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

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

College of Oral and Maxillofacial Surgery JBCOMS

Geração de guias cirúrgicos Imaging

Management

Aquarium ©

Foto: Mike Bueno

3/27/17 7:00 PM

EDITOR-IN-CHIEF Belmiro Cavalcanti do Egito Vasconcelos

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

ASSOCIATE EDITOR-IN-CHIEF Gabriela Granja Porto

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

SECTION EDITORS Oral Surgery and Implants Cláudio Ferreira Nóia Danilo Passeado Branco Ribeiro Fernando Bastos Pereira Júnior Luis Carlos Ferreira da Silva Waldemar Daudt Polido Trauma Liogi Iwaki Filho Márcio Moraes Nicolas Homsi Ricardo José de Holanda Vasconcellos Orthognathic Surgery and Deformities Fábio Gamboa Ritto Fernando Melhem Elias José Laureano Filho José Nazareno Gil José Thiers Carneiro Júnior TMJ Disorders Eduardo Hochuli Vieira Eduardo Seixas Cardoso João Carlos Birnfeld Wagner Luis Raimundo Serra Rabelo Pathologies and Reconstructions Darceny Zanetta Barbosa Martha Alayde Alcântara Salim Renata Pittella Ricardo Viana Bessa Nogueira Sylvio Luiz Costa de Moraes Wagner Henriques de Castro Ad-hoc Editors André Luiz Marinho Falcão Gondim Diogo Souza Ferreira Rubim de Assis Eider Guimarães Bastos Hernando Valentim da Rocha Junior

Faculdade Ciodonto - Porto Velho/RO - Brazil Universidade Estadual do Rio de Janeiro - UERJ - Rio de Janeiro/RJ - Brazil Universidade Estadual de Feira de Santana - UEFS - Feira de Santana/BA - Brazil Universidade Federal de Sergipe - UFS - Aracaju/SE - Brazil Clínica particular - Porto Alegre/RS - Brazil Universidade Estadual de Maringá - UEM - Maringá/PR - Brazil Universidade de Campinas - FOP/Unicamp - Piracicaba/SP - Brazil Universidade Federal Fluminense - UFF - Niterói/RJ - Brazil Universidade de Pernambuco - FOP/UPE - Camaragibe/PE - Brazil Hospital Universitário Pedro Ernesto - UERJ - Rio de Janeiro/RJ - Brazil Universidade de São Paulo - Hospital Universitário - São Paulo/SP - Brazil Universidade de Pernambuco - FOP/UPE - Camaragibe/PE - Brazil Universidade Federal de Santa Catarina - UFSC - Florianópolis/SC - Brazil Universidade Federal do Pará - UFPE - Belém/PA - Brazil Universidade Estadual Paulista Júlio de Mesquita Filho - FOAR/Unesp - Araraquara/SP - Brazil Universidade Federal Fluminense - UFF - Niterói/RJ - Brazil Santa Casa de Misericórdia - Porto Alegre/RS - Brazil Universidade Federal do Maranhão - UFMA - São Luís/MA - Brazil Universidade Federal de Uberlândia - UFU - Uberlândia/MG - Brazil Universidade Federal do Espírito Santo - UFES - Vitória/ES - Brazil Universidade Federal do Espírito Santo - UFES - Vitória/ES - Brazil Universidade Federal de Alagoas - UFAL - Maceió/AL - Brazil Universidade Federal Fluminense - UFF - Niterói/RJ - Brazil Universidade Federal de Minas Gerais - UFMG - Belo Horizonte/MG - Brazil Universidade Federal do Rio Grande do Norte - UFRN - Natal/RN - Brazil Universidade Federal do Maranhão - UFMA - São Luís/MA - Brazil Universidade Federal do Maranhão - UFMA - São Luís/MA - Brazil Hospital Federal de Bonsucesso - Rio de Janeiro/RJ - Brazil

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

Quadrimestral ISSN 2358-2782

- REVIEW/COPYDESK: Ronis Furquim Siqueira - DATABASE: Cléber Augusto Rafael - COURSES AND EVENTS: Poliana Rocha dos Santos - COMMERCIAL DEPARTMENT: Roseneide Martins Garcia - LIBRARY/NORMALIZATION: Simone Lima Lopes Rafael - DISPATCH: Rui Jorge Esteves da Silva - FINANCIAL DEPARTMENT: Cléber Augusto Rafael - Lucyane Plonkóski Nogueira - RH: José Luiz da Luz Silva. O Journal of the Brazilian College of Oral and Maxillofacial Surgery (ISSN 2358-2782) Is a journal published three times a year of Dental Press Ensino

1. Cirurgia Bucomaxilofacial. I. Dental Press International.

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

CDD 21 ed. 617.605005 _______________________________________________________________________

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

table of contents

Editorial: Facing a challenge Belmiro C. E. Vasconcelos

Letter from the President: Results of the period 2016-2017 Sylvio Luiz Costa de Moraes

Interview Florencio Monje Gil

Special Working Group: teaching in CTBMF

Articles

Airway stability after orthognathic surgery: systematic review

A case of large granuloma gravidarum

Oral lipomas: clinical-therapeutic aspects in a university hospital

Intraoral styloidectomy in an individual with styloid-stylohyoid syndrome

Report of rare tongue neoplasm: schwannoma

Endo-surgical approach of radicular cyst: case report

Benign lipomatous neoplasm: case report

Marsupialization as definitive treatment for odontogenic keratocyst: case report and literature review

Thalles Moreira Suassuna, Taciana Cavalcanti Abreu, Lucas Alexandre de Morais Santos, José Wilson Noleto, Eduardo Dias Ribeiro

Matheus Santos Carvalho, Éwerton Daniel Rocha Rodrigues, Alan Leandro Carvalho de Farias, Thalita Medeiros Melo, Diogo Rego da Silva, Julio Cesar de Paulo Cravinhos

Alexandre Maranhão Menezes-Neto, Fábio Wildson Costa Gurgel, Mário Rogério Lima Mota, Francisco Samuel Rodrigues Carvalho, Mariana Gomes Coutinho, Eduardo Costa Studart Soares

Andressa Bolognesi Bachesk, Willian Pecin Jacomacci, Diogo de Vasconcelos Macêdo, Marcello Piacentini, Angelo José Pavan, Edevaldo Tadeu Camarini

Éwerton Daniel Rocha Rodrigues, Thalita Medeiros Melo, Alan Leandro Carvalho de Farias, Antonione Santos Bezerra Pinto, Marcelo Breno Meneses Mendes

Paula Cristina Santos Alves, Luís Ronaldo Picosse, Camila Porto de Deco, Íris Maria Fróis, Renata Amadei Nicolau

Gabriela Santos Lopes, Deyvid Silva Rebouças, Katalyne Xavier Silva, Antonio Lucindo Sobrinho, Lívia Prates Soares Zerbinati, Antônio Márcio Marchionni

José Rômulo de Medeiros, Carlos Bruno Pinheiro Nogueira, Eduardo Emim, Marcelo Ferraro Bezerra, Eduardo Costa Studart Soares

Condyle reconstruction with methacrylate in individuals with osteoradionecrosis Luiz Renério Prestes Dantas, Roque Miguel Rhoden, Andréia Vargas

Editorial

Facing a challenge During the management of Dr. Nazareno Gil (2014-2015) and continuing with the president Dr. Sylvio Morais (2016-2017), I was pointed to coordinate the Journal of the Brazilian College of Oral and Maxillofacial Surgery (JBCOMS). Interesting facts were experienced, since the initial gathering of manuscripts by email until the current system of manuscript management, the GNpapers. More than 140 manuscripts were reviewed, leading to publication of 9 numbers of the journal. Besides the publication of papers, we also established the section Central role of Oral and Maxillofacial Surgery and interviews with national and foreign professors. Currently, the journal is indexed in Latindex and has full possibility to be indexed in other databases. In 2017, another large step was taken: its online version in English language, besides classification as B4 in Qualis/CAPES. This academic heritage of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology should be maintained, since it represents the alive memory of knowledge on Surgery, primarily from Brazilian individuals. I would especially like to thank Dr. Gabriela Porto, the reviewers and the staff at Dental Press, who have been fundamental for such work.

How to cite: Vasconcelos BCE. Diante de um desafio. J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):4-5. DOI: https://doi.org/10.14436/2358-2782.3.3.004-005.edt

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):4-5

Editorial

During the assembly of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology, held in September 8th 2017 in SĂŁo Paulo, the professors Gabriela Porto and Nazareno Gil were indicated to guide this work from 2018 onwards. I hope I have contributed to the College and especially to the members. With warm regards.

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

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):4-5

Letter from the President

Results of the period 2016-2017 Dear colleagues, I am writing to you for the last time as President. At this moment, in first place, I thank God, who has guided me so far in this mission of life assigned to me. Second, I thank my family: my beloved wife, Maritza; my beloved children and grandson, Roberta, Leonardo, Sylvio and Ethan. Their love, care and support have been the fuel and reason of my life. Then, I say goodbye initially highlighting some aspects addressed as important by the 2016-2017 Executive Direction. Twenty-four months of management have passed, segmented in 8 trimesters, based on the 12 items of the management program presented when we took over during the Ordinary General Meeting of COBRAC in 2015, at the city of Salvador. The program items generated more than 100 procedures, or sub-items, that represented goals considered important for our society and specialty. Following we present a synthesis of the 35 subitems, described in detail in the report of the 2016-2017 Direction, which was presented at the Ordinary General Meeting of the XXIV COBRAC, attended by a significant number of members, and unanimously approved. For obvious reasons of institutional safety, values are not presented in this text. The Yearly Update Courses (CAT) and Educational Meetings (EED), free for regular members and paid by other professionals, with issuing of certificates at completion of activities for attendees with minimum frequency of 70%, were well received and, overall, were attended by 939 specialists. Besides the successful attendance, we achieved higher financial resources than the sum of regional events. The Commission of Informatics and Audiovisual Identity worked on the stage I of website redesigning and on creating an app for mobile phones for both Android and IOS platforms. The administrative restructuration of the secretariat and physical space of the headquarter was important for the new operational dynamics according to the changes made. Routines were established to allow more transparent general guidelines on the procedures and their instructions, designations and dismissals of functions by the President. Therefore, “administrative guidelines” were created at the headquarter, and “presidency acts” in the website.

How to cite: Moraes SLC. Resultados da gestão 2016-2017. J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):6-9. DOI: https://doi.org/10.14436/2358-2782.3.3.006-009.crt

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):6-9

Letter from the President

Credits were recovered for the College, contracts were canceled and renegotiated, and delinquencies of members were solved, which allowed expressive saving and strong cash for our institution, thus enabling reinvestment in continuing education, which was the core of this period. The old Bylaws and General Regulations underwent reformulation and modernization, with emphasis on the “re-stratification of membership categories”, which further highlighted the specialist, full, emeriti and redeemed members, and allowed access to other important categories for the present and for the future. Seven events were organized: 10th ENNEC (Manaus/AM), VIII ECEC (Juazeiro do Norte/CE), 13th COPAC (Sorocaba/SP), XXIV COBRAC (São Paulo/SP), Seminar on Advances in Facial Surgery (Porto Velho/RO), Seminar on Advances in Facial Surgery (Florianópolis/SC) and the First National Meeting of Oral and Maxillofacial Surgery Residents - I ENFACE (Rio de Janeiro/RJ). These events gathered 3,313 participants. The creation of training courses for organizers of College events in regional modalities, the Forum for event organizers of the CBCTBMF (FOVEC) that had two editions (10th ENNEC and 13th COPAC), and the training course for CBCTBMF event organizers (CAPEVESC) during the XXIV COBRAC, represented an important step to develop learning in events organization, at any level, by fellow chapter coordinators, event presidents or any colleagues who are interested and/or have future intention to engage in this type of activity . Learning in this field reduced the risk of technical and financial failures, which represent a potential risk for our institution. Another learning process comprised the development of systematic evaluation of companies for organization of College events, which led to selection of the company that organized the XXIV COBRAC and the company that will organize the XV COBRAC (Belém/PA, 2020). The College logo registration was completed at Instituto Nacional da Propriedade Industrial (INPI). The JBCOMS journal received an English version, which will allow its insertion in international research databases. The Labor Market Analysis Commission for Oral and Maxillofacial Surgeons in Brazil prepared the “Market Analysis Project for OMFS in Brazil”, which was submitted to the Federal Dental Council (CFO) by the official letter 047/2017. The work of Commissions of Residents Evaluation, Residency Teaching and Training, and Relationship with the Ministry of Education and Culture (MEC) & Federal Dental Council (CFO) for Issues of Interest to the Specialty allowed preparation of a report in defense of interests of the specialty (official letter 042/2017) and the decision that the College Board Examination will be held during regional events, such as the “Voluntary Examination for Access to the College”, while the situation between MEC, CFO and the College is not definitively solved. It was also possible to prepare the “Plan for the Standardization of Specializations and Residences in OMST (PPER-CTBMF)”, sent to the CFO and MEC by official letters 049 and 055/2017. The CFO was supported by the College in the issue concerning the Joint Note of the AMB, CFM, SBCP and SBD. An Elucidation Note was pre-

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):6-9

Letter from the President

pared and sent by official letter 048/2017. The College also provided support as AMICUS CURIAE in the CFM Action against the CFO. The abusive practice of health care operators was publicly repudiated by preparation of a Repudiation Note sent to CFO, ANS and CRO-RJ, which hosted a Public Audience, in which the College was represented. The referrals occurred by official letters 051, 052 and 053/2017. The Commission on Bioethics and Good Practice Recommendations continues to work on preparation of the “OPME Project” and of the “Hospital Dental Clinical Staff Project”. The Commission for Creation of the Quality Seal of the College concluded the work of designing the “Quality Seal” for the future granting of “Standard Residency”, highlighting the period of validity, to stimulate the constant progress of Residency Programs. The e-learning commission completed the initial task of recording 15 video lessons that are part of an integrated continuing education project. The Distance Learning Commission consolidated the specialty within the Telemedicine University Network (RUTE), with monthly meetings. This commission will have a future interface with e-learning activities. The Brazilian & International Board Implantation Commission initially proposed the progressive conversion of the “Examination for Category Change”, applied during the COBRAC, into a “Brazilian Board Test”, according to the reality of our country. The Commission for Relationship with International Institutions finalized the negotiations for the College to enter as a member of ALACIBU, paying only the value referring to the sum of Full and Emeritus Members. To finish the process, ALACIBU should only send the “invoice” for value transfer. Another achievement was the possibility of individual “corporate membership” with the “International College for Maxillo-Facial Surgery” (www.icmfs.com) at an extremely low annual cost. The Social Networks Commission played a key role in contemporary institutional visibility. The management of diffusion of institution actions was fast, comprehensive and integrated with the activities of the Executive Board, General Council, Advisory Commissions, Headquarter and Chapters. The work of the Social Commission allowed humanized relationship with the members and brought a very positive transit with other health professions. With the evolution of events and the interest of several commercial segments, the College has been analyzing new possibilities for sponsors, such as the national and international automobile industry, jewelers, watchmakers, perfumeries, among others. The “New Partnerships” project seeks agreements with the Brazilian Soccer Confederation (CBF), Brazilian Volleyball Confederation (CBV), Brazilian Boxing Confederation (CBBOXE), Mixed Martial Arts (MMA) / Ultimate Fighting Championship (UFC), among others. This will be possible as soon as the “CBCTBMF manual” is ready, so that we may introduce our institution to these potential partners. An important advance was the provision of Liability Insurance, individually contracted at a discount for members of all CBCTBMF categories.

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):6-9

Letter from the President

Conclusion of the analysis of agreement between CBCTBMF and IPEMED College, aiming at organization of a Lato Sensu Postgraduate Course on “Aesthetic Complements in Oral and Maxillofacial Surgery” for members of the College and other non-member maxillofacial surgeons, will be an extremely important quality differential in this area of interest. Utilization of the “go-to-meeting” app allowed non-presential organization of almost all meetings of event organizing commissions, board and advisory commissions, yielding significant institutional economy. With more than 100 meetings and considering the average cost of air tickets, hotel rates, land transfers and meals, this would result in much lower finances than could be left. The College participated in the launch of the Parliamentary Front of Dentistry in the Deputies Chamber in Brasília, which allows utilization of the “political pathway” as a voice of our specialty. At that time, 398 parliamentarians had already joined the Front. Despite all these events and investments, this Board finished with an excellent financial result and leaves a positive balance of approximately 274% (two hundred and seventy four percent) in relation to the one received. However, it is important to note that our “cash flow” is still far behind the financially recommended, and one of the important tasks that are part of our mission is to ensure the economic viability of our institution. This farewell is also the moment to thank the members for trusting the Board 2016-2017. To be president of the second largest institution of our specialty in the world, besides being an honor and a distinction, is also an immeasurable responsibility, which requires extreme and full dedication and faithful fulfillment of the “office liturgy”. It is also important to highlight the gratitude to the Board team for the results achieved, since they represent the outcome of an integrated work and motivated by all, such as Executive Board, General Council, Advisory Commissions, Capital and Regional Chapter Coordinators, Editors of JBCOMS Magazine, Event Organizing Commissions, Headquarter Administrative Staff, and we also to thank the support of our Press and Legal Advisors. To the dear friends and colleagues who have been called by the Creator, my best memories and eternal respect. To the Presidents before me, I thank you for having paved the way that led us here. I wish temperance and success for my successor, Dr. José Rodrigues Laureano Filho and his Board team, in the conduct of our beloved Brazilian College of Oral and Maxillofacial Surgery and Traumatology, the largest and best option of representation of our specialty. Finally, to the younger, I leave the thought of Goethe: “Whatever you can do or dream you can, begin it. Boldness has genius, power and magic.” Let’s go on! The work is not over, it is only changing hands! Sylvio Luiz Costa de Moraes President of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):6-9

MAIS PREVISIBILIDADE PARA SUA MAIS PREVISIBILIDADE PARA SUAPARA VOCÊ. CIRURGIA E MAIS COMODIDADE CIRURGIA E MAIS COMODIDADE PARA VOCÊ.

As guias cirúrgicas SurgeGuide são planejadas virtualmente a partir da conversão da As guias cirúrgicas SurgeGuide são planejadas virtualmente a partir da conversão da tomografia de face com modelos digitais. tomografia de face com modelos digitais. Confeccionadas em material biocompatível garantem alta precisão nos procedimentos em material biocompatível garantem alta precisão nos procedimentos eConfeccionadas excelente resultado facial esquelético. e excelente resultado facial esquelético.

Escaneamento de modelo não incluído

GUIA GUIA INTERMEDIÁRIO INTERMEDIÁRIO

0800 601 7277 contato@compass3d.com.br 0800 601 7277 compass3d.com.br contato@compass3d.com.br compass3d.com.br

GUIA FINAL GUIA FINAL Preços Preços sujeitossujeitos a alteração. a alteração.

PLANEJAMENTO Escaneamento de modelo não incluído PLANEJAMENTO

CBCTBMF

Design of a program to allow the rotation of residents, registered in residency programs approved and/ or accredited by the CBCTBMF h) Costs related with feeding, transportation, personal health insurance and housing will be afforded by the resident student. i) The resident student will only perform observational activities in the host institution, participating in theoretical, laboratory and practical activities, including outpatient units, visit to inpatient wards and operating theater. j) The host program will indicate a tutor, who will be in charge of guiding and explaining the program guidelines and rules. k) The tutor shall prepare a final report to the program coordinator and CBCTBMF of origin about the resident studentâ&#x20AC;&#x2122;s performance. l) Programs offering rotation internship will have discounts in the events organized by the CBCTBMF for both resident students and preceptors. m) At completion of the internship, the CBCTBMF will issue a certificate to the resident student.

REQUIREMENTS FOR THE RESIDENCY PROGRAM OF ORIGIN: 1. To be accredited or approved by the CBCTBMF; 2. The program coordinator should be a regular member of the CBCTBMF. REQUIREMENTS FOR THE RESIDENT: 1. The resident should be a regular member of the CBCTBMF; 2. To have concluded R1; 3. To contract a personal accidents insurance for 1-2 months; 4. To sign a commitment form (this eliminates any job relationships and elucidates the rights and duties of involved parties). General guidelines: a) Every year, the CBCTBMF will inform the residency programs offering internship, by a public notice published in the website. b) One post will be offered in each program that will receive the resident students. c) There will be a registration period, during which the candidate should register and send the requested documents. d) A scoring system shall guide the selection. e) The candidates will be selected and classified according to the score achieved. f) Tiebreaking criteria will be defined. g) The selection will be made by the candidates, according to their classification.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Criteria for classification and/or tiebreaking: The criteria for classification and/or tiebreaking will be timely defined.

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):11

UFF

Universidade Federal Fluminense

Associate Laboratory for Clinical Dental Research is established in UFF, Rio de Janeiro This is the first multiuser center dedicated to clinical dental research in the state, with huge benefits to the field of Oral and Maxillofacial Surgery Diuana Calasans Maia. The structure includes two complete dental offices, laboratory of histology and immunohistochemistry, cell and molecular biology, besides a tomography machine. “The laboratory offers all tools for accomplishment of human studies, with high quality”, states Prof. Dr. Mônica. The goal of LPCO is to connect the technological and clinical research. It is part of the Bioengineering Network of the State of Rio de Janeiro and INCT of Regenerative Medicine, which include renowned and

After seven years of studies on a new bone substitute biomaterial in animals, and then in humans, the biomaterials research group of Fluminense Federal University (UFF) established, in Niterói/RJ, the Associate Laboratory for Clinical Dental Research (LPCO). According to the president of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology, board 2016/17, Dr. Sylvio Luiz Costa de Moraes, “This is a milestone in clinical research in the state”. The LPCO is coordinated by the Associate Professor of the Discipline of Oral Surgery of UFF, Mônica

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):12-3

UFF

productive scientists, such as Prof. Dr. José Mauro Granjeiro (INMETRO), Prof. Dr. Alexandre Rossi (CBPF), Prof. Dr. Marcos Farina (UFRJ) and Prof. Dr. Antônio Carlos Campos de Carvalho (UFRJ). According to the coordinator of LPCO, in relation to science and research, the new laboratory will be a reference for human studies, following the “Good Clinical Practices” and within the guidelines of Resolution 466/2012. “The clinical research in the field of Oral and Maxillofacial Surgery will also be benefited, since though located in UFF, the center will receive professors from other institutions for multicenter studies”, states Prof. Dr. Mônica Diuana Calasans Maia. This is the first multiuser center dedicated to clinical dental research in Rio de Janeiro, associated to the Clinical Research Unit (UPC) of the University Hospital Antônio Pedro, of UFF, which is part of the National Clinical Research Network. “It should be highlighted that this project was only feasible by the financial support from the State of Rio de Janeiro Research Foundation (FAPERJ)”, finalizes the laboratory coordinator,

J Braz Coll Oral Maxillofac Surg. 2017 set-dez;3(3):12-3

UniLeão

University center from Cariri, in countryside Ceará, is highlighted in the national scenery In five years, 239 dental professionals have graduated. Currently, the university has 1,100 students in the specialty.

in the month, LACO organizes a surgery course, with invited professors or from the institution, also with discussion of clinical cases that catch the interest and encourage the students to the need for research”, says Bringel. The University Center created the Research Center in Oral and Maxillofacial Surgery (NUPESC), with studies conducted by students in their term papers (TCC) and Scientific Initiation. The research fields include surgery, anesthesiology and autonomic cardiac modulation. In 2015, it hosted the VIII Ceará Meeting of Oral and Maxillofacial Surgery and Traumatology (ECEC) and impressed the president of the Brazilian College of oral and Maxillofacial Surgery and Traumatology, board 2016/17, Dr. Sylvio Luiz Costa de Moraes, during a technical visit to the campus. “UniLeão has an amazing infrastructure, which is compatible with many foreign colleges. I was very satisfied to see that”, he said.

For those who believe that only large centers may offer adequate training in Dentistry, the UniLeão, located in the metropolitan region of Cariri, in countryside Ceará, proves the opposite. With an international level infrastructure, it has graduated 239 dental professionals since the course was authorized by MEC, in 2011. “We received the maximum score, 5”, proudly states the University Center Dean, Prof. Jaime Romero. He further adds: “The faculty of this course has been working to reach a level compatible with the best university centers in the country. For that purpose, the institution has a first world structure combined to a modern pedagogical project. The institution constantly invests in pedagogical training of professors and employs innovative methodologies, always considering the student as the focus of the teaching process”. The result of this effort was demonstrated during the in loco evaluation by the commission of MEC specialists, who again assigned maximum score to the Dentistry course of UniLeão. Currently, the University Center has 1,100 students in the course. Professor of UniLeão and Full Member of the Brazilian College of oral and Maxillofacial Surgery and Traumatology, Dr. Romildo Bringel emphasizes that, besides investing in the institution’s infrastructure, UniLeão also encourages professors to research and publish scientific papers, besides participating and presenting case reports in scientific events of the specialty, such as COBRAC, ENNEC and ECEC. Another difference is the Academic League of Oral Surgery (LACO). “LACO is very active in the region; every last Friday

From College to University Center In 2016, the Metropolitan Region of Cariri achieved the first university center in countryside Ceará. “We completed 15 years of establishment and this was certainly the gift that was most expected by the entire academic community. “With three teaching units in Juazeiro do Norte (CRAJUBAR, Saúde and Lagoa Seca), UniLeão achieved greater possibility to offer new graduation courses and expand the fields of research, extension and post graduation”, celebrates the Dean.

