapse and development of ankylosis.3

creased pain, restriction of mouth opening and chewing difficulty. Micrognathia and progressive Class II malocclusion were very evident, caused by TMJ involvement by rheumatoid arthritis since her youth and destructive resorption of the mandibular condyle (Fig 1).

The patient’s sleep had poor quality and there was significant nocturnal snoring, resulting from progressive decrease in the upper airway in response to degeneration of the temporomandibular joint.

The proposed treatment plan was orthognathic surgery, with reconstruction of the temporomandibular joints with customized prostheses. Initially, helical computed tomography, occlusion scanning and virtual planning for orthognathic surgery were performed.

The customized TMJ prostheses were developed from a virtual model, using CAD/CAM technology, to precisely adapt to the anatomical particularities of the patient. During surgery, retromandibular and pre-auricular access, condylectomy, coronoidectomy and placement of the prostheses, with their respective mandibular and fossa components, were performed bilaterally. The next step, orthognathic surgery, consisted of Le Fort I osteotomy with maxillary segmentation, advancement and impaction, leading to counterclockwise rotation of the maxillomandibular complex. Maxillary fixation was performed using two Lindorf-type plates on the canine pillar and two L-shaped plates on the zygomatic pillar. Additionally, advancement mentoplasty was performed to improve esthetics and function, increasing the airway by advancing the geniohyoid and genioglossus muscles.

The removed coronoid processes were used as autogenous grafts in the chin (Fig 2). The postoperative evolution was satisfactory, and the patient presented stability of bone movements, satisfactory mandibular function, adequate facial esthetics and excellent nocturnal breathing pattern, without snoring (Fig 3).

CASE REPORT A 25-year-old female patient with rheumatoid arthritis that had evolved since the age of 14 years presented with significant involvement of the knee, hip, hands, feet, spine and temporomandibular joints.

The spine, cervical and thoracic, had great deformities, with a history of previous unsuccessful surgeries. Due to severe involvement of the spine, there was a change in natural head position and, consequently, in the maxillary occlusal plane in relation to the ground, giving the patient a false aspect of maxillary unevenness (cant).

As previously reported, involvement of the temporomandibular joints (TMJs) had been present since adolescence and, in recent years, it had evolved into in-

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Figure 1: A) Frontal view of the patient, showing mandibular and chin deficiency, lip incompetence and cervical spine deviation, with abnormal natural head position. B) Patient in lateral view. C) Patient in ¾ profile view. D) Presence of “swan neck deformity” on the fingers, characteristic of rheumatoid arthritis. E) Maximum mouth opening: about 25 mm. F) Frontal view of preoperative occlusion. G) Preoperative panoramic radiograph: destruction of the mandibular condyle can be observed. H) Virtual planning in orthognathic surgery, for the best position of the jaws for the patient. The maxillary occlusal plane was kept parallel to the ground, for better esthetics, since the patient had spinal deviation, with natural abnormal head positioning.

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Figure 2: A) Pre-auricular access and placement of the fossa component of the customized TMJ prosthesis (right view). B) Retromandibular access and placement of the mandibular component of the customized prosthesis (right view). C) Pre-auricular access and placement of the fossa component of the customized TMJ prosthesis (left view). D) Retromandibular access and placement of the mandibular component of the customized prosthesis (left view). E) Le Fort I osteotomy, with maxillary segmentation, advancement and impaction. Lindorf plates on the nasomaxillary pillar and L-shaped plates on the zygomatic pillar. F) Horizontal basilar chin osteotomy for advancement: coronoid processes were used for autogenous graft, providing greater stability for movement.

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Figure 3: A) Postoperative frontal view. B) Postoperative lateral view. C) Maximum opening after alloplastic TMJ reconstruction and coronoidectomy: approximately 30 mm. D) Frontal view of postoperative occlusion. E) Postoperative panoramic radiograph. F, G) Upper airway dilation after alloplastic reconstruction of the temporomandibular joint, Le Fort I osteotomy and advancement mentoplasty.

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DISCUSSION The pattern of TMJ involvement by rheumatoid arthritis follows the same pattern as in other joints: macrophages, granulocytes, and plasma cells infiltrate the synovial tissues; the synovial tissue thickens and is called “pannus”; the pannus grows into the joint space and forms

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protruding folds, which cause pain and limitation of joint function. Lysosomal enzymes released by granulocytes and macrophages into synovial tissue cause destruction and erosion of the condyle and temporal bone. Other sources responsible for bone destruction are the release of interleukins, cytokines, growth factors and proteinases.4

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and can lead to temporomandibular joint collapse. In patients with rheumatoid arthritis, arthrocentesis improves function and symptoms in the short term.

When there is joint collapse with open bite, which causes pain and functional impairment, joint reconstruction is the best option. All diseased tissue must be removed and replaced.2 Historically, autogenous tissues were recommended for TMJ reconstruction, although less successful results have been reported in patients with inflammatory arthritis. In inflammatory arthritic conditions that affect the upper and lower compartments of the temporomandibular joint, surgical reconstruction using autogenous grafts has low quality and risk of ankylosis, especially costochondral grafts.8 The influence of autoimmune disease in contributing to failure of autogenous graft reconstruction and subsequent ankylosis, even in the presence of pharmacological treatment, is significant. A higher success rate has been observed in alloplastic reconstruction of the temporomandibular joint in patients with autoimmune disease. The decision to reconstruct the TMJ with an alloplastic prosthesis is a biomechanical procedure aimed at reconstructing an anatomically distorted and dysfunctional joint, using materials that are not affected by the autoimmune disease. Alloplastic reconstruction offers an effective treatment compared to the autogenous modality and avoids morbidity at the donor site. This shortens the operative time and reduces the hospitalization time.

For the time being, alloplastic reconstruction of the temporomandibular joint is the only reliable and predictable method in the surgical treatment of patients with autoimmune disease.9 In patients with obstructive sleep apnea syndrome due to condylar resorption, in inflammatory arthritis, treatment with TMJ prostheses allows for expansion of the upper airway and restores masticatory function.6 The mandibular advancement obtained in these patients moves the anterior belly of the digastric muscle, the mylohyoid muscle, the genioglossus muscle and the geniohyoid muscle forward, moving the tongue up and forward, away from the pharynx and restoring the lost upper airway space. The maxillary advancement, by Le Fort I osteotomy, can be performed in combination, for better results, in the obstructive sleep apnea syndrome, providing forward and upward traction of the

Patients with rheumatoid arthritis tend to have more severe and frequent signs and symptoms in the temporomandibular joint compared to those with ankylosing spondylitis and psoriatic arthritis. Crackling is an important indicator of joint destruction. Radiographic changes found in TMJ include cortical erosion, condylar resorption, subchondral cysts, flattening of the condyle and articular eminence, subcortical sclerosis and joint space narrowing. However, neither of these signs are pathognomonic of rheumatoid arthritis. When undergoing resorption, the condyle can take a “sharpened pencil” shape or even become completely destroyed.5 There are painful symptoms, which may originate from the temporomandibular joint itself and from the masticatory muscles. There is also change in occlusion and limited mouth opening (smaller than 35 mm).3 When rheumatoid arthritis affects the TMJ, it causes destructive resorption of the mandibular condyle, with consequent retrusion of the chin, shortening of the mandibular ramus, progressive Class II malocclusion, with premature dental contacts in the posterior teeth and anterior open bite.3 Thus, due to mandibular shortening in anteroposterior direction, there is a decrease in the upper airway volume. In severe cases, TMJ involvement by rheumatoid arthritis can result in obstructive sleep apnea syndrome. Airway obstruction can also be assigned, in some cases, to involvement of the cervical spine, due to the atlantoaxial subluxation present in rheumatoid arthritis.6 TMJ ankylosis rarely occurs in rheumatoid arthritis; however, it can affect the temporomandibular joints bilaterally in advanced stages of disease. In children, rheumatoid arthritis can result in jaw growth disorder, facial deformity and ankylosis.7 The initial treatment for patients with inflammatory arthritis involves the use of disease-modifying antirheumatic drugs, nonsteroidal anti-inflammatory drugs, and corticosteroids. Surgical treatment begins with arthrocentesis and arthroscopy, to clear debris and inflammation mediators, together with excision of the affected synovial tissue.2 Arthroscopy is less effective in treating the temporomandibular joint affected by rheumatoid arthritis, and it is difficult, if not impossible, to be performed in cases where there is ankylosis. TMJ corticosteroid injections are ineffective in the long term

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thologies affect the child, conservative measures can be taken, such as arthrocentesis and occlusal plates, to maintain the occlusion until growth is complete.

