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

Dolphin 3D Imaging 11.9

C e p h Tr a c i n g • Tr gPlus™ • eatmen

t Sim u

lation

•

ys 3D • rS e t t 3 D S u rg e r y ™ • L e

tem

3D Surgery™

Volume 4, Número 1, 2018

Imagin

Volume 4, Número 1, 2017 - ISSN 2358-2782

Journal of the Brazilian

Dolphin 3D Surgery é a ferramenta completa para seu planejamento e apresentação, que o conduz por cada passo do processo do plano de tratamento, da avaliação inicial à geração dos splints. As mudanças esqueléticas e faciais do paciente são animadas em tempo real e resultam num guia cirúrgico preciso. São necessário apenas os dados tomográficos 3D e uma foto frontal

Planejamento preciso da osteotomia

opcional. Combine com um escaneamento intraoral ou modelos digitais para uma cirurgia virtual acurada. Esta ferramenta, em conjunto com outras funções exclusivas, fazem do Dolphin3D o software de eleição mundialmente. Para mais informações visite www.dolphinimaging. com/3dsurgery ou fale conosco: (11) 3286-0300 / contato@renovatio3.com.br.

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

Planejamento Detalhado e Preciso • Resultados em Tempo Real • Fácil de usar

College of Oral and Maxillofacial Surgery JBCOMS

Geração de guias cirúrgicos Imaging

3D

Management

Aquarium ©

Foto: Mike Bueno

© 2014 Patterson Dental Supply, Inc. All rights reserved. © 2013 Patterson Dental Supply, Inc. All rights reserved.

EDITOR-IN-CHIEF Gabriela Granja Porto

ASSOCIATE EDITOR-IN-CHIEF José Nazareno Gil

EDITORES POR SEÇÃO

SECTION EDITORS Cláudio Ferreira Nóia Danilo Passeado Branco Ribeiro Fernando Bastos Pereira Júnior Luis Carlos Ferreira da Silva Waldemar Daudt Polido

Universidade de Pernambuco - FOP/UPE - Camaragibe/PE - Brazil Universidade Federal de Santa Catarina - UFSC - Florianópolis/SC - Brazil

Faculdade Ciodonto - Porto Velho/RO - Brazil Universidade Estadual do Rio de Janeiro - UERJ - Rio de Janeiro/RJ - Brazil Universidade Estadual de Feira de Santana - UEFS - Feira de Santana/BA - Brazil Universidade Federal de Sergipe - UFS - Aracaju/SE - Brazil Clínica particular - Porto Alegre/RS - Brazil

Trauma

Liogi Iwaki Filho

Márcio Moraes

Nicolas Homsi Ricardo José de Holanda Vasconcellos

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

rthognathic Surgery and Deformities O

Fábio Gamboa Ritto

Fernando Melhem Elias

José Laureano Filho

José Thiers Carneiro Júnior

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 do Pará - UFPE - Belém/PA - Brazil

TMJ Disorders Eduardo Hochuli Vieira Eduardo Seixas Cardoso João Carlos Birnfeld Wagner Luis Raimundo Serra Rabelo

Universidade Estadual Paulista Júlio de Mesquita Filho - FOAR/Unesp - Araraquara/SP - Br azil Universidade Federal Fluminense - UFF - Niterói/RJ - Brazil Santa Casa de Misericórdia - Porto Alegre/RS - Brazil Universidade Federal do Maranhão - UFMA - São Luís/MA - Brazil

Pathologies and Reconstructions Belmiro Cavalcanti do Egito Vasconcelos Universidade de Pernambuco - FOP/UPE - Camaragibe/PE - Brazil

Darceny Zanetta Barbosa Universidade Federal de Uberlândia - UFU - Uberlândia/MG - Brazil

Martha Alayde Alcântara Salim Universidade Federal do Espírito Santo - UFES - Vitória/ES - Brazil

Renata Pittella​ ​​Universidade Federal do Espírito Santo - UFES​-​Vitória/ES - Brazil

Ricardo Viana Bessa Nogueira Universidade Federal de Alagoas - UFAL - Maceió/AL - Brazil

Sylvio Luiz Costa de Moraes Universidade Federal Fluminense - UFF - Niterói/RJ - Brazil

Wagner Henriques de Castro Universidade Federal de Minas Gerais - UFMG - Belo Horizonte/MG - Brazil

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

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

Dados Internacionais de Catalogação-na-Publicação (CIP) _______________________________________________________________________ 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 PUB-

Quadrimestral ISSN 2358-2782

LISHING: Gildásio Oliveira Reis Júnior - ARTICLES SUBMISSION: Stéfani Rigamonte - Kler Godoy - REVISÃO: Ronis Furquim Siqueira - DATABASE: Cléber Augusto Rafael - COURSES AND EVENTS: Poliana Rocha dos Santos COMMERCIAL DEPARTMENT: Roseneide Martins Garcia - DISPATCH: Rui Jorge Esteves da Silva - FINANCIAL DEPARTMENT: Cléber Augusto Rafael - Lucyane Plonkóski Nogueira. O Journal of the Brazilian College of Oral and Maxillofacial Surgery (ISSN 2358-2782) é uma publicação quadrimestral (três edições por ano), da Dental

1. Cirurgia Bucomaxilofacial. I. Dental Press International.

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

CDD 21 ed. 617.605005 _______________________________________________________________________

necessarily correspond to the opinions of the Journal. Advertising services are the responsibility of advertisers.

Subscription: dental@dentalpress.com.br or Tel./Fax: +55 44 3033-9818.

table of contents

4

Editorial: The challenge continues Gabriela Granja Porto

6

Letter from the President: Results of the Board of Directors 2016-2017 José Rodrigues Laureano Filho

8

10

Greatest Oral and Maxillofacial Event of the North-Northeast will gather Brazilian and foreign specialists in Maceió, Alagoas Interview Gregorio Sánchez Aniceto Articles

15

Effect of alcohol intake on submandibular salivary glands

22

Oral sedation in dental surgery: analysis of variations in blood glucose and blood pressure

28

Epidemiology of facial trauma in a hospital in the municipality of Manaus-Amazonas

33

Retrospective analysis of treated cases of trigger points

37

Management of parotid sialocele after retromandibular access

41

Closure of extensive oroantral and oronasal fistula due to maxillary tumor resection

Tatiana Wannmacher Lepper, Denise Bertin Rojas, Virginia Cielo Rech, Luciane Rosa Feksa, Felipe Nor, Anna Christina Medeiros Fossati, João Carlos Birnfeld Wagner, Clóvis Milton Duval Wannmacher

Natália Quinilatto Daróz, Fabiane Torres Maia Guimarães, Antonio de Melo Cabral, Mariana Camilo Negreiros Lyrio Alvares, Daniela Nascimento Silva, Rossiene Motta Bertollo, Martha Alayde Alcantara Salim Venancio

Márcia Arruda Lins, Gustavo Cavalcanti de Albuquerque, Amanda Lima de Oliveira, Valber Barbosa Martins, Flávio Tendolo Fayad, Marcelo Vinicius de Oliveira, Joel Motta Júnior

João Carlos Birnfeld Wagner, Mauricio Roth Volkweis, Luciana Zaffari, Gabriela Severo Meinke, João Ricardo Koch Brandalise, Rodrigo Andrighetti Zamboni, Tatiana Wannmacher Lepper

Flávio Tomazi, Manuel Schmitz, Marcelo Rocha, Felipe Búrigo6 | Claiton Heitz

Bruno Gomes Duarte, Victor Tieghi Neto, Eduardo Stedile Fiamoncini, Osny Ferreira Júnior, Eduardo Sanches Gonçales

47

Management of internal derangement of the temporomandibular joint: arthrocentesis

53

Atrophic maxilla reconstruction: case report

60

Information for authors

Alexandre Maranhão Menezes Neto, Fábio Wildson Gurgel Costa, Wagner Araújo de Negreiros, Mariana Gomes Coutinho, Eduardo Costa Studart Soares

Vitor José da Fonseca, Aécio Abner Campos Pinto Junior, Joanna Farias da Cunha, Luiz Felipe Cardoso Lehman, Felipe Eduardo Baires Campos, Wagner Henriques de Castro

Editorial

The challenge continues With pleasure and enthusiasm, I accepted the challenge to edit our Journal of the Brazilian College of Oral and Maxillofacial Surgery, the JBCOMS. Pleasure and enthusiasm, because the dream of having a scientific space for Brazilian oral and maxillofacial surgeons to express their ideas is very old. It was discussed by several boards and brought to reality after years of maturity, under direction of Prof. Nazareno Gil. Relying on the experience of Dental Press, together with Prof. Belmiro Vasconcelos as scientific leader, the dream was finally made true. We have now conquered a space!

I thank the current president, Prof. Laureano, for trusting me to continue this successful project.

Therefore, I face this mission as a challenge! The previous conquests should be kept, and we are committed to continue with consistent steps. The JBCOMS is currently scored as Qualis/CAPES B4, and we shall not stop there! We intend to achieve indexing in other databases and make it ready for a better score.

How to cite: Porto GG. The challenge continues. J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):4-5.

DOI: https://doi.org/10.14436/2358-2782.4.1.004-005.edt

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

4

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):4-5

Editorial

For that purpose, we rely on the priceless contribution of Prof.

Nazareno Gil, as adjunct editor, and the reviewers team. However, the support of members is mandatory, by the submission of original papers, which are fundamental to achieve a better score and success in this goal!

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

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

5

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):4-5

Letter from the President

Results of the Board of Directors 2016-2017 Dear colleagues, With a huge sense of responsibility and collaboration I take on the board 2018/2020 of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology (CBCTBMF), an organization established in BrasĂ­lia on July 23rd, 1970. I am proud to be head of the main organization that represents the specialty in Brazil, and the second largest organization of specialists in Oral and Maxillofacial Surgery and Traumatology in the world.

In this new beginning cycle, there is a renewal of desires, expectations and hope. The main challenge of this board is to positively address these feelings of the members. Therefore, it is fundamental to known in detail the problems and difficulties of this specialty, so as we may be actually important for our members and attractive to other specialists in the country.

The board 2018/20 is committed to continue and expand the achievements of the last board, besides innovating, leading knowledge, update, protocols and information to all regions of Brazil, using all tools for diffusion and social interaction available.

Other challenge of the new board is to update the continued education.

We have well-established important events that are successful, yet we have to enter the houses of members and offer online courses, information via apps, etc. In other words, we have to make the website an alive platform to allow professional update from any place in the country, at any time.

How to cite: Laureano Filho JR. Results of the Board of Directors 2016-2017. J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):6-7.

DOI: https://doi.org/10.14436/2358-2782.4.1.006-007.crt

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

6

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):6-7

Carta do Presidente

Within this scope, the Journal of the Brazilian College of Oral and Maxillofacial Surgery is the scientific tool that provides the diffusion and presents the work of the main national and international centers in the technical-scientific development of Oral and Maxillofacial Surgery and Traumatology and related areas. It also forms and informs, from undergraduate students to the most experienced surgeon, serving as basis for investigations from scientific initiation to postdoctoral theses. Therefore, this source is ready to be used and diffused – so as it may be stronger and reach international standards of quality and visualization, There are still many challenges! Yet the honor to represent this organization, the wish to collaborate, the love and union by Oral and Maxillofacial Surgery and Traumatology will overcome the difficulties in this field.

JosĂŠ Rodrigues Laureano Filho President of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

7

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):6-7

Greatest Oral and Maxillofacial Event of the North-Northeast will gather Brazilian and foreign specialists in Maceió, Alagoas International guests One speaker will be Adrian Carlos Bencini, from Argentina. He is Full Professor of Orthognathic Surgery at Facultad Odontología UNLP, director of G.IN.I (Grupo de Investigación Implantológica), former president of the Sociedad Argentina de Cirugía y Traumatología Bucomaxilofacial (SACyTBMF, AOA) and current president of the Asociación Latinoamericana de Cirugía y Traumatología Bucomaxilofacial (ALACIBU) board 2017/2019.

Other international speaker will be the Swiss Florian M. Thieringer, current assistant medical director and professor of Craniomaxillofacial Surgery at the University Hospital of Basel. He is also head of the Medical Additives Manufacture (MAM) research team from the Department of Biomedical Engineering at the University of Basel. There, he is exploring and promoting the integration of 3D modeling and printing technologies in clinical practice, such as

The 11th ENNEC 2018, official meeting of the specialty, will be held between May 3rd and 5th. Three international speakers will join, including a Swiss professor specialized in surgical planning using 3D modeling techniques.

The 11th ENNEC (North-Northeast Meeting of Oral and Maxillofacial Surgery and Traumatology) will be held in Hotel Ritz Lagoa da Anta, in Maceió, Alagoas, between May 3rd and 5th. The official event of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology (CBCTBMF) will gather specialists from all over Brazil, besides three international guests.

The registrations are open, at a special discount until May 1st (see below).

The official website of the event presents all details on the rules, accompanying persons and cancellation policy, besides the scientific program: www.ennec.com.br

Category

Until May 1st 2018

Until the event

College member Non-College member Resident/postgraduate student and College member Resident/postgraduate student and non-College member Undergraduate student Other professionals Accompanying person Undergraduate student and College member

R$ 684,00 R$ 1.370,00 R$ 455,00 R$ 730,00 R$ 365,00 R$ 1.525,00 R$ 155,00 R$ 219,00

R$ 790,00 R$ 1.575,00 R$ 525,00 R$ 840,00 R$ 420,00 R$ 1.750,00 R$ 175,00 R$ 252,00

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

8

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):8-9

JBCOMS News

program and is being organized and promoted by AO Foundation Latin America, with participation of professors Fernando Brinceño, Ricardo Holanda, André Vajgel and Fernando Lima.

the fabrication of specific titanium implants for patients, peek or other high-performance materials. Since 2016, Dr. Thieringer is co-director of the multidisciplinary 3D printing lab at the University Hospital of Basel.

The event will also receive the speaker Fernando Briceño, who is specialist in Maxillofacial Surgery, with emphasis on orthognathic surgery and temporomandibular disorders. Currently, Dr. Briceño works as Oral and Maxillofacial Surgery expert at Universidad Javeriana CO. and as temporomandibular joint expert at Loyola University US., in Chicago, USA. He is also active member of the Colombian Association of Oral and Maxillofacial Surgery, Colombian Dental Federation and Director of the AO Foundation Latin America.

The city Maceió, capital of Alagoas, is filled with lakes, a seacoast painted in turquoise blue and emerald green, and beautiful beaches surrounded by coconut trees. Known as the “Paradise of waters”, it is currently considered the “Brazilian Caribbean”, thanks to its natural beauties that attract tourists from all over the world.

The hotel Ritz Lagoa da Anta is the most acknowledged hotel in Maceió. It has a privileged seaside location at Lagoa da Anta beach, close to the beaches of Jatiúca and Ponta Verde. It offers a complete leisure and entertainment structure for children and adults, with all facilities of being inside the city. Modernly projected for the comfort of clients at work or leisure, the Hotel Ritz Lagoa da Anta also has the differential of thematic floors especially designed for each need, an exclusivity of hotels in Maceió.

Pre-congress courses

Hands-on NemoFAB Virtual planning for Orthognathic Surgery: from the computer to the operating theater.

Objective: accomplishment of virtual planning for Orthognathic Surgery by the protocol of Dr. William Arnett using the Software NemoFAB-Nemotec.

Note: participants should bring their own notebook, for installation of the software NemoFAB-Nemotec.

Cost: R$ 250,00. Limited places!

SERVICE 11th ENNEC – North-Northeast Meeting of Oral and Maxillofacial Surgery and Traumatology. » Date: May 3rd to 5th 2018. » Venue: Hotel Ritz Lagoa da Anta, in Maceió, Alagoas. » Address: Av. Brigadeiro Eduardo Gomes de Brito, 546, Lagoa da Anta, Maceió, 57038-230. » Information and registrations: www.ennec.com.br.

Course of the AO - Foundation Latin America The event will also include the course “AOCMF Seminar - Advances in Facial Trauma Treatment at ENNEC Congress”. The course will be incorporated to the ENNEC

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

9

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):8-9

Interview

Interview with Gregorio Sánchez Aniceto

» Associate Professor, Universidad Complutense de Madrid, Department of Surgery (Madrid, Spain). » Head of the Oral and Maxillofacial Surgery Service of Hospital Universitario 12 de Octubre (Madrid, Spain). » President-elect of the International Council of AOCMF.

How to cite: Aniceto GS, Porto GG, Germano A. Interview with Gregorio Sánchez Aniceto. J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):10-3.

DOI: https://doi.org/10.14436/2358-2782.4.1.010-013.oar Submitted: February 08, 2018 - Revised and accepted: March 04, 2018

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

10

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):10-3

Interview

Now that you shall take the presidency in the field of craniomaxillofacial surgery of the AOCMF International Board, what are your main objectives?

With more than 3,200 members and 120 educational activities per year held all over the world, the AOCMF is a world leader in continuing medical education in our field of knowledge. My objective is to deepen this leadership, with both existing and new courses and seminars, either presential or online, investing in workshops, simulation and 3D planning, always addressing a competency-based education.

We should continue growing as a multidisciplinary medical organization that gathers all specialists involved in craniomaxillofacial surgery, also in number of members (we are already among the three largest in the world), in a sustainable manner, optimizing economic resources and adapting to the needs and peculiarities of the different regions.

role. The AO Foundation acts parallel to the educational activity, promoting initiatives with the WHO and other international organizations about this aspect. Traffic accidents are still one of the most important causes of death in the world (10th in 2015), and the first in some regions for certain age ranges.

In Brazil, most facial traumas are caused by car accidents. How is it like in Spain?

In the last 15 years, the number of deaths and severe lesions in car accidents was drastically reduced in Spain (80%). This was due to several factors, including mandatory safety measures (seat belt, motorcycle helmet), improved quality of cars, establishment of driving license per "points", improved road network, and speed limit, basically. Currently, the main etiology of facial trauma is interpersonal violence, usually unarmed aggression (punches). Gunshot wounds are very infrequent, also due to the restrictive laws for owning guns. In summary, we live in a quiet country, with violence and car accident rates among the lowest in Europe.

Is there any interest in exchanges with Latin America – or intensifying them, where they already exist? Because, in this continent, facial trauma is a public health problem. Is there any strategy of the AO Foundation to intensify the multicenter research?

The has a marked presence in Latin America, with a delegation of this foundation (AOLAT) with offices in Colombia and Brazil, and a very active AOCMF LAT group, which organized 32 educational activities in 2017 and scheduled 33 courses and seminars for the year 2018. Besides the classical courses on facial trauma (Management of Facial Trauma), the offer includes educational activities on Orbital Surgery, Orthognathic Surgery, Reconstructive Surgery, Osteogenic Disorders and Temporomandibular Joint Surgery. Some of these activities include simulation workshops using anatomical models; others comprise dissection of cadavers. Besides these courses, others were promoted for training of our professors and, this year, a meeting of specialists was recently organized in Brazil, focused on research, to establish the lines of development and promotion not only of basic science, but also of clinical and translational research in Latin America. Traffic accidents are actually a public Health problem in Latin America, and in other regions of the world. Adequate and timely treatment of lesions is important, but prevention also plays a fundamental

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

How do you consider the use of technology in facial trauma? Is it currently fundamental for proper diagnosis and treatment of patients?

