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

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

College of Oral and Maxillofacial Surgery JBCOMS

Geração de guias cirúrgicos Imaging

Management

Aquarium ©

Foto: Mike Bueno

EDITOR-IN-CHIEF Belmiro Cavalcanti do Egito Vasconcelos

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

ASSOCIATE EDITOR-IN-CHIEF Gabriela Granja Porto

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

SECTION EDITORS

Oral Surgery and Implants Cláudio Ferreira Nóia Danilo Passeado Branco Ribeiro Fernando Bastos Pereira Júnior Luis Carlos Ferreira da Silva Waldemar Daudt Polido

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 Nazareno Gil 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 de Santa Catarina - UFSC - Florianópolis/SC - Brazil Universidade Federal do Pará - UFPE - Belém/PA - Brazil

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

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

Pathologies and Reconstructions 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

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

Quadrimestral ISSN 2358-2782

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

1. Cirurgia Bucomaxilofacial. I. Dental Press International.

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

CDD 21 ed. 617.605005 _______________________________________________________________________

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

table of contents

Editorial

Belmiro C. E. Vasconcelos Letter from the President

Sylvio Luiz Costa de Moraes Interview

José Nazareno Gil

Articles

Conservative treatment of mandibular fracture in patient with osteoradionecrosis

Wilkes self-retaining TMJ retractor: technical modification

Segmental maxillary osteotomy for simultaneous correction of Class III and malpositioned implants

Epidemiological study of two modalities for treatment of frontal fractures: retrospective analysis of 46 cases

Rubens Cardozo de Castro Junior, Mariana Quirino Silveira Soares, Paulo Sergio da Silva Santos, Cassia Maria Fischer Rubira, Eduardo Sant’Ana

Paulo Afonso de Oliveira Jr, Armando de Barros, Pérsio Azenha Faber, Danilo Dressano, Felipe Calile Franck, Fernando Afonso de Oliveira

Leonardo Matos Santolim Zanettini, Alexandre Abreu, Rodrigo Sofia da Rocha, Bruna Rodrigues Fronza, Waldemar Daudt Polido

Bruna de Rezende Marins, Natasha Magro Érnica, Eleonor Alvaro Garbin Jr, Geraldo Luiz Griza, Ricardo Augusto Conci, Maicon Douglas Pavelski

Pterygoid implants for dental rehabilitation in an atrophic maxilla

Extensive craniofacial reconstruction using polymethylmethacrylate prostheses

Rafael Zetehaku Araujo, Camila Lopes Cardoso, Cláudia Curra, Marcos Martins Curi

Eduardo de Lima Andrade, Ana Carolina Lemos Pimentel, Deyvid Silva Reouças, Livia Prates Soares Zerbinati, Adriano Freitas Assis

Editorial

Importance of the title, abstract and descriptors in scientific papers A huge quantity of papers is currently published. Every person writing a paper expects to publish it and see it well referenced (cited). For that purpose, authors should be concerned to properly write the title, abstract and descriptors, which are available in most databases. The reason for this concern is that, when a paper is published, it is initially retrieved by descriptors. The descriptors are standardized words indexed in databases, aiming to systematize the search process. These may be found on the MeSH database (Medical Subject Headings) or DeCS, within the Virtual Health Library of BIREME - OPAS - OMS. They should be closely related to the research. Thereby, the search and citation of papers is better achieved. Conversely, soon after the paper is found using the descriptors, the reader will initially read the title to decide whether the search is adequate and proceeds with reading, if there is interest on the paper. Additionally, during the initial evaluation of a paper submitted to a journal, the title may be a reason for

How to cite: Vasconcelos BCE. Importância do título, resumo e descritores no artigo científico. J Braz Coll Oral Maxillofac Surg. 2017 maio-ago;3(2):4-5. DOI: https://doi.org/10.14436/2358-2782.3.2.004-005.edt

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):4-5

Editorial

acceptance or reject by the editorial board. The title should express the study aspects and relevance in few words. Thus, words without useful information should be avoided. Another important aspect is the abstract, which should summarize the objective, methodology, results and conclusion. Emphasis should be given to the methodology and inferential outcomes. The objective and conclusion should be short. The correct presentation of this triad allows better performance in the search for papers, with the additional benefit of citations for the paper and the journal.