When growth ceases, orthognathic surgery may be necessary to correct the malocclusion. If the joint is collapsing, management of the situation should proceed in the same way as in adults.1

soft palate, repositioning the palatoglossus muscle and increasing the tongue support. The expansions favor a greater respiratory flow and reduced resistance over it.

Maxillary and mandibular advancement is considered a site-specific procedure to create a larger airway at multiple anatomical levels, such as nasopharynx, oropharynx and hypopharynx.10 According to Mercuri,8 alloplastic reconstruction of the temporomandibular joint should be indicated for the treatment of inflammatory arthritis involving TMJ unresponsive to other treatment modalities, such as recurrent ankylosis unresponsive to other treatment modalities, autogenous graft failure, loss of vertical height of the mandible or occlusal relationship due to bone resorption, trauma, developmental abnormalities or pathological injuries.

Rheumatic diseases in pediatric patients rarely involve the temporomandibular joint. If these pa-

FINAL CONSIDERATIONS Alloplastic surgical reconstruction offers an effective treatment for the temporomandibular joint destroyed by rheumatoid arthritis. Since these patients generally have mandibular and maxillary deformities associated with joint disease, the customized prosthesis, in association with orthognathic surgery, is the most predictable procedure for patients with advanced-stage autoimmune temporomandibular joint disease.

References:

1. Sidebottom AJ. Alloplastic or autogenous reconstruction of the TMJ. J Oral Biol Craniofac Res. 2013 SepDec;3(3):135-9.

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

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

3. Westermark A. Total reconstruction of the temporomandibular joint. Up to 8 years of follow-up of patients treated with Biomet(®) total joint prostheses. Int J Oral Maxillofac Surg. 2010 Oct;39(10):951-5.

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4. Dayer JM. The process of identifying and understanding cytokines: from basic studies to treating rheumatic diseases. Best Pract Res Clin Rheumatol. 2004 Feb;18(1):31-45.

5. Celiker R, Gökçe-Kutsal Y, Eryilmaz M. Temporomandibular joint involvement in rheumatoid arthritis.

Relationship with disease activity. Scand J Rheumatol.

1995;24(1):22-5.

6. Sugahara T, Mori Y, Kawamoto T, Sakuda M. Obstructive sleep apnea associated with temporomandibular joint destruction by rheumatoid arthritis: report of case. J Oral Maxillofac Surg. 1994 Aug;52(8):876-80.

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7. Kobayashi R, Utsunomiya T, Yamamoto H, Nagura H. Ankylosis of the temporomandibular joint caused by rheumatoid arthritis: a pathological study and review.

J Oral Sci. 2001 Jun;43(2):97-101.

8. Mercuri LG. Total joint reconstruction--autologous or alloplastic. Oral Maxillofac Surg Clin North Am. 2006 Aug;18(3):399-410, vii.

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Case Report

Surgical treatment of oro-sinusal fistula: Case report

VINÍCIUS RODRIGUES GOMES1 | JOSFRAN DA SILVA FERREIRA FILHO2 | RICARDO FRANKLIN GONDIM3 | BRENO SOUZA BENEVIDES4

ABSTRACT The maxillary sinusitis is characterized by the infection of this paranasal sinus, causing dysfunction, pain, bad odor and fever. The oro-sinusal fistula represents a complication in which communication occurs between the maxillary sinus and the buccal cavity. The objective of this study is to report the case of a 45 years-old male patient, who sought a clinic of Oral and Maxillofacial Surgery presenting history of traumatic tooth extraction #17, complaining of: liquid flux from the mouth into the nasal cavity and pain, with an evolution time of approximately four months.

Intraoral clinical exam showed the absence of teeth #16 and #17, fistula associated with these alveolar ridge and positive outcome of the Valsalva maneuver. Imagiologic exams showed continuity between the oral cavity and right maxillary sinus, with extensive opacification. Before the diagnostic confirmation of maxillary sinusitis and buco-sinusal fistula, the right sinusectomy and closure of the fistula were planned by sliding the buccal adipose flap. Currently the patient is in 90-day follow-up, in which the fistula is enclosed and regression of the associated symptoms. The treatment course proved to be safe and effective for solving this case.

Keywords: Oroantral fistula. Oral fistula. Paranasal sinuses.

How to cite: Gomes VR, Ferreira Filho JS, Gondim RF, Benevides BS. Surgical treatment of oro-sinusal fistula: Case report. J Braz Coll Oral Maxillofac Surg. 2021 Sept-Dec;7(3):59-63.

DOI: https://doi.org/10.14436/2358-2782.7.3.059-063.oar

Staff do Serviço de Cirurgia e Traumatologia Buco-Maxilo-Faciais, Hospital Batista Memorial (Fortaleza/CE, Brazil).

Residente de Cirurgia e Traumatologia Buco-Maxilo-Faciais, Hospital Instituto Doutor José Frota (Fortaleza/CE, Brazil).

3 Coordenador da residência de Cirurgia e Traumatologia Buco-Maxilo-Faciais, Hospital Instituto Doutor José Frota (Fortaleza/CE, Brazil).

4 Staff do Serviço de Cirurgia e Traumatologia Buco-Maxilo-Faciais, Hospital Batista Memorial e Instituto Doutor José Frota (Fortaleza/CE, Brazil).

1

2

Submitted: June 24, 2019 - Revised and accepted: April 24, 2020 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article.

Contact address: Josfran Ferreira Filho E-mail: josfranf@hotmail.com

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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

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Surgical treatment of oro-sinusal fistula: Case report

INTRODUCTION The maxillary sinus is represented by a pneumatized space, located bilaterally inside the maxillary bone, which has the function of distributing and decreasing the facial weight.1 Oroantral communication is an unnatural communication between the oral cavity and the maxillary sinus, often found by dentists, which must be treated in a specialized manner by an oral and maxillofacial surgeon. This complication most commonly occurs during extraction of upper molars and premolars (48%).2 The main reason is the anatomical proximity or projection of roots in the maxillary sinus.2 Other causes of this defect include fracture of the maxillary tuberosity, dentoalveolar infections, trauma, presence of cysts or maxillary tumors, osteoradionecrosis and complications of the Caldwell-Luc procedure.3 Oroantral fistula (OAF) is a pathological anatomical communication between the oral cavity and the maxillary sinus. It develops when oroantral communication is not treated, remains patent and the re-epithelialization process is likely to happen.4 This epithelialization usually occurs when the perforation persists for approximately 48-72 hours. In a short period of time, the fistula organizes and, when there is presence of osteitis in the surrounding bone margins, foreign bodies or the development of maxillary sinusitis, spontaneous healing is difficult, resulting in the formation of a chronic fistula.2 An average time of 7-8 days is taken for an oroantral perforation to epithelize and become a chronic fistulous tract.5 The oroantral defect is measured according to its size, in which: defects that present 1 mm, considered small, can be treated with occlusive suture, in case of immediate communication; defects from 1 to 4 mm, classified as medium size, require tissue flap for primary closure; above 4 mm, considered large defects, require a flap, for which the buccal adipose body has been widely used.6 The buccal fat pad translocation is a technique used for the treatment of oroantral communications

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

and consists of performing a pedicled flap of the buccal fat pad, with the advantage of easy availability of the flap and large blood supply to the receptor site, which results in high success rates.7 Complications that may occur include maxillary sinusitis, which trigger a symptomatic condition, with the presence of paranasal edema, headache, runny nose and deviation of the nasomaxillary anatomy, solved by opening the maxillary sinus using the Caldwell-Luc technique, to perform curettage in the area where tissue changes occurred without entirely removing the sinus mucosa, similarly called sinusectomy.8 CASE REPORT A 45-year-old male normosystemic patient sought an Oral and Maxillofacial Surgery and Traumatology outpatient clinic with history of traumatic extraction of tooth 17, complaining of fluid passage from the mouth to the nasal cavity, cacosmia and pain located in the right infraorbital region, with an evolution time of approximately four months. The intraoral clinical examination revealed absence of the upper right first and second molars, abscess associated with these alveoli and a positive result in the Valsalva maneuver (Fig 1). Imaging exams were requested, which showed continuity between the oral cavity and the right maxillary sinus, with extensive veiling of this compartment (Fig 2). Considering the diagnostic confirmation of maxillary sinusitis and oroantral fistula, the treatment planning included right sinusectomy, disorganization of the fistulous tract and occlusion of the fistula by sliding a flap of the buccal fat pad (Fig 3). The patient has been under 90-day follow-up, showing complete closure of the fistula and regression of associated symptoms. He presented incomplete resorption of the buccal fat pad pedicle brought into the dentoalveolar region of the communication, showing a notable mucogingival volume, yet without any pain complaint (Fig 4).