One great advantage: the management of images in an adequate digital platform is currently fundamental for three-dimensional planning and quality control in nearly all fields of craniomaxillofacial surgery.

The micro-osteosynthesis systems and new designs of plates, meshes and biomaterials are very helpful.

Intraoperative navigation is also a highly accurate method for planning and control, and very appreciated in our reconstructions.

In your opinion, what is the greatest challenge to provide earlier and better quality of care for patients with facial trauma?

The logistic availability, as well as adequate human and material resources, which implies commitment of authorities with health care, in both public and private sectors, to facilitate the access for patients with facial trauma. For optimal functioning of this care, the health system should provide coverage as universal as possible, always with rational utilization of resources.

11

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):10-3

Following is the description of a clinical case of complex frontal sinus fracture affecting both walls, with associated intracranial lesion (hematoma and frontal contusion):

Figure 1: Complex frontal sinus fracture (3D CT).

Figure 2: Axial section of CT evidencing fracture of both frontal sinus walls (with defect on posterior wall), intracranial hematoma and frontal contusion.

Figure 3: Coronal access by subcranial via; repair of intracranial lesions (without craniotomy).

Figure 4: Fracture reduction and osteosynthesis

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

12

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):10-3

Interview

Figure 5: Titanium mesh.

Figure 6: Tomograph demonstrating obliteration of right frontal sinus (autologous bone).

Figure 7: Postoperatively, on 3D CT.

Profa. Dra. Gabriela Granja Porto

Prof. Dr. Adriano Germano

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

- PhD Professor of the Field of Oral and Maxillofacial Surgery and Traumatology, UFRN. - Coordinator of the Residency Program of University Hospital Onofre Lopes.

- Post-doctorate at Hospital Universitario 12 de Octubre (Madrid, Spain).

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

13

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):10-3

28 a 30 de junho de 2018 Centro de Eventos da PUCRS - Porto Alegre / RS CORIG 2018 corig2018 eventos@abors.org.br (51) 3330-8866

www.corig.com.br Realização

Apoio

OriginalArticle

Effect of alcohol intake on submandibular

salivary glands

TATIANA WANNMACHER LEPPER1,2 | DENISE BERTIN ROJAS1,3 | VIRGINIA CIELO RECH1,4 | LUCIANE ROSA FEKSA1,4 | FELIPE NOR5,6 | ANNA CHRISTINA MEDEIROS FOSSATI5,7 | JOÃO CARLOS BIRNFELD WAGNER8,9 | CLÓVIS MILTON DUVAL WANNMACHER1,4

ABSTRACT Introduction: Chronic consumption of alcohol affects the oral mucosa and its annexes. Changes in the function of enzymes found in that tissue can change the present saliva. Objective: Thus, the objective of the present study was to investigate the effect of chronic ethanol intake on glandular regeneration and activity of the enzymes creatine kinase (CK), pyruvate kinase (PK), and acid phosphatase (AP), in the submandibular glands of Wistar rats. Materials and Methods: The test group was submitted to chronic ingestion of 40º GL ethyl alcohol for 45 days, and the control was given water. Then the animals were anesthetized with ketamine and subjected to partial excision of submandibular gland left lobe. After the regeneration period, the animals were sacrificed and the left and right submandibular glands were removed for dosage of CK, PK and AP enzymes activity and determination of proteins.

Results: It was found that chronic ethanol intake increased the activity of these enzymes in the regeneration period. Conclusion: These results suggest that the regeneration process of a gland stimulate the activities of the studied enzymes in both glands, probably by a compensation mechanism and functional balance. In addition, this enzymatic activity stimulus becomes more pronounced when the regeneration occurs in the presence of ethanol, possibly in response to its toxic effect.

Keywords: Creatine kinase. Submandibular gland. Ethanol.

Universidade Federal do Rio Grande do Sul, Instituto de Ciências Básicas da Saúde, Departamento de Bioquímica, Laboratório de Erros Inatos do Metabolismo de Aminoácidos (Porto Alegre/RS, Brazil).

2 Specialist in Oral and Maxillofacial Surgery and Traumatology, Hospital Santa Casa de Misericórdia (Porto Alegre/RS, Brazil).

3 Master’s degree in Biochemistry, Universidade Federal do Rio Grande do Sul, Programa de Pós-graduação em Ciências Biológicas (Porto Alegre/RS, Brazil).

4 Doctorate degree in Biochemistry, Universidade Federal do Rio Grande do Sul (Porto Alegre/RS, Brazil).

5 Universidade Federal do Rio Grande do Sul, Faculdade de Odontologia (Porto Alegre/RS,Brazil).

6 Doctorate degree in Dentistry, Universidade Federal do Rio Grande do Sul (Porto Alegre/RS,Brazil).

7 Doctorate degree in Cell and Tissue Biology, Universidade de São Paulo (São Paulo/SP, Brazil).

8 Irmandade Santa Casa da Misericórdia de Porto Alegre, Serviço de Cirurgia e Traumatologia Bucomaxilofacial (Porto Alegre/RS, Brazil).

9 Doctorate degree in Dentistry, Universidade Estadual Paulista Júlio de Mesquita Filho (São Paulo/ SP, Brazil).

1

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

How to cite: Lepper TW, Rojas DB, Rech VC, Feksa LR, Nor F, Fossati ACM, Wagner JCB, Wannmacher CMD. Effect of alcohol intake on submandibular salivary glands. J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):15-21.

DOI: http://dx.doi.org/10.14436/2358-2782.4.1.015-021.oar Submitted: March 23, 2017 - Revised and accepted: October 09, 2017 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article.

Contact address: Tatiana Wannmacher Lepper E-mail: tati-lepper@hotmail.com

15

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):15-21

Effect of alcohol intake on submandibular salivary glands

INTRODUCTION The chronic ingestion of alcohol is a habit accepted worldwide.11 Even though ethyl alcohol has great social acceptance and its ingestion is encouraged by the society, ethanol is a psychotropic drug that acts on the central nervous system and may cause dependence and behavioral change.

Ethyl alcohol may affect several organs and tissues. One of its effects is the direct action of ethyl alcohol or its metabolites, especially acetaldehyde.

When ingested in excess, alcohol is considered a health problem. Alcohol ingestion is associated with disorders in the upper digestive tract, local morphology, metabolism and function. The frequent alcohol ingestion causes damages to the oral mucosa and appendices, such as the salivary glands.1 Maintenance of integrity of these glands, to produce a good salivary flow, is fundamental, since a normal flow is mandatory for an adequate oral and general health.

The submandibular gland, investigated in this study, is located in the submandibular region, close to the mandibular angle. These are mixed glands, which majority (75% to 80%) of acini-type terminal secretory units, composed of serous cells. The remaining (20% to 25%) is formed by mucous tubular terminal secretory units; however, with predominance of serous semilunar. The terminal excretory duct of the submandibular gland, called Wharton’s duct, opens into the oral cavity floor, alongside the lingual frenum, at the sublingual caruncles. 8 The salivary glands are largely responsible for maintenance of the oral homeostasis of hard and soft tissues by salivary secretion10. The reduction in salivary flow may cause great damages to the oral health, such as reduced salivary buffer capacity, increased risk of caries and oral infections, taste disorders, and xerostomia. 4 Two thirds of salivary secretion are produced by the submandibular glands. Therefore, changes in the structure of these glands, as well as the function of some enzymes found in this tissue, may cause great impact on the quantity and quality of saliva present in the oral cavity. Additionally, recent studies demonstrated that chronic ethanol ingestion causes oxidative damage in submandibular and parotid salivary glands. Therefore, there is correlation between chronic alcoholism and oxidative stress, indicating the fundamental role of antioxidants in these gland tissues.5 For this reason, this

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

study addressed some enzymes involved in cell homeostasis, such as creatine kinase, pyruvate kinase and acid phosphatase.

The creatine kinase (CK) is an enzyme that plays a key role in cell energy homeostasis. CK catalyzes the reversible transfer of phosphate between creatine phosphate and ADP, forming ATP.10 There are four main isoenzymes of CK, whose names are correlated with the tissues where they were historically isolated. There are two cytosolic isoenzymes, the muscle (CK-MM) and brain (CK-BB), and two mitochondrial isoforms, the ubiquitous (Miu-CK) and sarcomeric (Mis-CK). The interaction between the cytosolic and mitochondrial isoforms is fundamental for cell energy homeostasis. Different functions have been suggested for communication between the cytosolic and mitochondrial creatine kinase isoforms by phosphocreatine and creatine, depending on the metabolic needs of the cell or tissue. 10 The pyruvate kinase (PK), as well as the creatine kinase, is an isoenzyme that plays a key role in energy metabolism in nearly all tissues of mammals.

It is fundamental for glucose metabolism, the main pathway for achievement of energy to the brain. At least four isoforms of PK are known in vertebrates, including L (found in the liver), M1 (in brain and muscles), M2 (in the kidney) and R (in erythrocytes).

The acid phosphatase catalyzes the conversion of an orthophosphoric monoester and water into alcohol and orthophosphate.2 It is a hydrolytic enzyme that labels lysosomes, which are fundamental organelles in the processes of cell regeneration and death. The activity of this enzyme is increased in Wistar rats with myocardial lesion, probably due to oxidative stress.5 In ethanol-induced hepatic lesion, this compound inhibits the lysosomal autophagic degradation, which is mandatory for lesion recovery. 3 High levels of acid phosphatase, as well as other lysosomal hydrolases, are found in crusts covering lesions in rabbits’ skin. 7 Based on this knowledge, this study analyzed the activity of cytosolic and mitochondrial creatine kinase enzymes, pyruvate kinase and acid phosphatase, and their relationship with the healing process of submandibular salivary gland of adult rats in tissue healing periods of 2 and 15 days, related with chronic ingestion of ethyl alcohol for a period of 45 days, in adult Wistar rats.

16

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):15-21

Lepper TW, Rojas DB, Rech VC, Feksa LR, Nor F, Fossati ACM, Wagner JCB, Wannmacher CMD

MATERIAL AND METHODS Material The study was conducted on adult male Wistar rats aged 60 days, kept in cages, in an environment at 22ºC with daylight cycles of 12 hours, fed with standard commercial food (Supra) and water ad libitum.

The principles of care with laboratory animals were followed in all experiments, and the study was approved by the Institutional Review Board of the Federal University of Rio Grande do Sul (Propesq, UFRGS 18196). The chemical reagents were obtained from Sigma Chemical Co., St. Louis, MO, USA.

was recovery during the time established for each group (2 or 15 days of healing). After the healing period, the animals were submitted to total gland excision and the specimens were submitted to biochemical tests related with the activity of cytosolic and mitochondrial creatine kinase, pyruvate kinase and acid phosphatase.

Preparation of gland tissue The rats were killed by decapitation, the submandibular glands were rapidly removed, diluted at 1:5 p/v in SET buffer (sucrose 0.32 M, tris HCl 10 mM, and EGTA 1 mM) at pH 7.4 and homogenized in a Teflon-Glasses homogenizer. The homogenate was centrifuged at 800 g for 10 minutes, the precipitate was discarded, and part of the supernatant was used to determine the activity of acid phosphatase. The other part was centrifuged at 10,000 g for 15 minutes. The supernatant of this second centrifugation, containing the cytosol and other cell components, such as the endoplasmic reticulum, was collected to determine the cytosolic fraction of CK and PK activity. The precipitate containing the mitochondrial fraction was rinsed twice with SET isotonic buffer and resuspended in buffer 100 mM MgSO4-Trizma, pH 7.5, to determine the mitochondrial fraction of CK activity. The cytosolic and mitochondrial fractions were stored in a freezer at -70ºC, and the CK activity was determined within one week.

In vivo study Initially, in pilot studies, it was observed that enzymes CK and acid phosphatase are present in the tissue of submandibular salivary glands. These tests basically comprise the supply of a substrate compatible with those required by the enzymes CK and acid phosphatase to perform their respective reactions inside the cell. Thus, to analyze the presence or absence of these enzymes, the study analyzed whether the substrate, characteristic for each enzyme, supplied to the cells was used or not for the reaction; if positive, the enzyme was present.

This study included two groups – test and control groups – each composed of 10 male adult Wistar rats (aged 60 days). The rats in the study group were progressively submitted to chronic ingestion of ethyl alcohol 40ºGL using graduated flasks (“bottle”), for 45 days. In the first seven days of ingestion, alcohol 10ºGL was used with sucrose at a concentration of 30g/l; in the second week, the alcohol was increased to 20ºGL and the sucrose concentration was reduced to 20g/l; in the third week the alcohol was increased to 30ºGL and sucrose was reduced to 10g/l; in the fourth week, the animals received alcohol 40ºGL without sucrose. The alcohol solution was prepared using an alcoholmeter. Counting of 45 days during which alcohol 40ºGL was administered without sucrose was initiated after the end of the fourth week. Rats in the control group received water with sucrose in the same aforementioned conditions, yet without alcohol. The weight of animals and alcohol ingestion were recorded weekly.

After 45 days of chronic alcohol ingestion, the rats were submitted to partial excision of the left lobe of the submandibular gland. In following days, there

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Determination of creatine kinase activity The reaction mixture contained the following final concentration: 60 mM buffer Tris-HCl pH 7.5; 7mM of phosphocreatine; 9mM MgSO4 and approximately 1µg of protein in a final volume of 0.13 ml. After 5 minutes of pre-incubation at 37ºC, the reaction was initiated by the addition of 0.42 µmol of ADP. The reaction was interrupted after 10 minutes, by the addition of 1 µmol of p-hydroxymercuribenzoic acid. The concentration of reagents and incubation time were selected to assure the linearity of the enzymatic reaction. The creatine formed by the enzymatic action was estimated according to the Hughes colorimetric method.7 The color was developed by the addition of 0.1 ml 2% a-naphthol and 0.1ml 0.05% of diacetyl in a final volume of 1mL. Reading was performed after 20 minutes at 540 nm.

The results were expressed as nmol of creatine formed per minute, per mg of protein.

17

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):15-21

Effect of alcohol intake on submandibular salivary glands

RESULTS The three-way ANOVA of cytosolic creatine kinase activity revealed interaction between the healing time and ethanol ingestion (F (1.35) = 127.68; p<0.001), indicating that ethanol interfered with the healing process over time. The one-way ANOVA (F (7.28) = 35.30; p<0.001) followed by the Tukey test indicated that the cytosolic creatine kinase activity increased in right and left salivary glands after 15 days of healing, both due to the healing process and due to chronic ethanol ingestion, as observed in Figure 1.

The three-way ANOVA of mitochondrial creatine kinase activity demonstrated interaction between the healing time and ethanol ingestion (F (1.30) = 17.98; p<0.001), indicating that ethanol interfered with the healing process over time. The one-way ANOVA (F (7.30) = 13.51; p<0.001) followed by the Tukey test indicated that the mitochondrial creatine kinase activity increased in right and left salivary glands after 15 days of healing, both due to the healing process and due to chronic ethanol ingestion, as observed in Figure 2.

The three-way ANOVA of pyruvate kinase activity demonstrated interaction between the healing time and ethanol ingestion (F (1.39) = 10.74; p<0.01), indicating that ethanol interfered with the healing process over time. The one-way ANOVA (F (7.32) = 13.33; p<0.001) followed by the Tukey test indicated that the pyruvate kinase activity increased in right and left salivary glands after 15 days of healing, both due to the healing process and due to chronic ethanol ingestion, as observed in Figure 3.

The three-way ANOVA of acid phosphatase activity demonstrated interaction between the healing time and ethanol ingestion (F (1.40) = 50.80; p<0.001), indicating that ethanol interfered with the healing process over time. The one-way ANOVA (F (7.33) = 11.62; p<0.001) followed by the Tukey test indicated that the acid phosphatase activity increased in right and left salivary glands both due to the healing process and due to chronic ethanol ingestion, as observed in Figure 4.

Determination of pyruvate kinase activity The pyruvate kinase activity was determined by the method described by Leong et al.15 The incubation medium contained 0.1 M of buffer Tris-HCl, pH 7.5, 10 mM MgCl2, 0.16 mM NADH, 75 mM of KCl, 5 mM of ADP, 7 units of L-lactate dehydrogenase, 0.1% (v/v) Triton X-100 and 10 µL of mitochondria-free supernatant fraction, in a final volume of 0.5 mL. The reaction was initiated after 30 minutes of incubation at 37ºC, by the addition of 1.0 mM of phosphoenolpyruvate. The oxidation of NADH was recorded in a spectrophotometer at 340 nm for 90 seconds. The testing time and concentration of reagents were selected to assure the linearity of the reaction. The results were expressed as nmol of pyruvate formed per minute, per mg of protein.

Determination of acid phosphatase activity The acid phosphatase activity was measured as described by Bodansky.2 The initial incubation medium contained buffer Tris-HCl 0.1 M pH 5.0, sodium ß-glycerophosphate mM, and the sample containing approximately 1 µg of protein. After 60 minutes of incubation at 37ºC, the reaction was interrupted by the addition of 5% trichloroacetic acid, centrifuged for 10 min at 800 rpm, and 50 µL of supernatant were added to 200 mL of water, 20 µL of molybdate reagent, and 20 µL of reducing reagent. The color developed was read after 10 min in a spectrophotometer at 650 nm. The enzyme activity was expressed as µmol of phosphate released per minute and as mg of proteins.

Determination of proteins The proteins were measured by the method of Lowry et al,10 using bovine serum albumin as standard.

Statistical analysis Data were statistically analyzed by three-way ANOVA (ethanol, healing time and surgery). When needed, comparison between groups was performed by one-way ANOVA, followed by the Tukey test, when F was significant. The entire analysis was performed in a computer using the software SPSS for Windows.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

18

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):15-21

Lepper TW, Rojas DB, Rech VC, Feksa LR, Nor F, Fossati ACM, Wagner JCB, Wannmacher CMD

200

** **

Creatine kinase activity

160

400

Creatine kinase activity

300

120

** **

80

40

0 D2D E2D D15D E15D AD2D AE3D AD15D AE15D

200

Figure 2: Effect of gland healing and chronic ethanol intake on the mitochondrial creatine kinase activity in submandibular gland of rats submitted to partial removal of the left submandibular gland. Data expressed as mean ± SD for 5-6 animals in each group. **P

100

0 D2D E2D D15D E15D AD2D AE3D AD15D AE15D

--

Figure 1: Effect of gland healing and chronic ethanol intake on the cytoplasmic creatine kinase activity in submandibular gland of rats submitted to partial removal of the left submandibular gland. Data expressed as mean ± SD for 5-6 animals in each group. **P

700

Acid phosphatase activity

600

60

Pyruvate kinase activity

45

30

**

** **

**

500

400

##

##

300

200

100

15 0 D2D E2D D15D E15D AD2D AE3D AD15D AE15D

--

0 D2D E2D D15D E15D AD2D AE3D AD15D AE15D

Figure 4: Effect of gland healing and chronic ethanol intake on the acid phosphatase activity in submandibular gland of rats submitted to partial removal of the left submandibular gland. Data expressed as mean ± SD for 5-6 animals in each group. **P

Figure 3: Effect of gland healing and chronic ethanol intake on the pyruvate kinase activity in submandibular gland of rats submitted to partial removal of the left submandibular gland. Data expressed as mean ± SD for 5-6 animals in each group. **P

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

19

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):15-21

Effect of alcohol intake on submandibular salivary glands

DISCUSSION The creatine kinase, acid phosphatase and pyruvate kinase enzymes are important for cell energy homeostasis, playing several integrated functions, such as energy storage for the metabolic capacity, energy transfer and metabolic control.12 The brain, heart and skeletal muscle are tissues with high rates of these enzymes that participate in energy homeostasis.