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

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):4-5

Carta do Presidente

Changes in the education of specialists in Oral and Maxillofacial Surgery and Traumatology: analysis of today and a vision of tomorrow Dear colleagues, One of the most important issues for our specialty refers to the training of young oral and maxillofacial surgeons (OMFS). There has always been debate about the need of more homogeneous residency programs and that specialization courses should be conducted in “residency modality’ format. As specialty, we wish a doubtless, serious and committed improvement in the generation of good specialists, which will allow the continuation of our dental specialty working in the medical environment. Many barriers have appeared during years of work of several heterogeneous groups aiming at the education and training of resident and “specialization” students. Problems related with workload, contents, and questions related to the holistic view of the paper and relevance of the OMFS in the hospital context in the last decades are some points that contributed to disorganization in the formation of specialists, yielding large cognitive discrepancies and consequently inequalities in the achievement of a specialist degree. While some fulfill an extensive and high-quality program, others attend courses of questionable quality, either due to the program or workload, or the environment in which they are held.

How to cite: Moraes SLC. Modificações na formação do especialista em Cirurgia e Traumatologia Bucomaxilofacial: análise do hoje, visão no amanhã. J Braz Coll Oral Maxillofac Surg. 2017 maio-ago;3(2):6-9. DOI: https://doi.org/10.14436/2358-2782.3.2.006-009.crt

J Braz Coll Oral Maxillofac Surg. may-aug;3(2):6-9

Carta do Presidente

As a contribution to the certification of specialists, our College had an important participation by applying the exam for degree achievement, under authorization of the Federal Dental Council (CFO), by Resolution CFO n. 27 of July 24th 2002, article 23: “For achievement of a specialist degree, the final report should comprise the certificate or approval issued by the Brazilian College of Oral and Maxillofacial Surgery”. However, within the understanding of Brazilian law, Regional Councils are not entitled to regulate the education, which should only be under responsibility of the Ministry of Education (MEC), by the Superior Education Commission (CES) of the National Education Council (CNE). Therefore, all “specialization courses” were considered as “lato sensu” post graduation, as “specialization degree”. Article 5 of the Resolution CNE/ CES n. 1, of June 8th 2007, establishes that this “lato sensu post graduation” should have a minimum workload of 360 hours, not including the individual or group study times, not assisted by a professor, as well as the time dedicated for individual preparation of the monograph. The Resolution CNE / CES n. 1/2007 points an important aspect, due to the evident lack of knowledge about the work of our specialty, as well as its interfaces and particularities. It also allows specializations in the field of Oral and Maxillofacial Surgery and Traumatology (OMFST) with low workload and, notwithstanding, recognizing their degrees. This is very important and worrying, since the minimum time requirement disregards the need for a much longer workload to enable quality training in the specialty. Based on the CNE / CES Resolution n. 1/2007, many courses with short workload have been mistakenly authorized and, despite the lack of CFO Regulation and by judicial means, their “certificates of completion” were mandatorily registered. Therefore, under judicial decisions, CFO Resolution n. 27/2002 was revoked by CFO Resolution n. 173 of May 2nd 2016, whose article 23 was amended: “To obtain the specialist degree, the final report should comprise the certificate or diploma of approval issued by the institution responsible for the residency program.” Colleagues! On behalf of the interest of Brazilian Oral and Maxillofacial Surgery and Traumatology, the time has come to re-discuss changes that may provide substantial improvements in the training of OMFST specialists. Even though it is a dental specialty, OMFST should be considered from a different standpoint, neither better nor worse, yet different from other dental specialties, because of its potential for morbidity, multi and interdisciplinarity feature, and continued practice of medical-hospital interface. Within this context, by the integrated work of our Commissions for Residents Evaluation, Residency Teaching and Training, Interrelation with MEC & CFO of Interest of the Specialty and volunteer colleagues, a Special Working Group (SWG) was created to establish a Plan for Standardization of Specializations and Residencies in Oral and Maxillofacial Surgery and Traumatology (PSSR-OMFST), which was successfully concluded and presented for analysis by the Executive Board and General Council of years 2016-2017.

J Braz Coll Oral Maxillofac Surg. may-aug;3(2):6-9

As highlighted by the Special Working Group: “[...] Currently, in Brazil, there is no standardized model for training the OMFST specialists. The professional can choose from a specialization course, joining a group of 12 (twelve) students with monthly activities for a maximum period of 24 (twenty-four) months, up to a hospital residency program, with daily activities, including working shifts, with duration of 36 (thirty-six) months and a limit of 2 (two) students per group. Many courses are “weekends” or “organized in modules”, and have extremely negative influence on the training of surgeons. The specialty has evolved and currently there is a diversified and sophisticated scope, which requires more learning time to allow a solid formation with consequent positive insertion in the working market, avoiding bad outcomes for patients and consequently for the image of Dentistry. Most countries have standardized teaching, with longer training period for the specialist. In the United States and Canada, to obtain a specialist degree, the OMFS must have been a graduate in Dentistry, passed an exam that certifies him or her to work as dental professional, should have attended a four- or six-year residency program – in which case the surgeon will finish the program with both medical and dental training – and finally should be approved on a certification exam that allows him or her to act as a specialist. In Japan, the OMFST residency program requires five years of training. In Germany, UK and most European countries, the OMFST specialist must have both medical and dental degrees and should have completed a five-year residency program, besides a final exam for certification as specialist. In Latin America, the OMFS formation varies between countries, yet there is predominance of four-year programs without any two-year programs, except for Brazil. Currently, in Brazil, the programs are divided into: 1) specialization programs lasting two years or shorter; 2) three-year specializations; 3) three-year residency programs. These programs do not have regular monitoring and many of them do not require certification. In addition to the great difference in training time observed between courses in our country, the workload and content also differ widely, consequently leading to training of specialists with different qualification levels who, notwithstanding this discrepancy, will ultimately have their title recognized. [...]”