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Figure 2: Panoramic reconstruction of cone beam computed tomography, showing extensive veiling in the right maxillary sinus.

Figure 1: Initial clinical appearance, showing intraoral fistula in the maxillary alveolus.

Figure 3: Surgical wound in the right hemimaxilla, evidencing access to the right maxillary sinus, with exposure and translocation of the buccal fat after sinusectomy.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Figure 4: Intraoral view after 90 days of postoperative follow-up, with sealing of the oroantral fistula and regression of associated symptoms.

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Surgical treatment of oro-sinusal fistula: Case report

DISCUSSION The presence of oroantral communication and foreign bodies in the maxillary sinus is uncommon, and the highest prevalence of cases occur from a penetrating injury or trauma.1 The presence of these two events together causes pain and often purulent exudate.9 The clinical case reported shows an episode of complication after tooth extraction that caused an oroantral fistula, drainage of purulent exudate, odor and the passage of liquids through the nose, compromising the patient’s quality of life. Requesting imaging tests is essential for the diagnosis and indication of correct treatment, and panoramic radiography is the most used, although computed tomography (CT) is considered the gold standard.1 In the present case, the imaging exams, besides confirming the hypothesis, help in choosing the surgical technique. CT was chosen for better diagnostic complementation and treatment choice. The Caldwell-Luc procedure is one of the techniques most used to treat chronic sinusitis and is commonly indicated for various surgical procedures, such as removal of foreign bodies from the maxillary sinus, resection of lesions within the maxillary sinus, treatment of chronic sinusitis, among others.4 The Caldwell-Luc technique was chosen for the sinusectomy procedure, since this technique is associated with few complications and has a good success rate. The buccal fat pad has a good blood supply, efficient adhesion in the receptor area and spontaneous epithelialization by metaplasia in the oral cavity. It has the advantage of not causing morbidity to the donor site and its favorable anatomical topography makes it widely used for closing oroantral defects; thus, its pedicled translocation represents a good treatment option for cases of oroantral fistula.6 However, there are some disadvantages of this technique,

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

such as decreased buccal sulcus depth, postoperative pain and edema. This technique also has limitations in large defects, due to traction of a larger tissue portion, which increases the likelihood of postoperative complications, such as esthetic cheek depression.10 Alkan et al.11 reported successful closure in defects of up to 50 x 30 mm in the area. Likewise, Rapidis et al.12 recommended limiting the use of pedicled fat.

Since it has its own lipolysis mechanism, neither the patient’s age nor sex are important in determining the result of this technique.5 The closure of OAFs with platelet-rich fibrin (PRF) is a less invasive technique than the buccal fat pad and maintains the depth of the buccal sulcus, besides being autogenic and including growth factors in its content. The technique that uses PRF is simple and effective and can be used in the treatment of OAFs with a diameter of 5 mm or less, with low risk of complications8 and limited availability of acquisition of material necessary for making and managing the PRF, which was not present in the clinic mentioned in the study. In the present case, we opted for the buccal fat pad, without intraoperative and postoperative complications. It appears that 3 to 6 months of postoperative follow-up are sufficient to assess the success of therapy.10 The case presented is under follow-up for three months, during which no signs of complications or recurrence of the oroantral communication or maxillary sinusitis were noticed.

FINAL CONSIDERATIONS Considering the series of communications and oroantral fistulae as a result of accidents and complications associated with tooth extractions, the use of translocation technique of buccal fat represents a viable and effective option, with little morbidity and associated with high success rates, as in the reported case.

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References:

1. Oliveira RS, Costa RO, Carvalho Neto LG, Araújo FF. Aplicação da técnica cirúrgica de Caldwell-Luc para remoção de corpo estranho do seio maxilar: relato de caso. J Health Sci Inst. 2010;28(4):318-20.

2. Hassan O, Shoukry T, Raouf AA, Wahba H. Combined palatal and buccal flaps in oroantral fistula repair. Egypt J Ear, Nose, Throat Allied Sci. 2012 Jul;13(2):77-81.

3. Scattarella A, Ballini A, Grassi FR, Carbonara A, Ciccolella F, Dituri A, et al. Treatment of oroantral fistula with autologous bone graft and application of a non-reabsorbable membrane. Int J Med Sci. 2010 Aug 11;7(5):267-71.

4. Watzak G, Tepper G, Zechner W, Monov G, Busenlechner D, Watzek G. Bony press-fit closure of oro-antral fistulas: a technique for pre-sinus lift repair and secondary closure. J Oral Maxillofac Surg. 2005 Sep;63(9):1288-94.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

5. Freitas TMC, Farias JG, Mendonça RG, Alves MF, Ramos Jr. RP, Câncio AV. Fístulas oroantrais: diagnóstico e propostas de tratamento. Rev Bras Otorrinolaringol.

2003 Dez;69(6):838-44.

6. Egyedi P. Utilization of the buccal fat pad for closureof oroantral and/or oronasal communications. J Maxillofac Surg. 1977;5:241-4.

7. Singh J, Prasad K, Lalitha RM, Ranganath K. Buccal pad of fat and its applications in oral and maxillofacial surgery: a review of published literature (February) 2004 to (July) 2009. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 Dec;110(6):698-705.

8. Demetoglu U, Ocak H, Bilge S. Closure of oroantral communication with plasma-rich fibrin membrane.

J Craniofac Surg. 2018 Jun;29(4):e367-e70.

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9. 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 Jan/Mar;14(1):55-8.

10. Poeschl PW, Baumann A, Russmueller G, Poeschl E, Klug C, Ewers R. Closure of oroantral communications with Bichat’s buccal fat pad. J Oral Maxillofac Surg. 2009 Jul;67(7):1460-6.

11. Alkan A, Dolanmaz D, Uzun E, Erdem E. The reconstruction of oral defects with buccal fat pad. Swiss Med Wkly. 2003 Aug 23;133(33-34):465-70.

12. Rapidis AD, Alexandridis CA, Eleftheriadis E, Angelopoulos AP. The use of the buccal fat pad for reconstruction of oral defects: review of the literature and report of 15 cases. J Oral Maxillofac Surg. 2000 Feb;58(2):158-63.

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Series of Cases

Polymethylmethacrylate in the aesthetic correction of anteroposterior maxillary hypoplasia: a series of 20 cases WEBER CÉO CAVALCANTE1 | PAULA RIZÉRIO D’ANDRÉA ESPINHEIRA2 | KÁTIA MONTANHA ANDRADE1 | LEONARDO MORAES GODÓI FIGUEIREDO2 | MARIA CRISTINA CANGUSSÚ3 | ROBERTO ALMEIDA AZEVEDO1

ABSTRACT Introduction: Anteroposterior maxillary hypoplasia (AMH), with or without dental discrepancy, has repercussions that cause aesthetic and psychological damage to the patients. Many therapeutic measures have been used for this condition, such as orthognathic surgery and filling with various materials. Methods: This retrospective, observational, and descriptive study evaluated patients with AMH undergoing polymethylmethacrylate (PMMA) implantation, through a series of 20 cases with follow-up for a mean period of four years, treated by means of a technique using PMMA in solid form implanted on the maxillary bone structure laterally to the bilateral pyriform aperture, with safety and predictable results. Results: Among the 20 patients followed-up, three complications were recorded: mild pain was noted upon palpation in one of the implants; displacement of one of the implants, requiring removal; and mild paresthesia of the central incisor, without loss of pulp vitality, in the third case. Fifteen (75%) patients were very satisfied and five (25%) were satisfied with the aesthetic result. No patient was dissatisfied. Conclusion: The aesthetic resolution of AMH with PMMA proved to be an efficient form of treatment, with a low rate of complications and a good grade of patient satisfaction on long-term follow up.

Keywords: Orthognathic surgery. Polymethyl methacrylate. Prostheses and implants.

Universidade Federal da Bahia, Faculdade de Odontologia, Departamento de Clínica Odontológica (Salvador/BA, Brazil).

Universidade Federal da Bahia, Serviço de Cirurgia e Traumatologia Bucomaxilofacial (Salvador/BA, Brazil).