The present results indicate that the salivary glands present moderate rate of activity of these enzymes compared to sites where they have greater activity.10 The treatment with ethanol reduced the activity of kinases, possibly due to induction of oxidative stress, since ethanol induces the production of free radicals, to which the kinases are sensitive because they are thiol enzymes.10 Conversely, when the left submandibular salivary gland was submitted to surgical procedure while the right gland was kept intact, both presented similar enzymatic activities, both in the control and ethanol groups, suggesting that the activity of one submandibular salivary gland influences the other, possibly by mechanisms for maintenance of gland function.

Therefore, the present results corroborate the findings of Fagundes et al,4 who reported difference in the oxidative stress levels by the increase in lipid peroxidation in submandibular and parotid salivary glands in the presence of chronic alcohol ingestion.

The acid phosphatase labels the lysosomal activity and is increased in degenerative and cicatricial processes.7 In the present study, animals submitted to surgery presented increase in acid phosphatase activity in both submandibular glands after 15 days, suggesting that the increase of enzymatic activity is mainly associated with the regenerative process. The chronic ethanol ingestion stimulated the acid phosphatase activity, more markedly two days after sur-

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

gery, suggesting a response to the toxic effects of this compound. Data in the literature indicate that ethanol increases the activity of lysosomal enzymes by the induction of oxidative stress5 and interferes with tissue healing, since it reduces the regenerative autophagic process.3 Considering the present results, ethanol reduced the activities of creatine kinase, acid phosphatase and creatine kinase enzymes in submandibular salivary glands of Wistar rats. The findings revealed that mitochondrial and cytosolic CK and PK exhibited an increase in their activity at 15 days of healing, suggesting a decrease in their activity at 2 days of healing and return to homeostasis at 15 days, without increase related to ethanol, but rather a return to homeostasis after the initial reduction caused by ethanol. With regard to acid phosphatase, the study suggested an increase in activity at 2 days of healing and return to homeostasis at 15 days of healing.

CONCLUSION The results suggest that the healing process of one gland stimulates the enzymatic activities in both glands, probably by a mechanism of compensation and functional balance. Also, there is a possible reduction of CK, PK and AP enzymes activities when healing occurs in the presence of ethanol, possibly as a reaction to its toxic effect. However, after a certain healing period, the tissue may return to its previous homeostasis. Further studies are necessary to evaluate if there is tissue damage that may alter the morphology and function of submandibular salivary glands, consequently affecting the saliva production and excretion. Also, further investigations may elucidate the mechanisms through which the lesion of one gland affects the activity of the other.

20

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):15-21

Lepper TW, Rojas DB, Rech VC, Feksa LR, Nor F, Fossati ACM, Wagner JCB, Wannmacher CMD

References:

1. Born IA, Zöller J, Weidauer H, Maier H. Effects of chronic alcohol drinking on mouth mucosa. A morphometric study. Laryngorhinootologie. 1996 Dec;75(12):754-8.

2. Bodansky A. Phosphatase studies: II. Determination of serum phosphatase: factors influencing the accuracy of the determination. J Biol Chem. 1993;99:197206.

3. Donohue TM Jr. Autophagy and ethanol-induced liver injury. World J Gastroenterol. 2009 Mar 14;15(10):1178-85.

4. Fagundes NC, Fernandes LMP, Paraense RSO, Farias-Junior PMA, Teixeira FB, Alves-Junior SM, et al. Binge drinking of ethanol during adolescence induces oxidative damage and morphological changes in salivary glands of female rats. Oxidative Med Cell Long. 2016(2016):ID 7323627, 11 pages.

5. Fejerskov O, Kidd E. Cárie dentária: a doença e seu tratamento clínico. 1ª ed. São Paulo: Ed. Santos; 2005.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

6. Ganesan B, Anandan R. Protective effect of betaine on changes in the levels of lysosomal enzyme activities in heart tissue in isoprenaline-induced myocardial infarction in Wistar rats. Cell Stress Chaperones.

2009 Nov;14(6):661-7.

7. Hughes BP. A method for the estimation of serum creatine kinase and its use in comparing creatine kinase and aldolase activity in normal and pathological sera. Clin Chim Acta. 1962 Sept;7:597-603.

8. Kajiki A, Higuchi K, Nakamura M, Liu LH, Pula PJ, Dannenberg AM Jr. Sources of extracellular lysosomal enzymes released in organ culture by developing and healing inflammatory lesions. J Leukoc Biol. 1988 Feb;43(2):104-16.

9. Katchburian E, Arana V. Histologia e Embriologia oral. 2a ed. Rio de Janeiro: Guanabara Koogan; 2004.

10. Lowry OH, Rosebrough NJ, Farr AL, Randall RJ. Protein measurement with the Folin phenol reagent.

J Biol Chem. 1951 Nov;193(1):265-75.

21

11. Rech VC, Feksa LR, Fleck RM, Athaydes GA, Dornelles PK, Rodrigues-Junior V, et al. Cysteamine prevents inhibition of thiol-containing enzymes caused by cystine or cystine dimethylester loading in rat brain cortex. Metab Brain Dis. 2008 June;23(2):133-45.

12. Riedel F, Goessler UR, Hormann K. Alcohol-related diseases of the mouth and throat. Dig Dis. 2005;23(34):195-203.

13. Campos SC, Moreira DA, Nunes TD, Colepicolo P, Brigagão MR. Oxidative stress in alcohol-induced rat parotid sialadenosis. Arch Oral Biol. 2005 July;50(7):661-8.

14. Wallimann T, Wyss M, Brdiczka D, Nicolay K, Eppenberger HM. Intracellular compartmentation, structure and function of creatine kinase isoenzymes in tissues with high and fluctuating energy demands: the ‘phosphocreatine circuit’ for cellular energy homeostasis.

Biochem J. 1992 Jan 1;281(Pt 1):21-40.

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):15-21

OriginalArticle

Oral sedation in dental surgery: analysis of

variations in blood glucose and blood pressure NATÁLIA QUINILATTO DARÓZ1 | FABIANE TORRES MAIA GUIMARÃES1 | ANTONIO DE MELO CABRAL2 | MARIANA CAMILO NEGREIROS LYRIO ALVARES2 | DANIELA NASCIMENTO SILVA3 | ROSSIENE MOTTA BERTOLLO3 | MARTHA ALAYDE ALCANTARA SALIM VENANCIO3

ABSTRACT Introduction: Fear and anxiety are conditions that can trigger changes in blood sugar levels and blood pressure. Objective: To evaluate blood glucose and blood pressure variations in patients submitted to oral surgery with and without the use of oral sedation. Methods: The sample consisted of 68 healthy patients (aged 18-40 years) divided into two groups: group I (control) and group II, which received 5 mg diazepam as preoperative oral medication. All patients underwent surgery under local anesthesia. Systolic blood pressure (SBP), diastolic blood pressure (DBP) and blood glucose were recorded and values were compared at the beginning and end of surgery between the groups and also within the same group. Results: Group I presented an increase in SBP and DBP when compared to baseline and at the end of surgery (SBP p = 0.000; DBP p = 0.025); group II did not present significant variations in SBP and DBP. When comparing BP values between groups at the end of surgery, a significant increase in DBP was observed in group II (p = 0.017). Conclusion: The use of diazepam as pre-surgical medication maintained constant SBP and DBP values, suggesting cardiovascular protective action during surgery.

Keywords: Surgery, oral. Glucose. Blood pressure. Anxiety.

Graduated in Dentistry, Faculdades Integradas Espírito-Santenses (Vitória/ES, Brazil).

Faculdades Integradas Espírito-Santenses, Departamento de Cirurgia Bucomaxilofacial (Vitória/ES, Brazil).

3 Universidade Federal do Espírito Santo, Departamento de Cirurgia Bucomaxilofacial (Vitória/ ES, Brazil).

1

How to cite: Daróz NQ, Guimarães FTM, Cabral AM, Alvares MCNL, Silva DN, Bertollo RM, Venancio MAAS. Oral sedation in dental surgery: analysis of variations in blood glucose and blood pressure.

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):22-7.

DOI: http://dx.doi.org/10.14436/2358-2782.4.1.022-027.oar

2

Submitted: July 28, 2017 - Revised and accepted: October 09, 2017 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article.

Contact address: Martha Alayde Alcantara Salim Venancio E-mail: marthasalim@uol.com.br

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

22

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):22-7

Daróz NQ, Guimarães FTM, Cabral AM, Alvares MCNL, Silva DN, Bertollo RM, Venancio MAAS

INTRODUCTION Anxiety is one of the most common psychiatric disorders in adults and is an important public health problem in the country, affecting the individual’s quality of life and impairing the health, with risk to develop hypertensions and variations in blood glucose, besides other disorders. Blood hypertension has a multifactorial etiology, related with genetics, environments as dental clinics and hospitals, and psychosocial factors. It is estimated to affect one fourth of all Brazilian adults, and has been identified as one of the main causes of death. Therefore, stress control in sites where it is triggered is fundamental to protect the cardiovascular system during surgical procedures, especially for individuals with risk factors.1 During a stressful situation, the insulin level may be reduced, triggering acute hyperglycemia both trans- and postoperatively. This reduced insulin concentration occurs due to insufficient secretion.2 When a permanent stressful situation is maintained, the blood glucose levels are increased, both in diabetic and non-diabetic individuals, which may lead to a very dangerous opposite situation, the hypoglycemia.3 It is known that stress, by itself, causes the release of endogenous catecholamines; thus, the circulating levels of this substance are increased, which may trigger cardiovascular alterations such as increase in cardiac output and systolic volume. A marked stress level may affect the patient’s physiology, causing psychosomatic diseases and increasing the systolic and diastolic blood pressure and heart rate. 4 These conditions may be controlled by psychological management and drugs, aiming to maintain the balance of the central nervous system and consequently enhancing the safety to the patient. Benzodiazepines are the drugs of choice, due to the easy administration, clinical safety and effective anxiolytic activity, with sufficient half-life for the procedure duration, besides presenting low toxicity and side effects that do not harm the patients. 5 Several drugs have been described and demonstrate that, at different doses, the may or may not interfere with blood glucose, as well as other associated disorders. This group of medications include Lorazepam, Bromazepam, Cloxazolam, Flunitrazepam, Oxazepam, Midazolam, Alprazolam, besides Diazepam, the most used in Dentistry, being the standard drug of this group. 6

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Therefore, this study evaluated the variations in blood pressure and blood glucose in patients submitted to tooth extraction, using preoperative oral sedation with Diazepam.

METHODS Patient selection Sixty-eight volunteer individuals were analyzed, by clinical and radiographic examination, and selected to perform the dental surgical procedure. All individuals were informed on the study, agreed to participate and signed an informed consent form. The following inclusion criteria were considered: healthy patients of both genders, with indication for tooth extraction, age ranging from 18 to 40 years, without systemic diseases identified during anamnesis. The exclusion criteria comprised patients who refused to participate in the study; with incompatible age; requiring complex surgical procedures; or in regular use, presenting allergy or any adverse effect to Diazepam. The patients’ anxiety was evaluated by the Corah Dental Anxiety Scale.4 The patients were randomly divided in two groups with 34 participants: group I (control); and group II, who received an oral dose of 5mg of Diazepam one hour before surgery. The blood glucose and systolic and diastolic blood pressure were measured at surgery onset and immediate completion.

Institutional Review Board The study was registered in Plataforma Brasil and approved by the Institutional Review Board, protocol n. 19313013.0.0000.5059.

Data collection As surgical protocol, the systolic and diastolic blood pressure and blood glucose were measured, according to preestablished techniques, immediately before the surgical procedure. Blood glucose was assessed by antisepsis of the index finger tip of either hand with alcohol 70% and puncture for collection of a blood sample, which was placed on a reagent strip and the outcome was obtained in some seconds, by optical reading (G-Tech Free system). The blood pressure was obtained using an automatic wrist digital blood pressure monitor (G-Tech Free). The second collection was obtained after completion of surgery, estimated in 60 minutes, and data were recorded in a control form.

23

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):22-7

Oral sedation in dental surgery: analysis of variations in blood glucose and blood pressure

out normality (final SBP and blood glucose) were assessed by the non-parametric Mann-Whitney test.

All surgical procedures were performed under local anesthesia using lidocaine hydrochloride with epinephrine 1/100,000, and were conducted by a calibrated investigator.

RESULTS Group I (control) presented significant increase in systolic blood pressure (SBP) comparing the values between surgery onset and completion (SBP p=0.000). Group II (Diazepam) did not exhibit significant variations in SBP (SBP p=0.299) (Tab. 1).

Comparison of the mean values of diastolic blood pressure (DBP) between groups I and II at surgery completion revealed increased values in group II (final DBP p=0.017) (Table 2).

Group I exhibited an increase in DBP comparing the measurements at surgery onset and completion (final DBP p=0.025). Group II did not present significant variations in DBP (DBP p=0.990) (Table 1 and 2).

The blood glucose values obtained in the evaluation of both groups did not reveal significant variation (initial p=0.061; final p=0.056).

The Corah Dental Anxiety Scale, individually applied to the patients, did not present significant difference between groups (p=0.303).

Statistical analysis Collected data were entered in Excel worksheets (.xls). The categoric variables were expressed in absolute and percent numbers, and the quantitative variables were expressed by measurements of central position and variability (median, mean and standard deviation). Statistical analysis was performed by the t test for means when the distribution fitted the Gauss model (normal distribution), or by the MannWhitney test in case of non-Gaussian distribution.

Both tests analyzed the hypothesis of similarity between groups: when the p value was smaller than 0.05 (5%), the hypothesis was rejected, i.e. there was difference between groups. All tests considered a significance level of 5%. Variables for which the normality hypothesis was not rejected (initial SBP, initial and final DBP and final blood glucose) were analyzed by the t test for means; and variables with-

Table 1: Descriptive statistics and results of comparison tests between periods.

Groups

With Diazepam

Without Diazepam

Variables (periods)

Median

Mean

Standard deviation

SBP (initial) SBP (final) DBP (initial) DBP (final) Blood glucose (initial) Blood glucose (final) SBP (initial) SBP (final) DBP (initial) DBP (final) Blood glucose (initial) Blood glucose (final)

128.00 130.00 89.50 89.50 101.00 96.00 124.00 131.50 87.00 92.00 106.00 109.00

123.32 126.15 86.59 86.62 100.97 99.76 122.94 133.44 88.03 95.88 107.94 108.15

15.32 17.79 12.92 16.01 19.39 17.29 12.21 14.18 13.64 15.33 24.68 18.28

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

24

p-value

0.299 0.990 0.659 0.000 0.025 0.950

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):22-7

Daróz NQ, Guimarães FTM, Cabral AM, Alvares MCNL, Silva DN, Bertollo RM, Venancio MAAS

Table 2: Descriptive statistics and results of comparison tests between groups.

Variables

SBP (initial)* SBP (final)** DBP (initial)* DBP (final)* Blood glucose (initial)** Blood glucose (final)* Anxiety score**

Groups

Median

Mean

Standard deviation

With Diazepam Without Diazepam With Diazepam Without Diazepam With Diazepam Without Diazepam With Diazepam Without Diazepam With Diazepam Without Diazepam With Diazepam Without Diazepam With Diazepam Without Diazepam

128.00 124.00 130.00 131.50 89.50 87.00 89.50 92.00 101.00 106.00 96.00 109.00 10.00 9.00

123.32 122.94 126.15 133.44 86.59 88.03 86.62 95.88 100.97 107.94 99.76 108.15 10.32 9.44

15.32 12.21 17.79 14.18 12.92 13.64 16.01 15.33 19.39 24.68 17.29 18.28 3.45 4.32

p-value

0.910 0.244 0.656 0.017 0.061 0.056 0.303

* t test for means. ** Mann-Whitney test. SBP = systolic blood pressure. DBP = diastolic blood pressure.

DISCUSSION Cross-sectional studies analyzing anxiety and hypertension revealed a relationship with cardiac diseases and heart rate. A literature review demonstrated increased risk of blood hypertension in depressed individuals, and increased risk of depression in hypertensive individuals. Usually, anxiety increases the blood pressure, systemic vascular resistance, sympathetic activity, plasma renin activity, blood homeostasis and blood lipids. At first, anxiety increases the blood pressure, in the short term. Second, there is a strict relationship between anxiety and the renin-angiotensin system, increasing the angiotensin level. Third, some studies demonstrated that anxious individuals usually have physiological signs of sympathetic activation and may strongly stimulate the sympathetic nerve flow and vasovagal reflex. 7 In the long term, an anxious state may increase the response of the sympathetic nervous system, reducing the renal blood flow, increasing the sodium retention, rising the blood pressure, which damages the endothelial cells causing endothelial dysfunction and increasing the risk of atherosclerosis.8

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Pan et al 1 conducted a study correlating anxiety and hypertension using data of cross-sectional studies. They demonstrated a direct relationship between people with high level of stress and a predisposition to develop diseases related to hypertension. Usually, exacerbated levels of anxiety increase the systemic vascular resistance and plasma activity, strongly stimulating the sympathetic system and vasovagal reflex, increasing the cardiac output and raising the blood pressure. Thus, control of the blood pressure levels during stressful situations, such as dental surgical procedures, is fundamental for the stability of the cardiovascular system, thereby avoiding transoperative complications.

The levels and degrees of anxiety are evaluated by specific scales used for research. The present study adopted the scale of Corah, Gale and Illig, 9 which served as basis for the creation of different scales that are now applied in several investigations on adult individuals, aiming to measure the level of anxiety of participants, besides being simple, objective, valid, reliable and easy to apply.

Luyk et al,10 comparing the effect of Diazepam and Midazolam on anxiety in 33 adult patients sub-

25

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):22-7

Oral sedation in dental surgery: analysis of variations in blood glucose and blood pressure

of systolic and diastolic blood pressure did not vary significantly in the group that used Diazepam. However, in the control group, the systolic (p = 0.000) and diastolic (p = 0.025) blood pressure levels were high at completion of the surgical procedure.