J Braz Coll Oral Maxillofac Surg. may-aug;3(2):6-9

Carta do Presidente

Among the fundamental operational changes proposed by the SWG, emphasis should be given to the proposal that programs should present a minimum workload of 8,640 (eight thousand, six hundred and forty) hours, with minimum duration of 3 (three) years in full-time dedication of 60 (sixty) hours per week. The extension of a fourth year would still be optional, but would bring an unquestionable add-on in OMFS formation. Therefore, after analysis and preliminary approval by the General Council, the PSSR-OMFST was forwarded to CFO, for referral to MEC for analysis, discussion and approval. Regardless of these measures, there is a need for action in the political field, to formalize a Law Project to assure the final referral of the matter, so that we can definitely establish guidelines for adequate formation of the future of OMFST in Brazil. The Presidency would like to publicly thank, in alphabetical order, the individuals who were directly involved with preparation of the PSSROMFST: Adriano Rocha Germano, Daniel Falbo Martins de Souza, Geraldo Prestes de Camargo Filho, José Thiers Carneiro Junior, Liogi Iwaki Filho and Marisa Aparecida Cabrini Gabrielli. The board emphasizes the appreciation for the support received and reaffirms to be open to constructive suggestions and criticisms of institutional interest. After all, the College belongs to all of us. Let’s go further! Analyzing and re-writing today, with a vision of tomorrow!

Sylvio Luiz Costa de Moraes President of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology

J Braz Coll Oral Maxillofac Surg. may-aug;3(2):6-9

Arte: David Normando - Foto: Everaldo Nascimento VER-O-PESO: entre os 10 melhores mercados de rua do mundo

Promoção:

ESTAÇÃO DAS DOCAS

Realização

“Cidade criativa da Gastronomia” (UNESCO, 2015)

Apoio

CÍRIO DE NAZARÉ

Patrocinadores Diamante:

INSCRIÇÕES: www.abor.org.br/congresso 2017

Cursos José Augusto Miguel

Carlos Flores-Mir

Carlo Marassi

Jorge Faber

Uso dos propulsores fixos para tratamento da Classe II.

Dicas para facilitar e melhorar a finalização ortodôntica!

Pós verdades ortodônticas dos 8 aos 80.

Kevin O’Brien

Leopoldino Capelozza

Marco Rosa

Marcos Janson

O tratamento interdisciplinar: da dentição mista ao paciente idoso.

Ortodontia de resultados: a arte da escolha.

Na terra da incerteza, o vendedor é rei?

A ortodontia, o tempo e a alquimia.

Novos recursos para ampliar os limites da compensação ortodôntica.

Data do curso: 11-10-2017 Ao realizar a inscrição até 31 de março, os sócios da ABOR receberão, gratuitamente, o curso do Prof. Marco Rosa. Aos não sócios, o desconto será de 50% até esta data.

Mario Polo

Nelson Mucha

Rodrigo Viecilli

Weber Ursi

Correção ortocirúrgica e estética facial.

Sorrisos - detalhes essenciais.

Controvérsias em biomecânica: salvando a ciência da técnica e do marketing.

Ortodontia: ontem, hoje e amanhã.