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):14-5

UniLeão

UniLeão and the community Another important aspect is the experience and availability of the Surgery professors for inpatient and outpatient services in the entire Cariri region. This enhances the poor population access to surgical treatments for free, and allows the students to closely observe the details of procedures performed in each treatment. “For example, in Dentistry, always under supervision of professors, the students perform clinical procedures, including esthetic restorations, endodontic treatments, oral surgeries and dentures. UniLeão has 100 dental offices, divided into 4 clinics with 25 offices each”, highlights Prof. Rodrigo Dutra Murrer. “Oral and Maxillofacial Surgery and Traumatology should be increasingly known and diffused to the society; so that, with institutions and well-trained professionals, we may request more attention, value and dedication from municipal, state and federal managers, for awareness, creation and maintenance of services of the specialty, offering proper care to the population”, finalizes the Full Members of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology, Dr. Romildo Bringel.

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2016/2017 Management Board Updated in May 21st, 2017 We shall work to achieve our “Institutional Mission” and thus to reach the “Vision” we intend to have, considering the highlighted “Values”.

Executive Direction President: Sylvio Luiz Costa de Moraes

Therefore, it is important to mention the Mission, Vision and Values of our College:

Vice-president: Manoel de Jesus Rodrigues Mello

MISSION OF CBCTBMF

General secretary: Alexandre Maurity de Paula Afonso

“To promote the development of Oral and Maxillofacial Surgery and Traumatology in Brazil, by scientific advances achieved by advanced education, enhanced research and exchange of experiences.”

Financial director: Hernando Valentim da Rocha Junior

VISION OF CBCTBMF

Scientific director: Alan Panarello

“To be acknowledged, by specialists in Oral and Maxillofacial Surgery and Traumatology and by the Scientific Community, as an Institution of National and International Reference”.

Executive director: Ricardo Pereira Mattos

Auxiliary Commissions 1. Labor Market Analysis Commission for Oral and Maxillofacial Surgeons in Brazil: Antonio Brito e Fernanda Brasil Daura Jorge Boos Lima 2. Commission of Residents Evaluation: Renata Pitella Cançado e Daniel Falbo Martins de Souza 3. Commission on Bioethics and Good Practice Recommendations: Sérgio Antônio Schiefferdecker 4. Commission for Creation of the Quality Seal of the College: Fernando Cesar Amazonas Lima e João Vitor Canellas

VALUES OF CBCTBMF Training and development – to promote conditions to enhance the professional performance of its members, with development of competences, which is the outcome of knowledge. Innovation – to search and encourage creativity in the establishment of innovative solutions for problem solving and for continuous improvement in patient care. Respect – to treat people with equity, dignity and cordiality. Trust – to develop credibility as a fundamental aspect in all relationships, and self-confidence as a consequence of training. Integration – to perform “benchmarking” and search for integration with health organizations in municipal, state and federal scopes. Commitment – involving people in the construction of a quality culture.

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JBCOMS News

5. E-learning commission: André Vajgel 6. Distance Learning Commission: João Carlos Birnfeld Wagner 7. Commission of Residency Teaching and Training: José Thiers Carneiro Junior 8. Brazilian & International Board Implantation Commission: Gabriel Pires Pastore, Waldemar Daudt Polido e Fernando Melhem Elias 9. Commission of Informatics and Audiovisual Identity: Rafael Vago Cypriano e Rafael Seabra Louro 10. Commission for Relationship with International Institutions: José Rodrigues Laureano Filho, Gabriel Pires Pastore, Nicolas Homsi, Marcelo Melo Soares, Paulo da Costa Rodrigues e Leandro Napier 11. Commission of Relationship with the Ministry of Education and Culture (MEC) & Federal Dental Council (CFO) for Issues of Interest to the Specialty: Marisa Aparecida Cabrini Gabrielli, Liogi Iwaki Filho e Marcelo Marotta Araújo 12. Regional and National Event Organizing Commission: Chapter Coordinator + Executive Director + Assigned Counselor 13. Commission of Strategic Planning: Geraldo Prestes de Camargo Filho, Angela Alves de Aguiar Goto 14. Social Networks Commission: Edmundo Marques do Nascimento Junior 15. Social Commission: Aira Maria Bonfim Santos

President of COPAC 2016: José Flávio Ribeiro Torezan President of COBRAC 2017: Luciano Mauro Del Santo President of ENNEC 2018: Luciano Schwartz Lessa Filho President of COPAC 2018: Cassio Edward Sverzut President of ICOMS 2019: Luiz Henrique Moreira Marinho President of COBRAC 2020: José Thiers Carneiro Junior

General Council Full members 1) Antenor Araújo – SP 2) Clóvis Prada – SP 3) Clóvis Marzola – SP 4) Eduardo Hochuli Vieira – SP 5) Eduardo Seixas Cardoso – SP 6) João Gualberto C. Luz – SP 7) Jonathas Daniel Paggi Claus – SC 8) Liogi Iwaki Filho – PR 9) José Thiers Carneiro Junior – PA 10) Luiz Henrique Moreira Marinho – MG 11) Nicolas Homsi – RJ 12) Paulo José D’Albuquerque Medeiros – RJ 13) Paulo da Costa Rodrigues – RJ 14) Ricardo José de Holanda Vasconcelos – PE 15) Sérgio Antônio Schiefferdecker – RS Past President: José Nazareno Gil – SC Alternate Counselors Cassio Edward Sverzut – Ribeirão Preto David Moraes de Oliveira – PE Maiolino Thomaz Fonseca Oliveira – Uberlândia

JBCOMS Editor-in-chief: Belmiro C. do Egito Vasconcelos Associate Editor-in-chief: Gabriela Granja Porto

Chapter Coordinators

Events President of ENNEC 2016: Jean Glaydson de Souza Fialho President of ECEC 2016: Romildo José de Siqueira Bringel

CHAP II (MT, MS, TO, GO, DF): Alan Panarello CHAP III (PI, MA, PA, AM, RO, RR, AP, AC): Julio Cesar de Paulo Cravinhos CHAP IV (PB, RN): Adriano Rocha Germano

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CHAP V (SE, AL): Álvaro Bezerra Cardoso CHAP VI (MG): Sergio Monteiro Lima Junior CHAP VII (RJ): Ricardo Pereira Mattos CHAP VIII (SP): José Flávio Ribeiro Torezan CHAP IX (PR): Leandro Eduardo Klüppel CHAP X (PE): David Moraes de Oliveira CHAP XI (RS: Bruna Rodrigues Fronza CHAP XII (CE): Lécio Pitombeira Pinto CHAP XIII (ES): André Alberto Camara Puppin CHAP XIV (SC): Jonathas Daniel Paggi Claus CHAP XV (BA): André Carlos de Freitas

course will address the following issues: trauma, reconstruction, orthognathic surgery, TMJ, oral surgery and implantology.

Regional Coordinators

5) Creation of smaller one-day events, as Symposia or Advanced Seminars, in regions in which the “low demographic density of specialists” does not allow regular Educational Meetings.

4) Continuation of Educational Meetings as an option for Chapters where the “Yearly Update Course in Oral and Maxillofacial Surgery and Traumatology (CTBMF)” may not be held, due to “low demographic density of specialists”. Certificates were also issued for individuals with at least 75% of attendance. The Educational meeting will address the same issues as the “Yearly Update Course”.

CHAP II: CHAP III: CHAP III: CHAP III: CHAP III: CHAP IV: CHAP V; CHAP VI:

André Luís Vieira Cortez – DF Lucas Machado de Menezes – PA Marcel Kiyoshi Lima Kimura – AM Luis Raimundo Serra Rabêlo – MA Pedro Ivo Santos Silva – RO e AC Rafael Grotta Grempel – PB Ricardo Viana Bessa Nogueira – AL Maiolino Thomaz Fonseca Oliveira – Titular – Uberlândia CHAP VI: Sandro Isaías Santana – Asp – Sul de Minas CHAP VII: Roberto Gomes dos Santos – Asp – RJ CHAP VIII: Fernando Melhem Elias – Titular – SP Cassio Edvard Sverzut – Titular – SP Rubens Guimarães Filho – Titular – SP CHAP IX: Davani Latarullo Costa – Asp – PR CHAP XI: Rodrigo Sofia da Rocha – Asp – RS

6) Organization of Regional Congresses in 2016: 10th North-Northeast Meeting of Oral and Maxillofacial Surgery and Traumatology (10th ENNEC), in Manaus; the Ceará Meeting of Oral and Maxillofacial Surgery and Traumatology (ECEC); and the 13th São Paulo Congress of Oral and Maxillofacial Surgery and Traumatology (13th COPAC), in Sorocaba; besides organization of our national Congress in 2017: the XXIV Brazilian Congress of Oral and Maxillofacial Surgery and Traumatology (XXIV COBRAC) in São Paulo. 7) Creation of training courses for organizers of events of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology: in Regional Congresses, the Forums for Organizers of Events of the College (FOVEC); in the Brazilian Congress, the Training Course for Organizers of Events of the College (CAPEVESC). These courses aimed to prepare a new generation of event managers, enhancing the organization and technical, scientific and financial outcomes

MANAGEMENT PLAN 1) Maintenance of all achievements of Board 20142015. 2) Administrative Reformulation of the Secretariat (headquarter).

8) To continue the Social Projects in partnership with Rede Globo and SESI, in the TV shows “Bem Estar Global” and “Ação Global”.

3) Implantation of the “Yearly Update Course in Oral and Maxillofacial Surgery and Traumatology (CTBMF)” in the Chapters, issuing certificates for individuals with minimum attendance of 75%. The

9) Establishment of the Scoring system of all activities of members. The system aims to facilitate the evolution to Full Member, as well as maintenance of such status of Full Members.

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JBCOMS News

10) To propose a new “membership” for the College. Currently there are four member categories (*): Aspirant, Full, Emeritus and Redeemed. However, in practice there are two: Aspirant and Full. Our Board proposed the creation of other three member categories, with different percentages of yearly fee, thus the members would be divided as follows:

14) Revision of the College website, making the access easier to the external population and members, gathering important information of interest to the specialty.

a. Academic member: undergraduate dental student.

16) Project Memory and Transparency: to create digital files for consultation by all members, available in the College website as a page with publications of the General Board, of either permanent nature (e.g. the Bylaws, General Regulation, General Handout for National and Regional Events, Chapter Coordinator Handout, Handout for Organizers of Educational Meetings, etc.) or temporary nature (related to the administration period: reports of Board Meetings, Decisions, Designations, Economy-Finance Reports).

15) Development and finalization of the College app for “smartphones”.

b. Collaborator member: graduate dental professional, not specialist in CTBMF. c. Aspirant member* (pre-existing, this will be reorganized): dental professional studying Specialization, Residency, Master and/or PhD programs in CTBMF. d. Effective member: dental professional specialist in (registered in CFO/CRO as specialist in CTBMF).

17) Aid to the College Members with need of juridical support will be analyzed by the Juridical Advisory Board (hired office), since a Board member could not take such responsibility.

e. Full member * (pre-existing): dental professional specialist in CTBMF (registered in CFO/ CRO as specialist in CTBMF), with score enough to maintain its category or score enough for pre-habilitation to undergo the examination and achieve this category.

18) Establish the actions proposed by the 15 created Commissions. The work of Commissions and goals of the Board aim at the future creation of conditions to make the College a “certifying institution” of the specialty.

f. Emeritus member (previous Redeemed member *).

19) To encourage the utilization of a “direct suggestions link”, in the website, to the Executive Board.

g. Honorary member* (pre-existing). 20) To routinely establish the Technical Visit to the Chapters.

11) Indexation of the College Journal, whose fourth number was published in the first semester of 2016.

21) To create the Report “1st Edition”, to diffuse updated information on the President and all Board members, besides the Executive Board: General Council, Commissions and Chapter Coordinators (both from capitals a

12) Utilization of videoconference app, such as the “Go-To-Meeting”, allowing integration of the entire country, and enhancing the diffusion of continuing education. 13) Project for establishment of the “Brazilian Board” of the specialty.

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interview

An interview with Florencio Monje Gil

Âť Head of the Oral and Maxillofacial Surgery Service of the University Hospital Infanta Cristina de Badajoz. Full Professor of the Medical School at Estremadura, Spain.

How to cite: Gil FM, Vasconcelos BCE. Entrevista com Florencio Monje Gil. J Braz Coll Oral Maxillofac Surg. 2017 set-dez;3(3):20-1. DOI: https://doi.org/10.14436/2358-2782.3.3.020-021.int Submitted: August 11, 2017 - Revised and accepted: September 12, 2017

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):20-1

Interview

What would you guide about the step by step of arthroscopy technique? The step by step of arthroscopy should always be the same. Since this is a virtual joint with reduced volume, it is necessary to perform arthrocentesis to expand the joint space, and a cannula with 2- to 2.5-mm diameter is introduced alike any endoscopy. First, a sharp and then blunt trocar is introduced. Then, a high-definition camera is introduced for interior inspection of the temporomandibular joint, only in the upper articular space. To allow some instrumentation, a second pathway of endoscopic access is necessary, usually anterior, through which you may introduce any type of instrument or small equipment to facilitate the maneuver. We always do this under general anesthesia.

How do you consider the current and future advances in TMJ surgery? The advances in temporomandibular joint surgery are not very modern. We have been working specifically on minimally invasive surgery for 23 years, yet it was never as popular as now, because there was lack of interest from the industry to manufacture the equipment used in this type of intervention. I believe that minimally invasive or arthroscopic surgery is here to last, and we should trust that it will gradually achieve better results. The future of temporomandibular joint surgery is based on endoscopy, and will possibly involve stem cells in the future. Do current surgical techniques have strong scientific evidence? In general, the temporomandibular joint surgery had slight problems regarding the scientific evidence. Retrospective studies, small sample sizes, and especially the lack of control group and lack of double-blind studies have been employed. Notwithstanding, there are very interesting publications about minimally invasive surgery. Currently, the percentage of improvement is 73 a 92% in a period of 2 to 13 years of follow-up. I believe this percentage of success is very interesting and valuable.

Prof. Dr. Belmiro C. E. Vasconcelos - Editor-in-chief of JBCOMS. - Associate Professor at the University of Pernambuco. - Coordinator of PhD and Master programs in Dentistry (Oral and Maxillofacial Surgery and Traumatology) at the University of Pernambuco.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):20-1

CBCTBMF

Special Working Group: teaching in CTBMF

I- IDENTIFICATION a) Name: Plan for Standardization of Specializations and Residencies in Oral and Maxillofacial Surgery and Traumatology (PPERCTBMF). b) Institution: Brazilian College of Oral and Maxillofacial Surgery and Traumatology.

Surgery and Traumatology. The programs vary from specialization courses, including groups of 12 (twelve) students, with monthly activities, for a maximum period of 24 (twenty-four) months, up to hospital residency programs, with daily activities, including oncall work, with duration of 36 (thirty-six) months and limit of 2 (two) students per group. Many courses are “on weekends” or “organized in modules”, yielding an extremely negative effect on the surgeon’s training. The specialty has evolved; currently, it has a diversified and sophisticated scope of work, requiring longer learning time to allow solid training and positive insertion in the labor market, avoiding unfortunate outcomes for the patients and, consequently, for Dentistry. Most countries present standardized training, with longer period for training of specialists. In the United States and Canada, to achieve a specialist degree, the surgeon should be graduated in Dentistry, approved in a board examination that certifies him or her to work as dentist, and should attend a residency program of 4 (four) or 6 (six) years; in this case, the oral and maxillofacial surgeon (CBMF) will finalize the program with both medical and dental training, and finally should be approved in an examination for certification and to allow working as specialist. In Japan, the residency program in Oral and Maxillofacial Surgery and Traumatology requires training for 5 (five) years. In Germany, United Kingdom and

II- PRESENTATION Oral and Maxillofacial Surgery and Traumatology (CTBMF) is the dental specialty that aims at diagnosis and treatments, surgical or coadjutant, of diseases, traumas, lesions and anomalies, either congenital or acquired, of the masticatory system and associated craniofacial structures, according to Guideline CFO n. 54, of November 2nd 1975. This regulation assures to the specialist the right to perform from minimally invasive surgical procedures in the dental office up to procedures with potential morbidity requiring hospital structure, including intensive care unit. The safe work of specialists requires a solid training, including a training program that offers wide knowledge not only on specific procedures of the field of work, but also on medical areas that work in collaboration, as a multidisciplinary team. The professional should also be able to make procedures to maintain the patient’s life when needed. Currently, in Brazil, there is no standardized model for training of specialists in Oral and Maxillofacial

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CBCTBMF

All this concern to organize this important dental specialty aims to maintain its space within Dentistry, and to allow the evolution of the specialty over the years to be based on solid knowledge and strict training, allowing individuals assisted by professionals in the field of Oral and Maxillofacial Surgery and Traumatology to have a worthy, updated and scientifically based treatment

most European countries, the specialist in Oral and Maxillofacial Surgery and Traumatology should be graduated in Medicine and Dentistry and should attend a residency program for 5 (five) years, plus a final examination for certification as specialist. In Latin America, the training of CBMF differs according to each country. In Argentina, there are 4 (four) specialization courses, being 2 (two) with duration of 4 (four) years and 2 (two) of 3 (three) years. In Cuba, there are 18 (eighteen) 3 (three)-year specialization programs. In Colombia, there are 7 (seven) specialization programs that last 4 (four) years. In Ecuador, there is 1 (um) 4 (four)-year specialization program. In Chile, there are 4 (four) specialization programs of 3 (three) years. In Dominican Republic, there is 1 (one) program of 3 (three) years. In Panama, there is 1 (one) program with duration of 3 (three) years. In Peru, there are 2 (two) programs of 4 (four) years. Venezuela has 3 (three) programs of 4 (four) years. In Uruguay there is 1 (one) 4 (four)-year program, and in Mexico there are 14 (fourteen) programs of 4 (four) years. Therefore, there is predominance of programs with duration of 4 (four) years in Latin America countries, and no program lasting 2 (two) years, except for Brazil. Currently, in Brazil, the programs are divided as follows: specialization programs lasting 2 (two) years or shorter, 3 (three)-year specializations and 3 (three)-year residencies. These programs do not undergo regular audit and do not require any examination for certification. In addition to the large difference in training period between courses in our country, the workload and program are also widely different, which consequently leads to formation of specialists with different qualification levels. It should also be mentioned that Resolution CNE/CES n. 1, of June 8th 2007, article 5, states that lato sensu post graduation courses for achievement of specialist degree should have minimum duration of 360 (three hundred and sixty) hours, besides the time of individual or group studies, without support from a professor, and the mandatory time dedicated for individual preparation of the monograph or term paper. This Resolution allows the recognition of specialist degrees even by specialization programs in the field of Oral and Maxillofacial Surgery with reduced workload

III- RATIONALE Currently, in Brazil, there is no standardized model for training of specialists in Oral and Maxillofacial Surgery and Traumatology. There are programs with diversified training in oral and maxillofacial procedures, mainly in full-time hospital residency scheme; and programs basically comprising surgical procedures outside the hospital environment, with a very short workload dedicated to inpatient procedures, besides division of procedures by a large number of students. If compared to most programs from North America and Europe, the Brazilian programs are behind in relation to medical and surgical disciplines. This evidences the need of standardization of programs for training of specialists in Oral and Maxillofacial Surgery and Traumatology, with solid training in procedures related with the specialty but also in related medical disciplines. IV- OBJECTIVES 1- Standardization of training of oral and maxillofacial surgeons in Brazil including the curriculum, workload, program, minimum infrastructure, and to establish a system for evaluation of programs, besides final evaluation for certification. 2- Dialogue with CFO and MEC, to put this standardization into practice. V- PROPOSED TRAINING MODEL General considerations a) All training programs for dentists to work in the field of Oral and Maxillofacial Surgery and Traumatology should meet the criteria based on “RESIDENCY TRAINING”, either paid or free. The residency programs related to Ministries of Health and/or Education, Municipal and State Health Secretariats should be free. b) The ongoing specialization courses will have time for adequacy to the new guidelines, with a time frame yet to be defined.

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CBCTBMF

eighty percent (80%), should be dedicated ro practical activities. h) The fourth year is optional and is usually dedicated to deepening the knowledge in one or two areas of the specialty. i) The workload of the fourth year should be added to the 8,640 (eight thousand, six hundred and forty) hours of the 3 (three) first years, with minimum weekly dedication of 40 (forty) hours. j) All residents should present minimum attendance of ninety-five percent (95%) for theoretical activities and one hundred percent (100%) for practical activities, to allow the course completion. l) The preparation of a term paper (TCC) with formal presentation is mandatory for course completion. m) The programs should address ninety percent (90%) of the specialty scope: oral surgery, maxillofacial pathologies, oral and maxillofacial reconstructions, oral and maxillofacial infections, facial traumatology, treatment of cleft lip and palate, temporomandibular joint surgeries, orthognathic surgeries and implantology. n) Oral and maxillofacial traumatology is a mandatory scope in resident training. Fields of knowledge: Oral and Maxillofacial Traumatology, Orthognathic Surgery, Surgery for individuals with cleft lip and palate, Reconstructive surgery for implants, TMJ surgery, Surgery for treatment of pathology/reconstruction.

c) The courses should have a quantity of preceptors compatible with the number of students (1 permanent preceptor for every 2 students). The permanent preceptors and tutors should necessarily be dentists, with specialization in Oral and Maxillofacial Surgery and Traumatology by acknowledged residency and/or specialization courses. The coordinator should have at least an MSc degree. d) The number of students will be determined according to the possibility to assure sufficient number of procedures under local and general anesthesia, overall comprising at most 6 (six) students for courses with 3 (three) years of duration, and 9 (nine) students in courses of 4 (four) years. e) New students should be admitted yearly, and the selection should be transparent, with clear guidelines and publicly diffused, respecting the individuality of the selection process of each program, except for those funded by MEC, which should meet specific guidelines for selection, according to the MEC regulations. f) The programs should present a minimum workload of 8,640 (eight thousand, six hundred and forty) hours, with minimum duration of 3 (three) years, with full-time dedication of 60 (sixty) hours per week. g) Twenty percent (20%) of the program workload should be dedicated to theoretical and theoretical-practical activities. The remaining workload,

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

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CBCTBMF

Minimum mandatory curriculum:

1st YEAR (R1) 2,880 (two thousand, eight hundred and eighty) HOURS Activity

Workload

Characterization

Theoretical program

576 h

Outpatient care and surgery

724h

Consultations, interconsultations, follow-up, preoperative preparation and surgical procedures under local anesthesia, with and without sedation, within the scope of the specialty.

180 h

Suggestions: to participate in outpatient attendance and visit the hospital rooms, with the Medical Clinics staff, to understand the complexity of pre, trans and postoperative periods. To be able to identify, plan and intervene, by adequate clinical procedures, and raise specific questions for the accomplishment of clinical discussions, considering the clinical evaluation of individuals with cardiopathies, with endocrinal, hematological and neurological alterations, kidney diseases, pregnant women, with immunological, hepatic and transmissible diseases, and to know the indication and interpretation of clinical analyses. To participate, observing or aiding the anesthesiologists, understanding the types of general anesthesia. To deeply know the equipment and material necessary for anesthesia, drugs used, drug interactions and pathologies that may influence the anesthetics, and to understand the entire process of pre and transoperative evaluation and post-anesthetic recovery. To recognize the main complications and understand their prevention, to be able to identify a cardiac arrest, understand the CPR maneuvers and criteria for transfer of patients to the ICU. To follow the clinical routine of an ICU, understanding the diversity of pathologies and complications of individuals, identifying approaches for stabilization, criteria for hospital discharge and professionals involved.

Surgery in the Operating Theater (Elective â&#x20AC;&#x201C; General Anesthesia)

700 h

To observe and aid surgeries of the specialty (field of work in CTBMF), as well as preparing the individuals, either in stabilization of the endotracheal tube, placement of surgical drapes and antisepsis. To work as auxiliary or main surgeon in small procedures, such as abscess drainage, surgeries for small pathological lesions, biopsies, wound sutures, dental splints, small grafts, closed reduction of fractures, besides other procedures.

Attendance in hospital emergency center

500 h

To perform fixed or call attendance in a hospital with emergency center that assists cases of polytrauma.

Visit to hospital rooms

200 h

To prescribe, write, prepare reports, request examinations, interpret clinical and imaging examinations, and understand the discharge criteria and bureaucracy of the entire hospitalization system, including the importance of social work.

Observational internship in clinical medical specialties (Medical Clinics, Anesthesiology, ICU, Endoscopy)

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

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CBCTBMF

2nd YEAR (R2) 2,880 (two thousand, eight hundred and eighty) HOURS Activity

Workload

Characterization

Theoretical program

576

Outpatient care and surgery

804 h

Consultations, interconsultations, follow-up, preoperative preparation and surgical procedures under local anesthesia, with and without sedation, within the scope of the specialty, performing surgery for placement of multiple implants and grafts.

100 h

Surgery in the Operating Theater (Elective â&#x20AC;&#x201C; General Anesthesia)

700 h

To observe and aid surgeries of the specialty (field of work in CTBMF), as well as to work as main surgeon in medium complexity procedures, including treatment of fractures, grafts, extensive and complex sutures, extraoral surgical access, application of rigid fixation methods, besides other procedures.

Attendance in hospital emergency center

500 h

To perform fixed or call attendance in a hospital with emergency center that assists cases of polytrauma.