Metha14 analyzed the effect of Diazepam on blood glucose in patients without systemic disorders, before dental extractions, and revealed a decrease in blood glucose. However, the study suggested that this reduction was not associated with the use of anxiolytic drug, but rather with preoperative fasting. Conversely, the study of Okada et al15 observed that the chronic use of Fluodiazepam for 12 weeks led to a reduction in glycosylated hemoglobin, thus it may be an effective way through which the drug causes changes in blood glucose levels. Mohseni et al,16 also with the goal to evaluate the blood glucose variation in patients receiving Diazepam and undergoing oral surgeries, studied 80 patients dividing into two groups, one medicated with the anxiolytic drug and the other with a placebo; the authors found that Diazepam prior to surgery significantly decreased the hyperglycemic response of medicated patients. In the present study, no significant differences were found in blood glucose variation at onset and completion of surgery in both groups. Thus, the eventual use of benzodiazepine did not interfere with the variation in blood glucose during the surgical procedure in the present study.

mitted to oral surgeries, employed the Visual Analogue Scale (VAS) scale, which ranges from 0 (totally relaxed) to 10 (worst imaginable fear); and demonstrated that the use of both drugs promoted a significant decrease in the level of anxiety, concluding that there was no statistically significant difference between the drugs. Bortoluzzi et al,4 evaluating the level of anxiety and blood glucose variation of 37 adult patients aged 18-45 years, used the anxiety test with a numerical scale ranging from 0 to 100 and verified that the level of anxiety did not have significant variation between patients. Peckan et al11 studied the effect of oral Diazepam on anxiety in 100 patients submitted to surgery, divided into two groups; the authors observed that the medicated group presented lower levels of anxiety and blood cortisol in the two study periods, concluding that preoperative sedation with oral Diazepam inhibits the anxiety, stress and increased blood cortisol dosage during surgery. The present study applied the Corah Dental Anxiety scale and the results did not reveal significant differences in the level of anxiety between groups. This is possibly due to the fact that the majority of both groups presented moderate to low level of anxiety, and all patients were normotensive. The eighth edition of the American guideline, better known as Joint, also does not include anxiety as a possible factor interfering with blood pressure and does not present it as a factor of resistance to treatment.12 Raymond et al 13 analyzed the blood pressure variation, in which each subject was submitted to two dental surgeries, being previously medicated with Diazepam in the first and placebo in the second. The authors observed a significant difference between sessions; namely, Diazepam was able to reduce the blood pressure values ​​in the medicated patients. Corroborating with the aforementioned study, Luyk et al 10 observed that the systolic blood pressure decreased significantly in the group using Diazepam. This study demonstrated that the values​​

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

CONCLUSION The use of Diazepam as preoperative anxiolytic medication in healthy individuals presented a cardiovascular protective role during surgical procedures of tooth extractions, maintaining constant pressure, systolic and diastolic values until treatment completion. Conversely, the control group exhibited significant increase in systolic and diastolic blood pressure between surgery onset and completion. The use of Diazepam did not alter the blood glucose levels in the patients analyzed.

26

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):22-7

Daróz NQ, Guimarães FTM, Cabral AM, Alvares MCNL, Silva DN, Bertollo RM, Venancio MAAS

References:

1. Pan Y, Cai W, Cheng Q, Dong W, An T, Yan J. Association between anxiety and hypertension: a systematic review and meta-analysis of epidemiological studies. Neuropsychiatr Dis Treat. 2015 Apr 22;11:1121-30.

2. Desborough JP. The stress response to trauma and surgery. Br J Anaesth. 2000 July;85(1):109-17.

3. Strauss SM, Russell S, Wheeler A, Norman R, Borrell LN, Rindskopf D. The dental office visit as a potential opportunity for diabetes screening: an analysis using.

J Public Health Dent. 2010 Spring;70(2):156-62.

4. Bortoluzzi MC, Manfro R, Nardi A. Glucose levels and hemodynamic changes in patients submitted to routine dental treatment with and without local anesthesia. Clinics (Sao Paulo). 2010 Oct;65(10):9758.

5. Pinheiro MLP, Alcântara CEP, Moraes M, Andrade ED. Valeriana officinalis L. for conscious sedation of patients submitted to impacted lower third molar surgery: a randomized, double-blind, placebo-controlled split-mouth study. J Pharm Bioallied Sci. 2014 Apr;6(2):109-14.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

6. Meechan JG, Welbury RR. Metabolic responses to oral surgery under local anesthesia and sedation with intravenous midazolam: the effects of two different local anesthetics. Anesth Prog. 1992;39(12):9-12.

7. Bajkó Z, Szekeres CC, Kovács KR, Csapó K, Molnár S, Soltész P, et al. Anxiety, depression and autonomic nervous system dysfunction in hypertension.

J Neurol Sci. 2012 June 15;317(1-2):112-6.

8. DiBona GF. The sympathetic nervous system and hypertension: recent developments. Hypertension.

2004 Feb;43(2):147-50.

9. Corah NL, Gale EN, Illig SJ. Assessment of a dental anxiety and pain measures in dentistry. J Am Dent Assoc. 1978 Nov;97(5):816-9.

10. Luyk NH, Boyle MA, Ward-Booth RP. Minor Oral Surgery. Anesthesia Progress. 1987 MarApr;34(2):37-42.

11. Pekcan M, Celebioglu B, Demir B, Saricaoglu F, Hascelik G, Yukselen MA, et al. The effect of premedication on preoperative anxiety. Middle East J Anaesthesiol. 2005 June;18(2):421-33.

27

12. James PA, Oparil S, Carter BL, et al. Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the eighth joint National Committee. JAMA. 2013 Dec;2013 [Access in: 2013 Dec 18]. Available from: http://jamanetwork.com/journals/jama/fullarticle/1791497 13. Raymond A, Dionne DDS, David S. Effects of diazepam premedication and epinephrine-containing local anesthetic on cardiovascular and plasma catecholamine responses to oral surgery. Anesth Analg.

1984 July;63(7):640-6.

14. Metha S. The influence of premedication with diazepam on the blood sugar level. Anaesthesia. 1971 Oct;26(4):468-72.

15. Okada S, Ichiki K, Tanokuchi S, Ishii K, Hamada H, Ota Z. How blood pressure in patients with noninsulin-dependent diabetes mellitus is influenced by stress. J Int Med Res. 1995 Sept-Oct;23(5):377-80.

16. Mohseni G, Ranjbar A, Rezaei M. Oral Diazepam effect on surgical patient’s postoperative blood sugar.

Adv Environ Biol. 2012;3(9):4382-5.

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):22-7

OriginalArticle

Epidemiology of facial trauma in a

hospital in the municipality of Manaus-Amazonas MÁRCIA ARRUDA LINS1,2 | GUSTAVO CAVALCANTI DE ALBUQUERQUE1,3 | AMANDA LIMA DE OLIVEIRA1,2 | VALBER BARBOSA MARTINS1,4 | FLÁVIO TENDOLO FAYAD1,5 | MARCELO VINICIUS DE OLIVEIRA1,6 | JOEL MOTTA JÚNIOR1,6

ABSTRACT Introduction: Oral and maxillofacial trauma vary from country to country due to the existence of different social, local and cultural factors. Its prognosis depends on the stage of development, the time between the fracture event and its care, as well as the injured areas. Objective: The present study proposed to carry out an epidemiological survey of face traumas treated in a hospital in the municipality of Manaus/Amazonas (Brazil) in the years from 2013 to 2016. Methods: A retrospective cross-sectional survey was conducted, considering factors such as: etiology, gender, age, location and surgical procedure. Results: A total of 184 medical records were analyzed. The most prevalent etiology was traffic accidents, with 89 cases (48.

37%).The male sex stood out, with 161 cases (87.50%) in the age group of 21-30 years. The most affected region was the mandible, with 71 cases (31.56%). The most prevalent surgical procedure was the reduction with fixation of trauma, with 150 cases (66.66%). Conclusions: Young men are the most affected, and traffic accidents are the major causal factor.

Keywords: Epidemiology. Oral and maxillofacial trauma. Public hospital.

Universidade do Estado do Amazonas, Escola de Ciências da Saúde, Departamento de Odontologia (Manaus/AM, Brazil).

Universidade do Estado do Amazonas, Curso de Odontologia (Manaus/AM, Brazil).

3 Master’s degree in Oral and Maxillofacial Surgery and Traumatology, Universidade de São Paulo (Ribeirão Preto/SP, Brazil).

4 Master’s degree in Oral and Maxillofacial Surgery and Traumatology, São Leopoldo Mandic (São Paulo/SP, Brazil).

5 Master’s degree in Dental Clinic, Universidade de Marília (Marília/SP, Brazil).

6 Doctorate degree in Dental Clinic, Universidade Estadual de Campinas (Piracicaba/SP, Brazil).

1

How to cite: Lins MA, Albuquerque GC, Oliveira AL, Martins VB, Fayad FT, Oliveira MV, Motta Júnior J. Epidemiology of facial trauma in a hospital in the municipality of Manaus-Amazonas. J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):28-32.

DOI: http://dx.doi.org/10.14436/2358-2782.4.1.028-032.oar

2

Submitted: June 13, 2017 - Revised and accepted: October 22, 2017 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article.

Contact address: Márcia Arruda Lins E-mail: linsmarcia95@gmail.com

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

28

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):28-32

Lins MA, Albuquerque GC, Oliveira AL, Martins VB, Fayad FT, Oliveira MV, Motta Júnior J

INTRODUCTION Trauma may be considered a combination of disorders suddenly caused by a physical agent, with varied etiology, nature and extent, which may affect different body regions. Due to the anterior facial projection, the facial skin and bones are extremely exposed to aggression. Compression of soft tissues against the bones by external aggression forces may cause several lesions, potentiating the harmful effects of bone fractures. 1 The maxillofacial traumas and traumatic dental injuries, in increasing number, include fractures, avulsions, luxations and tooth cracks, which may cause esthetic and functional implications, affecting the individual’s life in physical, functional and emotional aspects. 2 The causes of maxillofacial fractures vary between countries, due to the presence of different local, cultural and social factors. Even though few reports are available on the prevalence of maxillofacial fractures in some countries, some studies mention car accidents, robbery and falls among the most frequent causes of this type of fracture.3 However, the etiology of facial trauma is heterogeneous and the predominance of one or other etiologic factor is related with some characteristics of the study population.4,5 For example, in children and adults, the facial fractures are associated with falls at home or childhood games and plays. In young adults until the fourth decade of life, the most common causes, besides car accidents, are aggressions and traumas related to sports practice, as well as alcohol abuse. Due to the thorough etiology, several conditions may interfere with the approach and selection of treatment for individuals with facial trauma. The extent of lesion, degree of involvement and tissue dysfunction, the physical and social characteristics of the patient, his or her compliance and the hospital structure available are some variables during the procedures.6 In turn, the prognosis varies according to the stage of development, the time between the occurrence of fracture and proper treatment, as well as the affected areas. Based on these factors, associated with the etiology, extent and severity of traumas to the oral and maxillofacial complex, an adequate planning may be defined for functional and esthetic recovery, also addressing alignment, and prioritizing the prevention of these traumas.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Knowledge on the maxillofacial and dental traumas may enhance the preventive and therapeutic measures for injuries at these regions, such as the adoption of mouthguards and facial shields in sports practice, preventing injuries to the oral and maxillofacial region. 7,8 Regular re-evaluation of facial traumas is fundamental to check the preestablished standards or to identify new characteristics during the evolution of this pathology.9 Thus, this study conducted an epidemiological survey – considering the etiology and location of trauma, gender, age range and surgical management adopted – in patients treated at a hospital in the city of Manaus/Amazonas, assisted by the Residency of Oral and Maxillofacial Surgery and Traumatology, in the period from 2013 to 2016.

METHODS This cross-sectional quantitative retrospective study was approved by the Institutional Review Board of the Amazonas State University (# 1.354.959 and CAAE 45316915.9.0000.5016). Data were collected from the patient records from a hospital in the city of Manaus/Amazonas, assisted by the Residency of Oral and Maxillofacial Surgery and Traumatology, considering a 4-year period. During this period, 184 patients with oral and maxillofacial trauma were identified.

The study included records from patients with trauma to the oral and maxillofacial region. Individuals with dentoalveolar trauma or incomplete records were excluded.

This study analyzed factors as the etiology and location of trauma, gender, age range and surgical management adopted.

The patients were grouped in the following age ranges, in completed years: 11 to 20 years; 21 to 30 years; 31 to 40 years; 41 to 50 years; 51 to 60 years; and 61 to 70 years.

The etiology of traumas was classified as: car accidents; physical aggression; fall from own height; sports accidents; work accidents; river accidents; and gunshot bullet.

The location of trauma according to region was classified as: mandible; maxilla; zygoma-orbital complex; nasal bones; nasoorbitoethmoid; and frontal bone. Analysis of the location of trauma also considered the patients presenting more than one affected region.

29

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):28-32

Epidemiology of facial trauma in a hospital in the municipality of Manaus-Amazonas

affected was 11 to 20 years, with 1 case (4.3%), and there were no female patients with oral and maxillofacial traumas in the age range 51-60 years (Fig 2).

The main etiologic factors were car accidents (89 cases, 48.37%) and physical aggression (52 cases, 28.26%). The least prevalent were river accidents (2 cases, 1.09%) and gunshot bullet (2 cases, 1.09%) (Fig 3).

Concerning the location, among the 225 affected regions, the most affected were the mandible with 71 cases (31.56%), and the zygoma-orbital complex with 70 cases (31.11%); the least affected were the nasoorbitoethmoid, with 7 cases (3.11%), and frontal, with 6 cases (2.67%) (Fig 4).

Concerning the surgical management adopted for the 184 patients, there was high prevalence of fracture reduction + fixation, in 150 cases (66.66%), and fracture reduction + stabilization, with 39 cases (17.33%); the procedure with the lowest rate of accomplishment was reduction + reconstruction, with only 4 cases (1.77%) (Fig. 5).

The surgical procedures performed were classified as: fracture reduction + fixation; only reduction; reduction + stabilization; refracture + reduction + fixation; reduction + fracture reconstruction.

Data were entered in a Microsoft Excel 2007 worksheet and analyzed by descriptive statistics.

RESULTS After analysis of records concerning the exclusion and inclusion criteria, 184 records with traumas to the oral and maxillofacial region were included in the study, adding up to 225 fractures. Among these, the most affected gender was male, with 161 cases (87.50%) (Fig 1). Regarding age, from 11 to 70 years, the age range most affected by oral and maxillofacial traumas in the male gender was 21 to 30 years, with 66 cases (40.99%); and the least affected was between 61 and 70 years, with only 2 cases (1%). In the female gender, the most affected range was 31 to 40 years, with 15 cases (65.21%), and the least

Age range x Gender

Number of cases

Number of cases x Gender

Male Female

Male Female

years

Figure 1: Gender distribution.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

years

years years Age range

years

years

Figure 2: Distribution of traumas according to age range.

30

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):28-32

Lins MA, Albuquerque GC, Oliveira AL, Martins VB, Fayad FT, Oliveira MV, Motta Júnior J

Prevalence: Location Prevalence: Etiology Nasal bones Mandible

Car accidents Sports accidents Physical aggression River accidents Fall from own height Work accidents Gunshot bullet

Zygoma-orbital complex Maxilla Nasoorbitoethmoid Frontal

Figure 3: Distribution according to the etiology of trauma.

Figure 4: Distribution of traumas according to their location.

The car accidents were the main etiologic factor of oral and maxillofacial traumas in both genders, with 89 cases (48.37%). The study agreed with findings in the literature.10,16 However, other studies presented discordant results, highlighting physical aggression as the main etiologic factor, with values of 38.8% (n = 711),13 36% (n = 222),14 and 25.4% (n = 657).15 These results demonstrate that the heterogeneity of etiology varies according to the study population.18 The most affected age range was young adults aged 21 to 30 years in males, with 66 cases (40.99%); while the most affected age range among females was 31 to 40 years, with 15 cases (65.21%). Several studies corroborate the present results. 11-16 This may be explained because young adults usually present a riskier behavior, including the exaggerated ingestion of alcoholic drinks, involvement in accidents and interpersonal violence. 19 Concerning the location of oral and maxillofacial trauma, the mandible was the most affected, with 71 cases (31.56%); followed by the zygoma-orbital complex, with 70 cases (31.11%); and nasal bones, with 52 cases (23.11%). Some studies corroborate the present findings, emphasizing the mandible as the most affected region. 14,15 However, other reports highlight the region of nasal bones as the most prevalent, with values of 20.6% (n = 1945)12 and 39.75% (n = 405). 16 Also, others indicated the zygoma as the most affected region, with 36% (n = 711).13 The higher prevalence in the mandible may be explained

n uc

n+ tio uc Re d

ac

tur e+

red

uc

rec

tio

on

str

n+

iza bil s ta Re fr

n+ tio uc

tio

ati fix

n tio

n tio uc Re d Re d

Re d

uc

tio

n+

fix

ati

on

on

Prevalence: Surgical management

Figure 5: Distribution according to surgical management adopted.

DISCUSSION The present study observed higher prevalence of oral and maxillofacial traumas in the male gender, with 87.,0% (161 cases) out of 184 patients. This predominance of males is compatible with previous reports in the literature. 10-16 This higher vulnerability of males to most traumas may be assigned to the fact that, in society, the males are more exposed to risk factors, involved in risky activities, making them more susceptible to accidents. 17

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

31

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):28-32

Epidemiology of facial trauma in a hospital in the municipality of Manaus-Amazonas

knowledge on this subject allows the establishment of support and preventive measures, besides the accomplishment of more adequate treatments.

because this is the only moving bone in the face, making it more susceptible to impacts; conversely, the nasal bones present a prominent structure centralized on the face, and the zygoma-orbital complex is close to the region of nasal bones, also making them more susceptible to fractures Regarding the surgical management, this study observed that the most common procedure was fracture reduction + fixation, with 150 cases (66.66%).

Findings in the literature corroborate this result.20 The high rate of this surgical procedure may be explained by the most affected regions in this study.

The results of this epidemiological survey are similar to previous studies in the literature, and

CONCLUSION According to the present methodology, it was concluded that the main etiologic factor were car accidents; and the male gender was the most affected. The most prevalent age range was 21-30 years in males and 31-40 years in females. Concerning the anatomical regions, the mandible and zygomaorbital complex were the most affected, and trauma reduction and fixation was the most frequent surgical approach.

References: 1. Freire E. Trauma: a doença dos séculos. 1a. São Paulo: Atheneu; 2001.

2. Araujo MA, Valera MC. Tratamento clínico dos traumatismos dentários série EAP/APCD. São Paulo: Artes Médicas; 1999.

3. Telfer MR, Jones GM, Shepherd JP. Trends in the etiology of maxillofacial fractures in the United Kingdom (1977-1987). Br J Oral Maxillofac Surg. 1991 Aug;29(4):250-5.

4. Silva, JJL, Aurélio AA, Lima S, Melo IF, Maia RC, Filho TR. Trauma facial: análise de 194 casos. Rev Bras Cir Plast. 2011 Fev;26(1):37-41.

5. Rodrigues FH, Miranda ES, Souza VEM, Castro VM, Oliveira DRF, Leão ED. Avaliação do trauma bucomaxilofacial no Hospital Maria Amélia Lins da Fundação Hospitalar do estado de Minas Gerais. Rev Soc Bras Cir Plást. 2006 Abr;21(4):211-6.

6. Carvalho TBO, Cancian LRL, Marques CG, Piatto VB, Maniglia JV, Molina FD. Seis anos de atendimento em trauma facial: análise epidemiológica de 355 casos.

Braz J Otorhin. 2010 Set;76(5):265-74.

7. Thompson BD. Protection of the head and neck. Dent Clin North Am. 1982;26:626-59.

8. Garon MW, Merkle A, Wright JT. Mouth protectors and oral trauma: a study of adolescent football players. J Am Dent Assoc. 1986 May;112(5):663-5.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

9. Haug RH, Prather J, Indresano AT. An epidemiologic survey of facial fractures and concomitant injuries. J Oral Maxillofac Surg. 1990 Sept;48(9):92632.