3 Universidade Federal da Bahia, Faculdade de Odontologia, Departamento de Odontologia Social (Salvador/BA, Brazil).

1

2

How to cite: Cavalcante WC, Espinheira PRD, Andrade KM, Figueiredo LMG, Cangussú MC, Azevedo RA. Polymethylmethacrylate in the aesthetic correction of anteroposterior maxillary hypoplasia: a series of 20 cases. J Braz Coll Oral Maxillofac Surg. 2021 Sept-Dec;7(3):64-70.

DOI: https://doi.org/10.14436/2358-2782.7.3.064-070.oar

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

Submitted: July 18, 2018 - Revised and accepted: June 26, 2019

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

Contact address: Weber Céo Cavalcante E-mail: weberccavalcante@gmail.com

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Cavalcante WC, Espinheira PRD, Andrade KM, Figueiredo LMG, Cangussú MC, Azevedo RA

INTRODUCTION Anteroposterior maxillary hypoplasia (APMH), with or without dental discrepancy, has repercussions causing esthetic damage to affected patients; it usually causes flattening of the lateronasal region, with deepening of the nasolabial fold, a virtual increase in nose size and mental prominence, favoring the appearance of early aging in affected individuals. Thus, the search for the resolution of this condition is old, and many therapeutic measures have been used for its resolution, such as orthognathic surgery and filling with different materials.1-6 Thus, the objective of the present paper is, by a series of 20 operated cases followed for a mean period of 4 years, to present the technique of using polymethylmethacrylate (PMMA) implanted in solid form on the maxillary bone structure lateral to the piriform openings bilaterally, to solve APMH with predictability of results, safety and reversibility, if necessary.

The situation for placement in cases who did not need Le Fort I osteotomy will be described in detail and then reported on how it was performed when needed.

An incision was made in the mucosa, from the mesial aspect of the first molar on the right side to the mesial aspect of the first molar on the left side, and then a subperiosteal detachment was performed. It was not necessary to extend the subperiosteal detachment posteriorly to the zygomaticomaxillary crest. After this stage, the entire area lateral to the piriform opening up to the zygomaticomaxillary crest was observed, and in vertical direction from the tooth apices to approximately 5 to 10 mm below the inferior orbital ridge.

A template was made with a suture envelope in a “crooked drop” format, positioned laterally to the piriform opening and extending laterally approximately up to the mesial aspect of the first premolar. From a vertical view, the lower part of the implant extended over the middle root third of incisors and canines, and the upper part of the implant was 3 to 5 mm below the infraorbital foramen, not extending over the lateral portion to the nose bones. Only the lateral extension, the uppermost portion should not surpass the canine pillar (Fig 1A).

The material manipulation (Orthopedic Surgical Cement - MBC®) was started by placing 10 ml of liquid (methyl methacrylate monomer) in a sterile metallic flask, and then 20 g of powder (polymethylmethacrylate) were added, gently homogenizing with a spatula until the mixture was uniform. The plastic phase was waited for approximately 2 minutes, until the material began to detach from the flask walls.

Before curing, the PMMA was manipulated manually, with fingers lubricated with sterile petroleum jelly, and placed into the maxillary bone bed, being adapted to it and modeled as close as possible to what was considered ideal, in a thickness ranging from 5 to 8 mm.

After this step, we emphasize that the PMMA was removed, and completion of polymerization and its exothermic phase was awaited without any contact with the surgical wound. The completion of polymerization occurred approximately 5 minutes after completion of the exotherm reaction, and the need for finishing with surgical burs was frequent, being performed far from the surgical site, to prevent PMMA residues from falling into the surgical wound. The implant was placed in the definitive location and compared with the contralateral side, which had not yet received it.

MATERIAL AND METHODS A retrospective, observational and descriptive study was conducted based on data collected from the application of a specific questionnaire of patients with APMH undergoing PMMA, assisted at the Oral and Maxillofacial Surgery Outpatient Clinic of the School of Dentistry, Federal University of Bahia (Salvador/BA), and conducted to surgical treatment under general anesthesia or local anesthesia with intravenous sedation at Hospital Santo Antônio (Irma Dulce Social Works, Salvador/BA).

Eligibility criteria After free and informed consent, patients with APMH with small or even absent dental discrepancy, but with esthetic complaints about APMH, who received PMMA implants, were included for review. Patients who needed sufficient maxillary movement to correct their dental discrepancies and simultaneously solve their esthetic problem, without the use of PMMA, were considered ineligible.

This paper was submitted to Plataforma Brasil for evaluation by the Institutional Review Board of the School of Dentistry of the Federal University of Bahia and was approved with report #1.023.057.

Description of surgical technique The patients were operated on under general anesthesia, except for two of them, who had placement of PMMA without Le Fort I osteotomy, under local anesthesia associated with intravenous sedation.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Polymethylmethacrylate in the aesthetic correction of anteroposterior maxillary hypoplasia: a series of 20 cases

(muscle and mucosa), with 4-0 Johnson and Johnson® monocryl resorbable sutures.

In the immediate postoperative period, dipyrone 1g was administered IV at every 6 hours, cefazolin 1g IV at every 8 hours, dexamethasone 6 mg IV at every 12 hours, and patients were discharged on the second postoperative day, when maxillary movement was performed; or on the same day of surgery, when they received only the implants. After discharge, the patients received home prescription of dipyrone 1g orally at every 6 hours for 3 days, nimesulide 100mg orally at every 12 hours for 3 days, and amoxicillin 500mg orally for 7 days.

Patients were evaluated weekly for one month, biweekly for the second month, once in the third month, at six months, and annually thereafter (Figs 2, 3, and 4).

The same steps were followed to make the implant on the contralateral side, trying to mirror the shape of the first implant. The right and left implants did not touch, being about 10 mm apart from each other. The implants were fixed with one or two titanium screws (Fig 1B).

When implant placement was performed concomitantly with maxillary advancement, the latter was performed until complete maxilla fixation, and the implants were placed on the maxillary fixation plates, taking care to avoid interposition of PMMA in the osteotomy gap, to avoid harming the bone consolidation.

In all cases, alar base reduction was performed with nylon 2.0 Johnson and Johnson®. The surgical wounds were sutured with absorbable sutures in two planes

A

B

Figure 1: A) Simulation of the positioning of PMMA implants. B) Trans-surgical demonstration of implant fixation.

A

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Figure 2: Preoperative (A) and postoperative (B) frontal views of the use of PMMA without Le Fort I osteotomy.

B

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A

A

Figure 3: Preoperative (A) and postoperative (B) lateral views of the use of PMMA without Le Fort I osteotomy.

B

Figure 4: Frontal (A, B) and lateral (C, D) views, respectively, preoperatively and postoperatively after PMMA placement, associated with maxillary advancement of only 4 mm (E, F).

B

E

C

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

D

F

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Polymethylmethacrylate in the aesthetic correction of anteroposterior maxillary hypoplasia: a series of 20 cases

RESULTS Data were entered into an electronic spreadsheet and processed in the MINITAB version 14 package. Relative and absolute frequencies were presented for categorical variables, and measures of central tendency and dispersion for continuous variables. To evaluate the groups, the chi-square and Student’s t tests were used, both at a significance level of 95%.

The mean age of patients was 31.5 ± 9.53 years, and the mean follow-up time was 48.1 ± 37.2 months. Three complications were recorded, namely mild pain on firm palpation of one of the implants, in the case of a patient who had frequent episodes of chronic sinusitis prior to surgery; displacement of one of the implants, requiring its removal, in another case; and mild central incisor paresthesia, without loss of pulp vitality, in the third case. The first two

complications were verified in the group that underwent PMMA associated with Le Fort I osteotomy; and the third, in which only PMMA was placed. No patient had suture dehiscence or postoperative infection. Regarding satisfaction, 15 (75%) patients said they were very satisfied and 5 (25%) said they were satisfied with the esthetic result of the procedure; none were dissatisfied (Table 1).

Table 2 shows that, among individuals who received placement of PMMA with orthognathic surgery, there was no variation in the degree of satisfaction correlated with complications that occurred (p = 0.52), and that among patients who received only placement of PMMA, there was statistically significant difference (p = 0.04), with the only complication not interfering with patient satisfaction. In this segment, the patient who had the complication belonged to the group of very satisfied patients.

Table 1: Clinical/demographic characteristics of the sample.