Visit to hospital rooms

200 h

Observational internship in clinical medical specialties (Medical Clinics, Anesthesiology, ICU, Endoscopy)

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):22-9

CBCTBMF

3rd YEAR (R3) 2,880 (two thousand, eight hundred and eighty) HOURS Activity

Workload

Characterization

ATLS; perioperative care; clinical and surgical management of individuals with systemic disease; contents on anesthesiology, pharmacology, healing/repair, pathology, semiology; ethics and bioethics, surgical technique, nutrition, nursing, speech therapy and physical therapy; contents of the specialty (trauma, infections, principles of fixation, treatment of pathologies, reconstructions of soft and hard tissues, implantology, orthognathic surgery, cleft lip and palate, craniofacial syndromes, TMJ, facial pain, minor oral surgery, imaging examinations applied to CTBMF); content of related medical fields and related dental fields and presentation of term paper. Consultations, interconsultations, follow-up, preoperative preparation and surgical procedures under local anesthesia, with and without sedation, within the scope of the specialty, performing surgery for placement of implants and grafts, including advanced techniques.

Theoretical program

576 h

Outpatient care and surgery

804 h

Observational internship in clinical medical specialties (Neurosurgery, Head and Neck, Plastic Surgery, Ophthalmology and Otolaryngology) (observational)

100 h

To observe and understand the work of related surgical areas, to identify procedures that may aid the resolution of cases and know the specificities of surgical technique in the field of internship.

Surgery in the Operating Theater (Elective – General Anesthesia)

700 h

To observe and aid surgeries of the specialty (field of work in CTBMF), as well as to work as main surgeon in high complexity procedures, including treatment of complex fractures, grafts, extensive and complex sutures, wide extraoral surgical access, treatment of sequelae, application of rigid fixation methods, orthognathic surgeries, TMJ surgeries, tumor resections and reconstructions, besides other procedures.

Attendance in hospital emergency center

500 h

To perform fixed or call attendance in a hospital with emergency center that assists cases of polytrauma.

Visit to hospital rooms

200 h

4th YEAR (R4) 1,920 (one thousand, nine hundred and twenty) HOURS Activity

Workload

Characterization

Theoretical program

384 h

Outpatient care

300 h

Specific theoretical content of the selected field of knowledge. Evaluation, planning and follow-up of cases that will be operated in the field or fields of knowledge offered by the service for R4 students.

Surgery in the Operating Theater (Elective – General Anesthesia)

1000 h

To observe, aid and accomplish procedures in the field or fields of knowledge offered by the service.

Visit to hospital rooms

236 h

To prescribe, write, prepare reports, request examinations, interpret clinical and imaging examinations of cases operated in the field of knowledge of R4 student.

NOTES: The fourth year is not required.

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CBCTBMF

VI – EVALUATION OF PROGRAMS AND CERTIFICATION AS SPECIALIST

g) All residents/specialist students from programs approved or approved with restriction should undergo the certification examination applied by the BRAZILIAN COLLEGE OF ORAL AND MAXILLOFACIAL SURGERY AND TRAUMATOLOGY (CBCTBMF), which will be offered yearly, to have their titles validated by MEC. For that purpose, the program coordinator should submit the resident’s grade report, attendance, certificate of term paper presentation, and a brief report about the resident, mentioning that the resident/specialization student is ready to undergo the examination. h) If the resident is reproved, he or she may repeat the examination as many times as necessary; however, the examination will only be applied once a year. i) The title will be validated by MEC after examination by the Brazilian College of Oral and Maxillofacial Surgery and Traumatology (CBCTBMF). The examination will be prepared by professionals from MEC, CFO and CBCTBMF.

General considerations a) The programs will be evaluated by a mixed commission, including specialists in CTBMF, from another state than that of the program. The Commission will be composed of 3 (three) trained professionals, being 1 (one) member indicated by the Brazilian College of Oral and Maxillofacial Surgery and Traumatology (CBCTBMF); other indicated by the Federal Dental Council (CFO), also of this specific area of knowledge; and the last member will be indicated by Ministry of Education and Culture (MEC) from a bank of professionals trained for that purpose. The Commission’s president will be the member with highest academic degree, initially, and of older age in case of similar titles. b) The evaluation shall be applied to new and ongoing programs and should be renewed at every 6 (six) years. The evaluation will occur upon request of the program coordinator to the CBCTBMF, which will be in charge to define the yearly evaluation cycle and invite the other examiners from the CFO and MEC. If the programs DO NOT require evaluation, the residents shall not be allowed to participate in the certification examination. c) The costs related with airfare and lodging of examiners will be afforded by each institution indicating the member (CBCTBMF, CFO and MEC). d) The evaluation system should last at most 48 (forty-eight) hours, including visit to the facilities, interview for filling of questionnaires by the coordinator and residents/specialization students, as well as documents to verify if the minimum curriculum and infrastructure are being met to provide the necessary training. e) If the institution offering the residency/specialization program wishes to speed up the evaluation process, it may cover the payment of all expenses for the examiners. f) After evaluation, the programs may be classified as approved, approved with restrictions and reproved. The approved with restrictions should solve the indicated problems until the following re-evaluation. The reproved programs will NOT be accredited until regularization, as observed in the following evaluation.

VII– MINIMUM INFRASTRUCTURE REQUIRED To develop Residency Programs in Oral and Maxillofacial Surgery and Traumatology, the following minimum structure is necessary: a) Hospital or Hospitals should include: » staffs of different medical specialties; » urgency and emergency center with reference to assist cases of polytrauma; » imaging sector: - ultrasound; - computed tomography; - conventional X-ray machine; - magnetic resonance imaging; » intensive care unit; » adults’ and children’s wards; » equipped operating theater; » blood bank; » clinical analysis laboratory; » pharmacy sector; » call room; » meal room. b) Supporting structure » library; » classroom and/or auditorium; » meal room;

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):22-9

CBCTBMF

Authors: Adriano Rocha Germano. Daniel Falbo Martins de Souza. Geraldo Prestes de Camargo Filho. José Thiers Carneiro Junior. Liogi Iwaki Filho. Marisa Aparecida Cabrini Gabrielli.

» equipped outpatient unit for attendance and outpatient surgeries; » computer room; » availability of media and tools for search in scientific databases. c) Human resources: » supporting staff (administrative); » professors/tutors and preceptors, in compatible number with the number of resident students: ideally, 2 (two) residents / 1 (one) preceptor; » adequate training and titles for preceptors/tutors and professors. Special Working Group (GET)

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):22-9

OriginalArticle

Airway stability

after orthognathic surgery: systematic review THALLES MOREIRA SUASSUNA1,2 | TACIANA CAVALCANTI ABREU1,3 | LUCAS ALEXANDRE DE MORAIS SANTOS4,5 | JOSÉ WILSON NOLETO6,7 | EDUARDO DIAS RIBEIRO8,9,10

ABSTRACT Objective: The aim of this study was to perform a systematic review on the dimensional stability of the upper airway (UAW) after orthognathic surgery. Methods: A systematic search in PubMed and Web of Science was performed, using the acronym PICO strategy and a guiding question to conduct the search. The research used the medical subjects headings (MeSH) terms and frequently used keywords, associated with the Boolean operators “and” and “or”. Main inclusion criterion used were: articles that evaluated, through CT scans, the upper airways of patients undergoing orthognathic surgery preoperatively and at least two times after the surgery. Results: A total of 3,490 articles from the two databases were found and subjected to the eligibility criteria. At the end, only eight articles were included. In a wide age range and balanced distribution between genders, different results in postoperative evaluations were observed, tending to return to the initial volumes. Conclusion: The UAW are extremely dynamic structures, however more studies with more controlled methods should be conducted to confirm these impressions. Keywords: Orthognathic surgery. Sleep apnea, obstructive. Osteotomy.

Hospital Getúlio Vargas, Clínica Bucomaxilofacial (Recife/PE, Brazil). Graduated in Dentistry, Universidade Federal da Paraíba (João Pessoa/PB, Brazil). Doctor in Oral and Maxillofacial Surgery, Universidade de Pernambuco, Faculdade de Odontologia de Pernambuco (Camaragibe/PE, Brazil). 4 Universidade de Pernambuco, Faculdade de Odontologia de Pernambuco, Programa de Doutorado em Odontologia - Cirurgia e Traumatologia Bucomaxilofacial, (Camaragibe/PE, Brazil). 5 Master’s Degree in Oral and Maxillofacial Surgery, Faculdade de Odontologia de Pernambuco (Camaragibe/PE, Brazil). 6 Universidade Federal da Paraíba, Disciplina de Traumatologia Bucomaxilofacial (João Pessoa/PB, Brazil). 7 Doctor, Master and Specialist in Oral and Maxillofacial Surgery, Universidade do Estado do Rio de Janeiro (Rio de Janeiro/RJ, Brazil). 8 Universidade Federal de Campina Grande, Disciplina de Cirurgia e Traumatologia Bucomaxilofacial (Campina Grande/PB, Brazil). 9 Doctor and Specialist in Oral and Maxillofacial Surgery, Faculdade de Odontologia da Universidade Estadual Paulista (Araçatuba/SP, Brazil). 10 Master and Specialist in Stomatology, Universidade de São Paulo, Faculdade de Odontologia de Bauru (Bauru/SP, Brazil). 1

How to cite: Suassuna TM, Abreu TC, Santos LAM, Noleto JW, Ribeiro ED. Estabilidade das vias aéreas após ortognática: revisão sistemática. J Braz Coll Oral Maxillofac Surg. 2017 setdez;3(3):30-6. DOI: https://doi.org/10.14436/2358-2782.3.3.030-036.oar

2 3

Submitted: July 14, 2016 - Revised and accepted: August 31, 2017 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. Contact address: Thalles Moreira Suassuna Av. General San Martin, s/n, Cordeiro – Recife/PE – CEP: 50.630-060 Hospital Getúlio Vargas, Trauma C, 2º andar E-mail: thallesms_@hotmail.com

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):30-6

Suassuna TM, Abreu TC, Santos LAM, Noleto JW, Ribeiro ED

INTRODUCTION Orthognathic surgeries are performed for the treatment of congenital or acquired dentofacial deformities, aiming to restore the occlusion and facial harmony. Several techniques and movement options (advancement, setback and rotations) allow repositioning of the maxilla and mandible and, considering the muscle attachments, they may also cause direct effects on the soft tissues.1,2,3 Several studies indicate narrowing of the upper airway (UA) after correction of Class III dentofacial deformities (DFDs) by mandibular setback.4-7 They also indicate that maxillomandibular advancement may widen the airway, to an extent enough to indicate it for the treatment of obstructive sleep apnea.1,8,9 The obstructive sleep apnea (OSA) is the dynamic occlusion of the pharynx with interruption of the airflow due to lack of muscle tonus, during sleep, with or without oxygen desaturation.8,10,11 This persists until the occurrence of micro-awakening for breathing recovery, which causes fragmentation of sleep. There are signs and symptoms as snoring, daytime somnolence, cognitive deficiencies, loss of libido, predisposition to cardiovascular diseases and involvement in accidents.12,13 Due to the high occurrence of OSA (estimated in up to 24% in males13) and its close relationship with the posterior airway space, there is increasing interest in the study of the UA and its relationship with orthognathic surgery.1,2,3 Several systematic reviews corroborate the impact of surgeries on these structures.14,15 However, little is known about the long-term stability. This study conducted a systematic review on the stability of the UA in individuals submitted to orthognathic surgeries

MATERIAL AND METHODS A protocol based on the PICO acronym strategy was developed and a guiding question was established to guide the study onset and conclusion (Table 1). The goal was to gather studies with similar methodologies that allowed to evaluate whether the UA measurements remained stable during the postoperative period. The inclusion criteria comprised papers fully indexed in PubMed or Web of Science (without restriction of language or date); studies conducting tomographic evaluation (without restriction of software) of the UA in individuals submitted to orthognathic surgery (any facial pattern); studies with preoperative and at least two postoperative evaluations; and, necessarily, performing sagittal osteotomy of the mandibular ramus, total Le fort I maxillary osteotomy, or horizontal basal osteotomy of the chin. The exclusion criteria were papers in which the study population presented syndromic facial characteristics; papers on individuals previously submitted to other airway surgeries; and papers without statistical analysis of results. For the literature survey, the databases were searched using the combinations of selected terms and Boolean operators “AND” e “OR”, to relate the UA and orthognathic surgery. The selection of terms included the controlled vocabulary (MeSH and entry terms of PubMed), which are descriptors indexed in the database. However, to extend the search, a non-controlled vocabulary was also included, e.g. synonyms, abbreviations, related terms, keywords and spelling variations.

Table 1: PICO acronym and guiding question.

P – “Population”

Individuals submitted to orthognathic surgery

I – “Intervention”

Surgical correction involving the anteroposterior region of the maxilla and/or mandible

C – “Comparison”

Comparison between different orthognathic surgeries indicated for different groups of individuals

O – “Outcomes”

Dimensional alterations (volumetric) of UA at different postoperative periods, measured on the tomograph

Guiding question

Are changes from orthognathic surgery on the UA stable?

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):30-6

Airway stability after orthognathic surgery: systematic review

Table 2: MeSH terms and entry terms employed. MeSH Term

Orthognatic Surgery

Airway Remodeling

Entry Terms

Orthognathic Surgeries Surgeries, Orthognathic Surgery, Orthognathic Maxillofacial Orthognathic Surgery Maxillofacial Orthognathic Surgeries Orthognathic Surgeries, Maxillofacial Orthognathic Surgery, Maxillofacial Surgeries, Maxillofacial Orthognathic Surgery, Maxillofacial Orthognathic Jaw Surgery Jaw Surgeries Surgeries, Jaw Surgery, Jaw

Airway Remodelings Remodeling, Airway Remodelings, Airway Airway Wall Remodelling Airway Wall Remodellings Remodelling, Airway Wall Remodellings, Airway Wall Wall Remodelling, Airway Wall Remodellings, Airway Airway Remodelling Airway Remodellings Remodelling, Airway Remodellings, Airway

The selected papers were case series ex post facto published between 2012 to 2015. Five were from South Korea; one from USA, and one from Brazil, all related to university hospitals and colleges and post graduation programs in the field of Dentistry. Most papers (six) were restricted to individuals with Class III (submitted to double-jaw surgeries); one was heterogeneous (Classes II and III submitted to advancement or setback single-jaw surgeries) and one was restricted to Class II individuals (submitted to bimaxillary advancement). No study included a specific group of individuals with diagnosis of OSAS. The mean age of individuals ranged around the third decade of life, with maximum variation of 15 to 57 years (between different papers) and reasonably balanced distribution between genders (Table 2). Among the eight papers, six had evaluations at two postoperative periods and two papers conducted three postoperative evaluations. All studies were conducted on cone-beam computed tomographies (CBCT). Several softwares were used for observation of CTs and measurement of UA, and the InVivo Dental 3D was used in three studies; OnDemand 3D in two studies; and the others (Mimics, Osirix, BrainLab, CB Works and Dolphin) in a single study. Also, there was variation in the subdivisions of UA: six studies

The search strategy was performed as follows: “Orthognathic Surgery” OR “entry terms” AND “Airway remodeling” OR “entry terms” OR “Upper Airways” OR “Pharyngeal Airway” OR “Oropharyngeal airway”. The systematic search was independently performed by two previously calibrated authors, followed by reading of titles and abstracts. Papers fully meeting the inclusion criteria or suspected to meet the methodology were selected for full-text reading. After reading, final selection was performed, and data were extracted using a form. RESULTS The systematic search was performed on January 2016 and retrieved 978 papers in PubMed and 2,512 in Web Of Science, published between 2003 and 2015. Among these, 90 aimed to evaluate the UA in individuals submitted to orthognathic surgery and their titles and abstracts were read. After reading, 9 were included for full-text reading, and ultimately only 8 papers fully met the inclusion criteria and were selected for the study. Due to the previous calibration of examiners and objectivity of inclusion criteria, there was no disagreement between examiners concerning the selection of papers.

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Suassuna TM, Abreu TC, Santos LAM, Noleto JW, Ribeiro ED

ther statistically significant or not, for advancement or setback of segments (Table 3). These postoperative changes (instability) were not directly related with skeletal relapse. Meta-analysis of data of the primary studies could not be performed due to lack of information on the standard deviation, which is mandatory for such statistics.

divided the UA in nasopharynx, oropharynx and hypopharynx (varying the method of delineation of each subregion); one subdivided in upper and lower space; and other paper conducted the analysis referring to the total volume of the UA (Table 2). There was large variation between the follow-up period and periods of achievement (T) of CTs. The first postoperative T (T1) ranged from one day to six months; and the period of achievement of the last CT (TF) ranged from two years (two papers) and six months (four papers) (Table 3). Concerning the stability, only one group of individuals (20 Class III submitted to mandibular setback) did not present changes in the Total Volume (VT) between T1 (≈4.6 months) and TF (1.4 years). However, there was morphological alteration. In the other studies, there were always changes in the dimensions, ei-

DISCUSSION These complex dynamic structures were traditionally analyzed on lateral cephalograms. This method had the advantage of low cost and low radiation dose. However, it caused superimposition of contralateral structures and allowed evaluation only in two dimensions, in the sagittal plane.9,16 However, the advent of digital images – such as computed tomography (CT)

Table 3: Overall data of selected papers. M: male; F: female; Ts: Postoperative period when tomographies were obtained; TC: Computed tomography; CB: Cone Beam; UA: Upper airway. M/F ratio

Type of CT

Software

Subdivisions of the UA

21 - 33

8/7

CBCT

InVivo Dental 3D

Class III

17 - 44

16/22

CBCT

InVivo Dental 3D

San Francisco, USA

Class II Class III

15 - 43

11/22

CBCT

CB Works

2014

Zurich, Switzerland

Class III

19 - 44

3/8

CBCT

Mimics Osirix Brainlab

Kim et al.16

2013

Seoul, South Korea

Class III

17 - 48

14/11

CBCT

InVivo Dental 3D

Lee et al.17

2012

Seoul, South Korea

Class III

22,7* (average)

6/15

CBCT

OnDemand 3D

Park et al.8

2012

Busan, South Korea

Class III

19 - 29

23/13

CBCT

OnDemand 3D

Carvalho et al.3

2012

Araraquara, Brazil

Class II

19 - 57

11/9

CBCT

Dolphin Image 3D

Author

Year

Place of origin

Group of Age range patients (years)

Shin et al.9

2015

Seoul, South Korea

Class III

Kim et al.2

2016

Seoul, South Korea

Chang et al.18

2015

Burkhard et al.1

* Paper did not informed the age range of the sample.

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Airway stability after orthognathic surgery: systematic review

The subdivision of the airway space in naso, oro and hypopharynx is important to identify the narrowest areas and which movement affects which area more accurately.2 The exact delineation of these regions is not consensual, even though there are efforts to standardize the method, as suggested in the validation study of Guijarro-MartĂnez.20 This study proposed delineation of the total volume and subregions exclusively based on hard tissue parameters. It should be mentioned that, since the airway space is essentially surrounded by muscle tissue, the references for delineation should also consider soft tissue landmarks. For example, the method adopted by Shin et al9 and Kim et al.16 divided the total area with sections parallel to the Frankfurt horizontal plane (PHF) passing through the posterior nasal spine, uvula tip and epiglottis base (Fig 1). It is known that factors as patient positioning, head positioning and even respiration stage may also influence the values. In vertical position, the soft tissue contour is maintained by the tonus and low action of gravity; however, this may not be advantageous, since in cases of apnea the individual is usually laying down. Conversely, hyperextension of the head might allow anterior positioning of the hyoid, thus projecting the parapharyngeal infrahyoid muscles.1 There may be large individual variation, with differences between responses, which may also be influenced by body constitution, age and gender.17 The studies of Kim et al2 indicated more marked adaptive responses (accommodation of the UA) to surgery in male individuals. In 100% of papers included in this systematic review, there was no restriction as to gender, ethnicity or age for adult individuals. This assigned heterogeneity to the study, since there was variation from 15 to 57 years, balanced distribution between genders, and inclusion of individuals from four continents. The periods of image acquisition (T) are very important, and physiological parameters should be considered in their selection. For analysis of stability, the periods should include preoperative (initial) and at least two postoperative periods. In tomographic evaluations in very early postoperative periods, the edema may affect the result.3 Similarly, the final evaluation should be sufficiently apart from the initial to allow soft tissue adaptation in the long term. Concerning this aspect, there may be criticism to papers

and cone beam computed tomography (CBCT) â&#x20AC;&#x201C; allowed greater accuracy of limits, three-dimensional evaluation and great possibility of formatting of DICOM files (Digital Imaging and Communication in Medicine). Particularly, CBCT has low radiation dose, reduced cost, minimizes the occurrence of metallic artifacts and the individual is vertically positioned for image acquisition.1,2,3,8,17,18,19 The study of Sears et al,19 comparing the results obtained on lateral cephalograms and CTs, observed results with significant differences. Burkhard et al1 analyzed the UA on lateral cephalograms and by CT, using three different softwares, and concluded that there were differences between the results. However, between softwares, there was reliability of 96%. Thus, the tomographic method was considered highly accurate, provided the achievement and evaluation are standardized.

Figure 1: Delineation of the upper airway and subdivision into naso, oro and hypopharynx. Axial sections parallel to the FHP passing through the posterior nasal spine, end of soft palate and base of epiglottis. Source: adapted from Shin et al.9, 2015.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):30-6

Suassuna TM, Abreu TC, Santos LAM, Noleto JW, Ribeiro ED

the smaller will be the mandibular setback required. Therefore, double-jaw surgeries in individuals with Class III may have minimum narrowing or even widen the total volume of the UA, depending on the maxillary advancement and vertical movements.1,17 This understanding should be useful in the planning of orthognathic surgeries in general, and especially in individuals with diagnosis or predisposition to OSAS. In surgeries with the chief goal of airway space gain, the possibility of over-advancement should be considered.3 Considering the current knowledge, further studies are still necessary. The maximum scientific evidence on this subject may be reached by studies on homogeneous groups of individuals submitted to similar surgeries, including individuals with OSAS submitted to maxillomandibular advancement. The evaluations should be conducted on tomographies obtained at standardized postoperative periods with longitudinal follow-up. Also, it is important to correlate these volumetric data with polysomnography and spirometry assessments.

with T1 shorter than three months (four papers) and TF shorter than one year (five papers). Despite all these variables and possibilities of bias, there was similarity in the results, indicating that the UA do not remain stable over time.1,2,3,8,9,16,18,19 However, no result suggested the return to initial volumes.1,2,3,8,9,16,18,19 This â&#x20AC;&#x153;instabilityâ&#x20AC;? may be caused by tissue adaptations on the muscle tendons and attachments in response to the strains applied.1,8,9,16 These findings did not vary according to the group of individuals or surgery performed, since individuals with Class III and Class II malocclusions exhibited the same tendency. However, the quantity of groups of individuals with Class II was very small and present in only two papers.3,18 Individuals with Class III submitted to bimaxillary surgeries (maxillary advancement and mandibular setback) presented instability in dimensions,1,2,8,9,16,18 with two exceptions. The study of Lee et al17 divided the UA in only two regions (upper and lower), and did not reveal changes in total volume, but rather progressive increase in the upper space and reduction in the lower space. The study of Park et al8 revealed maintenance of total volume in individuals submitted to isolated mandibular setback. It is known that the outcomes are also influenced by the magnitude of movements and that, for some skeletal discrepancies in individuals with prognathism, the greater the maxillary advancement,

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

CONCLUDING REMARKS It could be concluded that the UA are extremely dynamic structures and present tendency to volumetric alterations postoperatively. However, further studies with more controlled methods should be conducted to corroborate these findings.

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):30-6

Airway stability after orthognathic surgery: systematic review

References:

Burkhard JP, Dietrich AD, Jacobsen C, Roos M, Lübbers HT, Obwegeser JA. Cephalometric and three-dimensional assessment of the posterior airway space and imaging software reliability analysis before and after orthognathic surgery. J Craniomaxillofac Surg. 2014 Oct;42(7):1428-36. Kim HS, Kim GT, Kim S, Lee JW, Kim EC, Kwon YD. Three-dimensional evaluation of the pharyngeal airway using cone-beam computed tomography following bimaxillary orthognathic surgery in skeletal Class III patients. Clin Oral Investig. 2016 June;20(5):915-22. Carvalho ACGS, Magro-Filho O, Garcia Junior LR, Araujo PM, Nogueira RLM. Cephalometric and three-dimensional assessment of superior posterior airway space after maxillomandibular advancement. Int J Oral Maxillofac Surg. 2012 Sept;41(9):1102-11. Degerliyurt K, Ueki K, Hashiba Y, Marukawa K, Nakagawa K, Yamamoto E. A comparative CT evaluation of pharyngeal airway changes in Class III patients receiving bimaxillary surgery or mandibular setback surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008 Apr;105(4):495-502. Marşan G, Oztaş E, Cura N, Kuvat SV, Emekli U. Changes in head posture and hyoid bone position in Turkish Class III patients after mandibular setback surgery. J Craniomaxillofac Surg. 2010 Mar;38(2):113-21. Hong JS, Park YH, Kim YJ, Hong SM, Oh KM. Three-dimensional changes in pharyngeal airway in skeletal Class III patients undergoing orthognathic surgery. J Oral Maxillofac Surg. 2011 Nov;69(11):e401-8. Athanasiou AE, Toutountzakis N, Mavreas D, Ritzau M, Wenzel A. Alterations of hyoid bone position and pharyngeal depth and their relationship after surgical correction of mandibular prognathism. Am J Orthod Dentofacial Orthop. 1991 Sept;100(3):259-65.