10. Mota VC, Aguiar, EG, Dutra, CE. Levantamento sobre os atendimentos de trauma facial realizado em Hospital Pronto Socorro. RGO. 2001 Out;49(4):1879.

11. Silva JJ, Nascimento MM, Machado RA. Perfil dos traumatismos maxilofaciais no serviço de CTBMF do Hospital da Restauração. Int J Dent. 2003 Jul;2(2):244-9.

12. Camarini E, Pavan AJ, Iwaki Filho L, Barbosa CE. Estudo epidemiológico dos traumatismos bucomaxilofaciais na região metropolitana de Maringá/PR entre os anos de 1997 e 2003. Rev Cir Traumatol Bucomaxilofac. 2004 Fev;4(2):125-29.

13. Macedo JL, Camargo LM, Almeida PF, Rosa SC. Perfil epidemiológico do trauma de face dos pacientes atendidos no pronto socorro de um Hospital Público. Rev Col Bras Cir. 2008 Jan;35(1):180-94.

14. Martins JC, Keim FS, Helena ETS. Aspectos epidemiológicos dos pacientes com trauma maxilofaciais operados no Hospital Geral de Blumenau, SC de 2004 a 2009. Arq Int Otorrinolaringol. 2010 AbrJun;14(2):192-8.

32

15. Santos CM, Musse JO, Cordeiro IS, Martins TM. Estudo epidemiológico dos traumas bucomaxilofaciais em um Hospital Público de Feira de Santana, Bahia de 2008 e 2009. Rev Baiana Saúde Pública. 2012 AbrJun;36(2):502-13.

16. Scartezini GR. Traumatismos bucomaxilofaciais em um hospital publico do Brasil Central: estudo retrospectivo [tese]. Goiânia (GO): Universidade Federal de Goiás; 2013.

17. Carvalho TBO, Cancian LRL, Marques CG, Piatto VB, Maniglia JV, Molina FD. Seis anos de atendimento em trauma facial: análise epidemiológica de 355 casos.

Braz J Otorhin. 2010 Set-Out;76(5):565-74.

18. Ferreira RS, Mendes JP, Silva TSO, Mendes JFG, Pinheiro COB, Nascimento EPA. Avaliação epidemiológica de pacientes acometidos por traumas craniofaciais em um hospital de referência. Rev Interd.

2013 Jul-Set:6(3):123-31.

19. Oliveira CMCS, Santos JS; Brasileiro BF, Santos TS. Epidemiologia dos traumatismos buco-maxilo-faciais por agressões em Aracaju/SE. Rev Cir Traumatol Buco-maxilo-fac. 2008 Jul-Set;8(3):57-68.

20. Furtado DR, Stabile GAV, Aita TG. Perfil do trauma de face em pacientes vítimas de acidentes motociclísticos [monografia]. Londrina (PR): Universidade Estadual de Londrina; 2015.

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):28-32

OriginalArticle

Retrospective analysis of treated

cases of trigger points JOÃO CARLOS BIRNFELD WAGNER1,2 | MAURICIO ROTH VOLKWEIS1,5 | LUCIANA ZAFFARI1,3,4 | GABRIELA SEVERO MEINKE1,3 | JOÃO RICARDO KOCH BRANDALISE1,3 | RODRIGO ANDRIGHETTI ZAMBONI1,3 | TATIANA WANNMACHER LEPPER1,3

ABSTRACT Objective: to carry out an analysis of medical records, evaluating the common patterns of painful symptoms and other symptoms among patients, in preoperative and postoperative moments, after deactivation of trigger points. Method: 100 records of patients of both genders, aged over 18 years, were selected, who were treated during the period from 2013 to 2016. Numbers and identification data were obtained from medical records of the patients through the Philips Tasy system, which contained pre- and post-operative information of patients who underwent deactivation of trigger points, at least once. Result: women were the most affected by the orofacial pain, with a rate of 100% of the analyzed cases. The masseter muscle was the region in which the pain points were most frequently identified in patients. It was noted that the procedure shown effective in 78% of cases treated with deactivation of the trigger points. Conclusion: when well indicated and executed, the technique is able to provide the patient a better quality of life by decreasing myofascial pain and improving their psychosocial capacity, which, therefore, reveals the importance of a correct anamnesis and individualized diagnosis.

Keywords: Masseter muscle. Trigger points. Facial muscles.

How to cite: Wagner JCB, Volkweis MR, Zaffari L, Meinke GS, Brandalise JRK, Zamboni RA, Lepper TW. Retrospective analysis of treated cases of trigger points. J Braz Coll Oral Maxillofac Surg.

2018 jan-abr;4(1):33-6.

DOI: http://dx.doi.org/10.14436/2358-2782.4.1.033-036.oar

Irmandade Santa Casa de Misericórdia de Porto Alegre, Serviço de Cirurgia e Traumatologia Bucomaxilofacial (Porto Alegre/RS, Brazil).

Doctorate degree in Oral and Maxillofacial Surgery and Traumatology, Universidade Estadual Paulista Júlio de Mesquita Filho (Araraquara/SP, Brazl).

3 Specialist in Oral and Maxillofacial Surgery and Traumatology, Sociedade Brasileira dos Cirurgiões-Dentistas, Santa Casa de Misericórdia de Porto Alegre (Porto Alegre/RS, Brazil).

4 Specialist in Pain, Hospital Albert Einstein (São Paulo/SP, Brazil).

5 Doctorate degree in Clinical Stomatology, Pontifícia Universidade Católica do Rio Grande do Sul (Porto Alegre/RS, Brazil).

1

2

Submitted: August 29, 2017 - Revised and accepted: December 13, 2017 » The authors report no commercial, proprietary or financial interest in the products or companies described in this article.

Contact address: Tatiana Wannmacher Lepper E-mail: tati-lepper@hotmail.com

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

33

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):33-6

Retrospective analysis of treated cases of trigger points

INTRODUCTION The temporomandibular dysfunction (TMD) may be defined as a combination of clinical disorders affecting muscle and bone structures, the stomatognathic system, besides associated conditions1, with emphasis to the Myofascial Pain Syndrome (MPS).

In turn, this is mainly characterized by muscle stiffness, pain and hypersensitivity2. Therefore, these tenser sites present specific hypersensitive nodules known as trigger points, which are clinically located in rigid bands or fascia of skeletal muscles3,4.

The trigger points are a small focal elevated area, measuring 2 to 5 mm, which trigger local and referred pain after mechanical stimuli or spontaneously 3. Thus, they may be classified as active when they trigger referred pain upon stimulation, reproducing the symptomatology reported by the patient, which is often observed in masticatory muscles 5, reducing the function of the affected muscle and limiting the motility of related structures6. However, the latent trigger points, though sensitive, are less painful and may persist for years, with possibility of reacutization and reactivation of the pain site7.

The theory on the etiology of this lesion suggests that this mechanism occurs due to ischemia caused by localized muscle spasms, or fatigue of overloaded muscles, often caused by parafunctional habits, microtraumas, inadequate posture, insufficient sleep, nutritional deficiencies, stress, etc. 2 Therefore, knowledge on the characteristics of myofascial pain, as well as its complexity concerning the etiology, diagnosis and treatment 8, is relevant because a great number of patients are expected to present total or partial resolution of the facial pain, due to deactivation of painful points, as well as improvement in the care to these patients by the greater knowledge achieved on this subject.

Thus, this study analyzed the records of assisted patients, evaluating the common standards among them concerning the pain symptomatology and other symptoms both pre- and postoperatively, after deactivation of trigger points, in the period from 2013 to 2016.

Name Age Record Continuous-use drugs TMD drugs Affected muscles Date of procedure Subjectivity of treatment Chat 1: Instrument of data collection.

undergone pre- and postoperative consultations, besides deactivation of trigger points. The deactivation of trigger points was evaluated in consultations at 5, 30, 60 and 120 days after the procedure. The sample was obtained by random selection of participants, and data were collected on the health management software Philips Tasy.

The survey comprised an instrument for data collection, distributed as presented in Chart 1, which included data on identification of individuals, number of patient record, pre- and postoperative information, which were later counted, separated by segments and inserted into an Excel worksheet.

RESULTS Among the 100 patient records, after counting, 64 records that did not meet all items of the instrument for data collection were excluded. Therefore, the final sample included 36 records.

The data revealed that 100% of patients were females in the age range 21 to 77 years, with mean age 48.5 years. Previous drug therapy for muscle spasm was reported in 98% of cases. Individuals whose pain did not improve required deactivation of trigger point by needling, which consists of anesthetic infiltration of 1% xylocaine without vasoconstrictor.

It was observed that 64% of the sample used other continuous-use drugs for different associated comorbidities, including the use of antidepressants in 25% of cases.

METHODS This retrospective cross-sectional observational study analyzed the records of 100 patients older than 18 years, in the period from 2013 to 2016, who had

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

34

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):33-6

Wagner JCB, Volkweis MR, Zaffari L, Meinke GS, Brandalise JRK, Zamboni RA, Lepper TW

may indicate an involvement between these trigger points and temporomandibular dysfunction, since the masseter is an important mastication muscle and its bilateral involvement in most cases may suggest a stronger association between the presence of triggers point and the presence of TMD. Conversely, the outcomes of Wright 14 indicated the following muscles with higher prevalence of trigger points, in decreasing order: trapezius, lateral pterygoid and masseter.

The treatment should address not only the pain reduction, but also an increased quality of life of patients, which may require a multidisciplinary approach for that purpose3,10, to interfere with the parafunctional habits and control the psychological and physiological factors associated with the disease 8.

Several treatment options are available to address the symptomatology of trigger points on the face; however, the needling technique described by Travell 12, which consists of injecting some drug in trigger points, is the most employed and has been shown as one of the most effective techniques to control the myofascial pain13,10.

Corroborating the present findings, Travell and Simons 10 described that middle-aged women are more frequently affected by myofascial pain, which may give rise to trigger points on the face; however, it may affect both genders. According to Han and Harrison5, the affected age range is between 30 to 49 years, suggesting a likely influence from hormones, since there are reports of increased pain during the menstrual cycle week.

The masseter was the most affected muscle (83%), and 62% of cases were bilateral. Other affected muscles, such as the sternocleidomastoid and temporal, added up to 11.2% of cases.

After the procedure for deactivation of trigger points, most individuals (78%) reported improvement in pain symptomatology or were satisfied when asked about their initial complaint of facial pain during the postoperative consultation.

DISCUSSION In cases of myofascial pain, appropriate diagnosis, planning and treatment are fundamental considering the subjective aspect of chronic pain and its multifactorial nature, which affect the patient’s response and expression9. According to some authors, palpation with firm and constant pressure is a simple method often employed to identify the trigger point 3,10,11, based on the professional’s sensitivity and guided by the patient’s physiognomy of pain, even though other diagnostic methods are available3.

This study revealed that more than half of the sample was using other continuous-use drugs for several associated comorbidities; among these, antidepressants were taken by 25% of the sample, suggesting a relationship of utilization of these drugs with psychosomatic involvement and the presence of trigger points.

According to the Brazilian Association of Rheumatology, among all diseases that require differential diagnosis with fibromyalgia, the myofascial pain syndrome should be highlighted due to its greater clinical similarity with fibromyalgia. This is a regional pain syndrome characterized by the presence of trigger points located in equidistant points. Therefore, it is believed that the presence of trigger points may be an indication of the presence of other comorbidities, such as fibromyalgia, myofascial syndrome and temporomandibular dysfunctions.

Data in this study demonstrated that the masseter was the most affected muscle bilaterally, which

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

CONCLUSIONS » The treatment of myofascial pain using the injection technique was effective. » The masseter muscle was the most affected by trigger points. » Women had greater prevalence of myofascial pain in different regions.

35

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):33-6

Retrospective analysis of treated cases of trigger points

References:

1. Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am Fam Physician. 2002 Feb 15;65(4):653-60.

2. Fricton JR. Masticatory myofascial pain: an explanatory model integrating clinical, epidemiological and basic science research. Bull Group Int Rech Sci Stomatol Odontol. 1999 Jan-Mar;41(1):14-25.

3. Graboski CL, Gray DS, Burnham RS. Botulinum toxin A versus bupivacaine Trigger Point injections for the treatment of myofascial pain syndrome: a randomised double blind crossover study. Pain. 2005 Nov;118(1-2):170-5. Epub 2005 Oct 3.

4. Grossmann E, Lorandi CS. Ponto gatilho miofacial: localização atípica. Rev Odonto Ciência.

1994;17(9):129-34.

5. Han SC, Harisson P. Myofascial pain syndrome and trigger point management. Reg Anesth. 1997 JanFeb;22(1):89-101.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

6. Murphy GJ. Myofacial trigger points. J Clin Orthod.

1989 Sept;23(9):627-31.

7. Okeson JP. Dor orofacial:guia para avaliação, diagnóstico e tratamento. São Paulo: Ed. Santos; 1998.

8. Provenza JR, Pollak DF, Martinez JE, Paiva ES, Helfenstein M, Heymann R, et al. Fibromialgia. Rev Bras Reumatol. 2004;44(6):443-9.

9. Suvinen Ti, Reade PC. Temporomandibular disorders: a critical review of the nature of pain and its assessment. J Orofac Pain. 1995 Fall;9(4):317-39.

10. Travell J, Simons DG. Myofascial pain and dysfunction: the trigger point manual, upper half of body.

2nd ed. Baltimore: Williams & Wilkins; 1999.

11. Travell J, Simons DG. Myofascial pain and dysfunction: the trigger point manual. Baltimore: Willians and Wilkins; 1983.

36

12. Travell JG. Temporomandibularjoint pain referred from muscles of the head and neck. J Prosthet Dent.

1960 July-Aug;10(4):745-63.

13. Venancio RA, Alencar FG Jr, Zamperini C. Botulinum toxin, lidocaine, and dry-needling injections in pacients with myofascial pain and headaches. Cranio.

2009 Jan;27(1):46-53.

14. Wright, EF. Referred craniofacial pain patterns in patients with temporomandibular disorder.J Am Dent Assoc. 2000 Sept;131(9):1307-15.

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):33-6

CaseReport

Management of parotid sialocele

after retromandibular access FLÁVIO TOMAZI1,2 | MANUEL SCHMITZ3,4 | MARCELO ROCHA1,5 | FELIPE BÚRIGO6 | CLAITON HEITZ1,7

ABSTRACT Sialocele is the extravasation of salivary fluid to the adjacent tissues of the affected salivary gland or duct, and may have a varied etiology. This article reports the treatment of a clinical case of sialocele after surgery for reduction and fixation of mandible fracture. After undergoing surgery for reduction and repair of mandibular condyle fracture, the patient evolved with increased volume in the region. After puncture and confirmation of the diagnosis of sialocele, a compressive dressing was performed to help in the treatment. The patient evolved well and in 30 days after drainage, already presented total regression of symptoms. There are several types of treatment for sialocele, and less invasive ones, such as puncture and compressive dressing, are indicated and with good results.

Keywords: Parotid gland. Biopsy. Needle. Postoperative complications.

Pontifícia Universidade Católica do Rio Grande do Sul, Departamento de Odontologia (Porto Alegre/RS, Brazil).

Master’s degree in Oral and Maxillofacial Surgery and Traumatology, Pontifícia Universidade Católica do Rio Grande do Sul (Porto Alegre/RS, Brazil).

3 Hospital Nossa Senhora da Conceição, Departamento de Cirurgia e Traumatologia Bucomaxilofacial (Tubarão/SC, Brazil).

4 Specialist in Oral and Maxillofacial Surgery and Traumatology, Complexo Hospitalar Padre Bento (Guarulhos/SP, Brazil).

5 Specialist in Oral and Maxillofacial Surgery and Traumatology, Universidade Federal de Minas Gerais (Belo Horizonte/MG, Brazil).

6 Private practice (Criciúma/SC, Brazil).

7 Doctorate degree in Clinical Stomatology, Pontifícia Universidade Católica do Rio Grande do Sul (Porto Alegre/RS, Brazil).

1

2

How to cite: Tomazi F, Schmitz M, Rocha M, Búrigo F, Heitz C. Management of parotid sialocele after retromandibular access. J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):37-40.

DOI: http://dx.doi.org/10.14436/2358-2782.4.1.037-040.oar Submitted: February 01, 2017 - Revised and accepted: September 28, 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: Flávio Tomazi E-mail: fhtomazi@hotmail.com

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

37

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):37-40

Management of parotid sialocele after retromandibular access

INTRODUCTION Maxillofacial traumas are usually caused by highintensity injuries and may cause severe damages to the facial structures. In traumas affecting the middle and lower facial thirds, structures as the parotid gland, facial nerve branches and facial artery may be impaired.1 The sialocele is an outflow of salivary fluid to the tissues surrounding the gland or affected salivary ducts. Its etiology may be due to trauma, type of access employed for surgical approach, neoplasias, infections, stenosis of the gland duct, or idiopathic.1,2 The sialocele may cause great facial edema, associated with fistulae, later leading to areas of necrosis and/or scars. 3 The lesion is diagnosed by analysis of disease history, clinical examination and aspiration of the viscous content. Complementary imaging examinations, sialography, blood tests and biopsy are also indicated.1,4 Several treatment options are available including content aspiration, injection of sclerosing agents, marsupialization, radiation, incision and drainage, use of catheters or gland removal. 1,5,6 This paper presents a case report of sialocele caused by surgical sequel after mandibular fracture.

The initial diagnosis was sialocele and the lesion was drained by puncture, whose content was compatible with saliva and blood, confirming the previous diagnosis (Fig. 3). Compressive dressing was placed to aid the treatment, and the patient was prescribed cefalexin 500mg at every 6 hours for 7 days, ketoprofen 150mg at every 12 hours for 3 days, and sodium dipyrone 500mg at every 6 hours for 3 days.

On the follow-up 7 days after puncture, the overall status was improved, with reduction of edema and absence of pain symptomatology (Fig 4). The patient was maintained in follow-up and did not report any complaint or lesion relapse after 30 days.

CASE REPORT A male patient aged 55 years, victim of motorcycle accident, attended the service with complaint of pain on the left mandibular region and mastication difficulty.

Clinical and tomographic evaluation revealed mandibular fracture (low condylar) on the left side.

The patient was submitted to general anesthesia and nasotracheal intubation. The condylar fracture was accessed by retromandibular incision and dissection by planes. Maxillomandibular block was performed to achieve a stable occlusion, and the fracture was fixed using two plates and eight screws of the 2.0mm system (Fig 1). The patient was instructed to perform mouth opening physical therapy in the first days postoperatively.

The patient evolved without complaints of pain or paresis of the facial nerve branches. At 7 days postoperatively, the patient presented middle-sized edema, fluctuating consistency and mild pain to palpation on the left mandibular angle (Fig 2). The patient did not report fever, and the stable internal fixation was not affected.

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

Figure 1: Postoperative radiograph evidencing fixation of left condyle fracture.

38

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):37-40

Tomazi F, Schmitz M, Rocha M, BĂşrigo F, Heitz C

Figure 2: Volume increase with fluctuating consistency on the left retromandibular region.

Figure 4: Postoperative aspect after 7 days.

Figure 3: Aspiration puncture.