Simpósios:

• Antonio Carlos Ruellas • Flavia Artese • Márcio Almeida • Mario Polo • Mayra Seixas • Renato Martins

Minicursos:

• Adilson Ramos • Alexandre Moro • Carlos Câmara • Carlos Tavares • Daniela Garib • Ertty Silva • Flávio Cotrim-Ferreira • Guilherme Almeida • Guilherme Janson • Henrique Villela • Jonas Capelli • José Valladares • Júlio Gurgel • Laurindo Furquim • Leandro Marques • Liliana Maltagliati • Marco Almeida • Matheus Pithon • Paulo Conti • Roberto Brandão • Silvia Reis • Telma Martins

Conferências:

• Ana Conti • André Machado • Bruno Furquim • Carlos Flores-Mir • Carlos Câmara • Carlo Marassi • Cauby Júnior • Deise Cunha • Daltro Ritter • Dauro Oliveira • Enio Tonani Mazzieiro • Fábio Santana • Felipe Carvalho • Fernanda Angelieri • Flávio Calçada • Geórgia Thi Lau • Gerson Ribeiro • Gilberto Queiroz • Gladys Dominguez • Graziane Pereira • Flávio Ferrari • Haiane Cavalcante • Ildeu Andrade • João Milki Neto • Jorge Faber • José Rino Neto • Luciane Menezes • Lilian Martins • Lincoln Nojima • Luiz Guilherme Maia • Marcos Janson • Maurício Araújo • Maurício Sakima • Marcelo Freire • Omar Ayub • Orlando Tanaka • Ricardo Moresca • Romero Souto • Sabrina Gama • Vilmar Lima

Atividade Paralela - SIMPÓSIOS ABOL:

• Carla Melleiro Gimenez • Guaracy Fonseca • Lucilene Calliare • Luis Fernando Eto • Marcos Prieto • Marcelo Marigo • Rita Baratela Thurler • Rodrigo Prata Rocha • Silvana Kairalla

Conferências Expositores: • Alécia Louzada • Bruno Gribel • Daniel Tocolini • Marco Schroeder • Rowan Vilar

Até o dia 28 de abril

De 29 de abril a 31 de julho

De 01 de agosto a 29 de setembro

Após o dia 29 de setembro

Sócios ABOR/ALADO

R$ 590,00

R$ 700,00

R$ 770,00

R$ 850,00

Não sócios ABOR/ALADO

R$ 790,00

R$ 900,00

R$ 990,00

R$ 1.080,00

Pós-graduandos em Ortodontia

R$ 590,00

R$ 700,00

R$ 770,00

R$ 850,00

Acadêmicos de Odontologia

R$ 550,00

R$ 630,00

R$ 690,00

R$ 770,00

Curso Marco Rosa

R$ 120,00**

R$ 140,00

R$ 160,00

R$ 180,00

Formas de pagamento

Até 6 x no cartão Boleto à vista

Até 4 x no cartão Boleto à vista

Até 2 x no cartão Boleto à vista

Cartão à vista

* Para todas as categorias (exceto não sócios) é necessário a comprovação por documento;

** Ao realizar a inscrição até 31 de março, os sócios da ABOR receberão, gratuitamente, o curso do Prof. Marco Rosa. Aos não sócios, o desconto será de 50% até esta data. Marco Rosa

Patrocinadores Ouro:

Patrocinadores Prata:

www.orthocamp.com.br

Apoio:

A JBCOMS também está disponível na versão digital, que pode ser lida pelo Portal Dental Press, tablet ou smartphone, sem a necessidade de conexão com a internet. Você, assinante da versão impressa, tem acesso digital gratuito. Baixe o aplicativo na App Store ou Play Store do Google e experimente uma nova maneira de ler seu periódico.

To innovate is to make history São Paulo will host the XXIV COBRAC between September 5th to 9th 2017

the most important scientific destinations of the Americas. “Therefore, we are organizing a high-quality event to meet the level of our specialists, from the standpoint of the main word of the 21st century: innovation”. The themes related to great fields of Oral and Maxillofacial Surgery and Traumatology and technological innovations of the specialty will be presented and discussed in different formats, including crossfire of controversial issues; cycles of specific themes; step-by-step presentation of techniques, focused on the new generation; expository lectures and debates of “worst cases”, targeted for case reports in which there was failure in treatment planning or accomplishment. According to Luciano Del Santo, “it is necessary to re-invent, to offer the participant new models of case reports. Thus, the event will have entirely different dynamics”. Among the speakers will be Drs. Eduardo Rodriguez (USA), who conducted the most complex face transplantation yet performed in the world, in 2015; Achille Tarsitano (Italy); Benjamin Davis (Canada); Daniel Simon (Spain); Florencio Monje Gil (Spain); Mirco Raffaini (Italy); Paulo Coelho (USA) and Louis Mercuri (USA). The full list is available on the website www.cobrac2017.com.br