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Park SB, Kim YI, Son WS, Hwang DS, Cho BH. Cone-beam computed tomography evaluation of short- and long-term airway change and stability after orthognathic surgery in patients with Class III skeletal deformities: bimaxillary surgery and mandibular setback surgery. Int J Oral Maxillofac Surg. 2012 Jan;41(1):87-93. Shin JH, Kim MA, Park IY, Park YH. A 2-year follow-up of changes after bimaxillary surgery in patients with mandibular prognathism: 3-dimensional analysis of pharyngeal airway volume and hyoid bone position. J Oral Maxillofac Surg. 2015 Feb;73(2):340.e1-9. Manganello LCS, Silveira ME. Cirurgia Ortognática e Ortodontia. 2ª ed. São Paulo: Ed. Santos; 2010. Eggensperger N, Smolka W, Iizuka T. Long-term changes of hyoid bone position and pharyngeal airway size following mandibular setback by sagittal split ramus osteotomy. J Craniomaxillofac Surg. 2005 Apr;33(2):111-7. Epub 2005 Jan 28. Butterfield KJ, Marks PLG, McLean L, MD, Newton J. Pharyngeal airway morphology in healthy individuals and in obstructive sleep apnea patients treated with maxillomandibular advancement: a comparative study. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015;119(3):285-92. Kendzerska T, Mollayeva T, Gershon AS, Leung RS, Hawker G, Tomlinson G. Untreated obstructive sleep apnea and the risk for serious long-term adverse outcomes: A systematic review. Sleep Med Rev. 2014 Feb;18(1):49-59. Christovam IO, Lisboa CO, Ferreira DMTP, CurySaramago AA, Mattos CT. Upper airway dimensions in patients undergoing orthognathic surgery: a systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2016 Apr;45(4):460-71. Mattos CT, Vilani GN, Sant’Anna EF, Ruellas AC, Maia LC. Effects of orthognathic surgery on oropharyngeal airway: a meta-analysis. Int J Oral Maxillofac Surg. 2011 Dec;40(12):1347-56.

16. Kim MA, Kim BR, Choi JY, Youn JK, Kim YJ, Park YH. Three-dimensional changes of the hyoid bone and airway volumes related to its relationship with horizontal anatomic planes after bimaxillary surgery in skeletal Class III patients. Angle Orthod. 2013 July;83(4):623-9. 17. Lee Y, Chun YS, Kang N, Kim M. Volumetric changes in the upper airway after bimaxillary surgery for skeletal Class III malocclusions: a case series study using 3-dimensional Cone-Beam Computed Tomography. J Oral Maxillofac Surg. 2012 Dec;70(12):2867-75. 18. Chang MK, Sears C, Huang JC, Miller AJ, Kushner HW, Lee JS. Correlation of airway volume with orthognathic surgical movement using Cone-Beam Computed Tomography. J Oral Maxillofac Surg. 2015 Dec;73(12 Suppl):S67-76. 19. Sears CR, Miller AJ, Chang MK, Huang JC, Lee JS. Comparison of pharyngeal airway changes on plain radiography and Cone-Beam Computed Tomography after orthognathic surgery. J Oral Maxillofac Surg. 2011 Nov;69(11):e385-94. 20. Guijarro-Martínez R, Swennen GR. Three-dimensional Cone Beam Computed Tomography definition of the anatomical subregions of the upper airway: a validation study. Int J Oral Maxillofac Surg. 2013 Sept;42(9):1140-9.

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):30-6

Case Report

A case of

ABSTRACT The pyogenic granuloma is called granuloma gravidarum when occurring in pregnant women. It is a non-neoplastic reactional proliferative process with significant vascular involvement, which is caused by hormonal factors associated with local irritants and/or trauma. It usually presents as an exophytic lesion, either sessile or pedunculated, and its surface may be smooth or lobular, of red to pinkish color. The painful sensitivity depends on the degree of trauma involving the lesion, yet it is frequently painless. Since this is a benign lesion, therapy aims at surgical removal and control of local irritants. A female patient, aged 31 years, in the third month of pregnancy, complained of an uncommon volume increase at the region of tooth 37, masticatory disorders and malocclusion. Clinical diagnosis of the lesion, based on extraoral, intraoral and imaging examinations and anamnesis, suggested the diagnosis of granuloma gravidarum, thus surgery was indicated for lesion removal. The patient recovered uneventfully, and in the present case lesion removal was shown to be successful. Keywords: Oral surgery. Hyperplasia. Granuloma.

Universidade Estadual do Piauí, Curso de Odontologia (Parnaíba/PI, Brazil). Universidade Federal do Piauí, Hospital Universitário, Residência no Serviço de Cirurgia e Traumatologia Bucomaxilofacial (Teresina/PI, Brazil). 3 Oral and Maxillofacial Surgeon, Universidade Federal do Piauí (Teresina/PI, Brazil). 4 Universidade Federal do Piauí, Área de Cirurgia e Traumatologia Bucomaxilofacial (Teresina/ PI, Brazil). 1

How to cite: Carvalho MS, Rodrigues EDR, Farias ALC, Melo TM, Silva DR, Cravinhos JCP. Granuloma gravídico de grandes proporções. J Braz Coll Oral Maxillofac Surg. 2017 set-dez;3(3):37-43. DOI: https://doi.org/10.14436/2358-2782.3.3.037-043.cre

Submitted: January 21, 2017 - Revised and accepted: July 11, 2017 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. » Patients displayed in this article previously approved the use of their facial and intraoral photographs. Contact address: Julio Cesar de Paulo Cravinhos E-mail: juliocravinhos@ufpi.edu.br - juliocravinhos@yahoo.com.br

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):37-43

A case of large granuloma gravidarum

CASE REPORT A female patient, aged 31 years, in the third month of pregnancy, presented to the outpatient clinic with complaint of volume increase at the region of tooth 37. During anamnesis, the patient reported she had not searched for immediate care when she noticed the change in her oral cavity and that, though painless, the lesion bled during toothbrushing and impaired mastication, because it precluded the complete contact between teeth at the lesion site. Extraoral physical examination did not demonstrate any signs. However, intraoral examination revealed midline deviation and buccal displacement of tooth 37, because of the lesion on the mandibular left second molar (Fig 1A). Intraoral clinical examination evidenced a nodular lesion, with smooth surface and fibrous aspect, well-circumscribed, of reddish, mucosa-like color, sessile, lobular, with small areas of ulceration and hemorrhage upon touch. The examination also revealed poor oral hygiene and displacement of tooth 37, with an unsatisfactory temporary restoration (Fig 1B). To evaluate the tissue component and bone structures adjacent to the lesion and rule out the diagnosis of other lesions with similar clinical aspect, a panoramic radiograph was obtained and did not reveal any bone alteration related with the lesion (Fig 1C). Based on the aforementioned characteristics, the differential diagnosis included granuloma gravidarum, peripheral giant cell lesion and ossifying fibroma. Clinical diagnosis of the lesion, based on the extraoral, intraoral and imaging examinations and anamnesis, suggested the diagnosis of granuloma gravidarum, thus surgery was indicated. The treatment planning considered the gestational period (awaiting until the second trimester of pregnancy), lesion size and functional involvement, since the patient had impaired masticatory function and painful symptomatology, due to the chronic trauma with maxillary teeth. Surgery was initiated by local anesthetics of the inferior alveolar, buccal and lingual nerves, using 2.5 cartridges of 2% mepivacaine with epinephrine 1:100,000.

INTRODUCTION Pyogenic granuloma (PG) is a non-neoplastic hyperplastic reactional lesion, with significant vascular involvement. Its etiology is usually related with local irritants, trauma and/or hormonal factors. 1-9 The painful sensitivity depends on the degree of traumatic injury related with the lesion, yet it is often painless. 1,3,7 It primarily affects women between the second and fourth decades of life. Its most common location is the buccal and lingual surfaces of gingiva, lips and oral mucosa. 1-10 When occurring in women, it is often named granuloma gravidarum (GG) and is usually related with an increase in hormone levels in these patients. Even though it may appear at any stage of pregnancy, its higher prevalence is observed after the seventh month of pregnancy. 2,3,5-8 The histopathological examination reveals host defense cells, such as polymorphonuclear and mononuclear leukocytes, besides other aspects characteristic of granulation tissue. There may also be epithelial hyperplasia and clinically evident ulcerated regions. 1,3,5-9 Some conditions observed during oral examination, such as health status, infections or local irritants, may predispose to this lesion.3,6,9 Clinically, it may be nodular, sessile or pedunculated, either single or multilobulated, with color ranging from red to brownish. 3-9 It is usually ulcerated, with marked tendency to hemorrhage spontaneously or after slight stimuli. 1-9 Even though the treatment varies according to the lesion features and patient response, the surgical removal and control of local irritants is usually the treatment of choice.3,5,6-9 However, the relapse rate is relatively high when surgically treated, especially in pregnant women; therefore, postoperative follow-up is mandatory. 1,3,4,5,7,8,9 In some cases, the lesion may regress spontaneously, and conservative treatment with clinical follow-up may be the most indicated option.3-9 This paper presents the case of a female patient, whose chief complaint was volume increase at the region of tooth 37. The patient was submitted to excisional biopsy, and histopathological analysis revealed the diagnosis of granuloma gravidarum.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):37-43

Carvalho MS, Rodrigues EDR, Farias ALC, Melo TM, Silva DR, Cravinhos JCP

For lesion removal, intrasulcular incisions were performed on the region of teeth 38 and 37, surrounding the lingual region of the lesion, besides a releasing incision on the mesial side of tooth 36. Incision was followed by mucoperiosteal detachment and the lesion was entirely removed, measuring 20 mm (Fig 2A and 2C). The specimen was placed in a flask containing 10% formalin and submitted to histopathological analysis. Tooth 37 was removed with the lesion, since it was displaced and presented endodontic involvement (Fig 2B).

The histopathological examination revealed fragment of mucosa containing a dome-shaped nodular lesion, characterized by proliferating blood vessels with delicate walls within edematous stroma, with intense polymorphonuclear infiltrate. The mucosa was hyperplastic and presented an ulcerated area, confirming the diagnostic hypothesis of granuloma gravidarum, corroborating the favorable prognosis, since the patient recovered without postoperative or gestational complications nor any signs of lesion relapse (Fig 3).

Figure 1: A) Intraoral examination, evidencing displacement of tooth 37, uncommon increase of tissue volume, midline deviation and posterior crossbite. B) View of the lingual region. C) Panoramic radiograph, without any bone alteration associated with the lesion.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):37-43

A case of large granuloma gravidarum

Figure 2: A) Lesion removal. B) Microscopic view of the specimen, presenting nearly 20mm. C) Aspect after lesion removal.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):37-43

Carvalho MS, Rodrigues EDR, Farias ALC, Melo TM, Silva DR, Cravinhos JCP

Figure 3: Postoperative aspect of the patient. A) Immediate postoperative, with sutures. B) 60-day postoperative follow-up, evidencing good healing without signs of lesion relapse. C) Histological section of dome-shaped nodular lesion, with proliferating blood vessels with delicate walls within edematous stroma, with intense polymorphonuclear infiltrate, compatible with granuloma.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):37-43

A case of large granuloma gravidarum

DISCUSSION The PG, including GG, is a non-neoplastic hyperplastic reactional lesion, most commonly occurring in the cutaneous region with rare occurrence in the gastrointestinal system, except for the oral cavity, in which it is often reported, especially in the gingiva.3 This occurrence is related with the presence of female hormone receptors at this region, leading to common disorders in gingival physiology in females.6,7,9 The present case was referred to a female patient, affecting the gingival region of tooth 37, thus corroborating the aspects described in the literature concerning site and gender. Currently, it is known that the lesion is caused by multiple etiologic factors, with emphasis to the hormonal factor regarding the GG, which usually leads the tissues to respond intensely to irritating factors, leading to excessive production of connective tissue, thus assigning the fibrous aspect characteristic of this disorder.1,3,4 Even though the lesion is generally named pyogenic granuloma, its terminology is mistaken, since it does not contain purulent material, and is also not characterized as a true granuloma, since the histological examination does not reveal arrangement of cells comprising macrophages as epithelioid cells, nor giant cells surrounded by a collar of lymphocytes.1,3,4,8 The term â&#x20AC;&#x153;granuloma gravidarumâ&#x20AC;? is used to describe the occurrence of PG in pregnant women1,5-8. Due to the pregnancy, they present significant changes in hormone levels, which may affect the oral cavity, predisposing to periodontal inflammation and occurrence of GG due to these alterations.5,8,9 Occasionally, during the gestational period, there are changes in both dietary habits and frequency. However, this is not accompanied by oral hygiene, which often does not follow this new routine for reasons as nausea, sleepiness and other associated reasons.6,7 Due to this imbalance, it is common to observe pregnant women with poor oral hygiene, as in the present case, whose clinical examination demonstrated dental plaque accumulation and ineffective oral hygiene by the patient. The GG is a lesion, usually sessile or pedunculated, which generally appears on the buccal gingiva, with globous or smooth aspect, of variable size, measuring few millimeters to several centimeters. However, it is usually not larger than 2.5 cm, and this size may be achieved in weeks or months.1-9 In the present case, corroborating the literature, the lesion size was

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

approximately 2 cm in diameter, which combined to the characteristic clinical appearance of the lesion, led the patient to search for treatment. The differential diagnosis often includes capillary hemangioma, inflammatory gingival hyperplasia, peripheral giant cell lesion (PGCL) and peripheral ossifying fibroma (POF).1,3,4,8 The lesions considered as differential diagnosis in the present case were mainly PGCL and POF, and histopathological analysis was necessary for final diagnosis of the pathology. Lesion removal, combined with control of irritants, is the treatment of choice1,3,4,6-9 and was performed in the present case. It should be highlighted that the risks for the patient and pregnancy were minimum; the lesion dimensions were well-delineated and it was sessile, yet there was no difficulty for removal. In cases of relatively small lesions, depending on the stage of pregnancy and physical and emotional health, the dentist may decide to only follow the case during and after pregnancy, without the need of surgical intervention, since reports in the literature evidence the spontaneous regression or fibrous maturation of the lesion after normalization of hormone levels.1,3,4,5,6,9 The follow-up of these patients is important to detect possible postoperative complications and/or lesion relapse1,3,4,6,8,9. In the present case, after surgery, the patient was instructed to perform careful oral hygiene and was informed on the importance of dental follow-up during pregnancy. After two-year follow-up, there was no relapse nor any associated complication. CONCLUDING REMARKS The hormone changes during pregnancy may affect the oral cavity, predisposing to the occurrence of inflammatory lesions with fast and remarkable growth, such as GG, which may raise concern for the patient and less informed professionals2,4,5,8. Therefore, an adequate approach should be adopted to establish an accurate diagnosis and effective treatment. In the present surgical treatment, excisional biopsy was sufficient for the case, presenting favorable prognosis without any evidence of relapse or postoperative complication. It is important to highlight the need of oral hygiene care and regular follow-up by the dentist, to prevent the relapse of these lesions.2,3,5,8

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):37-43

Carvalho MS, Rodrigues EDR, Farias ALC, Melo TM, Silva DR, Cravinhos JCP

References:

1. 2.

Neville BW, Damm DD, Allen CM, Bouquot JE. Patologia Oral e Maxilofacial. 2ª ed. Rio de Janeiro: Guanabara Koogan; 2004. Menezes RER, Silva SO, Zanata A, et al. Patogênese e aspectos clínicos do granuloma gravídico: relato de caso e revisão de literatura. Salusvita. 2014 Jan;33(1):111-27. Mubeen K, Vijayalakshmi KR, Abhishek RP. Oral pyogenic granuloma with mandible involvement: an unusual presentation. J Dent Oral Hyg. 2011 Jan;3(1):6-9.

5. 6.

Cardoso JA, Spanemberg JC, Cherubini K, Figueiredo MA, Salum FG. Oral granuloma gravidarum: a retrospective study of 41 cases in Southern Brazil. J Appl Oral Sci. 2013 Jan;21(3):215-8. Gaetti Jardim EC, Vieira JB, Castro AL, Jardim Junior EG, Felipini RC. Granuloma gravídico - relato de caso. RFO. 2009 Ago;2(14):153-7. Trento CL, Veltrini VC, Santos RNM, Santos VTG. Gravidarum granuloma associated to an osseointegrated implant: case report. Rev Odontol UNESP. 2014 Apr;43(2):148-52.

8. 9.

Reyes A, Pedron IG, Utumi ER Aburad A, Soares MS. Granuloma Piogênico: enfoque na doença periodontal como fator etiológico. Rev Clín Pesq Odontol. 2008 Abr;1(4):29-33. Mendonça JCG, Jardim ECG, Manrique GR, et al. Granuloma piogênico: relato de caso clínico-cirúrgico. Rev Bras Ciênc Saúde. 2011 Set;29:92-5. Skinner RL, Davenport WD Jr, Weir JC, Carr RF. A survey of biopsied oral lesions in pediatric dental patients. Pediatr Dent. 1986 June;8(3):163-7.

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):37-43

CaseReport

Oral lipomas:

ABSTRACT Lipomas are benign mesenchymal neoplasms composed of mature adipocytes, with rare manifestation in the oral and maxillofacial regions. Its pathogenesis is uncertain, and different histological variants are found in the literature. This paper reports three cases of intraoral lipomas from an Oral and Maxillofacial Surgery and Traumatology service. In the reported cases, the patients did not complain of pain, but presented nodular volume increase, of rubbery consistency, with smooth surface and yellowish color. All were treated by excisional biopsy and the histopathological pattern was simple lipoma, being observed in the alveolar mucosa, lip and buccal mucosa. The mean age in the present study was 61.3 years. The diagnosis in the three cases was based on clinical evaluation and histopathological characteristics. The prognosis was favorable, corroborating the findings in the literature. Keywords: Lipoma. Surgery, oral. Biopsy.

Universidade Federal do Ceará, Hospital Universitário Walter Cantídio (Fortaleza/CE, Brazil). Resident in Oral and Maxillofacial Surgery, Universidade Federal do Ceará (Fortaleza/CE, Brazil). 3 Universidade Federal do Ceará, Faculdade de Farmácia, Odontologia e Enfermagem, Departamento de Clínica Odontológica, Disciplinas de Radiologia e Clínica Integrada (Fortaleza/ CE, Brazil). Doctor and Master in Clinical Dentistry, Universidade Federal do Ceará (Fortaleza/ CE, Brazil). 4 Universidade Federal do Ceará, Faculdade de Farmácia, Odontologia e Enfermagem (Fortaleza/CE, Brazil). 5 Doctor in Pharmacology, Universidade Federal do Ceará (Fortaleza/CE, Brazil). 6 Universidade de Fortaleza, Curso de Odontologia (Fortaleza/CE, Brazil). Doctoral student, Master and Specialist in Oral and Maxillofacial Surgery, Universidade Federal do Ceará (Fortaleza/CE, Brazil). 7 Graduated in Dentistry, Universidade Federal do Ceará (Fortaleza/CE, Brazil). 8 Specialist in Oral and Maxillofacial Surgery, Universidade Federal do Ceará (Fortaleza/CE, Brazil). Master in Oral and Maxillofacial Surgery, Doctor in Stomatology, Pontifícia Universidade Católica do Rio Grande do Sul (Porto Alegre/RS, Brazil). 1

How to cite: Menezes-Neto AM, Gurgel FWC, Mota MRL, Carvalho FSR, Coutinho MG, Soares ECS. Lipomas bucais: aspectos clínico-terapêuticos de um hospital universitário. J Braz Coll Oral Maxillofac Surg. 2017 set-dez;3(3):44-9. DOI: https://doi.org/10.14436/2358-2782.3.3.044-049.cre

Submitted: March 03, 2017 - Revised and accepted: August 13, 2017 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. » Patients displayed in this article previously approved the use of their facial and intraoral photographs. Contact address: Alexandre Maranhão Menezes-Neto Rua Coronel Nunes de Melo, 1392 - Fortaleza/Ceará - CEP: 60.430-275 E-mail: alexandremaranhaobucomaxilo@gmail.com

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):44-9

Menezes-Neto AM, Gurgel FWC, Mota MRL, Carvalho FSR, Coutinho MG, Soares ECS

INTRODUCTION Lipoma represents a benign mesenchymal neoplasm composed of mature adipocytes, first described in 1948 by Roux as an “alveolar mass”, which was referred to as yellow epulis.1 It is uncommon in the oral cavity 3-6 and, when observed in oral tissues, the most frequent location is the buccal mucosa, with scarce occurrence at the gingival region. 2 Clinically, it presents as a nodule with rubbery texture, with or without yellowish coloration, possibly similar to the oral mucosa color. 1 It presents slow growth, medium size of 2 cm, and mainly affects the age range 40 to 60 years, with slight female predilection.3,5,7 Complementary examinations, including magnetic resonance imaging, computed tomography and ultrasound, have been important tools for preoperative evaluation; however, the gold standard is still the histopathological examination, by accomplishment of biopsy. 1,6,9 Regarding treatment, the conservative surgical removal is considered to present satisfactory results, with favorable prognosis, and relapse is uncommon. 6,8,9 Within this context, this paper reports three cases of lipoma affecting the oral tissues. The importance of the present study is emphasized, especially in the field of Oral and Maxillofacial Surgery, since though this is an uncommon neoplasm, this pathology may be observed in several Oral and Maxillofacial Surgery and Traumatology services.

and located in the alveolar mucosa at the region of tooth #33. The lesion was sessile, presented rubbery texture, smooth surface and yellowish color. Radiographic examination was unremarkable. Excisional biopsy was performed under local anesthesia, in the outpatient clinic. The specimen was submitted to histopathological examination and was described as a benign neoplasm, composed of lobular accumulations of typical adipocytes, interspersed with fibrous thin septa and rare blood vessels, with diagnosis of lipoma (Fig 1A and 1B). No signs of relapse were observed one year after surgery. Case 2 Female individual, aged 64 years, attended the Oral and Maxillofacial Surgery and Traumatology outpatient clinic on April 2016, complaining of asymptomatic nodular lesion in the left lower lip, with two years of evolution. The patient reported smoking for approximately fifty years and was under medical treatment for hypertension and diabetes. Intraoral examination revealed a round lesion with rubbery texture, yellowish color, smooth surface, sessile implantation, measuring approximately 2.5 cm in its greatest diameter, at the left lower lip (Fig. 2). Imaging examination was unremarkable. Excisional biopsy was performed under local anesthesia in the outpatient clinic. The specimen measured 2.5 x 1.5 x 1.0 cm and was submitted to histopathological analysis, which revealed a benign neoplasm of mesenchymal origin, composed of mature fat cells, with lobular arrangement, separated by thin bundles of fibrous connective tissue, compatible with diagnosis of lipoma (Fig. 1C and 1D). No relapse was observed on the one-year follow-up.

CASE REPORTS The report includes clinical and histopathological data of three individuals submitted to biopsy at the Residency in Oral and Maxillofacial Surgery and Traumatology service of a university hospital. The individuals were retrospectively analyzed, evaluating the age, gender, histological type, size, location and clinical characteristics of the lesions.

Case 3 Male individual, aged 75 years, without systemic diseases, attended the oral and maxillofacial surgery outpatient clinic on June 2015, with complaint of intraoral volume increase with undetermined time of evolution, which impaired feeding. Physical examination evidenced a nodular pedunculated lesion with smooth surface, soft texture, yellowish color, measuring approximately 3 cm in its greatest diameter, in the buccal mucosa (Fig 3). Radiographically, there were no alterations in the bone trabeculae. Excisional biopsy was performed under local anes-

Case 1 Female individual, aged 45 years, without systemic diseases, was referred to the Oral and Maxillofacial Surgery and Traumatology outpatient clinic on May 2013, with complaint of painless lesion in the oral cavity. Physical examination revealed an oval nodular lesion, measuring approximately 3 x 2 cm

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):44-9

Oral lipomas: clinical-therapeutic aspects in a university hospital

encapsulated proliferation of well-differentiated adipocytes, with symmetric and regular proliferations, interspersed with collagenized fibrous connective tissue (Fig 1E and 1F). No relapse was observed at the one-year follow-up.

thesia, in the outpatient clinic. The specimen measured 2.5 x 2.3 x 1.6 cm and was submitted to histopathological examination. The analysis revealed a diagnosis of lipoma, with histopathological observation of benign mesenchymal neoplasm composed of

Figure 1: Photomicrographs of histological sections stained with hematoxylin and eosin (HE) of cases 1 (A and B), 2 (C and D) and 3 (E and F). In A, C and E (40x magnification), there are areas with adipocytes delimited by a peripheral fibrous capsule. In B, D and F (100x magnification), there are well-differentiated adipocytes, often grouped in lobules surrounded by fibrous septa.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):44-9

Menezes-Neto AM, Gurgel FWC, Mota MRL, Carvalho FSR, Coutinho MG, Soares ECS

Figure 2: Lipoma in left lower lip. Note the rounded shape, yellowish color, smooth surface, sessile implantation, measuring approximately 2.5 cm in the largest diameter.

Figure 3: Lipoma in left buccal mucosa. Observe nodular lesion, with pedunculated implantation, smooth surface, yellowish color, with approximately 3 cm in the largest diameter.