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

39

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):37-40

Management of parotid sialocele after retromandibular access

DISCUSSION Facial injuries may cause difficulties to the patient, e.g. for speech, mastication, and other important functions. Also, in more severe cases, there may be psychological and social consequences. 3,7 The main objective of any surgical treatment for mandibular and/or maxillary fracture is the recovery of masticatory function and satisfactory occlusion.¹ The occurrence of sialocele is not related with gender, age or body mass index. However, it occurs more frequently after accomplishment of superficial, lower or medium parotidectomy.4 In cases of retromandibular access for reduction of mandibular fractures, the prevalence of gland disorders is nearly 5%.1 When the trauma affects the region of major glands, it should be observed if this involves only the gland parenchyma, duct, or both. This classification is related with the prognosis and occurrence of complications6.

The most common complications of trauma to the parotid region are fistulae and sialoceles4. However, most complications are treated conservatively2,8.

Even though the lesion is described as self-limiting, the sialocele is a matter of concern for both dentist and patient. There is a significant number of treatment options, which should be evaluated according to the surgeon’s experience and patient’s clinical condition. 1,7,9

In a previous study on 68 patients, four treatment options were selected: 12 patients were followed up, 18 received antibiotic therapy, 35 were submitted to drainage, and in only 3 patients a drain was placed on the lesion site. 10 Drainage was the most prevalent treatment and achieved resolution of cases in 6 months to 1 year.

Puncture combined with compressive dressing was the treatment of choice, allowing patient improvement in 7 days; however, total disappearance may last up to 3 weeks, 7 corroborating the present findings.

Good outcomes are achieved by less invasive treatments, employing compressive dressing performed twice a day, combined with a sialagogue drug to inhibit the saliva accumulation.2 CONCLUDING REMARKS The sialocele may cause changes in appearance and masticatory function. The diagnosis and treatment should be performed early.

The time since trauma, site of injury and systemic condition of the patient should be evaluated for treatment selection.

Local puncture, combined with compressive dressing, is a viable option and achieves good outcomes in the treatment of sialocele.

References:

1. Morais HHA, Grempell RG, Barbalho JC, Sousa TS, Silva AL. Sialocele parotídea: complicação pós-operatória de acesso retromandibular. Rev Cir Traumatolo Buco-MaxiloFac. 2014;14(1):49-54.

2. Balaji SM. Parotid fistula from transparotid approach for mandibular subcondylar fracture reduction. Ann Maxillofac Surg. 2013 July-Dec;3(2):182-4.

3. Narayanan V, Ramadorai A, Ravi P, Nirvikalpa N. Transmasseteric anterior parotid approach for condylar fracture: experience of 129 cases. Br J Oral Maxillofac Surg. 2012 July;50(5):420-4.

4. Downie JJ, Devlin MF, Carton AT, Hislop WS. Prospective study of morbidity associated with open reduction and internal fixation of the fractured condyle by tranparotid approach. Br J Oral Maxillofac Surg. 2009 July;47(5):370-3.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

5. Capaccio P, Cuccarini V, Benicchio V, Minorati D, Spadari F, Ottaviani F. Treatment of iatrogenic submandibular sialocele with botulinum toxin. Br J Oral Maxillofac Surg. 2007 July;45(5):415-7.

6. Lee J, Nolan P, Baker J. Treatment of parotid sialocele after sustaining a facial injury. Case report and literature review. N Y State Dent J. 2016 Mar;82(2):27-32.

7. Betts NJ, Cotrell KR. Diagnosis and management of traumatic salivary gland injuries. In: Fonseca RJ WR, Betts NJ, Barber HD, Powers MP, editors. Oral and maxillofacial trauma. St. Louis: Elsevier Saunders; 2005. p. 865-7.

8. Landau R, Stewart M. Conservative management of post-traumatic parotid fistulae and sialoceles: a prospective study. Br J Surg. 1985 Jan;72(1):42-4.

40

9. Bouchard C, Perreault MH. Postoperative complications associated with the retromandibular approach. A retrospective analysis of 118 subcondylar fractures. J Oral Maxillofac Surg. 2014 Feb;72(2):370-5.

10. Britt CJ, Stein AP, Gessert T, Pflum Z, Saha S, Hartig GK. Factors influencing sialocele or salivary fistula formation postparotidectomy. Head Neck. 2017 Feb;39(2):387-91.

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):37-40

CaseReport

Closure of extensive oroantral and

oronasal fistula due to maxillary tumor resection BRUNO GOMES DUARTE1,2 | VICTOR TIEGHI NETO1,3 | EDUARDO STEDILE FIAMONCINI1,4 | OSNY FERREIRA JÚNIOR1 | EDUARDO SANCHES GONÇALES1

RESUMO The proximity of the alveolar process of the maxilla to the maxillary sinuses and nasal cavity can be related to communication between these structures due to loss of bone and soft tissue after treatment of tumors in this region. The untreated communication results in epithelization of its path, characterized as oronasal/oroantral fistula, and should be surgically treated by means of rotational or advancement flaps, with or without use of the buccal fat pad. Thus, the present paper aims to report a case of treatment of an extensive oronasal and oroantral fistula, resulting from the resection of a tumor in the maxilla. The fistula was closed by means of a sliding buccal flap associated with interposition of the buccal fat pad and a releasing incision perpendicular in the palatal region. During postoperative follow-up of 5 months, the presence of small remaining communications was observed, which were closed with new advancement flaps and inversion of the fistula borders. An association between the available techniques may be an option for closing of oroantral and oronasal fistulas, but difficulties may arise when aiming for full closure of extensive communications in a single procedure.

Keywords: Maxilla. Maxillary sinus. Oroantral fistula.

Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Cirurgia, Estomatologia, Patologia e Radiologia (Bauru/SP, Brazil).

Universidade de São Paulo, Faculdade de Odontologia de Bauru, Programa de Pós-graduação em Ciências Odontológicas Aplicadas, Oral and Maxillofacial Surgery and Traumatology area (Bauru/SP, Brazil).

3 Doctorate in Clinical Stomatology, Universidade de São Paulo, Faculdade de Odontologia de Bauru (Bauru/SP, Brazil).

4 Universidade de São Paulo, Faculdade de Odontologia de Bauru, Programa de Pós-graduação em Ciências Odontológicas Aplicadas, Stomatology area (Bauru/SP, Brazil).

1

How to cite: Duarte BG, Tieghi Neto V, Fiamoncini ES, Ferreira Júnior O, Gonçales ES. Closure of extensive oroantral and oronasal fistula due to maxillary tumor resection. J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):41-6.

DOI: http://dx.doi.org/10.14436/2358-2782.4.1.041-046.oar

2

Submitted: January 13, 2017 - Revised and accepted: November 21, 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: Eduardo Sanches Gonçales E-mail: eduardogoncales@usp.br

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

41

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):41-6

Closure of extensive oroantral and oronasal fistula due to maxillary tumor resection

CASE REPORT A Caucasoid female individual, aged 22 years, presented with an extensive oroantral/oronasal fistula (Fig 1A) left by resection of a myxoid lesion nearly four years before. The patient wore a provisional removable partial denture (RPD) with an obturator (Fig 1B) and complaint of food entering the nose. Due to the extent of the oroantral/oronasal fistula, the treatment option comprised closure with a buccal sliding flap, associated with palatal flap displacement by the Langenbeck technique and sliding of the cheek fat pad, under general anesthesia.

The initial incision included the alveolar ridge, posterior region, oroantral/oronasal fistula (OAF/ ONF), and region around the bone defect, associated with an oblique incision on the mesial part of the OAF/ONF. Then a split thickness flap was raised, and the buccal flap was slid without tension to cover the OAF/ONF (Fig 2A). Following, the cheek fat pad was accessed at the zygoma region and dissected with a curved hemostatic forceps, allowing mobilization and repositioning on the fistula. The anterior portion of the cheek fat pad was sutured at the palatal region, followed by distension using simple sutures throughout the defect. extent (Fig 2B).

To reduce the flap tension, an incision was performed parallel to the palatal mucosa and a full thickness flap was raised (von Langenbeck incision), 9 with lateral rotation of the palatal mucosa toward the bone defect (Fig. 2C). Then, a buccal sliding flap was sutured to the palatal margin of the defect (Fig 2D).

At the 14-day postoperative follow-up, it was possible to observe the presence of two small remaining communications; it was decided to wait for complete healing, and these communications were later closed under local anesthesia, after five months. The procedure comprised a circular incision around the two orifices and inversion of the margins of fistulas, associated with releasing oblique incisions for sliding of a full thickness flap for coverage of communications. At the 7-month postoperative follow-up the initial defect was completely closed, and this situation has been maintained so far, i.e. 13 months after the second surgery for closure (Fig 3).

INTRODUCTION Oroantral and oronasal communications consist, respectively, of the path created between the mouth and the maxillary sinus 1,2 or between the mouth and the nasal cavity1. The occurrence of this complication is associated with tooth extraction, infection, radiotherapy sequel, orthognathic surgery, trauma, or removal of jaw cysts or tumors2,5.

When not treated, these communications may lead to food or fluid into the nasal cavity and/or maxillary sinus, which may result in nasal congestion, irradiated pain at the site of communication and sinusitis. 2 In the absence of maxillary sinus infection, communications between 1 and 2 mm can heal spontaneously heal,3,6 unlike larger communications, which require surgical closure.3,6 Communications greater than 5 mm that are not readily treated can evolve to epithelialization and are then classified as fistulas 3,6, which can cause communication between the mouth and maxillary sinus (oroantral fistula) or mouth and nasal cavity (oronasal fistula1).

Selection of the technique for the treatment of fistulas is based on: a) defect location and size and its relationship with adjacent teeth; b) alveolar crest height; c) presence of maxillary sinus infection; and d) systemic conditions of the patient5. The several treatment options include rotation, advancement or transposition of flaps in the oral cavity (e.g. from the tongue, buccal or palatal region) 4 and utilization of the cheek fat pad, which may be associated or not. 3,4 Regardless of the technique selected, two principles should be followed: 1) the maxillary sinus should be free of infection and with adequate nasal drainage; and 2) the flap should be positioned free of tension.3 The cheek fat pad was initially mentioned by Heister in 1732 and described in 1802 by Bichat,7 being first used for oral reconstructions in 1977,8 presenting a high success rate.7 The main advantages of using the cheek fat pad are its favorable anatomic location, adequate blood supply, absence of buccal sulcus depth loss, low morbidity, easy handling and high success rate.5 This paper reports the utilization of a buccal sliding flap, associated with utilization of the cheek fat pad, for closure of an extensive oroantral/oronasal fistula.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

42

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):41-6

Duarte BG, Tieghi Neto V, Fiamoncini ES, Ferreira Júnior O, Gonçales ES

A

B

C

D

Figure 1: A, B) Intraoral views evidencing the extensive defect communicating the mouth and nose, allowing observation of the inferior turbinate. C, D) Removable partial denture with obturator worn by the patient.

A

B

C

D

Figure 2: A) Accomplishment of buccal sliding flap to cover the OAF/ONF. B) After dissection of the cheek fat pad, it was sutured on the defect. Margins to allow closure of the entire extent of the OAF/ONF. C) Buccal sliding flap moved to the new position; and D) suture of buccal sliding flap on the palatal margins after accomplishment of a Langenbeck incision on the palatal mucosa, to reduce the flap tension.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

43

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):41-6

Closure of extensive oroantral and oronasal fistula due to maxillary tumor resection

Figure 3: Intraoral clinical view at the 13-month postoperative follow-up, evidencing complete closure of the OAF/ONF.

DISCUSSION Extraction of the first molars has been considered the most common etiology of oroantral communications. 1,3,4,6 Notwithstanding, the surgical treatment of lesions in the maxilla may also lead to oroantral/oronasal communication (OAC/ONC),1,which was the cause of OAF/ONF in the present case.

Considering that extensive communications that are not treated timely “evolve” to a fistula, their treatment involves the utilization of local or regional flaps, aiming at fistula closure, thus interrupting the transit of solids and fluids from the mouth to the maxillary sinus and nose. However, it should be highlighted that it is necessary to consider the necessary quantity of soft tissue, in extent and thickness, for adequate defect closure without tension.

Despite of that, selection of the treatment option is not free of possible complications, such as

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

loss of buccal sulcus depth and flap necrosis, 2 or even fistula reopening, especially in extensive fistulas. It should be mentioned that the absence of clinically evident infection is mandatory for the successful surgical treatment of oroantral and oronasal fistulas, 2,3 regardless of their extent; however, this is much more critical in cases of more extensive fistulas.

According to Jain et al. 4, defects greater than 5 cm should be treated using the cheek fat pad associated with the buccal flap, in order to allow greater stability, tension-free suture, and provide additional tissue for defect closure. In the present case, an extensive oroantral/oronasal fistula was closed by a buccal sliding flap associated with utilization of the cheek fat pad. However, the 14-day postoperative follow-up revealed presence of two small communications, which may have been caused by the initial

44

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):41-6

Duarte BG, Tieghi Neto V, Fiamoncini ES, Ferreira Júnior O, Gonçales ES

defect extent, requiring great advancement of soft tissue, which was deficient due to the initial surgical procedure. In the authors’ opinion, the need of another surgical intervention for closure of remaining communications does not represent a failure of the surgical technique proposed.

The buccal sliding flap 2 consists of a classical option for the treatment of oroantral communications, presenting as a safe option, associated with a high success rate (87.2%).2 In the present case, utilization of a buccal sliding flap promoted complete transoperative closure; notwithstanding, two small communications remained postoperatively, which was expected due to the initial extent of the oroantral/oronasal fistula.

The utilization of a buccal sliding flap has some disadvantages, including pain, edema and risk to reduce the buccal sulcus depth.2,3 The later may require accomplishment of a vestibuloplasty,2,3 6 to 8 months after complete flap healing.2 In the present case, there was loss of sulcus depth due to the first surgical intervention associated with posterior accomplishment of a buccal sliding flap to cover the oroantral/oronasal fistula.

Elimination of tension of the buccal sliding flap is related with increased success rates,2 requiring incisions to release the periosteum, allowing greater mobility of the buccal sliding flap. In the present case, to enhance the blood supply to the operated region, the palatal mucosa was brought closer to the defect and a von Langenbeck incision was made, to reduce the tension on the palatal mucosa and increase the flap mobility.

Utilization of the cheek fat pad to close the oroantral/oronasal fistula is reported with high success rates in the literature,1-6,10 and may be indicated for cases greater than 5 mm.1 The success of this tech-

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

nique is related with absence of sulcus depth loss,10 rich blood supply 7 and low morbidity to the donor site.4 Additionally, the cheek fat pad presents a constant volume, regardless of the total body weight and fat distribution in the individual. 4 When properly dissected and mobilized, the cheek fat pad provides a pedicle with extent of 7 x 4 x 3 cm; 7 this is a simple procedure that may be performed under local anesthesia.10 Conversely, utilization of the cheek fat pad for closure of oroantral/oronasal fistula may present limitations, such as maxillary defects greater than 4 x 4 x 3 cm, with possibility of partial flap dehiscence, which may be assigned to the poor blood supply of stretched margins sutured on the palatal mucosa.7 Within this context, utilization of the cheek fat pad associated with local or regional flaps has presented the best results, 1,3 since it increases the tissue thickness for fistula closure, with positive contribution to maintain this closure.

CONCLUDING REMARKS The oroantral or oronasal communications may occur due to surgical procedures involving the maxilla, and should be immediately diagnosed to allow proper treatment, thereby avoiding the evolution to oroantral and/or oronasal fistula. The literature presents local flaps and utilization of the cheek fat pad as the options most commonly employed for the treatment of these cases. According to the present report, the combination of buccal sliding flap and utilization of the cheek fat pad seems to be an option for the treatment of extensive oronasal and oroantral defects. It should be remembered that the buccal sliding flap reduces the buccal sulcus depth, which may require another procedure to increase the buccal sulcus depth (vestibuloplasty).

45

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):41-6

Closure of extensive oroantral and oronasal fistula due to maxillary tumor resection

References:

1. Abuabara A, Cortez AL, Passeri LA, Moraes M, Moreira RW. Evaluation of different treatments for oroantral/oronasal communications: experience of 112 cases. Int J Oral Maxillofac Surg. 2006 Feb;35(2):155-8.

2. Dym H, Wolf JC. Oroantral Communication. Oral Maxillofac Surg Clin North Am. 2012 May;24(2):239-47.

3. Lazow SK. Surgical management of the oroantral fistula: flap procedures. Oper Tech Otolaryngol Head Neck Surg. 1999;10(2):148-52.

4. Jain MK, Ramesh C, Sankar K, Lokesh Babu KT. Pedicled buccal fat pad in the management of oroantral fistula: a clinical study of 15 cases. Int J Oral Maxillofac Surg. 2012 Aug;41(8):1025-9.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

5. Daif ET. Long-term effectiveness of the pedicled buccal fat pad in the closure of a large oroantral fistula.

J Oral Maxillofac Surg. 2016 Sept;74(9):1718-22.

6. Yalçın S, Oncü B, Emes Y, Atalay B, Aktaş I. Surgical treatment of oroantral fistulas: a clinical study of 23 cases. J Oral Maxillofac Surg. 2011 Feb;69(2):333-9.

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

8. Egyedi P. Utilization of the buccal fat pad for closure of oro-antral and/or oronasal communications. J Maxillofac Surg. 1977 Nov;5(4):241-4.

46

9. Trindade IEK, Filho OGS. Fissuras labiopalatais: uma abordagem interdisciplinar. São Paulo: Ed. Santos; 2007.

10. Batra H, Jindal G, Kaur S. Evaluation of different treatment modalities for closure of oro-antral communications and formulation of a rational approach.

J Maxillofac Oral Surg. 2010 Mar;9(1):13-8.

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):41-6

CaseReport

Management of internal derangement of the

temporomandibular joint: arthrocentesis ALEXANDRE MARANHÃO MENEZES NETO1,3 | FÁBIO WILDSON GURGEL COSTA1,2,4 | WAGNER ARAÚJO DE NEGREIROS2,5 | MARIANA GOMES COUTINHO2 | EDUARDO COSTA STUDART SOARES1,2,6

ABSTRACT Arthrocentesis is a minimally invasive surgical technique, with a high success rate and low risk, used in treatments of temporomandibular joint (TMJ) disorders. This technique works with lyses and washes in the upper compartment of the TMJ, to decrease intra-articular pressure, eliminate adhesions, remove inflammatory mediators and offer therapeutic action from direct-acting medications. The aim of the present study was to report the efficacy of arthrocentesis in a clinical case of a 49-year-old patient with temporomandibular dysfunction, treated in a Buccomaxillofacial Surgery and Traumatology department. Arthrocentesis is reported as the first choice for pain reduction treatment and functional deficit of TMJ when conservative treatment does not show results, in addition to producing effect more quickly. It is believed that the pressure wash technique allows lubrication of the joint space, tearing of adhesions as well as removing foreign bodies present, providing greater pain relief and resolution of the treatment. This results are corroborated by most of the clinical research studies reviewed in the present study.

Keywords: Temporomandibular joint. Arthrocentesis. Minimally invasive surgical procedures.

Universidade Federal do Ceará, Hospital Universitário Walter Cantídio, Serviço de Cirurgia e Traumatologia Bucomaxilofacial (Fortaleza/CE, Brazil).

Universidade Federal do Ceará, Faculdade de Odontologia (Fortaleza/CE, Brazil).