The XXIV COBRAC, Brazilian Congress of Oral and Maxillofacial Surgery and Traumatology, will be an event with new educational format and new approaches in a totally innovative and 100% interactive environment. For the first time, the largest scientific meeting of the specialty in Brazil will be organized in arena format, with four simultaneous conferences. Over 2,000 participants are expected at the WTC Events Center, in southern São Paulo. “This is a tendency in corporative events in São Paulo and is totally innovative in the health field. The new structure meets the demands of professionals of our specialty, who will find high-quality content from a more dynamic and lighter viewpoint. We are sure that the arena format promotes greater interaction between lecturers, participants and commercial exhibitors. We will provide a unique experience for our colleagues”, as stated by the president of COBRAC 2017, Dr. Luciano Del Santo. Parallel to the Central Arena, other three rooms with capacity for 800 people will also host simultaneous sessions. The president of the Brazilian College of Oral and Maxillofacial Surgery and Traumatology, Dr. Sylvio Luiz Costa de Moraes, highlights that Brazil is one of

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):14-7

JBCOMS News

Arena format

scientific contribution worldwide”, highlights the president of XXIV COBRAC. The innovative format also allows the exhibitors a greater opportunity to interact with the participants, who will walk through the space also during sessions. Interactive rooms for accomplishment of workshops and hands-on will also be available. “Innovating has a sense beyond technology. It should be understood as a new way of encouraging, promoting creative thinking, inspiring the knowledge, stimulating the debate. Based on this premise, the XXIV COBRAC will be an event in line with contemporaneous Oral and Maxillofacial Surgery, without dismissing the memory of great individuals that contributed until we reached the current state of the art”, finalizes Sylvio Luiz Costa de Moraes.

The four content modules that constitute the Arena of the new COBRAC will have contents simultaneously presented throughout the event. All participants will receive a headphone and may select which theme to follow. Large screens will reproduce the images of speakers and invited individuals, in each session. In some moments, the space will be transformed in a single arena and the entire audience may follow the same issue. “We are establishing a new concept of scientific presentation and consequently of the manner of knowledge achievement. This format favors the relationship of participants with the renowned national and international speakers, all of whom have expressive

Evento: Cobrac

Projeto: Vitor Saito

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):14-7

The WTC

& Gabbana and Gucci. Alike, Cidade Jardim is also known to have great brands as Carolina Herrera, Dior, Giorgio Armani, Louis Vuitton and Ralph Lauren. At Vila Olímpia, besides the 191 stores, movies and theater, it is possible to have fun in a bowling place with the 12 newest bowling tracks of the country. Market Place offers good options of restaurants, including Badebec, Braugarten, Italy, Ici Brasserie and Coco Bambu. Morumbi offers 483 stores of diverse segments as Apple, Sephora, New Balance and Michael Kors; the mall also comprises 23 among the most prestigious restaurants of São Paulo, including Le Vin, Zucco, Pirajá and Saj. Other highlight is the Hotzone, one of the largest and most modern indoor parks of the country, which comprises more than 200 attractions for all age ranges. For children, Kidzania is an “Educational city”, where they can play to know and experience different professions – this is located inside Eldorado Mall, at 4km from the World Trade Center São Paulo. Other option for children and adults is the São Paulo Aquarium, which comprises 15,000 m² and 2 million liters of water, presenting nearly 3,000 animals from 300 different species. The Aquarium is located in the Ipiranga area, at nearly 11 km from southern São Paulo and close to the Ipiranga museum, one of the most visited in the state capital, which has a great collection of items related with the independence of Brazil.

The venue of XXIV COBRAC is a complete events center in Latin America. Integrating the WTC São Paulo, the WTC Events is located in Southern São Paulo, between Marginal Pinheiros and Av. Luis Carlos Berrini, at 6 km from the Congonhas airport and 36 km from the Guarulhos airport. Participants will have access to a covered parking lot for 1,700 cars, with valet service; food court with nearly 20 choices of restaurants; bank agencies and diverse facilities as fast printing services, lottery shop, money exchange, travel agency, bookstore, digital services, drugstores, optics, laundry, hairdresser, clothing and shoes in general.

São Paulo offers optimal leisure options for the whole family COBRAC 2017 will be strategically held during the extended September 7th holidays. Bring your family to the state capital, which provides the best cultural and gastronomic programs of Brazil. Also, southern São Paulo gathers some of the main shopping malls of the city, with national and international brands. Close to the hotels where participants will stay, there are malls as JK Iguatemi, Cidade Jardim, Vila Olímpia, Morumbi and Market Place. The JK Iguatemi comprises international brands as Bvlgari, Burberry, Chanel Beauté, Prada, Dolce

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):14-7

JBCOMS News

Â© Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):14-7

Interview

An interview with José Nazareno Gil

» Full Professor of Universidade Federal de Santa Catarina. » PhD and MsC in Dentistry – Oral and Maxillofacial Surgery and Traumatology.