DISCUSSION The lipomas are the group of most common mesenchymal soft tissue neoplasms at the head and neck region,1,10 being relatively rare in the oral and maxillofacial region,3-6 with prevalence between 1 and 4%.1,9 Also, these pathologies account for only 0.5% of all benign oral tumors.4,8 In the oral cavity, the buccal mucosa was indicated by most previous studies as the most affected region, followed by the tongue, lips, mouth floor, palate and gingiva.1,2,4,5,7-13 This aspect related with the anatomical location is corroborated in the present paper, considering that the sites affected in reported cases are regions with high prevalence of oral lipomas. Clinically, it presents as a submucous nodule with rubbery texture, movable, of yellowish color,3 with sessile or pedunculated implantation.11 The three reported cases presented such features. Though similar to normal body fat, the adipocytes component is not available for the metabolism, which is clinically important for differential diagnosis.1,3,4,9 These neoplasms usually present slow growth and are mostly asymptomatic. In some cases, they are deeply located, exhibiting a less yellowish color. 3 In these situations, they may reach huge dimensions, 1,6 yielding discomfort and functional problems, including difficult swallowing, speech, crossbite and mastication. 3,5,6,9,14 In two of the present cases, with undetermined time of evolution, there

were no disturbances affecting the normal functions of the stomatognathic system of individuals. The literature reports significant predominance in individuals aged 40 to 60 years.3,5,7 This was observed in the three present cases. Also, in contrast with the predominance of lipomas in other body regions in males, 4,8 the studies revealed relatively higher frequency among females. The etiopathogenesis of lipomas is still not defined in the literature. However, theories and mechanisms as inheritance, hormonal aspects, trauma, fatty degeneration, infection, infarction, metaphasis of muscle cells, occurrence of nests of lipoblastic embryonic cells in its origin and chronic irritation have been suggested to explain the presence of lipomas.1,3,5,9,12,14 Histopathologically, the lipomas have been classified as angiolipoma, angiomyolipoma, angiomyxolipoma, fibrolipoma, hibernoma, lipoma with chondro-osseous metaplasia, chondroid lipoma, congenital lipoma, infiltrating lipoma, soft tissue myolipoma, pleomorphic lymphoma / lipoma, myxolipoma, dendritic myofibrolipoma, sialolipoma and atypical lipomatous tumor.4,15 Among these subtypes, there is higher prevalence of simple lipomas and fibrolipoma described in the literature.5 It should be emphasized that the study of Manor et al.4 identified 48% of cases as simple lipomas and 33% as fibrolipomas. In the present paper, histopathologically, all characteristics suggested simple lipomas.

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):44-9

Oral lipomas: clinical-therapeutic aspects in a university hospital

has also been reported; however, further studies should be conducted to allow routine utilization of this treatment method.4,5,6,9 The surgical staff established conventional surgical removal as the definitive therapy. This approach considered the reduced size of lesions, as well as their anatomical location. Even though lipoma presents favorable prognosis in most cases7, the rare relapses that may occur have been described after inadequate surgical removal or even in cases of deep lipomas, which are not encapsulated.14 The infiltrating lipoma, also known as intramuscular lipoma, is not encapsulated and complete removal is difficult, due to the diffuse muscular infiltration. The fact that all three present cases were described as the simple variant contributed to non-relapse of lesions postoperatively. Additionally, adequate surgical procedure was performed in all cases.1 Though rare, the malignant transformation into liposarcoma has been reported in the literature.3,15

The differential diagnoses for oral lipoma include: pleomorphic adenoma, thyroglossal duct cysts, ectopic thyroid tissue, oral dermoid and lymphoepithelial cysts, mucoepidermoid carcinoma, 3 mucocele, hemangioma, rhabdomyoma and traumatic neuroma. 6 Most cases represent single tumors,5,9 and the rare occurrence of multiple lipomas is associated with Cowden syndrome.3,4 The three reported cases revealed clinical aspects compatible with benign lesions. Also, the yellowish color was a clinical sign emphasizing the hypothesis of lipoma. It is relatively difficult to microscopically distinguish the lipoma from a specimen of normal fat tissue. Therefore, it is important to provide clinical data to the pathologist to allow an accurate diagnosis.1,7,14 Magnetic resonance imaging has considerably improved the preoperative definition of tumor limits, vascularization and proximity of tumors with great blood vessels and other anatomical structures, providing better definition of soft tissues than computed tomography. Ultrasound is a non-invasive preoperative technique that may be used to aid the early diagnosis. 1,6,9 The gold standard for the diagnosis of lipomas is the histopathological examination, from excisional or incisional tumor biopsy. The treatment commonly described for oral lipomas comprises conservative local surgical removal, and relapse is rare. 6,8,9 Other treatment that has also been suggested involves the injection of steroids, aiming to promote atrophy of fat tissue. Liposuction

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

CONCLUDING REMARKS Lipomas in the oral cavity are relatively rare lesions, of slow growth, which often do not cause pain to the patient, being only found on routine examinations. The discomfort or esthetics may lead the patient to search for treatment. The diagnosis in the present three cases was based on clinical evaluation and histopathological characteristics, which should be adopted by health professionals, especially in the field of oral and maxillofacial surgery.

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):44-9

Menezes-Neto AM, Gurgel FWC, Mota MRL, Carvalho FSR, Coutinho MG, Soares ECS

References:

1. 2.

4. 5.

Agarwal R, Kumar V, Kaushal A, Singh RK. Intraoral lipoma: a rare clinical entity. BMJ Case Rep. 2013 Jan 28;2013. pii: bcr2012007889. Taira Y, Yasukawa K, Yamamori I, Iino M. Oral lipoma extending superiorly from mandibular gingivobuccal fold to gingiva: a case report and analysis of 207 patients with oral lipoma in Japan. Odontology. 2012 Jan;100(1):104-8. Studart-Soares EC, Costa FW, Sousa FB, Alves AP, Osterne RL. Oral lipomas in a Brazilian population: a 10-year study and analysis of 450 cases reported in the literature. Med Oral Patol Oral Cir Bucal. 2010 Sept 1;15(5):e691-6. Manor E, Sion-Vardy N, Joshua BZ, Bodner L. Oral lipoma: analysis of 58 new cases and review of the literature. Ann Diagn Pathol. 2011 Aug;15(4):257-61. Egido-Moreno S, Lozano-Porras AB, SiddharthMishra, Allegue-Allegue M, Marí-Roig A, LópezLópez J. Intraoral lipomas: review of literature and report of two clinical cases. J Clin Exp Dent. 2016 Dec;8(5):e597-603.

Magadum D, Sanadi A, Agrawal JM, Agrawal MS. Classic tongue lipoma: a common tumour at a rare site. BMJ Case Rep. 2013 Jan 30;2013. pii: bcr2012007987. 7. Masayasu-Iwase, Naotaka-Saida, Yoko-Tanaka. Fibrolipoma of the buccal mucosa: a case report and review of the literature. Case Rep Pathol. 2016; 2016: 5060964. 8. Juliasse LE, Nonaka CF, Pinto LP, Freitas RA, Miguel MC. Lipomas of the oral cavity: clinical and histopathologic study of 41 cases in a Brazilian population. Eur Arch Otorhinolaryngol. 2010 Mar;267(3):459-65. 9. Surej-Kumar LK, Mathew-Kurien N, Raghavan VB, Varun-Menon P, Khalam AS. Intraoral lipoma: a case report. Case Rep Med. 2014, Article ID 480130. 10. Tommasi MHM. Diagnóstico em Patologia bucal. 4ª ed. Rio de Janeiro: Elsevier; 2013. 11. Coêlho-Bandéca M, Magalhães-de-Pádua J, Regina-Nadalin M, Vieira-Ozório JE, Silva-Sousa YTC, Cruz-Perez DE. Oral soft tissue lipomas: a case series. J Can Dent Assoc. 2007 June;73(5):431-4.

12. Amirth-Raj A, Shetty PM, Kumar-Yadav S. Lipoma of the floor of the mouth: report of an unusually large lesion. J Maxillofac Oral Surg. 2014 Sept;13(3):328-31. 13. Ravi-Kiran A, Purnachandrarao-Naik N, Samatha Y, Vijay-Kumar A, Kalyan-Kumar D. Intraoral lipoma: a rare case report and review of literature. J Clin Diagn Res. 2013 Dec;7(12):3090-1. 14. Ankit-Srivastava, Vijayalakshmi KR, Mubeen-Khan. Lipoma; a rarity in the oral cavity: a case report. J Oral Med Oral Surg Oral Pathol Oral Radiol. 2016;2(2):85-7. 15. Tettamanti L, Azzi L, Croveri F, Cimetti L, Farronato D, Bombeccari G, et al. Oral lipoma: many features of a rare oral benign neoplasm. Head Neck Oncol. 2014 June 10;6(3):21.

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):44-9

CaseReport

Intraoral styloidectomy in an individual with

ABSTRACT The styloid-stylohyoid Syndrome is characterized by neck pain caused by elongation of the styloid process or mineralization of the stylohyoid ligament. Its symptoms include neck pain, foreign body sensation in the pharynx, dysphagia, odynophagia and otalgia. The diagnosis is based on clinical and imaging examination, and treatment may be pharmacological or surgical. This paper reports a case of an individual diagnosed with this syndrome and presents a thorough literature review. Even though conservative treatment is a viable option, surgical treatment (intraoral or extraoral) is the most effective option in cases of persistent symptomatology. This case was treated by an intraoral surgical approach for bilateral styloidectomy, which is safer and allowed shorter surgical time, better postoperative recovery and absence of cutaneous scar. Keywords: Maxillofacial abnormalities. Neck pain. Surgery, oral.

Universidade Estadual de Maringá, Centro de Ciências da Saúde, Departamento de Odontologia, Cirurgia e Traumatologia Bucomaxilofacial (Maringá/PR, Brazil). Resident in Oral and Maxillofacial Surgery, Universidade Estadual de Maringá (Maringá/PR, Brazil). 3 Specialist in Oral and Maxillofacial Surgery, Universidade Estadual de Maringá (Maringá/PR, Brazil). 4 Doctor and Master in Oral and Maxillofacial Surgery, Universidade de São Paulo (Bauru/SP, Brazil). 5 Doctor and Master in Oral and Maxillofacial Surgery, Universidade Estadual Paulista Júlio de Mesquita Filho (São Paulo/SP, Brazil). 1

How to cite: Bachesk AB, Jacomacci WP, Macêdo DV, Piacentini M, Pavan AJ, Camarini ET. Estiloidectomia intrabucal em paciente portador de Síndrome Estiloide-estilo-hioide. J Braz Coll Oral Maxillofac Surg. 2017 set-dez;3(3):50-5. DOI: https://doi.org/10.14436/2358-2782.3.3.050-055.cre

Submitted: April 24, 2017 - Revised and accepted: August 01, 2017 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. » Patients displayed in this article previously approved the use of their facial and intraoral photographs. Contact address: Andressa Bolognesi Bachesk E-mail: andressabachesk@gmail.com, andressa_bolognesi@hotmail.com

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):50-5

Bachesk AB, Jacomacci WP, Macêdo DV, Piacentini M, Pavan AJ, Camarini ET

INTRODUCTION The styloid process is a thin, cylindrical and elongated bony projection originating from the tympanic portion of the temporal bone and anteromedially to the mastoid process.1 With length between 2 and 3 cm,2,3 it is located between the internal and external carotid arteries, acting as areas of attachment for the stylohyoid and stylomandibular ligaments and to the stylohyoid, styloglossus and stylopharyngeus muscles, which are respectively innervated by the facial (VII cranial nerve), hypoglossal (XII cranial nerve) and glossopharyngeal nerves (IX cranial nerve).1,4 The styloid-stylohyoid syndrome, also known as Eagle syndrome,5,6,7 styloid syndrome8 or stylohyoid syndrome,4 is characterized as a symptomatic condition caused by elongation of the styloid processes (greater than 3 cm)1,2,5 or due to mineralization of the stylohyoid or stylomandibular ligaments.4 The symptoms of this syndrome include neck pain, recurrent sore throat, foreign body sensation in the pharynx, dysphagia, odynophagia, otalgia, headache, tinnitus and trismus,2,4,6 besides other less common symptoms as voice alterations, local edema and vertigo.3 Due to the variable symptomatology, the diagnosis is difficult and is based on the clinical history, physical and imaging examination, with careful palpation of the tonsillar fossa,2,4 and complementary examinations including orthopantomogram, posteroanterior and lateral skull radiographs, or computed tomography with 3D reconstruction.3 Concerning the radiographic aspects, the elongated styloid processes may be classified into three types. Type I presents continuous and full mineralization of the complex, characterizing the processes as elongated. In type II (pseudoarticulated), the styloid process articulates with the stylomandibular and stylohyoid ligaments by a single pseudoarticulation, and type III (segmented) is characterized by the lack of contiguous mineralization of the stylohyoid process or ligament.4 The prevalence of the syndrome is predominant between 30 and 50 years of age,3,7 among females,3,4,7 and even though approximately 4% of the population present elongated styloid processes, only a small percentage of this group (between 4 and 10.3%) is actually symptomatic.1 The treatment depends on the individual’s general conditions and pain intensity and may be conserva-

tive (pharmacological) or surgical. The first comprises prescription of non-steroidal anti-inflammatories, glucocorticoids1,4,6 and local anesthetic injections in the tonsillar fossa;3 and the second, considered the most effective and definitive, may be performed by intraoral/transpharyngeal access or by extraoral incision.1,5 This paper presents a case report of styloid-stylohyoid syndrome treated by intraoral approach and presents the advantages and safe applicability of this technique. CASE REPORT Female individual, aged 58 years, was referred by the medical doctor to the Oral and Maxillofacial Surgery and Traumatology service of a university with complaint of pain on neck hyperextension and mouth opening. She reported onset of pain two years before, and history of recurrent previous treatments with antimicrobials and analgesics. She also reported bilateral tonsillectomy in childhood. Physical examination revealed diffuse pain on palpation of the tonsillar fossa and submandibular region, bilaterally, with palpable sharp bony projections. The orthopantomogram exhibited radiopaque structures extending from the styloid process to the mandibular angle, toward the hyoid bone. Cone-beam computed tomography with 3D reconstruction was requested, which confirmed the diagnosis of mineralization of the styloid processes, bilaterally, which presented pseudoarticulated elongation (Fig 1), evidencing the diagnosis of styloid-stylohyoid syndrome. Surgery was performed by general anesthesia, with bilateral styloidectomy, by intraoral access. After palpation of the styloid process in the tonsillar fossa, a blade n. 15 was used for incision anterior to the tonsil. Kelly scissors were used for soft tissue divulsion, until the end of the styloid apophysis was located and held with the same scissors. The styloid was fractured and removed bilaterally, using piezo and chisel instruments. Suture by layers was performed with Vicryl 4.0 (Fig 2). A computed tomography was obtained in the immediate postoperative period, which confirmed the total removal of styloid apophyses (Fig 3). Outpatient follow-up was performed for six months, with satisfactory outcomes and complete remission of symptoms.

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):50-5

Intraoral styloidectomy in an individual with styloid-stylohyoid syndrome

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Figure 1: Imaging examinations demonstrating elongated styloid processes: orthopantomogram (A); 3D reconstruction of computed tomography on the right (B) and left sides (C).

Figure 2: Surgical approach: A) intraoral incision; B) styloid process exposed in the oral cavity (right side); C) removal of styloid process (left side); D) removed styloid apophyses.

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):50-5

Bachesk AB, Jacomacci WP, MacĂŞdo DV, Piacentini M, Pavan AJ, Camarini ET

Figure 3: Postoperative computed tomography evidencing absence of styloid processes: coronal section (A); 3D reconstruction of the right side (B) and left side (C).

DISCUSSION The styloid-stylohyoid syndrome is characterized as a symptomatic condition caused as a direct outcome of an elongated styloid process (longer than 3 cm)2,4 or mineralization of the stylomandibular and stylohyoid ligaments.1,5,9 The causes of elongation of the styloid process are discussed in the literature. Steinmann8 suggested three theories to explain this phenomenon. The theory of hyperplastic reaction suggests that, if the styloid process is properly stimulated by a pharyngeal trauma, there would be mineralization of the terminal portion of this process. The bone metaplasia theory also involves a previous traumatic stimulus, which would induce some sections of the stylohyoid complex to undergo metaplastic alterations and thus

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

become intermittently mineralized. The third theory would be an anatomical variation, affecting the stylohyoid ligament and/or styloid process as mineralized structures developing in the first years of formation after birth.4,8 Concerning the semiological aspects, two variants have been described in the literature: the classical syndrome and the carotid artery-styloid apophysis syndrome. The first is related with the healing process occurring after tonsillectomy or neck trauma. 2,4 It presents with recurrent sore throat, otalgia, dysphagia, foreign body sensation in the pharynx, 4,5,10 and hypersalivation in some cases.9 It may occur at any age and the pain is believed to be caused by distortion and compression of nerve ends

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):50-5

Intraoral styloidectomy in an individual with styloid-stylohyoid syndrome

advanced age or presence of other disease.2,3 The surgical procedure comprises fracture and removal of the styloid processes and may be performed by intraoral/ transpharyngeal access or by extraoral incision.4,5 The extraoral approach is advocated by authors who state that this access provides better exposure of noble structures, avoiding lesions to cranial nerves and large blood vessels.1,4 It also allows lower risk of bacterial contamination and blood loss.7 However, this access demands longer time, need of general anesthesia with presence of postoperative skin scar, morbidity and involvement of adjacent anatomical structures.3,4,5 Additionally, two surgical complications have been reported in the literature: thrombosis of the internal carotid artery and neck subcutaneous emphysema.1 Conversely, other authors advocate treatment by intraoral access, reporting good outcomes by this technique. Despite the increased risk of infection of deep neck spaces,2,3,4 damage to nerves and arteries, and greater risk of hemorrhage, this procedure is simpler and safer.4,5 It demands shorter surgical time, provides better postoperative recovery, absence of skin scar, and allows outpatient treatment in some cases.3,4,6,9 Also, the potential complications may be avoided by careful tissue divulsion and separation, allowing successful and uneventful treatment.3,6 In the present case, there was no infection of deep neck spaces or any unexpected alteration.

of cranial nerves V, VIII, IX and X. 4 The carotid artery-styloid apophysis syndrome is not related with tonsillectomy 2 and occurs due to compression of the internal and external carotid artery, stimulating the sympathetic chain present on the wall of these blood vessels. The resulting symptoms include temporal or frontal headache, otalgia, vertigo and tinnitus, besides syncope and visual loss.4 The prevalence of styloid-stylohyoid syndrome in the general population is variable. Authors as Carlini et al.6 and Chrcanovic et al.9 reported values between 1.4 and 30%. Its prevalence is higher in females,3,4,7 at the mean age 30 to 53 years.3,7 The literature highlights that elongation of the styloid process does not necessarily indicate that the individual has the syndrome. It is only characterized in the presence of symptoms. Authors advocate that the syndromic symptomatology is only manifested in a small part of the population with elongated styloid processes because of their direction and angulation.10 Since there is no pathognomonic sign or symptom, the combination of symptoms present in the syndrome may be confounded with those assigned to a wide variety of facial neuralgias, dental and TMJ disorders. Therefore, adequate anamnesis, physical and imaging examinations is fundamental to achieve an accurate diagnosis.1,3 During physical examination, by careful palpation of the tonsillar fossa, the elongated styloid process may be palpated as a firm and sharp structure. This maneuver usually worsens the pain, yet local anesthetic infiltration in the tonsillar fossa promotes remission of symptoms, aiding the diagnosis of the disease.1,2 The diagnosis is confirmed by the findings of imaging examinations â&#x20AC;&#x201C; such as orthopantomogram, posteroanterior and lateral skull radiographs and computed tomography with 3D reconstruction.3,4 Treatment for this syndrome includes conservative and surgical approaches. The first comprises the utilization of non-steroidal anti-inflammatories, glucocorticoid injections1,4,6 and local anesthetics (1% lidocaine),3 on the lesser horn of the hyoid bone or tonsillar fossa, to minimize the pain. This approach is not definitive and should be conducted only in case without severe pain or in individuals who may not undergo surgical procedures, due to the systemic conditions,

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

CONCLUDING REMARKS The styloid-stylohyoid syndrome is characterized by a combination of painful symptoms caused by elongation of the styloid process of mineralization of the stylohyoid and stylomandibular ligaments. The diagnosis is based on clinical and imaging examinations, and treatment may be conservative or surgical, being the latter considered the most effective, presenting marked remission of symptoms. The intraoral approach should be considered due to the easy and fast accomplishment, for being safe and esthetically favorable, and providing little postoperative morbidity. The possible complications may be avoided by careful accomplishment of the technique. Thus, the surgeonâ&#x20AC;&#x2122;s experience is a determining factor for the success of therapy.

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):50-5

Bachesk AB, Jacomacci WP, Macêdo DV, Piacentini M, Pavan AJ, Camarini ET

References:

1. 2. 3.

Kapoor V, Jindal G, Garg S. Eagle’s Syndrome: a new surgical technique for styloidectomy. J Maxillofac Oral Surg. 2015;14(Suppl 1):360-5. Higino TCM, Tiago RSL, Belentani FM, Nascimento GMS, Maia, MS. Síndrome de Eagle: relato de três casos. Arq Int Otorrinolaringol. 2008;12(1):141-4. Cerqueira CCR, Batista ACC, Medeiros JO, Silva EP, Rosa ELS. Acesso Intraoral em três casos de Síndrome de Eagle. Rev Cir Traumatol Buco-Maxilo-Fac. 2014 Abr-Jun;14(2):9-14. Pereira FL, Iwaki Filho L, Pavan AJ, Farah GJ, Gonçalves EA, Veltrini VC, et al. Styloid-stylohyoid syndrome: literature review and case report. J Oral Maxillofac Surg. 2007 July;65(7):1346-53.

7. 8.

Al Weteid AS, Miloro M. Transoral endoscopic-assisted styloidectomy: How should Eagle syndrome be managed surgically? Int J Oral Maxillofac Surg. 2015 Sept;44(9):1181-7. Carlini JL, Strujak G, Biron C, Gebert AO, Romanowisk M. Síndrome de Eagle: relato de caso tratado por abordagem intraoral e revisão de literatura. Rev Bras Cir Traumatol Buco-maxillofac. 2010;10(1):77-82. Fini G, Gasparini G, Filippini F, Becelli R, Marcotullio D. The long styloid process syndrome or Eagle’s syndrome. J Craniomaxillofac Surg. 2000 Apr;28(2):123-7. Steinmann EP. Styloid syndrome in absence of an elongated process. Acta Otolaryngol. 1968 Oct;66(4):347-56.

Chrcanovic BR, Custódio ALN, Oliveira DRF. An intraoral surgical approach to the styloid process in Eagle’s syndrome. Oral Maxillofac Surg. 2009 Sept;13(3):145-51. 10. Yavuz H, Caylakli F, Yildirim T, Ozluoglu LN. Angulation of the styloid process in Eagle’s syndrome. Eur Arch Otorhinolaryngol. 2008 Nov;265(11):1393-6.

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):50-5

CaseReport

Report of rare

tongue neoplasm: schwannoma ÉWERTON DANIEL ROCHA RODRIGUES1,2 | THALITA MEDEIROS MELO1,2 | ALAN LEANDRO CARVALHO DE FARIAS1,3 | ANTONIONE SANTOS BEZERRA PINTO4,5,6 | MARCELO BRENO MENESES MENDES7,8

ABSTRACT Schwannomas are benign encapsulated tumors that proliferate from Schwann cells. They commonly arise from the roots of spinal, cranial, facial, neck and limb nerves. These lesions account for nearly 1% of all head and neck tumors. In the oral cavity, the tongue is the most affected. The tumors usually present as a firm, asymptomatic, solitary and well delineated mass. Its etiology is unknown. The diagnostic investigation may include computed tomography, ultrasound and magnetic resonance imaging. The treatment of choice is surgical excision, and prognosis is good. Female patient, Caucasoid, aged 20 years, complained of tongue lesion. Physical examination revealed a volume increase on the right tongue dorsum, sessile, hardened, measuring nearly 7 mm in the largest diameter and similar color as the healthy tissue, without painful symptomatology. No changes were observed on the panoramic radiograph. Surgical excision was performed under local anesthesia, and histopathological examination of the tumor revealed a lesion compatible with schwannoma. Tongue schwannoma is a relatively rare tumor of the head and neck. Complete removal of this tumor allows a low relapse rate with unlikely possibility of malignant transformation. Keywords: Neurilemmoma. Tongue. Mouth neoplasms.