3 Universidade Federal do Ceará, Residência em Cirurgia e Traumatologia Bucomaxilofacial (Fortaleza/CE, Brazil).

4 Doctorate degree in Dentistry, Universidade Federal do Ceará (Fortaleza/CE, Brasil).

5 Doctorate degree in Dental Clinic, Universidade Estadual de Campinas (Campinas/SP, Brazil).

6 Doctorate degree in Clinical Stomatology, Pontifícia Universidade Católica do Rio Grande do Sul (Porto Alegre/RS, Brazil).

1

How to cite: Menezes Neto AM, Costa FWG, Negreiros WA, Coutinho MG, Soares ECS. Management of internal derangement of the temporomandibular joint: arthrocentesis. J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):47-52.

DOI: http://dx.doi.org/10.14436/2358-2782.4.1.047-052.oar

2

Submitted: October 24, 2017 - Revised and accepted: November 21, 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 – CEP: 60.430-275 – Fortaleza/CE E-mail: alexandremaranhaobucomaxilo@gmail.com

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

47

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):47-52

Management of internal derangement of the temporomandibular joint: arthrocentesis

INTRODUCTION The temporomandibular dysfunction (TMD) describes a series of derangements in the temporomandibular joint (TMJ), with greater occurrence in females, being considered the main cause of chronic facial pain.1 Several treatments are suggested for TMJ disorders, which may be conservative or surgical. When the conservative treatments have no effect, the minimally invasive surgical approach has been considered the first choice.1 It is believed that the physical actions of lysis and rinsing of the upper compartment of the TMJ, which reduce inflammation instead of repositioning the disc, are responsible for the success of arthroscopy.2 This discovery aided the development of arthrocentesis, which represents a simple surgical approach that comprises drug injections and aspirations, aiming to release the articular disc and remove adherences between its surface and the articular fossa. This action releases the pressure between the TMJ capsule and the glenoid fossa, allowing lysis of adherences, removal of inflammatory mediators,3 and providing therapeutic action by direct drug administration.4 The arthrocentesis has been used for the treatment of several TMJ disorders, including the treatment of TMJ arthralgia, internal derangement, limited mouth opening,3,5,6 osteoarthritis, early rheumatoid arthritis and acute intracapsular trauma with hemarthrosis of the TMJ.4 It is usually indicated in the presence of pain, incapacity to perform functions and/or failure in conservative treatment. It may be performed in the outpatient clinic under local anesthesia, with or without sedation, or under general anesthesia.1 Important studies have been conducted to determine the efficiency of arthrocentesis revealed high success rates, low morbidity and relief of pain and dysfunction in the long term, allowing good results not only in individuals with limited mouth opening, but for several TMJ disorders.7,10 Thus, this paper reports the utilization of arthrocentesis in an individual presenting limitation and pain in mouth opening.

complaint “I cannot properly open my mouth”, reporting severe pain bilaterally at the temporomandibular joint region. During anamnesis, the patient reported onset of dysfunction one day after accomplishment of a dental restoration, when she had spent some time in maximum mouth opening. Since then, the amplitude of movements related with mouth opening was gradually reduced, without improvement, despite the use of analgesic and anti-inflammatory drugs. Physical examination revealed bilateral arthralgia at the TMJ region and maximum mouth opening of 13 mm.

Intraoral examination revealed a mandibular removable partial denture, absence of teeth #31 and #41, without occlusal dysfunction or loss of posterior support (Fig 1). Imaging examination did not reveal bone abnormality at the mandibular joint region.

Initially, it was decided to perform conservative treatment by physical therapy, by the disc reduction maneuver, attempting to recapture it and enhance the mouth opening. However, this was not possible. The second option would be to take dental impressions from the patient for fabrication of an occlusal splint to relax the musculature and reduce the joint pressure; however, this was not possible due to the minimum mouth opening. As third option of conservative treatment, the patient was prescribed Meloxicam 7.5 mg at every 12 hours for 5 days and Tandrilax at every 12 hours for 7 days. After one week, the patient reported little pain relief, yet the limited mouth opening persisted. Disc reduction was once again attempted yet was unsuccessful. The patient was unable to remove the denture for cleaning, thus presented impaired oral hygiene and halitosis. Considering the clinical condition of the patient, the maxillofacial surgery team, in combination with the prosthodontics team, indicated arthrocentesis as the therapeutic option for the case.

Concerning the type of anesthesia, the patient preferred to perform the procedure at the hospital under general anesthesia.

The procedure initially consisted of placing the patient in horizontal position, under general anesthesia. After antisepsis of the surgical site, the external ear was covered with sterile gauze, for protection from the irrigation fluid and blood.

The reference points for needle insertion were marked on the skin using methylene blue, as recommended by McCain et al.11 Following, a reference line was traced from the middle of the tragus to the exter-

CASE REPORT A female individual, aged 49 years, without systemic disorders, was referred to an Oral and Maxillofacial Surgery and Traumatology service with the chief

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

48

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):47-52

Menezes Neto AM, Costa FWG, Negreiros WA, Coutinho MG, Soares ECS

tion was then connected to a syringe and needle at the glenoid fossa region, and 300 ml of solution was used for rinsing of the upper articular space.

After rinsing, the needles were removed and the mandible was gently manipulated with opening, protrusion and laterality movements, to aid the disc release and enhance the lysis of adhesions, thus allowing normal mandibular movement. Postoperatively, the patient was prescribed dipyrone 500mg at every 6 hours for 5 days, and dexamethasone 4mg at every 12 hours for 3 days.

In the first days postoperatively, there was improvement in mouth opening, though associated with pain. On the fourth month of follow-up, the patient did not complain of pain and presented mouth opening of 42mm. After 11 months she remained without pain, with normal mouth opening and significant improvement in quality of life (Fig 3).

nal eye canthus. Entry points were also defined below the line. The first was marked 10 mm anteriorly to the middle of the tragus and 2 mm inferiorly to the reference line, corresponding to the location of the glenoid fossa. The second point was marked at 20 mm from the middle of the tragus and 10 mm below the reference line, corresponding to the articular eminence (Fig 2). Local anesthetics (3 ml of ropivacaine diluted in 7 ml of 0.9% saline) was injected at the auriculotemporal nerve region.

A needle gauge 19, connected to a 10-ml syringe filled with 1 ml of ringer lactate, was then inserted into the upper compartment of the TMJ. The injected solution was immediately suctioned, and this procedure was repeated three times. Following, 2 to 3 ml of ringer lactate solution were injected to extend the upper articular space and allow insertion of a second needle into this compartment. The ringer lactate solu-

Figure 1: Maximum mouth opening of 13mm preoperatively.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

49

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):47-52

Management of internal derangement of the temporomandibular joint: arthrocentesis

Figure 2: Skin demarcation by the McCain technique.

DISCUSSION Arthrocentesis is reported as the first choice for the treatment of pain and functional deficit of the TMJ when conservative treatment fails, besides providing a faster effect.1,3 Among the several TMJ disorders, the articular internal derangements are reported more frequently in the population. They include painful clicks, anchored disc phenomenon, disc displacement without reduction and locking.1,12 This paper describes a case of derangement in which arthrocentesis was satisfactorily employed.

The complaint of pain in the present case may be explained by the physiopathology previously described for internal derangement of the TMJ of inflammatory nature.

In the presence of inflammation, the quantity of proteins in the synovial liquid is increased, as well as transferrin and immunoglobulin G, and the quantity of hyaluronic acid (HA) is reduced, due to cell changes in the medium.

This reduces the viscosity of the synovial liquid,10 directly influencing the pain triggered by TMJ movement. Biopsy, combined with analysis of the synovial liquid, provides information on the local physiopathology at the molecular

Figure 3: Mouth opening after 11-month follow-up.

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

50

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):47-52

Menezes Neto AM, Costa FWG, Negreiros WA, Coutinho MG, Soares ECS

techniques in 78 patients and concluded that both protocols presented similar efficacy. Alkan and Kilic15 suggested the use of an irrigation pump as a new device for articular rinsing, increasing the pressure of arthrocentesis and reducing the operative time.

After accomplishment of arthrocentesis, dipyrone and dexamethasone were prescribed postoperatively. This measure was adopted due to the previous knowledge that corticosteroids are a commonly employed option after arthrocentesis, due to their powerful anti-inflammatory effect in the synovial tissue and also because it may reduce the effusion.12 In a recent randomized double-blind study, Bouloux et al.6 compared the additional use of hyaluronic acid, corticosteroids and ringer lactate solution after arthrocentesis in 98 patients. The authors observed mean reduction of pain of 36% for the group using corticosteroids after procedures on the left side, which was statistically significant (p = 0.02).

The prognosis related to arthrocentesis may be influenced by several factors. Kim et al.10 evaluated the success of arthrocentesis in 145 patients, analyzing the following variables: gender, age, type of diagnosis, time of evolution and presence/absence of parafunctional habits. The authors observed that the group aged 30 to 49 years presented higher postoperative success rate (94%); however, with the increase in age, the success rate was significantly reduced. They also observed that the group with abnormal parafunctional habits (tooth clenching and grinding) presented worse prognosis. In another study, Monje-Gil et al.8 observed an overall success rate of 83.5% in 612 TMJs treated by arthrocentesis. In the present case, the prognosis was considered satisfactory based on the clinical aspects observed in follow-up consultations after the procedure. Even though the follow-up after arthrocentesis was based on clinical examinations, other authors as De Riu et al.2 evaluated the clinical outcomes of arthrocentesis in 30 patients, comparing the morphological parameters from treatment onset up to 60 days after the last arthrocentesis, using cone-beam computed tomography and magnetic resonance imaging. All patients in their study presented significant pain reduction after arthrocentesis.

level.9 However, this was not adopted in the present case, because it was considered unnecessary in the context of diagnosis, as well as the treatment planning established.

Among the minimally invasive approaches for TMJ disorders, the therapeutic approach adopted for this case included arthrocentesis instead of arthroscopy. Even though a systematic review with meta-analysis conducted

by Al-Moraissi1 concluded that arthroscopy provided better results compared to arthrocentesis, in relation to maximum interincisal opening and reduction of pain symptomatology, the present case was treated by arthrocentesis because of lack of infrastructure at the hospital where the patient was treated. It is believed that this may also apply to other services, probably because arthroscopy is more expensive than arthrocentesis. Additionally, concerning the morbidity, it has been reported that arthroscopy is relatively more invasive, presents greater morbidity and higher potential of complications compared to arthrocentesis.1 The following complications have been reported: lesion to the facial and auriculotemporal nerves, preauricular hematoma, aneurism of the superficial temporal artery, arteriovenous fistula, articular perforation, intracranial perforation, extradural hematoma, parapharyngeal swelling and intra-articular problems13. Even though these complications may also occur in arthrocentesis, their prevalence and extent have been reported as inferior to arthroscopy1. These complications were not observed in the immediate and late post-operative follow-ups in the present case.

Joint improvement by arthrocentesis seems to be the rationale to explain the efficacy of the technique in osteoarthritis with limited mouth opening.7 There was significant reduction in the complaints of pain and difficulty of mouth opening reported by the patient. It is believed that the technique of rinsing under pressure applied in the present case allowed lubrication of the articular space, rupture of adherences, as well as removal of occasional foreign bodies, as described in the literature.8 Nearly 3 ml of ringer lactate solution were injected to distend the upper articular space and allow accomplishment of intra-articular irrigation, which is corroborated in the literature that describes that the upper compartment of the TMJ may store up to 4 ml of liquid.8 The technique involving insertion of a needle as described

by Guarda-Nardini et al.13 presents advantages as reduced operative time, less trauma, low risk of facial nerve paresthesia, greater intra-articular pressure, enhanced lysis of adherences, and need of smaller quantity of local anesthetics. In another study, Guarda-Nardini et al.14 evaluated the effects of arthrocentesis by the one-needle and two-needle

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

CONCLUDING REMARKS It was concluded that arthrocentesis is a treatment option for patients with TMJ internal disorders not responding to conservative treatment. In the present case, arthrocentesis provided complete remission of pain symptomatology and satisfactory mouth opening.

51

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):47-52

Management of internal derangement of the temporomandibular joint: arthrocentesis

References:

1. Al-Moraissi EA. Arthroscopy versus arthrocentesis in the management of internal derangement of the temporomandibular joint: a systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2015 Jan;44(1):104-12.

2. De-Riu G, Stimolo M, Meloni SM, Soma D, Pisano M, Sembronio S, et al. Arthrocentesis and temporomandibular joint disorders: clinical and radiological results of a prospective study. Int J Dent. 2013;2013:790648.

3. Sharma A, Rana AS, Jain G, Kalra P, Gupta D, Sharma S. Evaluation of efficacy of arthrocentesis (with normal saline) with or without sodium hyaluronate in treatment of internal derangement of TMJ - A prospective randomized study in 20 patients. J Oral Biol Craniofac Res. 2013 Sept-Dec;3(3):112-9.

4. Malik AH, Shah AA. Efficacy of temporomandibular joint arthrocentesis on mouth opening and pain in the treatment of internal derangement of TMJ-A Clinical Study. J Maxillofac Oral Surg. 2014 Sept;13(3):244-8.

5. Nitzan DW, Dolwick MF, Martinez GA. Temporomandibular joint arthrocentesis: a simplified treatment for severe, limited mouth opening. J Oral Maxillofac Surg.

1991 Nov;49(11):1163-7; discussion 1168-70.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

6. Bouloux GF, Chou J, Krishnan D, Aghaloo T, Kahenasa N, Smith JA, et al. Is hyaluronic acid or corticosteroid superior to lactated ringer solution in the short-term reduction of temporomandibular joint pain after arthrocentesis? Part 1. J Oral Maxillofac Surg. 2017 Jan;75(1):52-62.

7. Leibur E, Jagur O, Voog-Oras Ü. Temporomandibular joint arthrocentesis for the treatment of osteoarthritis.

Stomatologija. 2015;17(4):113-7.

8. Monje-Gil F, Nitzan D, González-Garcia R. Temporomandibular joint arthrocentesis. Review of the literature. Med Oral Patol Oral Cir Bucal. 2012 July 1;17(4):575-81.

9. Leibur E, Jagur O, Voog-Oras Ü. Temporomandibular joint arthrocentesis for the treatment of osteoarthritis.

Stomatologija. 2015;17(4):113-7.

10. Kim YH, Jeong TM, Pang KM, Song SI. Influencing factor on the prognosis of arthrocentesis. J Korean Assoc Oral Maxillofac Surg. 2014 Aug;40(4):155-9.

11. McCain JP, de la Rua H, LeBlanc WG. Puncture technique and portals of entry for diagnostic and operative arthroscopy of the temporomandibular joint.

Arthroscopy. 1991;7(2):221-32.

52

12. Giraddi GB, Siddaraju A, Kumar B, Singh C. Internal derangement of temporomandibular joint: an evaluation of effect of corticosteroid injection compared with injection of sodium hyaluronate after arthrocentesis. J. Maxillofac. Oral Surg. 2012 July-Sept;11(3):258-63.

13. Guarda-Nardini L, Manfredini D, Ferronato G. Arthrocentesis of the temporomandibular joint: a proposal for a single-needle technique. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008 Oct;106(4):483-6.

14. Guarda-Nardini L, Ferronato G, Manfredini D. Two-needle vs. single-needle technique for TMJ arthrocentesis plus hyaluronic acid injections: a comparative trial over a six-month follow up. Int J Oral Maxillofac Surg. 2012 Apr;41(4):506-13.

15. Alkan A, Kilic E. A new approach to arthrocentesis of the temporomandibular joint. Int J Oral Maxillofac Surg.

2009 Jan;38(1):85-6.

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):47-52

CaseReport

Atrophic maxilla reconstruction:

case report

VITOR JOSÉ DA FONSECA1,2 | AÉCIO ABNER CAMPOS PINTO JUNIOR1,2 | JOANNA FARIAS DA CUNHA1,3 | LUIZ FELIPE CARDOSO LEHMAN1,5 | FELIPE EDUARDO BAIRES CAMPOS1,2,6 | WAGNER HENRIQUES DE CASTRO1,5,7

ABSTRACT Objective: To report and analyze the sequence of surgical and prosthetic events used in the rehabilitation of an edentulous patient, with severe atrophy of the alveolar bone of the maxilla. Case report: Patient submitted to multiple procedures aiming the rehabilitation of severely atrophic maxilla. Treatment plan included three surgical procedures: maxillary reconstruction with anterior iliac bone autograft; maxillary dental implants placement for the fixation of a decompensated upper prosthesis; maxillary advancement throughout Le Fort I osteotomy. Results: The planning and treatment were successfully performed and patient presents himself satisfied and without complaints. Conclusion: Implant-supported rehabilitation of edentulous patients, with large maxillo-mandibular skeletal discrepancies is a challenge for buco-maxillofacial surgeons and prosthetic dentist. The correct sequence of surgical-prosthetic procedures indicated in each case is related to the success of the treatment.

Keywords: Mouth rehabilitation. Orthognathic surgery. Alveolar bone loss.

Universidade Federal de Minas Gerais, Hospital das Clínicas, Programa de Residência em Cirurgia e Traumatologia Bucomaxilofacial (Belo Horizonte/MG, Brazil).

Specialist in Oral and Maxillofacial Surgery, Universidade Federal de Minas Gerais, Residência do Hospital das Clínicas (Belo Horizonte/MG, Brazil).

3 Master’s degree in Stomatology, Universidade Federal de Minas Gerais (Belo Horizonte/MG, Brazil).

4 Doctorate degree in Stomatology, Universidade Federal de Minas Gerais (Belo Horizonte/MG, Brazil).

5 Universidade Federal de Minas Gerais, Disciplina de Cirurgia e Traumatologia Bucomaxilofacial (Belo Horizonte/MG, Brazil).

6 Master’s and Doctorate degree in Oral and Maxillofacial Surgery, Universidade Federal de Uberlândia (Uberlândia/MG, Brazil).

7 Doctorate degree in Pathology, Universidade Federal de Minas Gerais (Belo Horizonte/MG, Brazil).

1

How to cite: Fonseca VJ, Pinto Junior AAC, Cunha JF, Lehman LFC, Campos FEB, Castro WH. Atrophic maxilla reconstruction: case report. J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):53-9.

DOI: http://dx.doi.org/10.14436/2358-2782.4.1.053-059.oar

2

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

Submitted: September 09, 2017 - Revised and accepted: October 29, 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: Wagner Henriques de Castro E-mail: wagnerhcastro@ufmg.br

53

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):53-9

Atrophic maxilla reconstruction: case report

INTRODUCTION The alveolar bone requires stimuli to maintain its shape and density. After tooth loss, there is a chronic and progressive process of bone resorption.

This process of atrophy is influenced by some factors, including individual differences, age and anatomical region.1,2 The rehabilitation of patients with severe maxillary atrophy using implant-supported dentures usually requires previous procedures to increase the alveolar bone support. Bone grafts are widely employed for that purpose. Autogenous bone is the material with most characteristics of an ideal graft, and the iliac crest is considered a potential donor site, due to the bone quantity available. 2,3 Even though reconstruction techniques are available for cases of moderate resorptions, in more severe cases the bone graft alone may be insufficient to recreate the correct intermaxillary relationship.