Variables

n (percentage %) or mean±SD

Age (years) Sex Male Female Chief complaint Esthetics Esthetics and masticatory function Treatment Orthognathic surgery and PMMA PMMA only Postoperative complications No Yes Period of follow-up (months) Patient satisfaction (result/expectation) Satisfactory Very good

31.5 ± 9.53 4 (20%) 16 (80%) 7 (35%) 13 (65%) 14 (70%) 6 (30%) 18 (85.71%) 3 (14.29%) 48.1 ± 37.2 5 (25%) 15 (75%)

Table 2: Relationship between type of intervention, satisfaction and surgical complications.

Treatment orthognathic surgery + PMMA

Complication (no) Complication (yes)

Satisfied n (%) 3 (25%) 1 (50%)

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Very satisfied n (%) 9 (75%) 1 (50%)

p 0.52

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Treatment only PMMA

Satisfied n (%) 1 (20%) -

Very satisfied n (%) 4 (80%) 1 (100%)

p 0.04

J Braz Coll Oral Maxillofac Surg. 2021 Sept-Dec;7(3):64-70

Cavalcante WC, Espinheira PRD, Andrade KM, Figueiredo LMG, Cangussú MC, Azevedo RA

DISCUSSION This paper presented the use of PMMA implanted in solid form in the lateronasal region as a treatment modality to solve the esthetic problem of APMH.6 When comparing this material with other existing possibilities for the same purpose, there are some advantages in its use.2,6-9 Comparing PMMA to bone and fat grafts, and also with materials such as hyaluronic acid and polylactic acid, the advantage presented by the PMMA implant is that it will not present losses over time; thus, it will maintain the filling as obtained immediately after surgery.2,10,11 Prefabricated implants such as high-density porous ethylene have a slightly more difficult adaptation to the receptor bed, since they have less plasticity and do not allow great individualization of their design, while PMMA has an excellent ability to model the maxillary relief and adapt to it before polymerization, allowing customization according to each case. Also, even comparing it to porous high-density polyethylene, there is the financial advantage of cost, which is approximately 100 times lower in Brazil.7,12 Unlike materials placed installed by infiltration, which present the possibility of chronic inflammation, formation of granulomas, foreign body reaction, vascular obstruction and its consequences, such as tissue necrosis,2,13 it should be noted that this possibility did not occur in this patient series – although this complication seems highly unlikely, since PMMA in its solid form is implanted at the subperiosteal level.14 Comparing it to implants placed by infiltration, the possibility of inadequate positioning of PMMA is also very reduced, since during material adaptation it is easy to see its repercussions on the soft tissues. If the results obtained are not satisfactory, it can be repositioned, increased or decreased.2,6,15 PMMA itself applied in liquid form is considered a material that is difficult to remove,16 unlike solid PMMA, which, in one case of the present study, required removal due to failure of the rigid fixation system, which was performed in about 10 minutes in an outpatient setting, under local anesthesia.

This was not the case in this study, yet it is possible that implants for this region could also be made using computer-aided technology prior to surgery, which would reduce the surgical time and increase surgical costs.17-19 Concerning the complications observed, it should be noted that, in the case of the individual who reported mild pain on palpation, he stated that pain had very low intensity and was reluctant to remove the implants, con-

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

trary to the authors’ recommendation. In the event that one of the implants was displaced due to failure of the rigid fixation material followed by removal, the authors are currently planning the replacement of a new PMMA implant and its fixation in a thicker portion of the maxillary bone structure. In the case of central incisor paresthesia, which occurred in a patient who did not undergo Le Fort I osteotomy, the image examination of the region showed that there was a large distance between the fixation screw and the tooth root, and this situation occurred despite of that. Therefore, the authors believe that such possibilities should be informed to the following patients. The three complications observed in this study are interpreted by the authors as complications of low severity, contributing to this impression by the fact that they did not significantly interfere by decreasing satisfaction (Table 2).

One possible complication that did not occur is related to root perforation with the PMMA fixation screw.

To avoid this situation, careful observation of previous imaging exams and measurements is recommended.

The indication for the use of PMMA implants concomitantly with orthognathic surgery in patients with APMH is important to optimize the esthetic resolution of cases in which the maxillary movement required to solve the functional issues is of small magnitude and thus insufficient to solve the esthetic issues (Fig 4) without the need of more complex movements, such as clockwise rotation of the maxillomandibular complex.6,10 The exclusive use of PMMA to treat APMH is indicated for cases in which, despite the patients’ good dental occlusion, their appearance is aging, with flattening of the lateronasal region and deepening of the nasolabial fold (Figs 2 and 3). It is believed that, eventually, some orthodontic treatments may, observing all basic principles, treat anteroposterior deformities with orthodontic camouflage, followed by surgical camouflage with PMMA.10,11 The disadvantage of this technique, even when used without osteotomies, is the need for surgical access and bone exposure, which perhaps is an inconvenience for some patients.1 CONCLUSION The esthetic resolution of APMH with PMMA in the lateronasal area, placed in solid form, proved to be an efficient treatment option, with low rate of complications.

However, additional prospective studies in larger populations may be needed to confirm the present results.

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Polymethylmethacrylate in the aesthetic correction of anteroposterior maxillary hypoplasia: a series of 20 cases

References:

1. Terino EO. Alloplastic midface augmentation. Aesthet Surg J. 2005 Sep-Oct;25(5):512-20.

2. Quatela VC, Chow J. Synthetic facial implants. Facial Plast Surg Clin North Am. 2008 Feb;16(1):1-10.

3. Thirumurthy VR, Bindhoo YA, Jacob SJ, Kurien A, Limson KS. Prosthetic rehabilitation of postsurgical nasomaxillary hypoplasia for a patient following reconstructive surgery: a clinical report. J Prosthodont. 2011 Apr;20(3):224-7.

4. Abdo Filho RC, Oliveira TM, Lourenço Neto N, Gurgel C, Abdo RC. Reconstruction of bony facial contour deficiencies with polymethylmethacrylate implants: case report. J Appl Oral Sci. 2011 Aug;19(4):426-30.

5. Fattahi T, Salman S, Steinberg B. Augmentation of the infraorbital rim in orthognathic surgery. Int J Oral Maxillofac Surg. 2017 Oct;46(10):1315-8.

6. Esteves LS, Ávila C, Campos PSF. Preenchimentos estéticos na cirurgia ortognática: há indicações? Rev Clín Ortod Dental Press. 2016 Jun-Jul;15(3):33-59.

7. Romo T 3rd, Baskin JZ, Sclafani AP. Augmentation of the cheeks, chin and pre-jowl sulcus, and nasolabial folds. Facial Plast Surg. 2001 Feb;17(1):67-78.

8. Cohen SR, Berner CF, Busso M, Clopton P, Hamilton D, Romano JJ, et al. Five-year safety and efficacy of a novel polymethylmethacrylate aesthetic soft tissue filler for the correction of nasolabial folds. Dermatol Surg. 2007 Dec;33 Suppl 2:S222-30.

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9. Cohen S, Dover J, Monheit G, Narins R, Sadick N, Werschler WP, et al. Five-year safety and satisfaction study of PMMA-Collagen in the correction of nasolabial folds. Dermatol Surg. 2015 Dec;41 Suppl 1:S302-13.

10. Yaremchuk MJ, Doumit G, Thomas MA. Alloplastic augmentation of the facial skeleton: an occasional adjunct or alternative to orthognathic surgery. Plast Reconstr Surg. 2011 May;127(5):2021-30.

11. Yaremchuk MJ. Facial skeletal reconstruction using porous polyethylene implants. Plast Reconstr Surg.

2003 May;111(6):1818-27.

12. Barreto S, Paula DM, Quintas PH, Santana CD, Cerqueira A. Reconstrução de defeito em osso frontal com polimetilmetacrilato: relato de caso. Rev Odontol Arac. 2017 Maio-Ago;38(2):22-5.

13. Salles AG, Lotierzo PH, Gemperli R, Besteiro JM, Ishida LC, Gimenez RP, et al. Complications after polymethylmethacrylate injections: report of 32 cases.

Plast Reconstr Surg. 2008 May;121(5):1811-20.

14. Akan M, Karaca M, Eker G, Karanfil H, Aköz T. Is polymethylmethacrylate reliable and practical in fullthickness cranial defect reconstructions? J Craniofac Surg. 2011 Jul;22(4):1236-9.

15. Sclafani AP. Soft tissue fillers for management of the aging perioral complex. Facial Plast Surg. 2005 Feb;21(1):74-8.

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16. Wolfram D, Tzankov A, Piza-Katzer H. Surgery for foreign body reactions due to injectable fillers. Dermatology. 2006;213(4):300-4.

17. Turgut G, Özkaya Ö, Kayali MU. Computer-aided design and manufacture and rapid prototyped polymethylmethacrylate reconstruction. J Craniofac Surg.