How to cite: Gil JN, Vasconcelos BCE. Entrevista com José Nazareno Gil. J Braz Coll Oral Maxillofac Surg. 2017 maio-ago;3(2):18-24. DOI: https://doi.org/10.14436/2358-2782.3.2.018-024.oar Submitted: November 24, 2016 - Revised and accepted: December 26, 2016

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):18-24

How do you see minimally invasive surgery in Orthognathic Surgery? The challenge of Orthognathic Surgery is to perform accurate movements within the treatment planning, and achieve stability with less surgical morbidity. Thus, I consider that minimally invasive surgery has its space within the correction of dentofacial deformities. I consider minimally invasive surgery as surgical procedures performed with small incisions and detachments, aiming to reduce the sequelae of traditional surgical dissections, consequently reducing the trauma and tissue lesions, bleeding and edema, leading to better patient recovery. Therefore, we might consider that, by performing maxillomandibular osteotomies with smaller incisions and detachments, we would be performing minimally invasive surgery. These minimally invasive techniques may eventually replace the traditional open procedures and allow surgeries without hospitalization, with local anesthesia and sedation instead of general anesthesia. This would reduce the costs and morbidity and improve the patientâ€™s acceptance of procedures. Endoscopic-assisted surgery is an example of minimally invasive approach for correction of dentofacial deformities. Technological advancements significantly improved the optics, imaging and instrumentation, which, associated with technical training of the OMFS in the field of endoscopy, have enabled less invasive procedures. Endoscopy allows adequate visualization even with small incisions and detachments. Surgically assisted maxillary expansion, vertical osteotomy of the mandibular ramus, Le Fort I osteotomy and bilateral sagittal osteotomy of the mandibular ramus are surgical techniques already performed with endoscopy.

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This association, when well used and indicated, may decrease the morbidity in orthognathic surgery. Considering that operating with smaller incisions and detachments, using endoscopic instruments, demands a greater learning curve and that professional experience is paramount for case selection, we can conclude that this minimally invasive surgical technique should be a sequence of the traditional, rather than the first choice of beginning surgeons. Alike all surgical techniques, there are limitations and indications. We cannot apply less invasive techniques and jeopardize the surgical accuracy and safety. When well indicated, optimized and performed by experienced surgeons, we can assume that a large number of dentofacial deformities may be corrected with less morbidity compared to traditional techniques. Another important aspect for those working in this area would be: which were the advances of Orthognathic Surgery in the last 10 years? Orthognathic surgery (OS) had great evolutions in the last 10 years, which may be didactically divided into technological and philosophical advancements. From a technological standpoint, the great advancement surely was the introduction of 3D technology (Fig. 1) in treatment planning. The 2D virtual planning (Fig. 2) has been used for more than 10 years, yet the use of computed tomography for three-dimensional visualization has disseminated in the last decade. Virtual planning softwares in OS are being enhanced to search for accurate dental and bone movements and consequent soft tissue changes. The understanding of OMFS of what will happen to the soft tissues after dental and bone movements is fundamental for the predictability of planning.

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):18-24

Figure 1: 3D planning: quantification of deformity and its correction. This view demonstrates correction of the occlusal plane (roll). Note that chin asymmetry was corrected by leveling.

Figure 2: Virtual 2D planning. This is often used in initial orthodontic-surgical planning, when tooth and bone movements are analyzed, as well as changes on the profile. These orthodontic-surgical simulations are conducted in combination with orthodontists, to decide the best surgery and orthodontic mechanics. It is also useful to aid the patient to understand the treatment planning.

» Quantification of anomalies. » Fabrication of sectioning guides. » Fabrication of biomodels. » Fabrication of customized plates. » Detailed evaluation of the airway. » Aid in positioning of proximal segment in ramus sagittal osteotomy. » Measurement of bone separations, which allows checking during surgery if they are the same as planned.

Concerning 3D planning in OS, the first aspect to be considered are procedures to be performed on the maxilla and mandible and fabrication of positioning surgical guide. However, many other important information is achieved by this planning, such as (Fig. 3 to 7): » Contacts between osteotomized edges. » Location of the inferior alveolar nerve, aiding the selection of osteotomy and position of fixation. » Direction of movements.

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):18-24

Figure 3: Contact between distal and proximal segments in mandibular ramus sagittal osteotomy. The left side exhibits good fit; however, on the right side there is a posterior contact that precludes the union of segments.

Figure 4: Knowledge of measurements between borders of mandibular ramus sagittal osteotomy guides the correct positioning of the proximal segment before fixation.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):18-24

Figure 5: Analysis of inferior alveolar nerve for safer accomplishment of mandibular ramus sagittal osteotomy concerning the positioning of fixation screws.