In these cases, orthognathic surgery with interposition of autogenous bone grafts allows more adequate maxillary repositioning, favoring the maxillomandibular relationship in both vertical and anteroposterior directions. 3,4,5 Thus, this paper repots the case of an edentulous patient, with severely atrophic maxilla, who was rehabilitated using autogenous graft from the anterior iliac crest, orthognathic surgery for maxillary advancement and implant-supported dentures. The paper also discusses the importance of the correct sequence of surgical and prosthetic procedures employed in such cases.

and good anteroposterior positioning of the mandible (Fig 1A, C). Intraoral examination evidenced severely resorbed maxillary and mandibular alveolar ridges (Fig 1B), associated with unstable removable partial dentures.

The panoramic radiograph and lateral cephalogram, as well as cone-beam computed tomography (Fig 1D), confirmed the severe atrophy of maxillary and mandibular alveolar ridges. There were no other significant skeletal alterations.

The case was diagnosed as maxillary hypoplasia and bimaxillary edentulism with severely atrophic alveolar ridges.

The treatment planning approved by the patient included three surgeries. The first procedure, performed under general anesthesia, comprised reconstruction of the atrophic maxilla using autogenous graft from the anterior iliac crest. Corticomedullary blocks were fixated to the anterior maxilla using bicortical screws and titanium plates with two orifices, from the 1.5-mm diameter mini- and microfragments fixation system (Synthes®, Switzerland).

Particulate bone graft was used for partial filling of maxillary sinuses, after sinus lift (Fig 2A, B).

After four-month clinical and imaging follow-up (Fig 2C), a second surgery was performed under local anesthesia for placement of six implants in the maxilla. The implants had external hex platform, being two implants measuring 4-mm diameter and 9-mm height, and the other four implants measured 4-mm diameter and 13-mm height (Neodent®, Brazil). A period of 35 days was allowed for osseointegration, during which one maxillary implant was lost, at the region of tooth #22 (Fig 3A). The Prosthodontics team was contacted to discuss the possibility of implant-supported denture without replacement of the missing implant.

Five implants were placed in the mandible (Fig 3A), also with external hex platform, between the mandibular foramina, both measuring 4-mm diameter and 9-mm height (Neodent®, Brazil). The initial torque in mandibular implants was greater than 45 N.cm, allowing immediate load in the mandible.

The implants were opened on the same session and a provisional complete mandibular denture was used, which had been fabricated at treatment onset.

Six months after placement and osteointegration of maxillary implants, a provisional complete denture was fabricated to allow the orthognathic surgery. The

CASE REPORT A female individual aged 58 years attended the Oral and Maxillofacial Surgery and Traumatology Service of HC-UFMG for evaluation concerning the possibility of dental rehabilitation by implant-supported dentures.

The systemic medical history of the patient was uneventful. She did not report harmful and/or parafunctional habits. During anamnesis, she reported having been edentulous for 30 years and the use of unstable removable partial dentures, which presented poor esthetics in her opinion.

Facial analysis revealed deficient projection of soft tissues of the midface, lack of upper lip support, inverted relationship between upper and lower lips

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

54

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):53-9

Fonseca VJ, Pinto Junior AAC, Cunha JF, Lehman LFC, Campos FEB, Castro WH

Except for the loss of one maxillary implant, all surgeries were uneventful, either trans- or postoperatively. Definitive dentures were placed six months after Le Fort I osteotomy (Fig. 3B).

Three-year postoperative follow-up evidenced normal aspect associated with the implants and stability of correction of the dentoskeletal and facial alteration (Fig. 3C, D).

procedure was performed under general anesthesia, eight months after implant placement. The single-jaw surgery comprised advancement of 8 mm with 2 mm of inferior maxillary positioning, by a Le Fort I osteotomy. Rigid internal fixation was achieved in the maxilla using four L-shaped plates and sixteen titanium screws from the 1.5-mm diameter mini- and microfragments fixation system (Synthes, Switzerland).

A

C

B

D

Figure 1: Preoperative images: A) frontal view at rest; B) lateral view at rest; C) alveolar ridge preoperatively; D) cone-beam computed tomography evidencing the atrophic alveolar ridges.

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

55

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):53-9

Atrophic maxilla reconstruction: case report

A

B

Figure 2: A) Preparation of corticomedullary blocks transoperatively. B) Fixation of blocks using bicortical screws and titanium plates with two orifices. C) Conebeam computed tomography obtained four months after reconstruction with bone graft from the iliac crest.

C

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

56

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):53-9

Fonseca VJ, Pinto Junior AAC, Cunha JF, Lehman LFC, Campos FEB, Castro WH

A

B

C

D

Figure 3: Postoperative images: A) cone-beam computed tomography after rehabilitation on five implants in the maxilla and five implants in the mandible; B) definitive dentures in place; C) panoramic radiograph at three-year follow-up; D) lateral view three years after implant-supported rehabilitation.

DISCUSSION Individuals with atrophic maxillae are still a challenge in implant-supported reconstructions, due to the proximity with the maxillary sinus and nasal floor. It is often necessary to use bone grafts, and unfavorable maxillomandibular relationship is often observed in these patients. 3 As demonstrated in the present case, the patient presented characteristics of maxillomandibular atrophy class VI according to the classification of Cawood and Howell,1 presenting functional and esthetic complaints. As described by Li et al.3, reconstructive pro-

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

cedures in isolation are often unable to solve all complaints of patients, which may impair the success and longevity of prosthetic rehabilitation.

To address the patientâ&#x20AC;&#x2122;s complaints, it was decided to perform grafting in the atrophic maxilla, placement of implants and uncompensated provisional dentures, combined to orthognathic surgery (Le Fort I) for maxillary advancement. This planning was considered necessary, since the patient presented negative overjet of 14 mm between the dental arches, with actual possibility of postoperative instability if only one technique was employed.

57

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):53-9

Atrophic maxilla reconstruction: case report

provisional implants simultaneously to autogenous bone grafting, compared to a control group submitted only to grafting from the same donor site. The authors did not observe significant differences in the evaluation of bone gain and resorption after a mean follow-up period of five months, by cone-beam computed tomography analysis.

Thus, it may be assumed that implant placement in the same surgical step is not an important aspect for maintenance of the grafted bone volume.

Gil et al.5 mention advantages of implant placement in a second surgical step, including reduced risk of ischemic necrosis of the graft, lower probability of implant loss and possibility of achievement of a perforation guide based on previous planning of the best position for implant placement. Treatment indication, planning and accomplishment of the present case was based on these facts.

Le Fort I osteotomies are indicated for individuals with skeletal Class III dental malocclusion due to anteroposterior maxillary deficiency, providing optimal outcomes with long-term stability. For achievement of success after surgical movements of the maxilla, it is necessary to restore the masticatory function, promote pleasant esthetics and provide long-term stability.4 According to Carlotti et al.10, the stability of the surgical outcome achieved is related to factors as appropriate wound healing, absence of vascular involvement, adequate maxillary mobilization and fixation, and quality of occlusion of the patient.

During bone consolidation, the fixation and stability of the complex should be sufficiently rigid to withstand the anteroposterior forces, in order to avoid relapse10. As reported by Gil et al.5, we believe that the accomplishment of bone grafting, implants and Le Fort I osteotomy in different surgical steps increases the predictability and stability of outcomes, since the patient will have an implant-supported provisional fixed denture in place during orthognathic surgery, with satisfactory tooth contacts.

If correction of the intermaxillary relationship is not planned, the result of implant-supported rehabilitation in these cases may cause unfavorable load of occlusal forces on the compensated dentures, reducing the predictability of cases in the long term, besides providing unsatisfactory esthetic and speech outcomes.5,6 It was decided to perform these procedures individually to allow more predictable results, despite the greater morbidity associated with multiple surgical procedures.

This was also reported by Nystron et al.6, who stated that techniques of maxillary reconstruction and Le Fort I osteotomy, when performed separately from implant placement, in different surgical moments, may provide greater predictability and higher success rate.

According to Gil et al.5, accomplishment of dental fixed rehabilitation before Le Fort I osteotomy aids the maxillary repositioning, enhancing the predictability of teeth positioning, as well as of their relationship with the upper lip. The authors further highlighted the importance of the maxillary central incisor as reference, which is fixated to the maxilla in the three-stage technique, aiding the treatment planning.

The study of Kahnberg et al.7 compared the implant loss after Le Fort I osteotomy associated with iliac crest graft with implant placement in the same procedure (study group) and Le Fort I osteotomy with iliac crest graft and implant placement after three to four months (control group). In a five-year follow-up, the authors observed lower rates of implant maintenance in the study group (60%) compared to the control group (85.6%). Thus, the authors concluded that accomplishment of two surgical steps is more adequate in this procedure.

Besides the success rate of implants, it is important to consider the rate of bone resorption after iliac crest grafting. According to Dreiseidler et al.8, most studies analyzing changes in the iliac crest volume demonstrated results with 23% to 59% of reduction, yet using different surgical approaches and follow-up periods. A tomographic study evaluating the bone volume loss after four months revealed 15% of bone loss, being the lowest value reported in the literature.8 Considering the maxillomandibular discrepancy of the patient and the volume loss expected due to bone remodeling, it was necessary to perform maxillary advancement by Le Fort I osteotomy, providing better anteroposterior maxillomandibular relationship at treatment completion.

Castagna et al.9 conducted a study comparing the bone gain and resorption in patients who received four

Š Journal of the Brazilian College of Oral and Maxillofacial Surgery

CONCLUDING REMARKS Implant-supported dentures, bone grafts and Le Fort I osteotomy may be indicated for the treatment of patients with severe atrophy causing significant dentoskeletal and facial alterations. This requires careful planning of treatment stages, involving professionals of oral and maxillofacial surgery and prosthodontics. The technique in three surgical stages, despite the greater morbidity, seems to provide more predictable results, which may lead to greater treatment stability.

58

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):53-9

Fonseca VJ, Pinto Junior AAC, Cunha JF, Lehman LFC, Campos FEB, Castro WH

References:

1. Cawood JI, Howell RA. A classification of the edentulous jaws. Int J Oral Maxillofac Surg. 1988 Aug;17(4):232-6.

2. Misch CE. Implantes dentais contemporâneos. Rio de Janeiro: Elsevier; 2008.

3. Li KK, Stephens WL, Gliklich R. Reconstruction of the severely atrophic edentulous maxilla using Le Fort I osteotomy with simultaneous bone graft and implant placement. J Oral Maxillofac Surg. 1996 May;54(5):542-6; discussion 547.

4. Bell WH, Jacobs JD, Quejada JG. Simultaneous repositioning of the maxilla, mandible, and chin. Treatment planning and analysis of soft tissues. Am J Orthod.

1986 Jan;89(1):28-50.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

5. Gil JN, Claus JD, Campos FE, Lima SM Jr. Management of the severely resorbed maxilla using Le Fort I osteotomy. Int J Oral Maxillofac Surg. 2008 Dec;37(12):1153-5.

6. Nyström E, Lundgren S, Gunne J, Nilson H. Interpositional bone grafting and Le Fort I osteotomy for reconstruction of the atrophic edentulous maxilla. A two-stage technique. Int J Oral Maxillofac Surg. 1997 Dec;26(6):423-7.

7. Kahnberg KE, Nilsson P, Rasmusson L. Le Fort I osteotomy with interpositional bone grafts and implants for rehabilitation of the severely resorbed maxilla: a 2-stage procedure. Int J Oral Maxillofac Implants. 1999 Jul-Aug;14(4):571-8.

59

8. Dreiseidler T, kaunisaho V, Neugebauer J, Zöller JE, Rothamel D, Kreppel M. Changes in volume during the ‘four months’ remodelling period of iliac crest grafts in reconstruction of the alveolar ridge. Br J Oral Maxillofac Surg. 2016 Sept;54(7):751-6.

9. Castagna L, Polido WD, Soares LG, Tinoco EM. Tomographic evaluation of iliac crest bone grafting and the use of immediate temporary implants to the atrophic maxilla. Int J Oral Maxillofac Surg. 2013 Sept;42(9):1067-72.

10. Carlotti AE Jr, Aschaffenburg PH, Schendel SA. Facial changes associated with surgical advancement of the lip and maxilla. J Oral Maxillofac Surg. 1986 Aug;44(8):593-6.

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):53-9

Information for authors

OBJECTIVE AND EDITORIAL POLICY The Journal of the Brazilian College of Oral and Maxillofacial Surgery is the official publication of the Brazilian College of oral and Maxillofacial Surgery and Traumatology targeted to the publication of relevant papers for education, information and science of the academic practice of surgery and related areas, aiming at the promotion and exchange of knowledge between the university community and health professionals.

• The publication categories include original papers (systematic reviews, clinical trials, experimental studies and case series with at least 9 clinical cases) and case reports.

• The manuscripts submitted to the Journal will be analyzed by the Editorial Board, which decides if the paper is acceptable for publication.

• The declarations and opinions expressed by the author(s) do not necessarily correspond to those of the editor(s) or publisher(s), who will not take responsibility over them. Neither the editor(s) nor the publisher offers guarantee of any product or service announced in this publication, or any statement of their respective manufacturers. Each reader should determine if he or she should act according to the information presented in the publication. The Journal or announcers are not responsible for any harm caused by the publication of mistaken information.

• The submitted manuscripts should be original, not previously published nor under consideration by another journal. The manuscripts will be analyzed by the editor and consultants and are subject to editorial review. The authors should follow the guidelines described below.

• The manuscripts should be submitted in Portuguese.

GUIDELINES FOR MANUSCRIPT SUBMISSION • The manuscripts should be submitted through the website: www.dentalpressjournals.com.br.

• The manuscripts should be written in a concise, clear and correct manner, in formal language, avoiding colloquial expressions.

• Whenever applicable, the text should be organized as follows: Introduction, Material and Methods, Results, Discussion, Conclusions, References, and Figure Legends.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

• The manuscripts should have at most 2,500 words, including the abstract, references and legends of figures and tables (yet excluding data on the tables).

• A maximum of four authors are allowed for case reports and six authors for research manuscripts.

If more authors are included, the participation of each author in the manuscript must be informed.

• The figures should be submitted as separate files.

• The figure legends should also be included within the text, to guide the final formatting of the paper.

• Title page: this page should contain only the manuscript title, in Portuguese and English languages, which should be as informative as possible, composed of at most 8 words. This page should not include information related to the identification of authors (e.g. full author names, academic degrees, institutional affiliations and/or administrative roles). This should only be included in specific fields in the manuscript submission website.

Therefore, this information shall not be visible for the reviewers.

ABSTRACT • Structured abstracts, in Portuguese and English, with 200 words or less, are preferred.

• Structured abstracts should contain the following sections: INTRODUCTION, presenting the study objective; METHODS, describing how it was conducted; RESULTS, describing the primary outcomes; and CONCLUSIONS, reporting the study conclusions and clinical implications of the outcomes.

• The abstracts should also present 3 to 5 keywords, also in Portuguese and English, which should comply with DeCS (http://decs.bvs.br/) and MeSH (www.nlm.nih.gov/mesh).

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

60

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):60-2

Information for authors

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

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

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

Figures • The digital images should be sent in JPG or TIFF format, with at least 7cm width and 300dpi resolution.

• They should be submitted as separate files.

• If a figure has been previously published, its legend should mention the original source.

• All figures should be cited in the text.

Institutional review board If applicable, the manuscripts should mention the Institutional Review Board approval.

Copyright transfer Assigning the manuscript copyright to Dental Press, in case the manuscript is published.

Graphs and cephalometric tracings • These should be cited in the text as figures.

• The authors should send the files containing the original versions of graphs and tracings, in the softwares used for their preparation.

• The submission of images in bitmap format (not editable) is not recommended.

• The submitted drawings may be enhanced or redesigned by the journal production, as indicated by the Editorial Board.

Conflict of interest If there is any interest of the authors concerning the study objective, it should be explicitly mentioned.

Human rights and animal protection If applicable, the authors should mention the compliance with international institutions for protection and the Helsinki declaration, following the ethical guidelines of the human/animal institutional review board. In case of studies on humans, the authors should mention the approval by the Institutional Review Board, according to Resolution 466/2012 CNS-CONEP.

Tables • The tables should be self-explanatory and should complement, but not duplicate the text.

• Tables should be numbered in Arabic numbers, in order of appearance in the text.

• Each table should have a short title.

• If a table has been previously published, a footnote should be included mentioning the original source.

• The tables should be submitted as text files (e.g.

Word or Excel), and not as graphs (non-editable image).

Permission to use copyrighted images Illustrations or tables, either original or modified, from copyrighted material should be accompanied by permission of utilization granted by the copyright owners and the original author (and the legend should properly refer the source).

Informed consent The patients have right to privacy, which should not be violated without an informed consent. Identifiable photographs of individuals should be accompanied by a consent form signed by the person or the parents or caretakers, in case of underage individuals. These authorizations should be kept indefinitely by the manuscript author. A cover letter should be submitted stating that all patients’ consents were obtained and are stored by the corresponding author.

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

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

61

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):60-2

Information for authors

REFERENCES - All papers cited in the text should be included in the reference list.

- All references should be cited in the text.

- To enhance reading, the references should be cited in the text indicating only their numbers.

- The references should be indicated in the text by superscript Arabic numbers in order of appearance.

- The abbreviations of journal titles should be formatted according to the publications “Index Medicus” and “Index to Dental Literature”.

- The authors are responsible for the accuracy of references, which should contain all data necessary for their identification.

- The references should be presented at the end of the text completion, following the Vancouver guidelines (http://www.nlm.nih.gov/bsd/uniform_requirements. html).

- Use the examples below:

Book chapter Baker SB. Orthognathic surgery. In: Grabb and Smith’s Plastic Surgery. 6th ed. Baltimore: Lippincott Williams & Wilkins. 2007. Chap. 27, p. 256-67.

Book chapter with editor Breedlove GK, Schorfheide AM. Adolescent pregnancy. 2nd ed. Wieczorek RR, editor. White Plains (NY): March of Dimes Education Services; 2001.

Dissertation, thesis and monograph Ryckman MS. Three-dimensional assessment of soft tissue changes following maxillomandibular advancement surgery using cone beam computed tomography [Thesis]. Saint Louis: Saint Louis University; 2008.

Electronic publication Sant´Ana E. Ortodontia e Cirurgia Ortognática – do planejamento à finalização. Rev Dental Press Ortod Ortop Facial. 2003 maio-jun;8(3):119-29 [Acesso 12 ago 2003]. Disponível em: http://www.dentalpress.com.br/ artigos/pdf/36.pdf.

Paper with up to six authors Espinar-Escalona E, Ruiz-Navarro MB, Barrera-Mora JM, Llamas-Carreras JM, Puigdollers-Pérez A, Ayala-Puente. True vertical validation in facial orthognathic surgery planning. Clin Exp Dent. 2013 Dec 1;5(5):e2318.

Paper with more than six authors Pagnoni M, Amodeo G, Fadda MT, Brauner E, Guarino G, Virciglio P, et al. Juvenile idiopathic/rheumatoid arthritis and orthognatic surgery without mandibular osteotomies in the remittent phase. J Craniofac Surg.

2013 Nov;24(6):1940-5.

© Journal of the Brazilian College of Oral and Maxillofacial Surgery

62

J Braz Coll Oral Maxillofac Surg. 2018 jan-abr;4(1):60-2