Universidade Federal do Piauí, Hospital Universitário, Serviço de Cirurgia e Traumatologia Bucomaxilofacial (Teresina/PI, Brazil). Resident in Oral and Maxillofacial Surgery, Universidade Federal do Piauí, Hospital Universitário (Teresina/PI, Brazil). 3 Specialist in Oral and Maxillofacial Surgery, Universidade Federal do Piauí, Hospital Universitário (Teresina/PI, Brazil). 4 Universidade Federal do Ceará, Departamento de Morfologia (Fortaleza/CE, Brazil). 5 Universidade Federal do Ceará, Programa de Pós-graduação em Ciências Morfofuncionais (Fortaleza/CE, Brazil). 6 Master in Dentistry, Centro de Pesquisas Odontológicas São Leopoldo Mandic (Fortaleza/CE, Brazil). 7 Universidade Federal do Piauí, Hospital Universitário (Teresina/PI, Brazil). 8 Doctor and Master in Oral and Maxillofacial Surgery, Universidade Estadual de Campinas, Faculdade de Odontologia (Piracicaba/SP, Brazil). 1

How to cite: Rodrigues EDR, Melo TM, Farias ALC, Pinto ASB, Mendes MBM. Relato de neoplasia rara em língua: schwannoma. J Braz Coll Oral Maxillofac Surg. 2017 set-dez;3(3):56-60. DOI: https://doi.org/10.14436/2358-2782.3.3.056-060.cre

Submitted: May 30, 2017 - Revised and accepted: August 02, 2017 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. » Patients displayed in this article previously approved the use of their facial and intraoral photographs. Contact address: Éwerton Daniel Rocha Rodrigues Conjunto IPASE, quadra C, casa 113, Aeroporto, Teresina/PI – CEP: 64.006-050 E-mail: ewertondaniel27@hotmail.com, ewertondanielbmf@gmail.com

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):56-60

Rodrigues EDR, Melo TM, Farias ALC, Pinto ASB, Mendes MBM

CASE REPORT Female patient, of African descent, aged 20 years, attended the outpatient Maxillofacial Surgery service of a public hospital reporting volume increase on the right tongue dorsum for approximately three months. She denied any systemic pathologies, continuous drug use or allergies. Extraoral physical examination did not reveal significant asymmetric changes in facial contour. Intraoral examination evidenced volume increase on the right tongue dorsum, sessile, hardened, measuring nearly 7 mm in the largest diameter, with similar color as the healthy tongue tissue, without radiographic changes or associated pain (Fig 1A). The patient was informed on the diagnostic hypotheses – lymphoepithelial cyst, lipoma and mucocele – and underwent excisional biopsy. After lingual nerve block and infiltrative anesthesia around the lesion, 3-0 nylon suture was used for tongue pulling, to enhance the manipulation. A linear incision was performed with blade n. 15, in anteroposterior direction, of about 10 mm, on the region of volume increase, followed by blunt dissection (Fig 1B e 1C). A cleavage point was identified, and the lesion was entirely removed (Fig 2A e 2C). Suture was made with Vicryl 4-0 (Fig 2B) and routine analgesics and anti-inflammatories were prescribed. The patient was kept under weekly follow-up in the first month postoperatively and returned to the outpatient service with the outcome of histopathological analysis, in which the histological sections stained with hematoxylin and eosin analyzed by light microscopy revealed a neoplasm of neural origin, composed of spindle-shaped cells with evident nuclei. In some regions, there was formation of Verocay bodies (Antoni A), i.e. there were Schwann cells arranged in palisade around eosinophilic acellular areas (Antoni B) (Fig 3A e 3B). The specimen did not exhibit malignancy and allowed the diagnosis of schwannoma. The patient recovered dwell, without postoperative complications, and was kept in outpatient follow-up without relapse or other complaints (Fig 3C).

INTRODUCTION The neurilemoma, or schwannoma, is an uncommon neural benign neoplasm, occurring from proliferation of Schwann cells.1 It is a rare tumor, first described in 1908 by Verocay; it presents slow growth, smooth surface and is encapsulated, with size up to 6 mm in the average. It is usually not associated with pain or neurological symptoms, even though painful symptomatology may occur in some cases. The symptoms depend on the tumor size and location.1,2 The tongue schwannoma occurs more commonly between the second and fourth decades of life3 without gender predilection.4 Even though its etiology is unknown, some studies reveal that the tumor is often observed in areas susceptible to trauma, such as the tongue.5 Few neurilemmomas are clinically diagnosed because other lesions present similar aspects, including salivary gland tumors, mucoceles, lipomas, hemangiomas, neurofibromas, leiomyomas, swollen lymph nodes, eosinophilic granuloma, epithelial hyperplasia, lymphangioma and traumatic fibroma.6,7 Alike any pathological condition, imaging examinations are important to aid the diagnostic process, including ultrasound, magnetic resonance imaging and computed tomography. They may be useful to determine the position of tumors and infiltration of adjacent structures, as well as to determine the surgical access. Postoperatively, these complementary exams may indicate if complete tumor resection was achieved. Radiographically, the schwannoma presents as a unilocular radiolucent image with thin sclerotic margin, when in intraosseous location, possibly associated with external root resorption and cortical expansion.8 Usually, the neurilemmoma demonstrates two microscopic patterns in variable quantities: Antoni A and Antoni B. The pattern Antoni A is characterized by parallel bundles of spindle-shaped Schwann cells. The pattern Antoni B presents fewer cells and less organization, and the spindle cells are randomly arranged within a loose and myxomatous stroma.4 The present paper reports a case of tongue schwannoma in a female individual, aged 20 years, affecting the right tongue dorsum.

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):56-60

Report of rare tongue neoplasm: schwannoma

Figure 1: A) Anteroposterior aspect of nodular lesion, sessile, hardened, well-delineated, on the right tongue dorsum. B) Linear incision on the lesion. C) Aspect of the lesion and cleavage after blunt dissection.

Figure 2: A) Complete removal of lesion. B) Suture with Vycril 4-0. C) Specimen measuring approximately 13 mm.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):56-60

Rodrigues EDR, Melo TM, Farias ALC, Pinto ASB, Mendes MBM

Figure 3: A) Formation of Verocay bodies (Antoni A). B) Schwann cells arranged in palisade around eosinophilic acellular areas (Antoni B). C) Aspect at 12 months postoperatively.

DISCUSSION Schwannomas are benign encapsulated tumors proliferating from the Schwann cells, which commonly arise from the roots of spinal, cranial, facial, neck and limb nerves.9 Approximately 25 to 40% of schwannomas are found at the head and neck region.10 Among these, only 1% are intraoral, and the tongue is the most common site of oral neurilemmomas, which may also develop in regions as the palate, buccal mucosa, mouth floor, lips, alveolar ridge and mandible. The location of the lesion in the present case corroborates data in the literature, which indicate that the tongue is the most commonly affected in the oral cavity. The tumors usually present as a firm, asymptomatic, single and well delineated mass,4,5,9 as observed in the present case. The clinical presentation of neurilemmomas is similar to other lesions as lipomas,

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

fibromas, mucoceles, leiomyomas, rhabdomyomas, lymphangiomas and epidermoid cysts.1,8,9 The preoperative diagnosis of schwannoma is difficult.6,9 The diagnostic investigation may include computed tomography, ultrasound, fine needle aspiration and magnetic resonance imaging, being the later the best choice to evaluate the lesion extent and correlation with operative findings.2,5,6,8,9 On radiographs, the schwannoma presents as a unilocular radiolucent lesion, with thin sclerotic margin, and may be associated with external root resorption and cortical expansion.7 In the present case, the radiographic findings were unremarkable, and other complementary diagnostic methods were not requested due to the size and clinical presentation of the lesion. Macroscopically, the neurilemmomas are well delineated and encapsulated, the surface color ranges from greyish to yellow, with myxoid solid aspect and hemorrhagic staining,9 similar aspect as observed

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):56-60

Report of rare tongue neoplasm: schwannoma

CONCLUDING REMARKS Even though the tongue schwannoma is a relatively rare neoplasm, it should be considered in the list of differential diagnosis of nodular, small, circumscribed and well-delineated nodular lesions. The conservative surgical removal is the treatment of choice for most such tumors. The relapse and malignant transformation are extremely rare. After 12-month postoperative follow-up, the present patient did not report relapse or any other associated complication.

in the present case. Microscopically it presents two growth patterns, namely Antoni A and Antoni B, being the former characterized by parallel bundles of spindle-shaped Schwann cells; the second, with fewer cells and less organized, presents spindle-shaped cells randomly arranged in a loose myxomatous stroma.1-4 Lesion removal is the treatment of choice and was performed in the present case. The prognosis is good due to the low relapse rate, and malignant transformation of this lesion is uncommon.3,5,7,8,10

References:

1. 2. 3.

Enoz M, Suoglu Y, Ilhan R. Lingual schwannoma. J Cancer Res Ther. 2006 Apr-June;2(2):76-8. Aslan G, Cinar F, Cabuk FK. Schwannoma of the submandibular gland: a case report. J Med Case Rep. 2014;8(1):231-4. Abreu I, Roriz D, Rodrigues P, Moreira Â, Marques C, Alves FC. Schwannoma of the tongue-A common tumour in a rare location: a case report. Euro J Radiol Open. 2017;2:1-3. Neville BW, Damm DD, Allem CM, Bouquot JE. Patologia Oral e Maxilofacial. 3ª ed. São Paulo: Elsevier; 2009.

5. 6.

Lukšić I, Müller D, Virag M, Manojlović S, Ostović KT. Schwannoma of the tongue in a child. J Craniomaxillofac Surg. 2011 Sept;39(6):441-4. Özgür A, Bedir R, Coskun ZO, Erdivanli OC, Terzi S, Dursun E. Schwannoma of the upper lip: a case report. J Oral Maxillofac Surg Med Pathol. 2015;27(6):843-5. Meundi MA, Anekar J, Raj AC, Patil US, Mustafa SM. Intraosseous Schwannoma of the maxilla mimicking a periapical lesion: a diagnostic challenge. J Clin Diagn Res. 2015;9(3):1-4.

Cohen M, Wang MB. Schwannoma of the tongue: two case reports and review of the literature. Eur Arch Otorhinolaryngol. 2009;266(11):1823-9. 9. Shibata A, Kimura M, Ohto H, Yamada H, Umemura M. Schwannoma of the anterior maxillary vestibular submucosa: a case report. J Oral Maxillofac Surg Med Pathol. 2017;29(1):45-8. 10. Humber C, Copete MA, Hohn FI. Anciant schwannoma of upper lip: report with distinct histologic features and review of the literature. J Oral Maxillofac Surg. 2011 June;69(6):e118-22.

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):56-60

CaseReport

Endo-surgical approach of

radicular cyst: case report PAULA CRISTINA SANTOS ALVES1 | LUÍS RONALDO PICOSSE2,3 | CAMILA PORTO DE DECO4 | ÍRIS MARIA FRÓIS5 | RENATA AMADEI NICOLAU2,6

ABSTRACT The radicular cyst is described as a pathological cavity coated by epithelium with liquid or semi-solid content inside the lumen, caused by an inflammatory response of the apex to low-intensity harmful stimuli. It is usually diagnosed on routine radiographs and is treated by endodontic treatment and surgical therapies. The present paper reports a case of an individual with a large radicular cyst in the maxilla. The individual exhibited a radicular cyst of approximately 3 cm in diameter, between the nasal fossa and hard palate (as observed on orthopantomogram, occlusal radiograph and computed tomography). Clinical examination revealed absence of vitality of teeth #11, #12, #21 and #22, which apexes were related with the cyst. Treatment comprised aspiration, antibiogram, decompression, endodontic treatment of teeth under systemic medication and surgical approach 24 hours after completion of endodontic treatment. After 12 months, on the occlusal radiograph, there was evident repair of the region. It was concluded that the endo-surgical approach adopted successfully solved the case. Keywords: Radicular cyst. Bone regeneration. Scar. Cystic fibrosis.

Universidade do Vale do Paraíba, Graduação em Odontologia (São José dos Campos/SP, Brazil). Universidade do Vale do Paraíba, Departamento de Odontologia, Disciplina de Cirurgia e Traumatologia Bucomaxilofacial (São José dos Campos/SP, Brazil). 3 Specialist in Oral and Maxillofacial Surgery and Traumatology, Conselho Federal de Odontologia (São Paulo/SP, Brasil). PhD in Morphofunctional Sciences, Universidade de São Paulo (São Paulo/SP, Brazil). 4 Universidade do Vale do Paraíba, Departamento de Odontologia, Disciplina de Estomatologia, Fisiologia Humana e Bioquímica Humana Geral (São José dos Campos/SP, Brazil). Specialist in Oral Pathology, Conselho Regional de Odontologia (São José dos Campos/SP, Brazil). MSc in Oral Biopathology and PhD in Pathology, Universidade Estadual Paulista Júlio de Mesquita Filho (São Paulo/SP, Brazil). 5 Universidade do Vale do Paraíba, Departamento de Odontologia, Disciplina de Endodontia (São José dos Campos/SP, Brazil). PhD and MSc in Dentistry, Universidade de São Paulo (São Paulo/SP, Brazil). Specialist in Endodontics, Associação Paulista de Cirurgiões-Dentistas (Ribeirão Preto/SP, Brazil). 6 PhD in Ciències Mèdiques Bàsiques, Universitat Rovira i Virgili (Tarragona, Spain). PhD and MSc in Biomedical Engineering, Universidade do Vale do Paraíba (São José dos Campos/ SP, Brazil). Specialist in Investigación en Ciències Experimentales Aplicada a la Biomedicina, Universitat Rovira i Virgili (Tarragona, Spain. Specialist in Periodontics, Associação Paulista de Cirurgiões-Dentistas (São José dos Campos/SP, Brazil). 1

How to cite: Alves PCS, Picosse LR, Deco CP, Fróis ÍM, Nicolau RA. Abordagem endocirúrgica de cisto periapical: caso clínico. J Braz Coll Oral Maxillofac Surg. 2017 set-dez;3(3):61-6. DOI: https://doi.org/10.14436/2358-2782.3.3.061-066.cre Submitted: June 15, 2017 - Revised and accepted: August 13, 2017 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. » Patients displayed in this article previously approved the use of their facial and intraoral photographs. Contact address: Paula Cristina Santos Alves Av. das Letras, 900, torre 1, apto 11 Villa Branca - Jacareí/SP – CEP: 12.301-330 E-mail: paulaalves.odontologia@gmail.com, paulaalves.odonto@gmail.com

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):61-6

Endo-surgical approach of radicular cyst: case report

INTRODUCTION Total sanitization of the root canal system is complicated by its complexity, especially in the presence of microorganism proliferation and lodging. Thus, the appearance and progression of common apical lesions are frequent.1 One such example is the radicular cysts, na inflammatory pathological cavity of odontogenic origin, caused by a secondary response of the apex to pulp necrosis, which may be caused by low-intensity harmful stimuli.1,2 Macroscopically, the radicular cyst is composed of a capsule, epithelial lining and liquid or semi-solid content in its lumen. Radiographically, it is observed as a radiolucent image surrounded by a radiopaque line.3,4 In addition to radiographic examinations, other resources as pulp vitality tests, aspiration and histopathological analysis, in surgical cases, may aid the diagnosis.2 Treatment may be endodontic or surgical. The first option is more conservative compared to the surgical approach. However, if not properly performed, a lesion may appear and require endodontic retreatment. In cases without lesion remission or cases with large lesions, complementary surgical therapy is indicated. This may be performed by three techniques: marsupialization, comprising removal of a lesion fragment and suture of the cyst capsule with the gingival mucosa; enucleation, described as complete removal of the lesion; and the combination of both techniques, i.e. marsupialization followed by enucleation. All approaches require strict radiographic follow-up.3 In cases of large lesion and need of endodontic treatment, the combined approach may be indicated. Considering the complex treatment of the radicular cyst, this paper presents a case report in detail, demonstrating the surgical technique, associated with a detailed diagnosis and endodontic approach to solve this case.

Thus, periapical radiographic examination was performed, which revealed a lesion suggesting a radicular cyst involving tooth #21. Additionally, there was root resorption of tooth #11, a small apical lesion in tooth #12 and Class III and IV unsatisfactory composite restorations on teeth #12, #11 and #21. To aid the diagnosis, testing was performed with Endo Frost and heated gutta-percha to check the pulp vitality, besides aspiration and computed tomography. The pulp vitality test was negative for all four teeth. However, pulp vitality of tooth #22 was observed on endodontic treatment. Aspiration using a needle and syringe retrieved, a liquid, light yellowish secretion, which was used for the antibiogram. Normal microbiota was observed, without any specific antibiotic resistance. Finally, computed tomography was requested, which revealed diffuse bone rarefaction affecting teeth #11 and #12 and external root resorption of teeth #21 and #22, with rupture of buccal wall integrity and communication with the nasal fossa (Fig 1B). Therefore, it was decided to perform endodontic treatment of the maxillary anterior teeth, followed by enucleation of the lesion. Some days before treatment onset (about two months after the first aspiration), there was significant increase in lesion volume. High blood pressure peaks were observed, and thus ear bloodletting was performed. This procedure reduced the blood pressure from 160 x 120 mmHg to 140 x 100 mmHg. Then, a new aspiration was performed, which presented similar result as the first, and a drain was placed. This procedure was performed by local anesthesia with 3% lidocaine with subsequent incision on the lesion. The rubber drain was then placed and fixated with a suture. After five days of drain placement, the necessary decompression was achieved to remove the artifact. The patient was prescribed Rescue floral and was referred to a cardiologist for preoperative evaluation. Subsequently, the medical report indicated patterns within the normal range in the preoperative evaluation. Seven days after drain removal, the treatment plan was continued. As planned, endodontic treatment was performed in a single session, with rubber dam isolation and by the Paiva-Antoniazzi technique. For that purpose, maxillary anterior alveolar and nasopalatine nerves were blocked with 3% lidocaine with vasoconstrictor. During therapy, Endo PTC, Dakin solution and EDTA were used as aux-

CASE REPORT A male individual aged 45 years, Caucasoid, attended the dental polyclinic with complaint of a “blister on the roof of mouth that was constantly swelling”. Physical examination did not reveal remarkable extraoral clinical characteristics; however, intraoral examination evidenced a well-delineated and circumscribed lesion at the anteroposterior portion of the palate, soft to palpation, with approximate diameter of 3 cm (Fig 1A).

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):61-6

Alves PCS, Picosse LR, Deco CP, Fróis ÍM, Nicolau RA

simple suture was made on the proximal aspect of teeth and in releasing incisions. The entire procedure was performed using sterile drapes and material (Fig. 2C and 2D). The preoperative prescription included Amoxicillin 500 mg for seven days, and Metronidazole 250 mg for five days, both at every eight hours, initiating 24 hours before surgery. Also, Diazepam 5 mg and Dexamethasone 4 mg were prescribed, one tablet each, one hour before the procedure, to control the inflammation and anxiety, avoiding alterations in heart rate and blood pressure of the patient. For postoperative prescription, besides Amoxicillin and Metronidazole, one tablet of Dexamethasone 4 mg was prescribed 24 hours after the procedure, and acetaminophen and codeine phosphate analgesics, one tablet at every six hours in case of pain, for at most two days. At seven days postoperatively, the patient complained of discomfort related to the sutures. Clinical examination revealed a supposed allergy to the suture, since there was erythema close to the suture. For control, periapical radiograph of the maxillary anterior teeth and maxillary occlusal radiograph were obtained, which evidenced normal aspect. Also, three days after surgery, there was drainage of a creamy yellowish liquid with red remnants. Therefore, the patient was instructed to perform intraoral therapy with moist warmth (warm water mouthrinses). On the 12th rinse there was drainage once again, followed by reduction of symptoms. Therefore, the teeth #11, #12, #21 and #22 were restored with composite. Thirty days after surgery the patient reported swelling of the upper lip, hypoesthesia of the nasal fossa and pain. For this reason, Azithromycin 500 mg was prescribed, one tablet a day, for seven days, without any discomfort or abnormality after its utilization. After two weeks, radiographic (periapical and occlusal) and clinical examinations were performed, which revealed a stable situation. This follow-up was maintained for 12 months. After surgical therapy, fifteen soft tissue fragments were obtained, of brownish color, irregular shape and surface and rubbery texture, which were placed in 20 ml of formaldehyde and submitted to histopathological analysis, confirming the diagnosis of radicular cyst. Also, altogether the fragments mea-

Figure 1: A) Initial clinical aspect of the lesion. B) Initial radiographic aspect of the lesion.

iliary substances. At completion, the teeth were sealed with temporary material (Fig 2A and 2B). For enucleation of the lesion, extraoral antisepsis was performed with 10% PVPI, and intraoral with 0.1% chlorhexidine, followed by infraorbital block using 3% mepivacaine with vasoconstrictor. To access the lesion, on the buccal aspect, an intrasulcular incision was performed from tooth #13 to #23 with two releasing incisions, followed by flap detachment and osteotomy. On the palatal aspect, no incision and/or detachment were performed. During flap detachment there was rupture of the cyst capsule, followed by outflow of intraluminal secretion. Therefore, it was decided to perform enucleation followed by surgical curettage, for total lesion removal. Finally, the surgical region was irrigated with 20 ml of saline and 300 mg of lincomycin, and cleaned with sterile gauze; then,

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):61-6

Endo-surgical approach of radicular cyst: case report

Figure 2: A, B) Endodontic treatment of maxillary anterior teeth. C, D) Surgical treatment (cyst enucleation).

Throughout treatment and post-operative follow-up, strict clinical and radiographic examination of the patient was performed, who presented stable clinical status within normal standards, with radiographically visible bone regeneration. Also, a radiolucent image suggesting cicatricial fibrosis was observed, which usually occurs when the cortical bone is disrupted.9 Therefore, aspiration was repeated, and the lesion did not contain any secretion. Finally, the case was followed and revealed continuation of bone regeneration and reduction of supposed cicatricial fibrosis (Fig 3A and 3B).

sured 25 x 20 x 7 mm and histologically presented connective origin, either dense or loose, partly lined by non-keratinized stratified squamous or pseudostratified cylindrical epithelium, hyperplastic and of variable thickness. The epithelia region revealed areas of hydropic degeneration and exocytose. Some areas exhibited epithelial fragments associated with mucous glands, which were interpreted as mucosa of the upper airway, and intensive diffuse chronic inflammatory infiltrate, which were mixed in some regions. Finally, there were several congested blood vessels, normal aspect of bone tissue and some areas of hemorrhage (Fig 3C).

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):61-6

Alves PCS, Picosse LR, Deco CP, Fróis ÍM, Nicolau RA

Figure 3: A) Clinical aspect 12 months after clinical intervention. B) Radiographic aspect 12 months after clinical intervention. C) Histopathological analysis.

DISCUSSION The radicular cyst, also known as radicular cyst, is commonly observed in dentistry. According to the study of Ribeiro et al,1 among 107 lesions analyzed, 48 (44.8%) were diagnosed as radicular cyst. The diagnosis requires a survey of information, including anamnesis, clinical examination, microbiological examinations, aspiration, periapical and occlusal radiographs and orthopantomograms. In case of surgical removal, it is necessary to request computed tomography to determine the lesion location and extent.2 In the present study, as also reported by Bhalerao et al,5 all these aspects were considered for diagnosis of the

case, with emphasis to aspiration, which revealed cholesterol crystals in both cases. Considering these findings, endodontic treatment with surgical complementation as indicated. The treatment was planned considering the lesion extent and location, general status of the individual and maximum maintenance of adjacent structures.3 Endodontic treatment is the first treatment choice. In some cases, endodontic treatment is sufficient for lesion regression, as reported by Carvalho et al.6 However, if this is ineffective or in cases of large cysts, surgical treatment is necessary. It may be different according to the technique employed: marsupialization; enucleation

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):61-6

Endo-surgical approach of radicular cyst: case report

simple, effective and selected by several authors reporting the success of treatment of radicular cyst.3,4,5,8 In the present case, the combination of cyst decompression, endodontic treatment and lesion enucleation promoted suggestive cure. Radiographic follow-up revealed a radiolucent image suggesting fibrotic scar. This scar occurs by induction of fibroblast proliferation and migration, promoted by cytokines and growth factors present on the surgical site and granulation tissue, initially formed on the surgical site.10 If this is diagnosed, there is no need of further treatment.9

or marsupialization followed by enucleation.3 According to Vasconcelos et al,3 other technique that may be used is cyst decompression, which promotes lesion regression and reduced the disadvantages of enucleation. In the present study, decompression was performed ten days before enucleation, using a sterile rubber drain, which was placed for five days and was also effective, as reported by the author. Among the surgical techniques, marsupialization is considered as conservative compared to enucleation. Conversely, the surgical site is exposed and prone to food impaction; therefore, oral hygiene should be properly performed by the patient.7 According to Pinto et al.7, marsupialization is more effective than decompression, since drain placement is uncomfortable for the individual and constitutes a niche for dental biofilm, which may lead to secondary infection. This technique was not performed in this case due to the active life of the individual as tourist guide at the mountains region and scarce oral hygiene, due to the individual’s daily routine. Even though enucleation is more aggressive to the adjacent structures, such technique is relatively

CONCLUDING REMARKS It is concluded that the radicular cyst presents accurate diagnosis and favorable prognosis. Selection of the adequate treatment should consider the maximum maintenance of adjacent structures and complete cure of the lesion. This may be achieved by a combination of techniques as in the present case, in which decompression of the lesion, followed by endodontic treatment complemented by cyst enucleation, were effective for resolution of the case.

References:

Ribeiro FC, Fabri B, Roldi A, Pereira RS, Intra JBG, Peçanha M, et al. Prevalência de lesões periapicais em dentes tratados endodonticamente. Rev Saúde Com. 2016;9(4)244-52. Assunção C, Cardoso A, Oliveira JA, Moreira DR, Soares SO, Fonseca LC. Aspectos imaginológicos de um cisto radicular atípico no interior do seio maxilar. Arq Bras Odontol. 2013;9(1):7-13. Vasconcelos RG, Queiroz LMG, Alves Júnior LC, Germano AR, Vasconcelos MG. Abordagem terapêutica em cisto radicular de grandes proporções: relato de caso. Rev Bras Ciênc Saúde. 2012;16(3):467-74.