2012 May;23(3):770-3.

18. Fiaschi P, Pavanello M, Imperato A, Dallolio V, Accogli A, Capra V, et al. Surgical results of cranioplasty with a polymethylmethacrylate customized cranial implant in pediatric patients: a single-center experience. J Neurosurg Pediatr. 2016 Jun;17(6):705-10.

19. Florentino VG, Mendonça DS, Bezerra AV, Silva Lde F, Pontes RF, Melo CV, et al. Reconstruction of frontal bone with custom-made prosthesis using rapid prototyping. J Craniofac Surg. 2016 Jun;27(4):e354-6.

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Case Report

Alternative technique with ductal preservation in sialolithiasis: case report CAIO CESAR SANTOS PATRON LUIZ1 | ANDRESSA BOLOGNESI BACHESK1 | LIOGI IWAKI FILHO1

ABSTRACT Sialolithiasis is an alteration derived from the development of calcified structures within the salivary duct system. Its treatment depends on the size and location of the sialolith and may range from salivary stimulation to surgical removal with or without the involved gland. Larger sialoliths located near the ductal ostium are often removed by intraoral access, with or without suture of the buccal floor mucosa. However, there are reports in the literature attesting the advantage of using materials that promote ductal repair during the healing process, thus avoiding complications such as fistula, stenosis and ductal fibrosis. Thus, this paper aims to report a successful clinical case of surgical excision by intraoral sialolith access in the Wharton duct, using a PVC catheter that was installed and sutured to the mucosa. This conduct resulted in the communication of the light of the duct with the external environment, maintaining its continuity, preventing its collapse, and consequently, promoting the formation of a new ductal ostium. It is concluded that the present technique brought a comfortable postoperative period, with symptomatology remission and restoration of the gland function more quickly, proving to be an adequate alternative approach for the treatment of this pathology.

Keywords: Salivary duct calculi. Submandibular gland. Surgery, oral.

How to cite: Luiz CCSP, Bachesk AB, Iwaki Filho L. Alternative technique with ductal preservation in sialolithiasis: case report. J Braz Coll Oral Maxillofac Surg. 2021 Sept-Dec;7(3):71-5.

DOI: https://doi.org/10.14436/2358-2782.7.3.071-075.oar

Universidade Estadual de Maringá, Departamento de Odontologia (Maringá/PR, Brazil).

1

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

Submitted: August 15, 2019 - Revised and accepted: October 23, 2019

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

Contact address: Caio Cesar Santos Patron Luiz E-mail: caiopatron@hotmail.com

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Alternative technique with ductal preservation in sialolithiasis: case report

INTRODUCTION Sialoliths are calcified structures that occur within the salivary ductal system. It is believed that they arise by the deposition of calcium salts around a focus of debris in the ductal lumen. 1 Its location is variable, with about 80% of salivary sialoliths in the submandibular gland or its duct, 6-15% in the parotid gland and about 2% in the sublingual salivary gland.2 The predominance of the submandibular gland can be explained by its anatomical characteristics (length and long, tortuous and ascending path of the Wharton’s duct), by its more alkaline saliva and by presenting a higher calcium concentration.3 Sialolithiasis does not have race predilection and is more common in middle-aged male adults, although it can happen in young, elderly and rarely in children.4 Edema is the most frequent clinical sign of sialolithiasis. In the anamnesis, it is common for the patient to report pain and swelling in the region of the affected gland during meals. 4,5 Clinical signs are often masked by partial obstruction of the duct, leading part of the saliva to overflow the stone and be eliminated. Conversely, complete obstruction of the duct can cause pain, constant swelling, associated or not with purulent secretion and clinical signs of infection. In addition, the persistence of infection for long periods can lead to atrophy of the affected gland, with consequent change in salivary secretion.5 The diagnosis of sialoliths located in the anterior 2/3 of the Wharton’s duct is associated with intraoral palpation and confirmed by occlusal and panoramic radiographs. 6 In situations where these techniques are not sufficient, it is necessary to use complementary methods such as computed tomography (CT), magnetic resonance (MR), ultrasonography (US), sialography or even duct endoscopy. 6 Treatment depends on the stone location. Small sialoliths, which do not obstruct the passage of saliva through the ducts, can be asymptomatic and may be treated by physiotherapy, milking of saliva and the use of acidic foods or sialogogues to stimulate saliva production, in an attempt to expel the sialolith. 1-3 However, larger sialoliths can obstruct the duct passage, causing pain, swelling and salivary infection of the involved gland, being treated by surgical removal. 5 When located in the distal portion of the duct, they are usually removed by intraoral access immediately above their position, and most cases are

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completed as follows: suturing only the mucosa; suturing the duct and mucosa separately; and, finally, suturing the duct with a cannula inside it, close to the mucosa.3-5 With the suture only in mucosa, there is a great risk of suture loosening with formation of fistula, with atrophy of the anterior portion of the duct.

Conversely, suturing the mucosa and the duct separately can lead to stenosis and fibrosis.3 Therefore, maintaining the duct continuity with the external environment is an important factor to be considered, since, besides avoiding these aforementioned complications, for cases in which there are clinical pictures of associated sialadenitis, it can help to eliminate purulent debris and foci of infection, promoting a comfortable and fast postoperative period and restoring glandular function.3 Thus, the objective of this study is to report, with informed consent of the patient involved, a successful clinical case of the use of an alternative technique, using a PVC tube, to preserve the continuity of Wharton’s duct with the external environment.

CASE REPORT A 70-year-old female patient attended the Maxillofacial Surgery service complaining of constant pain in the region of the left mandibular base, elevation of the left oral floor (Fig 1A), slight decrease in saliva production and increased pain during meals. On intraoral clinical examination, during the milking maneuver of the submandibular gland, there was purulent discharge from the duct ostium of this gland. Total occlusal radiographic examination and orthopantomography showed an irregularly shaped radiopaque image in the mouth floor on the left side (Figs 1B and 1C).

After medical evaluation regarding her underlying diseases (hypertension), the patient underwent a surgical procedure under local anesthesia to remove the stone. The procedure of choice was preceded by seven days of antibiotic therapy with 500 mg amoxicillin and a single 4 mg dose of dexamethasone 1 hour before surgery. The technique consisted of intraoral access, with anesthetic blockage of the lingual nerve on the left side and infiltrations surrounding the area to be incised. An incision was made in the mouth floor immediately over the hardened region of volume increase, with blunt divulsion, and then the sialolith was seen and removed (Figs 2A and 2B).

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A

A

B

B

C

C

Figure 1: A) Slight elevation of the left mouth floor. B) Occlusal radiograph of the mandible, showing radiopaque material in the lingual region of the left mouth floor. C) Panoramic radiography showing a radiopaque image in the edentulous region of the left mandible body.

Figure 2: A) Visualization and removal of salivary calculus. B) Sialolith removed. C) PVC catheter sutured to the margins of the ductal ostium.

A n. 14 urethral probe was placed and sutured to the mucosa, communicating the ductal lumen with the external environment, and maintained for 15 days (Fig 2C). There was regression of purulent discharge after one day of placement of this device and, consequently, a significant reduction in edema, as well

as relief of pain complaints on the second day after placement. At 30 days after surgery, the patient returned without clinical signs or pain in the region affected by the sialolith, showing complete ductal reconstitution obtained by maintaining her ostium with the PVC catheter (Fig 3).

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Alternative technique with ductal preservation in sialolithiasis: case report

A

B

Figure 3: A) Intraoral aspect, 30 days after surgery. B) Reconstituted Wharton’s duct ostium, 30 days postoperatively.

DISCUSSION The Wharton’s duct hilum or its distal third are the most prevalent sites for sialolithiasis. A retrospective study achieved findings in which approximately 67% were present in this location.7 Swelling is the most characteristic clinical sign and may be associated with pain and swelling in the gland region during meals. When the sialolith is not large enough to promote total duct obstruction, there may be no pain. However, with complete obstruction, saliva is not properly drained into the oral cavity, and thus its accumulated presence tends to become a focus of infection, with drainage of purulent secretions associated with pain and swelling in the region. In these situations, the literature reports the need for antibiotic prescription before surgical removal of the sialolith.5 In the case reported in this article, the patient appeared to have complete duct obstruction, both because of the absence of salivary drainage and because of the presence of a clinical status of acute infection.

Thus, antibiotic therapy was initiated prior to surgical planning.