Figure 6: The position of the inferior alveolar nerve on both sides reveals close contact between mandibular cortices throughout the extent of mandibular ramus and body, which would cause permanent bilateral paresthesia if bilateral mandibular ramus sagittal osteotomy was performed. An alternate osteotomy, such as vertical-sagittal, might be indicated to reduce morbidity.

Figure 7: We should transfer to surgery the measurements of movements (gaps) demonstrated by 3D planning. Their checking during surgery allows to evaluate if everything is occurring as planned.

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J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):18-24

avoids soft tissue migration, greatly enhancing the bone formation. These biomaterials are especially important in great separations in osteotomy. A great philosophical advancement of OS in the last decade concerns planning. Traditionally, it was performed to adjust the occlusion; following, esthetics was also considered in treatment planning as being so or even more important than adjusting the dental relationships. Currently, besides these two aspects, the airway (Fig. 8) and joints are considered in the quantification and direction of bone movements. This change is related to the greater knowledge about outcomes achieved by OS on obstructive sleep apnea and the real change in airway volume, as demonstrated by postoperative computed tomography. Similarly, the current understanding of changes promoted by OS on the temporomandibular joints and its effects in surgical stability, combined to three-dimensional images of resorptions, justifies the search for joint stability before surgery is performed.

Despite the advancements achieved by 3D planning, some limitations must yet be overcome. When setting the virtual patient, we need to combine, in the planning software, information from different sources. The superimposition between dental surfaces of the tomogram and scanning of dental casts (or intraoral) is challenging, as well as to achieve correct centric relationship and natural head positioning. Other important technological advancement is the utilization of piezoelectric surgery. There are several applications in OS, yet I consider this very useful for dissection of the inferior alveolar nerve during sagittal osteotomy. I consider this a fundamental tool, which should be available to the OMFS during surgery. Ultrasound sectioning provides greater safety and accuracy, especially in important anatomical structures. Also concerning the technological advancements, there are new biomaterials for filling of spaces created by bone movements. Dead space filling with these materials facilitates osteoconduction and

Figure 8: Volumetric evaluation of the airway. The colors demonstrate regions with greater and smaller volume, as well as the area with greater constriction.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):18-24

Another necessary philosophical change concerns the corticotomies. This technique is scientifically demonstrated, with unquestionable benefits, but was not yet incorporated in the daily orthodontic practice. When orthodontists find out that they may make use of bone remodeling after corticotomy and solve the cases in a faster and safer manner, they may offer this technique to their patients. This will bring to their offices a work possibility still scarcely explored. The change in approach in Orthognathic Surgery by surgeons and orthodontists is based on technological advancements, which allow greater surgical safety, providing better quality of life for the patients. Safe and effective technological advancements, such as 3D planning, ultrasound sectioning and filling materials obtained by tissue engineering, require current update of surgeons, who may then know and offer the most current, safe and predictable therapies. It is not enough to have the OMFS entering the operating room satisfied only because the fixation material was released: other technological advancements that increase the procedure safety and the final outcome should compose the armamentarium. This is evolution.

Other philosophical change was the acceptance of OS by orthodontists, who began to consider it a more viable option to solve dentofacial anomalies. For this reason, large dental compensations were abandoned and the indications for surgery increased. Compared with the past, we currently see fewer orthodontic compensations with significant esthetic involvement. Orthodontists are currently aware of the limit of compensations, as well as of the best outcomes achieved by OS. Another advancement in philosophy in the last 10 years was the paradigm shift for accomplishment of OS before Orthodontics, more known in our country as anticipated benefit. This option allows solving the deformities in shorter time. The efficacy and outcomes are maintained, yet with greater efficiency, since less time is demanded. Patient, orthodontist and OMFS are benefited by this approach. The patient shall not experience the stage of preoperative orthodontic treatment, during which esthetics and mastication are much worsened, which allows greater patient compliance and even acceptance. Orthodontists will have more patients to treat and will not face forces contrary to their orthodontic mechanics. Obviously, this approach requires accurate diagnosis for indication of cases, detailed planning, excellent relationship between orthodontist and OMFS and greater safety in orthodontic finalization.