5. 6.

Haverroth FN, Paza AO, Ávila LFC, Carvalho CC, Gregol LG. Marsupialização, erupção dental e exérese cística-relato de caso clínico. J Oral Investig. 2015;2(2):44-8. Bhalerao S, Tamgadge A, Borse V, Sandhya T, Periera T, Kandekar P, et al. An extensive radicular cyst: a case report. JIDA. 2012 Feb;6(2):128-30. Carvalho MGP, Dotto SR, Brondani GC, Filter VP, Kist PP. Reparo de lesão periapical: relato de caso. Rev Endod Pesq Ens on Line. 2012 Jan-Jun [Acesso em: 15 Jan 2015];9(15). Disponível em: http://w3.ufsm.br/ endodontiaonline/artigos/[REPEO]%20Numero%20 15%20Artigo%201.pdf

Pinto GNS, Figueira JA, Gonçales ES, Sant’Ana E, Tolentino ES. Marsupialização como tratamento definitivo de cistos odontogênicos: relato de dois casos. RFO UPF. 2015;20(3):361-6. 8. Milagres RM, Andrade BAB, Messora MR, Kawata LT. Cisto periapical de grande extensão: relato de caso. Rev Cir Traumatol Buco-maxilo-fac. 2012 AbrJun;12(2):37-42. 9. Neville B, Damm DD, Allen CM, Bouquot JE. Patologia oral e maxilofacial. Rio de Janero: Elsevier; 2011. 10. Cotran R, Kumar V, Collins T. Robbins. Bases patológicas das doenças - Patologia. 7ª ed. Rio de Janeiro: Guanabara Koogan; 2005.

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CaseReport

Benign lipomatous neoplasm:

case report

ABSTRACT This paper reports a case of a 54-year-old individual, who attended the Oral and Maxillofacial Surgery and Traumatology outpatient service of Bahia School of Medicine and Public Health/General Hospital Roberto Santos (EBMSP/HGRS) due to a rounded and softened volume increase, with approximately 6 cm in diameter, which compromised the lower right side of the face causing esthetic damage. Lipomas are common benign soft tissue neoplasms of mesenchymal origin, composed of mature fat cells. They are usually slow-growing soft nodular masses with flat surfaces, and may be pedunculated or sessile, single or lobed, asymptomatic, and may measure 3 cm or more, macroscopically presenting yellowish color. They affect mainly males between the third and fifth decades of life. The most common treatment is surgical removal. Relapse is rare, yet it can occur in some cases. Surgical treatment was performed by excisional biopsy, confirming the suspected diagnosis of lipoma. At this moment, the individual is under outpatient follow-up by the Oral and Maxillofacial Surgery and Traumatology team. Keywords: Lipoma. Pathology. Neoplasms.

Escola Bahiana de Medicina e Saúde Pública, Faculdade de Odontologia, Departamento de Cirurgia e Traumatologia Bucomaxilofacial (Salvador/BA, Brazil). MSc in Stomatology, Escola Bahiana de Medicina e Saúde Pública (Salvador/BA, Brazil). 3 Specialist in Oral and Maxillofacial Surgery and Traumatology, Escola Bahiana de Medicina e Saúde Pública (Salvador/BA, Brazil). 4 Universidade de Santo Amaro, Programa de Mestrado em Odontologia – Implantodontia (Santo Amaro/SP, Brazil). 5 Graduate in Dentistry, Escola Bahiana de Medicina e Saúde Pública (Salvador/BA, Brazil). 6 MSc in Implantology, Escola Bahiana de Medicina e Saúde Pública (Salvador/BA, Brazil). 7 PhD in Oral and Maxillofacial Surgery and Traumatology, Escola Bahiana de Medicina e Saúde Pública (Salvador/BA, Brazil). 8 Preceptor of the Oral and Maxillofacial Surgery and Traumatology service, Escola Bahiana de Medicina e Saúde Pública, Hospital Geral Roberto Santos (Salvador/BA, Brazil). 9 PhD in Laser in Dentistry, Universidade Federal da Bahia (Salvador/BA, Brazil). 1

How to cite: Lopes GS, Rebouças DS, Silva KX, Lucindo Sobrinho A, Zerbinati LPS, Marchionni AM. Neoplasia lipomatosa benigna: relato de caso clínico. J Braz Coll Oral Maxillofac Surg. 2017 setdez;3(3):67-71. DOI: https://doi.org/10.14436/2358-2782.3.3.067-071.cre

Submitted: July 20, 2015 - Revised and accepted: June 27, 2017 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. » Patients displayed in this article previously approved the use of their facial and intraoral photographs. Contact address: Gabriela Santos Lopes Av. Silveira Martins, nº 3386, Cabula – Salvador/BA CEP: 41.150-100 E-mail: gabrielaburaem@hotmail.com

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):67-71

Benign lipomatous neoplasm: case report

INTRODUCTION Lipomas are benign fat tumors of mesenchymal origin, rarely found in the oral cavity, even though they frequently occur in different body regions.1-7 Depending on the location, size and time of evolution of the tumor, it may cause orofacial deformity in some individuals, causing alterations in speech, mastication and esthetics of the affected region.1,3 They usually present as soft, slow-growing nodular masses, asymptomatic, measuring from 3 cm in diameter up to large dimensions. Macroscopically, they present yellowish color.7 Even though they also occur in females, the lipomas primarily affect males between the third and fifth decades of life. They are rarely observed in children.1,6 They are not common in the oral cavity, yet when occurring they mostly appear on the buccal mucosa and vestibule, mouth floor, palate and gingiva.2,5,6,7 There are several treatment options, comprising surgical removal of the benign neoplasm. There are reports of authors who used electrosurgery and surgical laser for tumor removal and achieved good outcomes. Relapse is rare, and the literature does not present calculations of percentage of lipoma relapse, even though this occurs in some cases.1,2,5,7,8 The differential diagnosis of lipomas may be associated with salivary gland lesions, fibrous hyperplasias and neurofibromas.9 This paper reports a case of a male individual aged 54 years, with volume increase causing orofacial deformity.

tioned treatment with oral antibiotics, prescribed by a medical doctor due to suspected skin infection; however, there was no regression of the lesion. Examination revealed a rounded and soft volume increase, measuring approximately 6 cm in diameter, affecting the right lower facial third (submandibular region), causing significant facial asymmetry and esthetic damage to the individual (Fig 1A, 1B). The tomographic examinations exhibited hypodense image below the subcutaneous tissue, with homogeneous content, rounded aspect and well-defined margins (Fig 2). Ultrasound revealed a lesion suggesting lipoma superficially to the masseter muscle. Aspiration was performed and was negative for liquid and air The patient was submitted to surgery under general anesthesia and orotracheal intubation for excisional biopsy. Extraoral submandibular access was achieved and the lesion was observed after blunt dissection with scissors (Metzenbaum) in the subcutaneous tissue and platysma muscle. The extensive lesion was carefully removed by cleavage between the capsule and normal tissues and then submitted to histological analysis (Fig 3). The yellowish color and tumor floating in saline led to diagnostic hypothesis of lipoma. The surgical wound was closed with internal sutures with coated Vicryl 3-0 polyglactin 910 (Ethicon, São Paulo/SP, Brazil), and the skin region by intradermal suture. On histopathological analysis, the sections revealed fragments of benign neoplasm, characterized by proliferation of mature fat cells interspersed within thin bundles of connective tissue (Fig 4), confirming the diagnosis of lipoma. On the 14th day postoperatively, the surgical wound presented satisfactory signs of repair, being esthetically unnoticeable, and the suture was removed. The muscle activity of facial mimics was maintained, and facial symmetry was reestablished. The individual was followed for 90 days, without relapse.

CASE REPORT Male individual aged 54 years, of male gender, attended the Oral and Maxillofacial Surgery and Traumatology service of HGRS/EBMSP with complaint of “facial swelling for three years, which did no disappear by any means”. During anamnesis, the individual did not report pain, paresthesia or feeding difficulties. He men-

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):67-71

Lopes GS, RebouĂ§as DS, Silva KX, Lucindo Sobrinho A, Zerbinati LPS, Marchionni AM

Figure 1: A) Frontal view of the individual, evidencing extensive round lesion in the lower facial third. B) Caudocranial image, illustrating the deformity and asymmetry caused by the lesion on the mandibular contour.

Figure 2: Axial image of computed tomography illustrating hypodense lesion between the mandible and subcutaneous region.

Figure 3: Image of yellowish lesion dissected from the tissues.

Figure 4: View of benign neoplasm with presence of mature fat cells (toluidine blue, 10x magnification).

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):67-71

Benign lipomatous neoplasm: case report

DISCUSSION Lipomas are common soft tissue benign neoplasms (adipose tissue) of mesenchymal origin, composed of mature fat cells, which are rarely found in the oral cavity, though frequently observed in other body regions.1-3 They are uncommon in female individuals and children, usually affecting males between the third and fifth decades of life, without ethnicity predilection,1,3,6 as in the present case, in an individual with such characteristics: male gender and 54 years of age. Their etiology and pathogenicity are controversial10, yet the literature reports influence from hormonal, endocrinological and inflammatory factors, local trauma and infection.3-6 The metabolism of lipomas is independent of the normal body fat; it is not deuced by the reduction of weight and fat tissue.1-3 This occurs because the metabolism of tumor cells is more intensive compared to fat cells.11 The lesion may be clinically diagnosed, by imaging examinations (computed tomography, magnetic resonance imaging, ultrasound) and accomplishment of incisional or excisional biopsy, for histopathological analysis of the tumor. Some authors report utilization of 10% formalin, saline or water as means for diagnosis, since a floating lesion is a characteristic sign of fat, which presents lower density than the liquid solutions.1,3,4,6 Their size may range from 3 cm to large dimensions, possibly causing facial deformities. If they reach large dimensions, they may cause masticatory difficulties, alterations and disturbances around their site, as in the present case, which caused esthetic damage at the submandibular region, yet without masticatory problems.1,2,3 On histopathological examination, the lesions presented as well-circumscribed nodules delineated by a thin fibrous tissue capsule (which reduces the infiltration patterns and risks of relapse); it may be sessile or pedunculated, single or presenting multiple lobules and blood vessels, and asymptomatic, with most individuals searching for treatment only when the lesion reaches large dimensions.1,4,6

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Macroscopically it presents yellowish coloration and soft texture to palption,1 accounting for 5% of benign tumors in the oral cavity, and 15 to 20% at the head and neck region.6 The main locations in the oral cavity are the buccal mucosa and vestibule, followed by the mouth floor, palate, gingiva, tongue, lips and facial region.1,2 There are some variants of the tumor, including fibrolipoma (fibrous and fat tissue), angiolipoma (mature fat cells and several small blood vessels), spindle cell lipoma (composed of a mixture of uniform spindle cells and a typical lipomatous component), pleomorphic lipoma (composed of spindle cells and hyperchromatic giant cells) and intramuscular lipomas (nearly always located deeply and presenting infiltrative growth pattern).1-4 There are also liposarcomas, a malignant variant with the same origin as the lipoma and similar characteristics. They may be classified as well-differentiated (atypical lipoma), undifferentiated, myxoid, round cells and pleomorphic. The histopathological diagnosis was classified within the most common type of lipoma; thus, its low relapse rate demonstrates little risk of new tumor intervention.1-4 The treatment primarily consists of surgical removal (excisional biopsy) of the tumor, electrosurgery and surgical laser for removal, especially in cases of infiltrating lipomas, to avoid possible relapse. Conversely, the intramuscular variant presents high relapse rate. When occurring at the facial region, the relapse rate is low compared to other body regions. It should be mentioned that it is important to evaluate the patient in the postoperative period, for better follow-up.1,4-6 CONCLUDING REMARKS Treatment by surgical excision is effective even in extensive lipomatous lesions. However, despite the low risk of relapse, regular follow-up is necessary. Even though this is an uncommon lesion in the oral and maxillofacial region, an accurate diagnosis is necessary.

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):67-71

Lopes GS, Rebouças DS, Silva KX, Lucindo Sobrinho A, Zerbinati LPS, Marchionni AM

References:

2. 3.

Resende R, Meirelles M, Varella R. Remoção cirúrgica de lipoma de grande proporção: relato de caso. Rev Cir Traumatol Buco-Maxilo-Fac. 2013 AbrJun;13(2):37-42. Neville BW, Damm DD, Allen CM, Bouquol JE. Lipoma. Patologia oral e maxilofacial. 3ª ed. Rio de Janeiro: Guanabara Koogan; 2009. Carvalho MF, Junqueira TP, Souza RR, Capistrano HM, Chaves MGAM. The importance of early diagnosis of large lipomas in the maxillofacial region. Rev Cubana Estomatol Ciudad La Habana. 2010 Ene-Mar;4(1):77-83. Noro Filho GAN, Caputo BV, Santos CC, Souza RS, Giovani EM, Scabar LF, et al. Diagnóstico e tratamento do lipoma intraoral: relato de caso. J Health Sci Inst. 2010;28(2):133-5.

5. 6.

7. 8.

Meneses RO, Tavares SSS, Peixoto TS, Aragão AS, Godoy GP. Unusual Facial Lipoma. Rev Gaúcha Odontol. 2014 Oct-Dec;62(4):425-30. Ribeiro Neto N, Marques JAF, Santos MAM, Parra GR, Mota GCC, Barreto AP. Lipoma de tamanho em lábio inferior. Rev Cir Traumatol BucoMaxilo-Fac. 2010 Out-Dez;10(4):9-12. Regezi JA, Sciubba JR. Patologia oral: correlações clinicopatológicas. 6ª ed. Rio de Janeiro: Elsevier; 2012. Tenorio JR, Paiva KM, Nogueira PTBCN, Silva EDO. Exérese de extensor lipoma em região submandibular: relato de caso. Rev Cir Traumatol BucoMaxilo-Fac. 2013;13(3):43-50.

Venkateswarlu M, et al. A rare case of intraoral lipoma in a six year-old child: a case report. Int J Oral Sci. 2011 Jan;3(1):43-6. 10. Kaur RP, Kler S, Bhullar A. Intraoral Lipoma: report of 3 Cases. Dent Res J (Isfahan). 2011 Winter;8(1):48-51. 11. Darling MR, Daley TD. Intraoral chondroid lipoma: a case report and immunohistochemical investigation Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005 Mar;99(3):331-3.

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):67-71

CaseReport

Marsupialization as definitive treatment for

odontogenic keratocyst: case report and literature review JOSÉ RÔMULO DE MEDEIROS1,2 | CARLOS BRUNO PINHEIRO NOGUEIRA3,4 | EDUARDO EMIM3,5 | MARCELO FERRARO BEZERRA6,7 | EDUARDO COSTA STUDART SOARES3,6,8

ABSTRACT This paper reports a case of odontogenic keratocyst diagnosed during an orthodontic routine appointment, under treatment by marsupialization. The paper presents a literature review and description of 48-month follow-up of a case of odontogenic keratocyst, under treatment by marsupialization, without mandatory indication of additional techniques for final lesion treatment. The lesion disappeared without any sign of relapse. It is possible to conservatively manage large odontogenic keratocysts, by the utilization of marsupialization. Keywords: Pathology, oral. Surgery, oral. Odontogenic cysts.

Universidade de Fortaleza, Curso de Odontologia (Fortaleza/CE, Brazil). Universidade Federal do Ceará, Programa de Pós-graduação em Odontologia - Cirurgia e Traumatologia Bucomaxilofacial (Fortaleza/CE, Brazil). 3 Universidade Federal do Ceará, Curso de Odontologia (Fortaleza/CE, Brazil). 4 MSc in Dental Clinics - Oral and Maxillofacial Surgery and Traumatology, Universidade Federal do Ceará (Fortaleza/CE, Brazil). 5 DDS, Universidade Federal do Ceará (Fortaleza/CE, Brazil). 6 Universidade Federal do Ceará, Curso de Odontologia (Sobral/CE, Brazil). 7 PhD in Dentistry, Universidade Federal do Ceará (Fortaleza/CE, Brazil). 8 PhD in Stomatology, Pontifícia Universidade Católica do Rio Grande do Sul (Porto Alegre/RS, Brazil). 1

How to cite: Medeiros JR, Nogueira CBP, Emim E, Bezerra MF, Soares ECS. Marsupialização como tratamento definitivo para ceratocisto odontogênico: relato de caso e revisão de literatura. J Braz Coll Oral Maxillofac Surg. 2017 set-dez;3(3):72-8. DOI: https://doi.org/10.14436/2358-2782.3.3.072-078.cre

Submitted: October 07, 2015 - Revised and accepted: May 01, 2017 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. » Patients displayed in this article previously approved the use of their facial and intraoral photographs. Contact address: Carlos Bruno Pinheiro Nogueira Rua Alexandre Baraúna, nº 949, Rodolfo Teófilo – Fortaleza/CE – CEP: 60.430-160 E-mail: cbrunopn@gmail.com

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):72-8

Medeiros JR, Nogueira CBP, Emim E, Bezerra MF, Soares ECS

INTRODUCTION The odontogenic keratocyst (OK) has always demanded special attention for treatment, especially due to the high relapse rates.1 Shear,2,3,4 in 2002, concluded that this pathology was better characterized as a neoplasm rather than a cystic lesion. In 2005, the World Health Organization (WHO) reclassified this lesion as odontogenic benign tumor, naming it keratocystic odontogenic tumor (KOT); in 2017, it was assigned a new name, returning to odontogenic cyst.5 Either in isolated lesions or associated with basal cell nevoid carcinoma syndrome, studies indicate that the etiology is related with mutations in tumor suppressor gene PTCH.6 The odontogenic keratocyst usually affects the mandibular posterior region and may or may not be associated with an impacted tooth. This cyst presents primarily medullary growth, which may cause late expansion of involved cortical bone without painful symptomatology. The prevailing imaging aspect is a circumscribed radiolucent area, uni or multilocular. The friable capsule and frequent presence of satellite cysts often impair its complete enucleation7. The association of these characteristics assigns an aggressive and infiltrative evolution to this lesion, which is related with the high relapse rates reported in the literature, ranging from 25 to 62.5%.8 The treatment of this condition demands detailed planning, since factors as patient’s age, size and location of the lesion, involvement of soft tissues and previous history of treatments may change the prognosis.9 Larger cysts may involve teeth and associated important structures. In these cases, the extent of surgery and its inherent sequelae may lead to undesirable morbidity. This understanding has led the scientific community to employ conservative treatment techniques, such as marsupialization and decompression, aiming to reduce the tumor volume for later utilization of complementary techniques for treatment finalization, such as secondary enucleation.10,11 The latter may also be associated with peripheral ostectomy, application of Carnoy solution of cryosurgery, depending on the characteristics of each case and surgeon’s experience. These techniques have demonstrated satisfactory resolution of cases with reduced relapse rates.12-15

Specifically, in OK, whose growth seems to occur due to an association between intraluminal osmotic pressure and cytokine release by the tumor epithelium,3 the simple marsupialization or decompression have been successfully performed in lesions that presented complete regression.8 Thus, this paper reports a case of OK diagnosed after orthodontic therapy, under treatment by marsupialization, without mandatory indication of additional techniques, after 48-month follow-up. CASE REPORT A female individual, aged 33 years, of African descent, attended the Oral and Maxillofacial Surgery and Traumatology service of University Hospital Walter Cantídio, with the chief complaint of “painless lesion in the mandibular bone observed on the radiograph”. Anamnesis was unremarkable concerning the previous medical history. In dental history, the individual had performed an orthopantomogram, requested for orthodontic purposes. There were no extraoral alterations; however, the oral examination revealed only intense mobility of tooth #38 (Fig 1). Concerning imaging examination, the patient presented two orthopantomograms obtained at two different moments, which revealed the lesion evolution. The radiograph obtained before orthodontic treatment evidenced bilateral radiolucent images distal to teeth #38 and #48, suggesting thickening of the pericoronal space or paradental cysts (Fig 2). After completion of orthodontic treatment, after three years and three months, the orthopantomogram requested for orthodontic evaluation unexpectedly exhibited a large radiolucent area, unilocular, with well-defined margins, involving the mandibular body, angle and ramus on the left side. The lesion was related with tooth #38 without image suggesting root resorption (Fig 3). Computed tomography revealed a hypodense image extending from the mesial root of tooth #37 up to the upper portion of the mandibular ramus, without images suggesting perforation of cortical bone. Considering the clinical and imaging hypothesis of OK, a single surgical procedure was performed for marsupialization, during which one fragment was ob-

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):72-8

Marsupialization as definitive treatment for odontogenic keratocyst: case report and literature review

was progressive reduction of the lesion volume. On the imaging examination obtained after 48 months, the computed tomography demonstrated adequate resolution, with image compatible with lesion regression and persistence of a bone canal with cortical, possibly filled with oral mucosa, without signs of lesion relapse (Fig 6). The patient denied any additional complaints.

tained for histopathological analysis, and extraction of tooth #38 (Fig 4). The histopathological findings confirmed the clinical hypothesis of OK (Fig 5). Orthopantomograms were obtained at every three months on the first year, at every six months on the second year and then once a year. Computed tomography images were obtained at every six months. There

Figure 1: Initial examination evidencing presence of tooth #38 with mobility.

Figure 2: Orthopantomogram before orthodontic treatment, with bilateral radiolucent images distal to teeth #38 and #48, suggesting thickening of pericoronal spaces or paradental cysts.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

Figure 3: Lesion related with tooth #38, with image suggesting root resorption.

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Medeiros JR, Nogueira CBP, Emim E, Bezerra MF, Soares ECS

Figure 4: Lesion related to tooth #38, with image suggesting root resorption.

Figure 5: A) Electron micrograph demonstrating histological section stained with HE (200x magnification), exposing the cystic wall lined by stratified squamous epithelium, with flat interface with the connective tissue. B) 400x magnification evidencing basal layer in palisade, with hyperchromatic cylindrical cells with occasional reverse polarization, and a luminal surface exhibiting parakeratotic cells.

Figure 6: Computed tomography demonstrating adequate resolution of the case, with image compatible with lesion regression and persistence of bone canal with cortical, possibly filled with oral mucosa, without signs of lesion relapse.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):72-8

Marsupialization as definitive treatment for odontogenic keratocyst: case report and literature review

Table 1: Literature review on the treatment of odontogenic keratocyst only by marsupialization/decompression. Author

Year

Treatment

Number of cases

Relapse

Follow-up period (variation)

Browne21 Hodgkinson et al.22 Eyre, Zakrzewska23 Zachariades et al.24 Partridge, Towers25 Forssell et al.26 Nakamura et al.8 Pogrel, Jordan19 Kolokytas et al.9 Tanimoto et al. 27 Chirapathomsakul et al.28 Habibi et al.29 Yamamotto et al.13 Madras, Lapointe30 Hyun et al.31 Zecha et al.32 Yang et al.33 Tabrizi et al.34 Deboni et al.35 Total cases

1970 1978 1985 1985 1987 1988 2002 2004 2007 2005 2006 2007 2008 2008 2009 2010 2011 2012 2012 -

M M M M M M M M D M M M Biopsy* M D M M/D M M -

12 3 4 1 2 5 5 10 3 1 6 6 1 3 2 10 17 10 2 103

3 3 2 3 1 1 2 1 4 2 22 (21.3%)

> 16 2 – 4 years > 5 years > 5 years 5 – 17 years 6.6 years (3 – 14 years) 2.8 years (1.8 – 4.8 years) 1.5 – 3 years 12 years 41.9 months (1 – 14.6 years) 32.5 months (9 – 117 months) 8 years and 5 months 1 – 3.5 years 3 years and 9 months 65.1 months (12 – 242 months) 27 months (2 – 168 months) > 60 months 7 years -

Legend: M: Marsupialization; D: Decompression. *In this case, the individual was submitted to incisional biopsy, neglected the follow-up and returned after 8 years and 5 months, with complete regression of the lesion.

DISCUSSION The current understanding on the nature of OK encourages the scientific community to use increasingly conservative therapies instead of aggressive techniques, which may cause permanent morbidities as paresthesia, tooth loss, alterations in facial contour and the need of rehabilitative surgeries. For this reason, marsupialization is an important treatment option in cases with large lesions.8,16,17 It should be highlighted that odontogenic cysts, such as the OK, tend to present coinciding histopathological diagnoses before and after decompression/marsupialization,18 which seems to rule out the possibility of degeneration to lesions with worse prognosis.