Stones located in the distal third of the Wharton’s duct, if small, can be removed by physical therapy of milking maneuvers and the use of sialogogues. However, those with larger diameter usually require surgical removal, mainly by intraoral access.3-5 In the present case, the patient used lemon as a sialagogue during the period concomitant with antibiotic therapy, in addition to salivary milking, yet without success and with little pain reduction. Thus, we chose to perform the surgical procedure by intraoral access.

Some approaches are adopted for this type of surgery, such as sutures on the duct margins or even closure by second intention; however, the risk of collapse is imminent,

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as well as the formation of stenosis, fistula and sialocele.3-9 Thus, alternative methods are being studied to minimize the risk of complications. The use of cannulas has been reported in the literature, which, besides promoting adequate ductal repair and consequently minimizing the risk of the aforementioned complications, also function as a means of drainage and thus tend to achieve a resolution of infectious conditions more quickly.3 This corroborates the study by Kulkarni et al.9 in 2014, who used a cannula to treat a sialocele resulting from complication after removal of a sialolith from the parotid duct, with short-term success.

In the present clinical case, we chose to place a urethral probe tube in the duct’s path, which served as a shield to avoid collapsing of its walls, providing a wide exit area for saliva and purulent material, and especially for complete reconstitution of the duct. The present case had purulent flow for just one postoperative day and remission of pain complaints in two days, achieving satisfactory postoperative comfort. Other authors also used a urethral probe for the same purpose and observed preservation of salivary flow and glandular function, supporting the case reported in this article.10 FINAL CONSIDERATIONS It is concluded that there are several effective methods for the management of salivary pathologies; however, the responsible surgeon must choose the best technique according to the available resources and the local and systemic condition of the patient. Thus, the remission of symptoms, restoration of masticatory comfort and anatomical reconstruction of the ductal ostium were the main focuses adopted in this case.

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References:

1. Alves NS, Soares GG, Azevedo RS, Camisasca DR. Sialolito de grandes dimensões no ducto da glândula submandibular. Rev Assoc Paul Cir Dent. 2014 Fev;68(1):49-53.

2. Costan VV, Ciocan-Pendefunda CC, Sulea D, Popescu E, Boisteanu O. Use of cone-beam computed tomography in performing submandibular sialolithotomy. J Oral Maxillofac Surg. 2019 Aug;77(8):1656.e1-e8.

3. Parkar MI, Vora MM, Bhanushali DH. A large sialolith perforating the Wharton’s duct: review of literature and a case report. J Maxillofac Oral Surg. 2012 Dec;11(4):477-82.

4. Neville WB, Damm DD, Allen CM, Bouquot JE. Patologia das glândulas salivares. In: Patologia oral e maxilofacial. 3. ed. Rio de Janeiro: Guanabara Koogan; 2009. p. 461-63.

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5. Landgraf H, Assis A, Klüppel L, Oliveira C, Gabrielli M. Extenso sialolito no ducto da glândula submandibular: relato de caso. Rev Cir Traumatol Buco-Maxilo-Fac. 2006 Out;6(2):29-34.

6. Manzi FR, Amaro I, Silva AIV, Dias FG, Ferreira EF. Sialolito na glândula submandibular: relato de caso clínico. Rev Odontol Bras Central.

2010;19(50):270-4.

7. Zheng LY, Kim E, Yu CQ, Yang C, Park J, Chen ZZ. A retrospective case series illustrating a possible association between a widened hilum and sialolith formation in the submandibular gland. J Craniomaxillofac Surg. 2013 Oct;41(7):648-51.

8. Cobos MR, Muñoz ZC, Caballero AD. Sialolitos en conductos y glándulas salivales: revisión de literatura. Av Odontoestomatol. 2009 Nov-Dez;25(6):311-7.

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9. Kulkarni A, Chandrasala S, Nimbeni BS, Singh SP, Golai S. Management of an unusual case of iatrogenic parotid sialocele using an infant feeding tube: a novel approach. BMJ Case Rep. 2014 Oct 19;2014:bcr2014205845.

10. Oliveira TP, Oliveira INF, Pinheiro ECP, Gomes RCF, Mainenti P. Giant sialolith of submandibular gland duct treated by excision and ductal repair: case report. Braz J Otorhinolaryngol. 2016 Jan-Fev; 82(1):120-3.

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Case Report

Lip Lift – an alternative for facial and smile harmonization: case report RENATO DOS SANTOS1

ABSTRACT Lip Lift is a surgical procedure performed on the upper lip in order to improve aesthetics and bring harmony to the smile. The objective of the present article was to report a clinical case of Lip Lift for the aesthetic-functional treatment of the smile and the lips region. This study reports a surgical procedure on the lower third of the face. The criteria for diagnosis of long and low smile lines were reviewed, identifying signs that, together with the patients complaints, were decisive factors for the surgical approach. Extraoral surgical treatment was performed by subnasal incision and excision of the intended area, conferring better appearance to the smile and the habitual posture of the lip. There are non-surgical and surgical means to achieve better lip-facial harmony, as well as recovering function. The diagnostic criteria should be accurate, taking into account the disposal of less invasive procedures. The surgical techniques may be extraoral or intraoral, both aiming at better positioning of the upper lip, in accordance with the face of the individual. It can be concluded that Lip Lift is a safe procedure, guarantees naturalness and facial harmony. However, not all cases of long lip or male smile should be treated surgically.

Keywords: Face. Maxillofacial injuries. Surgery, oral.

How to cite: Santos R. Lip Lift – an alternative for facial and smile harmonization: case report. J Braz Coll Oral Maxillofac Surg. 2021 Sept-Dec;7(3):76-81.

DOI: https://doi.org/10.14436/2358-2782.7.3.076-081.oar

Clínica particular (Passo Fundo/RS, Brazil).

1

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

Submitted: December 21, 2018 - Revised and accepted: May 26, 2019

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

Contact address: Renato dos Santos E-mail: dr.renatobucofacial@gmail.com

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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Santos R

INTRODUCTION The search for beauty has been increasingly highlighted in the practice of oral and maxillofacial surgeons.

Patients who have a long upper lip, over the aging process, may present esthetic and functional impairment of the lip and smile. Lip Lift is an operative technique that may improve the esthetic appearance of the face and restore the smile harmony, together with the ideal proportions for each individual.1 Notwithstanding, the upper lip is often omitted by surgical facial esthetic treatments, even though it is highly visible and centrally presented. Lips that are well defined, proportioned and with great emphasis produce sensuality and beauty, besides participating in communication, eating and breathing. Techniques for lip restoration should improve the spatial position of the lip on the face, proportion in size and volume in relation to the lower lip, restore the anterior tooth appearance, favor the appearance of the lip vermilion and provide more lasting results than compatible non-surgical procedures.2 Diagnosis and precision for the surgical approach require training and clinical experience. The fact that oral and maxillofacial surgeons routinely work with the lips and attached structures of the face makes them the most suitable professional to describe the alterations or dysmorphisms present, as well as the best tissue repair, both in the functional condition and in esthetics. Altered conditions are those that are not beautiful or impair the accomplishment of physiological activities in which the lips participate (speech, chewing, swallowing and breathing).3 This article shows a simple surgical alternative for facial and functional harmonization of the face that, together with an accurate diagnosis, allows to improve the individual’s physical and psychosocial condition.

She presented a slight nasal deviation to the right, in the nasal pyramid and apex; left nasal wing slightly lower than the right; nasal dorsum without rhinotopic feature; prominent nasolabial folds; and hyperdevelopment (asymmetry) of the left hemiface compared to the right (Fig 2).

Smile analysis revealed a low smile line, small deviation of the dental midline, short buccal corridor, and not evident gingival zenith and embrasure (Figs 3 and 4).

With a millimeter probe, the end of the upper lip vermilion was measured, in smile position, up to the cervical region of upper central incisors. Therefore, this measurement was transposed to the upper lip skin in the subnasal region, identifying how much tissue should be removed. The incision region was demarcated in three points: lateral nasal wing (A), columella region (B) and contralateral nasal wing (C). In the second demarcation, three new points (D, E, F) were marked, parallel to those described above – but inferior – aiming at aligning the regions for subsequent suture, as well as informing the distance of the second incisional line, to guide the amount of tissue to be removed. An accessory marking was performed on the midline, following the point on the lip tubercle, as a posterior reference for the sutures (G point) (Fig 5).

The surgical procedure was performed under bilateral infraorbital intraoral infiltrative local anesthesia, with complementary anesthetic points in the intraoral and extraoral midline, surrounding the demarcation previously performed.

A horizontal subnasal incision was used, traced according to the pre-established demarcation, along the patient’s natural contours, starting from the side of one nasal wing to the other. This incision was directed towards the endonasal region as it passed through the nostril openings. Compression maneuvers for hemostasis were performed to improve visualization of the operative field. The second incision started at the initial nasal wing, following the initial predefined design (points D, E, F), ending at the contralateral nasal wing. Dissection was started up to the subdermal level, using a scalpel blade n. 11 and iris scissors. The amount of tissue removed followed the predefined demarcation according to the proposed plan.

Finally, simple sutures were performed using nylon 6.0 suture, starting at the midline (Fig 6), which were removed on the seventh postoperative day.

CASE REPORT Female patient, Caucasoid, aged 36 years, was assisted in a private clinic in the city of Passo Fundo/RS. In the history of current disease, she had great visual discomfort with long upper lip and little exposure of anterior teeth.

The facial analysis revealed a type II facial pattern, convex face, brachyfacial, mandibular retrognathism, maxillary protrusion, without compromising asymmetries, disharmony of proportions in the relationship between upper lip and lower lip (1.25:2), slightly inverted upper lip and long philtral columns (Fig 1).

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Lip Lift – an alternative for facial and smile harmonization: case report

Figure 1: Facial profile showing excess of the upper lip in relation to the lower.

Figure 2: Frontal view showing long philtrum columns and slightly inverted upper lip vermilion, disproportionate to the lower.

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Santos R

Figure 3: One of the surgical inclusion criteria, the low smile line.

A D

B E

Figure 4: One of the surgical inclusion criteria, the low smile line.

C F

G

Figure 5: Demarcation with reference points of the first incision (A, B, C) and points of union (guide) posterior to the excision (D, E, F), in addition to the central line (G).

Figure 6: Simple sutures with 6.0 nylon.

DISCUSSION It is estimated that, since 2010, approximately 13 million cosmetic procedures have been performed, including 1.6 million surgical procedures and the remaining non-surgical, involving the use of botulinum toxin and treatments with hyaluronic acid. Indications for lip procedures are judicious, and there are several manners to restore the lip and smile harmony.3 Hyaluronic acid-based grafts are the most used, although in some cases the need is not only to delineate or add volume to the lip, but also to raise it, since this enhances the lip vermilion, shortening it and adding to a good looking smile. Mainly in cases of low smile line, the surgical techniques of lip surgery are present because, in these cases, lip fillings bring esthetic damage

and smile dysfunction.4 Also, in cases where the patient has a long philtrum region or the distance from the nasal base to the vermilion edge is elongated, the lip is disproportionate and the vermilion is inverted, making it unsightly and less functional. Therefore, the smile analysis is crucial both for the diagnostic performance of the labial-oral region and for facial harmony.5 In the present case, the diagnosis was a precise surgical indicator, among the means available to improve the lip pattern, together with the patient’s expectations, individual desires and esthetic discomfort. The biological cost of removing the excess tissue present is a relevant point of discussion, since it is a definitive, not palliative measure – i.e., skin excision is irreversible – and other non-surgical means of lip eversion and projection using

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Lip Lift – an alternative for facial and smile harmonization: case report

biomaterials are less morbid and reversible. However, lip fillers would not be effective in the context of causal discomfort in the reported case, with inaccurate and erroneous measurements of lip filling, which would not be able to shorten the upper lip in an attempt to reach the ideal lip pattern, besides undoing the previously studied diagnostic principle. The decision to perform the Lip Lift procedure must be idealized and converted into specific factors, in agreement between the responsible professional and the patient. Both must understand and exclude minor procedures that may satisfy the patient’s usual complaints, such as, for example, the use of lip fillers. The result obtained in this case was successful, reaching the patient’s goal and expectations. Even with the surgical side effects of paresthesia and peripheral partial paralysis of the incised region later reversed, there was a great visible esthetic change, projection, shortening and eversion of the upper lip, which helped in modifying the anatomical position previously present, as well as in movements performed by the lips, including speech, chewing, breathing, facial and smiling mimicry.

A good understanding of facial analysis and skeletal discrepancies is an essential denominator before taking a soft tissue surgical approach. People with vertical maxillary excess must correct the skeletal disorder first, for later refinement in adjacent tissues. Skin thickness, age and skin type, according to Fitzpatrick, are also auxiliary criteria for the diagnostic conclusion and surgical definition.6 The use of surgical techniques can have great benefit. It is important to understand the present muscle dynamics and Lang lines, besides systemic understanding of the patient, as well as the surgical history of predisposition to hypertrophic scars, keloids and underlying diseases such as diabetes, for example.

Lip shortening techniques were described in the mid1950s to 1980s, with some authors combining the subnames of surgical designs, such as “bull’s horn” and “seagull’s wing”. Over the years, they included small changes, such as the endonasal introduction of flaps below the nostrils and their narrowing, to produce smaller scars and better restore the esthetics,7

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Technical adjustments by different operative managements aim at undercorrections, both in nostril opening and in the alar region. The amount of skin resection should not be small, with a mean of 5 mm, so that really noticeable changes can be promoted. In general, there are limitations in the techniques used. The first relevant point is that the lip corners are rarely lifted, so that significant change can be seen – which could help in this respect would be a corner lip lift. Cupid’s bow is no longer narrowed or even evident; only greater emphasis is given to the lip center.8,9 The result presented in this clinical case followed the limitations described in the literature, i.e., without lifting the lip commissures by the procedure and without any gain in evidence in the Cupid’s bow.

The benefits of lip lift should be measured and evaluated before the operative procedure. With clinical diagnosis by facial analysis, cephalometry, threedimensional projections, photographs and software capable of transporting the patient’s craniomaxillofacial data, it is essential to use them when there is doubt whether the operative approach is the best option, since, due to the skeletal discrepancies, the present soft tissue problems would not be resolved either, since they accompany the development of the bone framework.10 CONCLUSION The option of performing surgery for the treatment of lip comorbidities should be judicious. The diagnosis defines the surgical indication and should exclude less invasive rehabilitative possibilities with the potential for compatible recovery. The operative decision is a joint decision between professional and patient, and both must be aware of the real benefit, the technical scope available and its limitations, as well as the irreversible biological cost. Although the surgical technique of Lip Lift with extraoral incision produces a visible subnasal scar, this scar is masked by a shadow on the face, not esthetically compromising the labiodental region, as well as in combination with the face. The Lip Lift surgical technique proved to be effective in the reported case.

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References:

1. Moragas JS, Vercruysse HJ, Mommaerts MY. Nonfilling procedures for lip augmentation: a systematic review of contemporary techniques and their outcomes. J Craniomaxillofa Surg. 2014;42(6):943-52.

2. Raphael P, Harris R, Harris SW. The endonasal lip lift: personal technique. Aesthet Surg J. 2014;34(3):457-68.

3. Hupp JR, Ellis E, Tucker MR. Cirurgia oral e maxilofacial contemporânea. 6a ed. St. Louis: Elsevier; 2015. Cap. 26, p. 554-74.

4. Bernard CSC, Prevot H. Lifting de la lèvre supérieure / Upper lip lift. Ann Chir Plast Esthét.

2017;62(5):482-7.

5. Spiegel JH. The modified bullhorn approach for the lip-lift. JAMA Facial Plast Surg. 2019;21(1):69-70.

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6. Raphael P, Harris R, Harris SW. Analysis and classification of the upper lip aesthetic unit. Plast Reconstr Surg. 2013;132(3):543-51.

7. Sarnoff DS, Gotkin RH. Six steps to the “perfect” lip.

J Drugs Dermatol. 2012;11(9):1081-8.

8. Ponsky D, Guyuron B. Comprehensive surgical aesthetic enhancement and rejuvenation of the perioral region. Aesthet Surg J. 2011;31(4):382-91.

9. Weston GW, Poindexter BD, Sigal RK, Austin HW. Lifting lips: 28 years of experience using the direct excision approach to rejuvenating the aging mouth.

Aesthet Surg J. 2009;29(2):83-6.

10. Perenack JD, Biggerstaff T. Lip modification procedures as an adjunct to improving smile and dental esthetics. Atlas Oral Maxillofac Surg Clin North Am. 2006;14(1):51-74.

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11. Lee DE, Hur SW, Lee JH, Kim YH, Seul JH. Central Lip Lift as aesthetic and physiognomic plastic surgery: The effect on lower facial profile. Aesthet Surg J. 2015;35(6):698-707.

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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.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

• 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

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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-

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

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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