Other advantage of marsupialization would be to reduce the aggressiveness of OK,8-10 probably due to simple induction of inflammation, which leads to epithelial metaplasia, transforming the OK epithelium into a non-keratinized epithelium, similar to common odontogenic cysts.17 It was shown to reduce the expression of IL-1a and IL-6,3 respectively responsible for bone resorption and tumor epithelial cell proliferation, which increases the possibility of tissue repair. Also, marsupialization is related with reduction of relapse rates in lesions enucleated at later stages.8,10 The literature suggests positive expression of antiapoptotic protein bcl-2 in specimens obtained by incisional biopsy before marsupialization of OK, yet neg-

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Medeiros JR, Nogueira CBP, Emim E, Bezerra MF, Soares ECS

ative after the period of marsupialization.19 August et al,20 in 2003, used the antibody cytokeratin-10 to investigate 14 cases of OK and concluded that there was interruption of production of cytokeratin-10 in a mean period of 9 months after lesion marsupialization. These findings also explain the reduction of aggressiveness after marsupialization, in cases of OK with large dimensions, as presently reported. As demonstrated by Zhao et al,16 in 2011, there was high rate of tissue repair three months after marsupialization, with bone remodeling and consequent reduction in cyst volume. Thus, according to these authors, this period, which could be increased in one or two months in large lesions, would be the ideal time before lesion enucleation. Others recommend a minimum period of twelve months and radiographic reduction of 50-60% or more of the cyst lumen.11 It should be highlighted that several authors demonstrated cases of complete regression by maintaining the marsupialization process for longer periods8,9,13,19,21-35. Table 1 presents all cases of non-syndromic OK reported between years de 1970 and 2012, treated by marsupialization or decompression, which exhibited satisfactory clinical and radiographic resolution and did not require additional surgical procedure. In cases in which marsupialization/decompression is the only treatment employed, patient compliance is fundamental for treatment success, considering the need of postoperative follow-up and daily irrigation of the cavity.36 In the present case, after approximately 13 months of marsupialization and 48 months of follow-up, there was acceptable resolution, which agrees with the report of Pogrel and Jordan,19 who reported

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

a maximum period of 19 months for complete resolution and absence of clinical and radiographic signs of relapse in up to 5 years postoperatively. Pogrel,7 in 2013, suggested a protocol of radiographic follow-up including orthopantomograms at every 6 months in the first 2 years, yearly for 5 years, and at every 2 years for 10 years in asymptomatic individuals, which is similar to the present report. The present literature review demonstrated a relapse rate of 21,3% for OK treated only by marsupialization or decompression. In absolute numbers, this result may not be much satisfactory. However, Nakamura et al,8 in 2002, concluded that marsupialization does not interfere with the potential relapse and reduces the aggressiveness of OK. Therefore, cases of relapse would not be as important as the benefits provided by marsupialization, since the technique would provide a less invasive complementary surgery, reduced morbidity and maintenance of facial structures.8 In these individuals, relapse would be easily solved by a minimally traumatic surgical procedure. CONCLUDING REMARKS Marsupialization of OK of large dimensions may be considered the first treatment option. This technique may be used to reduce the tumor volume and postoperative morbidity. In this case report, marsupialization presented to be a resolutive and minimally invasive treatment. After 48 months of postoperative follow-up, there were no signs of lesion relapse. Though considered a successful treatment so far, the patient is still under follow-up.

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Marsupialization as definitive treatment for odontogenic keratocyst: case report and literature review

References:

Brannon RB. The odontogenic keratocyst.Aclinicopathologic study of 312 cases. Part I. Clinical features. Oral Surg Oral Med Oral Pathol. 1976 July;42(1):54-72. 2. Shear M. The aggressive nature of the odontogenic keratocyst: is it a benign cystic neoplasm? Part 1. Clinical and early experimental evidence of aggressive behaviour. Oral Oncol. 2002 Apr;38(3):219-26. 3. Shear M. The aggressive nature of the odontogenic keratocyst: is it a benign cystic neoplasm? Part 2. Proliferation and genetic studies. Oral Oncol. 2002 June;38(4):323-31. 4. Shear M. The aggressive nature of the odontogenic keratocyst: is it a benign cystic neoplasm? Part 3. Immunocytochemistry of cytokeratin and other epithelial cell markers. Oral Oncol. 2002 July;38(5):407-15. 5. Philipsen HP. Keratocystic odontogenic tumour. In: Barnes L, Eveson JW, Reichart P, Sidransky D, editors. World Health Organization classification of tumour. Pathology and genetics of head and neck tumours. Lyon: IARC; 2017. p. 306-7. 6. Wang X, Lu Y, Shen G, Chen W. One germline mutation of PTCH gene in a Chinese family with non-syndromic keratocystic odontogenic tumours. Int J Oral Maxillofac Surg. 2011;40:829-33. 7. Pogrel MA. The keratocystic odontogenic tumor. Oral Maxillofacial Surg Clin N Am. 2013;25:21-30. 8. Nakamura N, Mitsuaysu T, Mitsuaysu Y, Taketomi T, Higuchi Y, Ohishi M. Marsupialization for odontogenic keratocysts: long-term follow-up analysis of the effects and changes in growth characteristics. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002 Nov;94(5):543-53. 9. Kolokythas A, Fernandes RP, Pazoki A, Ord RA. Odontogenic Keratocyst: to decompress or not to decompress? A comparative study of decompression and enucleation versus resection/peripheral ostectomy. J Oral Maxillofac Surg. 2007 Apr;65(4):640-4. 10. Brøndum N, Jensen VJ. Recurrence of keratocysts and decompression Treatment A long-term follow-up of forty-four cases. Oral Surg Oral Med Oral Pathol. 1991 Sept;72(3):265-9. 11. Marker P, Brøndum N, Clausen PP, Bastian HL. Treatment of large odontogenic keratocysts by decompression and later cystectomy: a long-term follow-up and a histologic study of 23 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996 Aug;82(2):122-31. 12. Tolstunov L, Treasure T. Surgical treatment algorithm for odontogenic keratocyst: combined treatment of odontogenic keratocyst and mandibular defect with marsupialization, enucleation, iliac crest bone graft, and dental implants. J Oral Maxillofac Surg. 2008 May;66(5):1025-36.

13. Yamamoto K, Matsusue Y, Shiotani H, Nogami S, Yagyuu T, Kirita T. Regression of a multilocular keratocystic odontogenic tumour without treatement. Assian J Oral Maxillofac Surg. 2008;20(1):37-40. 14. Giuliani M, Grossi GB, Lajolo C, Bisceglia M, Herb KE. Conservative management of a large odontogenic keratocyst: report of a case and review of the literature. J Oral Maxillofac Surg. 2006 Feb;64(2):308-16. 15. Kinard BE, Chuang SK, August M, Dodson TB. How well do we manage the odontogenic keratocyst? J Oral Maxillofac Surg. 2013 Aug;71(8):1353-8. 16. Zhao Y, Liu B, Han QB, Wang YN. Changes in bone density and cyst volume after marsupialization of mandibular odontogenic keratocysts (keratocistic odontogenic tumours). J Oral Maxillofac Surg. 2011;69(5):1361-6. 17. Rodu B, Tate AL, Martinez MG Jr. The implications of inflammation in odontogenic keratocysts. J Oral Pathol. 1987;16(10):518-21. 18. Schlieve T, Miloro M, Kolokythas A. Does decompression of odontogenic cysts and cystlike lesion change the histologic diagnosis? J Oral Maxillofac Surg. 2014 June;72(6):1094-105. 19. Pogrel MA, Jordan RCK. Marsupialization as a definitive treatment for the odontogenic keratocyst. J Oral Maxillofac Surg. 2004 June;62(6):651-5; discussion 655-6. 20. August M, Faquin WC, Troulis MJ, Kaban LB. Dedifferentiation of odontogenic keratocyst epithelium after cyst decompression. J Oral Maxillofac Surg. 2003 Jun;61(6):678-83; discussion 683-4. 21. Browne RM. The odontogenic keratocyst: clinical aspects. Br Dent J. 1970 Mar 3;128(5):225-31. 22. Hodgkinson DJ, Woods JE, Dahlin DC, Tolman DE. Keratocysts of the jaw. Clinicopathologic study of 79 patients. Cancer. 1978 Mar;41(3):803-13. 23. Eyre J, Zakrzewska JM. The conservative management of large odontogenic keratocysts. Br J Oral Maxillofac Surg. 1985 June;23(3):195-203. 24. Zachariades N, Papanicolaou S, Triantafyllou D. Odontogenic keratocysts: review of the literature and report of sixteen cases. J Oral Maxillofac Surg. 1985 Mar;43(3):177-82. 25. Partridge M, Towers JF. The primordial cyst (odontogenic keratocyst): its tumourlike characteristics and behaviour. Br J Oral Maxillofac Surg. 1987 Aug;25(4):271-9. 26. Forssell K, Forssell H, Kahnberg KE. Recurrence of keratocysts: a long-term follow-up study. Int J Oral Maxillofac Surg. 1988 Feb;17(1):25-8.

27. Tanimoto Y, Miyawaki S, Imai M, Takeda R, TakanoYamamoto T. Orthodontic treatment of a patient with an impacted maxillary second premolar and odontogenic keratocyst in the maxillary sinus. Angle Orthod. 2005 Nov;75(6):1077-83. 28. Chirapathomsakul D, Sastravaha P, Jansisyanont P. A review of odontogenic keratocyst and the behaviour of recurrences. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006 Jan;101(1):5-9; discussion 10. 29. Habibi A, Saghravanian N, Habibi M, Mellati E, Habibi M. Keratocystic odontogenic tumor: a 10-year retrospective study of 83 cases in an Iranian population. J Oral Sci. 2007 Sept;49(3):229-35. 30. Madras J, Lapointe H. Keratocystic odontogenic tumour: reclassification of the odontogenic keratocyst from cyst to tumour. J Can Dent Assoc. 2008 Mar;74(2):165-165h. 31. Hyun HL, Hong SD, Kim JW. Recurrent keratocystic odontogenic tumor in the mandible: a case report and literature review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009 Aug;108(2):e7-10. 32. Zecha JA, Mendes RA, Lindeboom VB, van der Waal I. Recurrence rate of keratocystic odontogenic tumor after conservative surgical treatment without adjunctive therapies — a 35-year single institution experience. Oral Oncol. 2010 Oct;46(10):740-2. 33. Yang S, Park YI, Choi SY, Kim JW, Kim CS. A retrospective study of 220 cases of keratocystic odontogenic tumor (KCOT) in 181 patients. Asian J Oral Maxillofac Surg. 2011;23(3):117-21. 34. Tabrizi R, Özkan BT, Dehgani A, Langner NJ. Marsupialization as a treatment option for the odontogenic keratocyst. J Craniofac Surg. 2012 Sept;23(5):e459-61. 35. Deboni MC, Brozoski MA, Traina AA, Acay RR, Naclério-Homem MG. Surgical management of dentigerous cyst and keratocystic odontogenic tumor in children: a conservative approach and 7-year followup. J Appl Oral Sci. 2012 Mar-Apr;20(2):282-5. 36. Pogrel MA. Decompression and Marsupialization of Keratocysts. J Oral Maxillofac Surg. 2005;63:1667-73.

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):72-8

CaseReport

Condyle reconstruction with

methacrylate in individuals with osteoradionecrosis LUIZ RENÉRIO PRESTES DANTAS1 | ROQUE MIGUEL RHODEN2 | ANDRÉIA VARGAS3

ABSTRACT This paper reports a case and presents to oral and maxillofacial surgeons a new option for condyle reconstruction, for cases with mutilating lesions and impossibility of other reconstruction alternatives. A male individual aged 53 years, irradiated, presenting osteoradionecrosis, received surgical treatment with reconstruction of the left condyle with PMMA. The procedure performed on the left condyle allowed improved quality of life, since the nasogastric tube was removed in the first week, with onset of cool/warm liquid or pasty feeding. After one month, the patient presented significant weight gain, being under control for bilateral placement of bone grafts. The alternative treatment for condyle reconstruction with poly(methyl methacrylate) is feasible and proved to be compatible with the body, considering that this material is used in surgeries for cranial bone repair. Keywords: Osteoradionecrosis. Radiotherapy. Treatment outcome.

Universidade Federal de Pelotas, Programa de Pós-graduação em Odontologia, ênfase em Clínica Odontológica (Pelotas/RS, Brazil). Specialization in Oral and Maxillofacial Surgery and Traumatology, Pontifícia Universidade Católica do Rio Grande do Sul (Porto Alegre/RS, Brazil). 3 Specialization in Oral and Maxillofacial Surgery and Traumatology, FASURGS - Faculdade Especializada na Área de Saúde do Rio Grande do Sul (Passo Fundo/RS, Brazil). 1

How to cite: Dantas LRP, Rhoden RM, Vargas A. Reconstrução de côndilo com metacrilato em pacientes osteorradionecrosados. J Braz Coll Oral Maxillofac Surg. 2017 set-dez;3(3):79-83. DOI: https://doi.org/10.14436/2358-2782.3.3.079-083.cre

Submitted: November 12, 2016 - Revised and accepted: May 25, 2017 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article. » Patients displayed in this article previously approved the use of their facial and intraoral photographs. Contact address: Luiz Renério Prestes Dantas Rua Angélica Otto, 160 – Passo Fundo/RS – CEP: 99.025-270 E-mail: luizrdantas@ibest.com.br

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):79-83

Condyle reconstruction with methacrylate in individuals with osteoradionecrosis

INTRODUCTION Osteoradionecrosis (ORN) is a causal factor of osteomyelitis, because the activity of osteoblasts is reduced and there is alteration in the genesis of blood vessels. This leads to reduced blood supply in areas affected by radiation, making them susceptible to infections. It should be considered that this pathology may often lead to mutilations, both in the maxilla and mandible. In some cases, osteoradionecrosis may manifest later, between one to two years after completion of radiotherapy, being caused by inadequate evaluation by the oncologist, if there is neglect to consider the importance of oral health adequacy before treatment onset. Other important factor is directly related with the dentist, who may not be aware of the proper time to act after radiotherapy, or by lack of adequate anamnesis, leading to iatrogenic mutilation. Careful intraoral examination should be performed before treatment, with removal of root remnants, restoration of caries lesions and treatment of periodontal disease. In many cases, this procedure avoids severe situations, both in the irradiated oral cavity and systemically. The literature reveals the need to wait for five years before accomplishment of more invasive surgical procedures. A simple tooth extraction, occurrence of trauma, utilization of poorly fitting dentures or presence of periodontal disease are high risk factors for the occurrence of osteoradionecrosis in the oral cavity. Depending on the intervention, there may be harm for the professional who acted mistakenly and great physical and psychological discomfort to the patient. This case report clearly demonstrates the results of a poorly planned treatment that led to an invasive treatment, with significant and mutilating bone loss. Afterwards, it was necessary to insert reconstruction plates and, to solve the left condyle loss, it was necessary to re-do the PMMA, allowing adequate functional stabilization. After more than one year and still under follow-up, the patient presented systemic and psychological evolution and significant weight gain.

which was treated by lesion removal followed by sessions of radiotherapy and chemotherapy. Nearly one and a half years after treatment completion, lesions appeared in the oral cavity. He was referred to a maxillofacial surgeon, who prescribed treatment including Bactrin®, Decadron®, Nystatin® mouthrinses, prilocarpine eye drops, 0.05% sodium fluoride and 0.12% chlorhexidine gluconate. Because of treatment failure and clinical worsening, at the end of 2014, the patient attended CICOF. Physical examination did not reveal any abnormal lymph node on palpation, yet there was limited mouth opening, extraoral fistula and pathological bilateral mandibular fracture at the first molar region. Intraorally, there was purulent discharge, reduced salivary flow, malodor, hyperemic mucosa and several areas of exposed darkened necrotic cancellous bone, including the mandibular body and maxilla, besides presence of tooth remnants in the maxilla. Imaging examinations exhibited diffuse and irregular radiolucency, compatible with osteolysis. After diagnosis of osteoradionecrosis, the patient was submitted to surgery. Tracheostomy was performed and, under general anesthesia, by extraoral access, the mandible was curetted until observation of vital bone tissue with normal bleeding (Fig 1). Then, sectioning

CASE REPORT Male individual, aged 53 years, Caucasoid, attended the Integrated Center of Ortho Facial Surgery (CICOF) for the treatment of oral cavity lesions. During anamnesis, the patient informed diagnosis of epidermoid carcinoma on the tongue base in 2013,

Figure 1: Surgical exposure of the mandible, left side with osteoradionecrosis.

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):79-83

Dantas LRP, Rhoden RM, Vargas A

Figure 2: Placement of reconstruction plate and PMMA to replace the condyle.

Figure 3: Last follow-up radiograph.

was performed from tooth #34 to the condyle, and from the region of tooth #44 to #48 and ascending ramus, leaving only the condylar stump (Fig. 2). The parasymphysis region was maintained. Mandibular repair was done using a reconstruction plate system 2.4mm Synthes® on the right side, while on the left side an artificial condyle was constructed with PMMA and fixated with a reconstruction plate system 2.4mm on the parasymphysis. On the maxilla, all tooth remnants and necrotic bone were removed, with curettage from one tuberosity to the other. Postoperatively, the patient was fed through a nasogastric tube. Hospitalization occurred from August 9th 2015 to October 13th 2015, and antibiotic therapy comprised the use of Clindamycin®, Keflex® and Rifampicin®. After hospital discharge, the patient resumed oral feeding, with liquid diet, and until the last follow-up on No-

vember 25th 2015 he had gained 6kg, did not have painful symptomatology or extraoral fistula, and exhibited a healthy mucosa. Since only verbal records were obtained, there was no information about the number of radiotherapy sessions, technique and dose employed, and the patient’s financial status did not allow utilization of hyperbaric oxygen therapy as a coadjutant to treatment. The patient continues to use mouthrinses at every 12h with 0.12% chlorhexidine gluconate without utilization of systemic medications and is regularly followed at CICOF (Fig. 3). DISCUSSION The ORN is a severe complication of radiotherapy in individuals with head and neck cancer. It is defined as the presence of exposed bone in an irradiated region, which does not heal in a period of three months. Ac-

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):79-83

Condyle reconstruction with methacrylate in individuals with osteoradionecrosis

with oral cancer present other severe diseases, and often have long history of alcohol use and smoking, which combined to malnutrition and poor oral hygiene lead to high risk to develop ORN.9,10 The diagnosis is based on the clinical signs and symptoms. The exposed bone presents altered color and strength, and radiographically there is structure loss, which presents as a diffuse transparency corresponding to bone destruction. Preventive measured may be adopted before and after radiotherapy, to reduce the incidence and severity of manifestations. Some risk factors should be considered, such as extractions in a period of two to five years after radiotherapy. Based on the current understanding of the pathophysiology of ORN, a single protocol for prevention and treatment should be developed. Oral health adequacy before onset of cancer therapy and clinical follow-up after radiation reduce the risk of complications.4,11 Several studies in the literature demonstrate the benefits of hyperbaric oxygen therapy, which increases the tissue oxygenation with proliferation of blood vessels, fibroblasts and osteoblasts. This is a well-established resource, since the therapeutic principle of this modality allows adequate tissue repair. Conversely, this therapy is expensive, time-consuming and often insufficient and contraindicated in some cases. Careful information should rule out the possibility of active tumor cells.12 The utilization of ozone is another option that has been investigated. According to Batinjan et al,11 it promotes tissue oxygenation, is strongly bactericidal, fungicidal and antiviral, and stimulates the immune response by the production of cytokines, interleukin 2 and interferon, besides increasing the cell energy by stimulating the Krebs cycle and ATP formation. Silvestre-Rangil and Silvestre,5 in a literature review, suggested that the treatment of osteoradionecrosis should be planned according to the disease staging. On the initial stage, when there is no discomfort associated with the lesion that is present for a short period, the individual should be evaluated at every 3 months during the first year and at every 6 months thereafter; oral mucosa irritants (smoking, alcohol, removable dentures) should be avoided, the individual should be instructed to have good oral hygiene, irrigate the lesion 3 times s day with 0.2% chlorhexidine and make use of pentoxifylline, a vasodilating drug that inhibits fibrosis (800mg/day) and vitamin E. In an intermediate stage,

cording to the location and extent, there may be symptoms as pain, malodor, pathological fracture, dysgeusia, dysesthesia, trismus and formation of fistulae.1-3 It is usually manifested between 6 months and 5 years after radiotherapy, and 90% of lesions are located in the mandible. In radiotherapy the immediate effects are observed in tissues with high cell turnover, such as the oral mucosa. Late effects are rare and occur when the tolerated doses of normal tissues are surpassed. The clinical management is difficult and includes the elimination of harmful habits, improvement in oral hygiene care, infection control with antibiotics and antiseptics, and removal of necrotic tissue as the disease evolves.4,5 There is a constant search for the best material, yet autogenous bone is still the first choice in reconstructions, due to its osteoinductive and osteoconductive properties. After resection, there is considerable morbidity, with adverse effects on speech, mastication and esthetics of individuals. The success of autogenous graft depends on the good blood supply to the grafted tissue. Thus, PMMA is an option to preserve the space and maintain the soft tissues.6 The rehabilitation techniques include bone grafts (autologous, allogeneic, heterogenous) and alloplastic materials (poly(methyl methacrylate) – or PMMA – titanium, hydroxyapatite). PMMA is a biocompatible acrylic resin that is non-degradable, of low cost, with particles between 30 and 40µm, and may be modeled before or during surgery. It presents the disadvantage of poor osteoconduction and high bacterial adhesion, and releases heat during polymerization. PMMA is widely used in neurological, orthopedic and plastic surgeries. It has low cost, is easy to handle and model, and eliminates the need of a second surgical area for graft removal.6-8 According to Marx,2 ORN is related with events of hypoxia, hypocellularity and hypovascularity, which impair the tissue repair mechanisms, preventing the replacement of connective tissue and cells to complete the turn over to maintain the homeostasis and wound healing. The affected cells include the vascular endothelium, fibroblasts that compose the stroma and parenchymal cells. Most individuals submitted to radiotherapy for treatment of head and neck tumors receive doses between 50 and 70 Gy. The adverse effects depend on the volume, irradiated site, total dose, fractioning, age, clinical conditions of the patient and associated treatments. It should be considered that many individuals

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):79-83

Dantas LRP, Rhoden RM, Vargas A

CONCLUSIONS Even though the treatment of osteoradionecrosis is complex, the early diagnosis allows reduction of complications and improves the quality of life of individuals with sequelae of the tumor and its treatment. The utilization of PMMA presented to be a viable and low-cost option for rehabilitation. The oncologist should refer the patient to a dentist for thorough evaluation of the oral and maxillofacial complex and for the treatment of lesions. The patient has been followed by the surgical team for more than two years.

when there is pain, hygiene measures should be continued, as well as irrigation with 0.2% chlorhexidine, prescription of amoxicillin and clavulanate (875mg, 3 times a day) and ciprofloxacin (500mg, twice a day) until pain remission. If pain and discomfort persist, a small surgery may be performed for tissue removal (lesions between 0.5 and 1 cm). In advanced stage, when there are complications as trismus, skin fistula and fracture, all measures of previous stages should be taken, besides ablative surgery to eliminate the osteolytic areas, with posterior reconstruction.5

References:

2. 3.

Gomes ACA, Piva Neto IC, Melo DG, Dias E. Osteorradionecrose resultando em fratura patológica de mandíbula: relato de caso clínico. Rev Odonto Cienc. 2007 Jul-Set;22(57):280-5. Marx RE. Osteoradionecrosis: a new concept of its pathophysiology. J Oral Maxillofac Surg. 1983 May;41(5):283-8. Rayatt Sukh S, Mureau Marc AM, Hofer Stefan OP. Osteoradionecrosis of the mandible: Etiology, prevention, diagnosis and treatment. Indian J Plast Surg. 2007;40(12):S65-71. Morais HHA, Vasconcelos BCE, Vasconcelos RJH, Caubi AF, Carvalho RWF. Oxigenoterapia hiperbárica na abordagem cirúrgica do paciente irradiado. Rev Gaúch Odontol. 2008 Abr-Jun;56(2):207-12.

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Silvestre-Rangil J, Silvestre FJ. Clinico-therapeutic management of osteoradionecrosis: a literature review and update. Med Oral Patol Oral Cir Bucal. 2011 Nov 1;16 (7):e900-4. Taylor BC, French BG, Fowler TT, Russell J, Poka A. Induced membrane technique for reconstruction to manage bone loss. J Am Acad Orthop Surg. 2012 Mar;20(3):142-50. Neumann A, Kevenhoerster K. Biomaterials for craniofacial reconstruction. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2009;8:1-17. Abdo Filho RCC, Oliveira TM, Lourenço Neto N, Gurgel C, Abdo RCC. Reconstruction of bony facial contour deficiencies with polymethylmethacrylate implants: case report. J Appl Oral Sci. 2011 Aug;19(4):426-30.

Caccelli EMN, Rapoport A. Para-efeitos das irradiações nas neoplasias de boca e orofaringe. Rev Bras Cir Cabeça Pescoço. 2008;37(4):198-201. 10. Rocha RA, Lehn CN, Oliveira JX, Marcucci M. Incidência de osteorradionecrose em pacientes com câncer de boca tratados com radioterapia exclusiva ou em associação com cirurgia. Rev Bras Cir Cabeça Pescoço. 2008;37(2):91-4. 11. Batinjan G, Filipović Zore I, Vuletić M, Rupić I. The use of ozone in the prevention of osteoradionecrosis of the jaw. Saudi Med J. 2014;35(10):1260-3. 12. Zanetin VP, Franzi SA. A oxigenoterapia hiperbárica no tratamento da osteorradionecrose de mandíbula em pacientes com carcinoma epidermóide avançado de boca. Rev Bras Cir Cabeça Pescoço. 2013;42(2):118-23.

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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.

• 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).

GUIDELINES FOR MANUSCRIPT SUBMISSION • The manuscripts should be submitted through the website: www.dentalpressjournals.com.br. • The manuscripts should be written in a concise, clear and correct manner, in formal language, avoiding colloquial expressions. • Whenever applicable, the text should be organized as follows: Introduction, Material and Methods, Results, Discussion, Conclusions, References, and Figure Legends.

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» 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.

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

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

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

J Braz Coll Oral Maxillofac Surg. 2017 sept-dec;3(3):84-6