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

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):18-24

CaseReport

Conservative treatment of

mandibular fracture in patient with osteoradionecrosis RUBENS CARDOZO DE CASTRO JUNIOR1 | MARIANA QUIRINO SILVEIRA SOARES1 | PAULO SERGIO DA SILVA SANTOS1 | CASSIA MARIA FISCHER RUBIRA1 | EDUARDO SANT’ANA1

ABSTRACT Osteoradionecrosis (ORN) of gnathic bones in patients undergoing head and neck cancer radiotherapy is a serious and severe problem. Poor bone vascularization, presence of cutaneous fistulas, trismus, odynophagia and dysphagia are characteristic of ORN. A 80-year-old male patient with diagnosis of ORN of the jaw, mouth-opening limitation because of cervical and masticatory muscles fibrosis, with diabetes and decompensated hypertension, and persistent alcohol abuse. The patient suffered a mandibular trauma, resulting in body region fracture without displacement and extraoral fistula with suppuration. Due to poor general health, the patient was submitted to a conservative treatment of the mandibular fracture and infectious process by means of antibiotic therapy, guidance regarding eating habits, local care and general health. Dental surgeons have the option of considering conservative management to solve cases of fractures resulting from ORN since the radical surgical management is often limited due to severely compromised systemic condition. Keywords: Mandibular Fractures. Osteoradionecrosis. Alcoholism. Elder. Therapeutics.

University of São Paulo (Bauru/SP, Brazil).

» The authors report no commercial, proprietary or financial interest in the products or companies

How to cite: Castro Junior RC, Soares MQS, Santos PSS, Rubira CMF, Sant’Ana E. Tratamento conservador de fratura de mandíbula em paciente com osteorradionecrose. J Braz Coll Oral Maxillofac Surg. 2017 maio-ago;3(2):25-30. DOI: https://doi.org/10.14436/2358-2782.3.2.025-030.oar

described in this article.

Submitted: April 20, 2015 - Revised and accepted: May 05, 2017

» Patients displayed in this article previously approved the use of their facial and intraoral photo-

Contact address: Rubens Cardozo de Castro Junior Rua Otávio Pinheiro Brisola, 9-75 Bauru/SP - Brasil - CEP: 17.012-901 E-mail: rubenscastroctbmf@yahoo.com.br

graphs.

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):25-30

Conservative treatment of mandibular fracture in patient with osteoradionecrosis

INTRODUCTION Osteoradionecrosis (ORN) is the exposure of irradiated bone tissue remaining for longer than three months without residual or recurrent tumor.1 ORN of the jaws is a late complication in patients submitted to radiotherapy on the head and neck region, and is difficult to treat.2 This lesion affects both the mandible and maxilla yet is more prevalent in the mandible, due to the compact structural characteristic of the mandibular bone and smaller blood perfusion compared to the maxilla.2 Additionally, in oral cancer – especially carcinomas of the tongue, retromolar region and mouth floor – there is direct involvement of the mandible on the irradiated site and treatment of the lesion often involves radical resection for tumor excision, which poses a trauma to the bone tissue.2 The hypocellularity theory is the most currently accepted to explain the etiology of ORN: irreversible changes and cellular dysfunctions that lead to vascular damage (hypovascularity), ischemia and hypoxia in areas exposed to treatment with ionizing radiation, when it reaches 72 to 80 Gray (Gy) after hyperfractionated radiotherapy or 64-72 Gy after fractionated radiotherapy. The main risk factors leading patients to develop ORN in the mandible include location of the irradiated site, irradiation dose, whether or not there were resections of mandibular segment, previous tooth extractions, dental implants, infections, immunodeficiencies and undernourishment. Additionally, many patients affected by oral cancer present history of alcoholism and smoking.3,5,8 The main clinical characteristics of ORN in the mandible include bone exposure, local inflammation, fragility, loss of bone elasticity and blood supply, orocutaneous fistulae, ulcers, secondary infections, speech and mastication disorders. There may also be spontaneous mandibular fractures with nonunion.3,4 Radiological investigation is necessary to determine the extent and severity, as well as to follow the conservative treatment of ORN, when established. Conventional radiographs and cone-beam computed tomograms (CBCT) may initially present bone rarefaction, disorganization and thickening of bone trabeculae, presence of bone sequestra and radiolucent/hypodense areas at the mandibular affected region. Over time, areas of pathological fractures may be observed, with rupture of cortical bone.5 This paper reports a case of an elderly patient with systemic impairment, who exhibited ORN in

the mandible and suffered mandibular fracture due to trauma. Because of the clinical status and general health of the patient, it was decided to perform a little invasive treatment. The paper discusses the main current conservative treatments for the management of ORN of the jaws. CASE REPORT Male patient, aged 80 years, of African descent, had history of squamous cell carcinoma on the mouth floor and right submandibular region. Six years after radiotherapy the patient presented pain on the right mandibular region. The patient reported treatment with ionizing radiation on the head and neck region and reported extraction of remaining teeth in the maxilla and mandible and rehabilitation with complete dentures; five months after using the dentures, there was bone exposure on the right mandibular alveolar region. The patient presented medical history of blood hypertension (mean 190mmHg / 130mmHg), uncontrolled diabetes, gastrointestinal disorders with utilization of omeprazole, Sustrate (propatylnitrate), finasteride, Cardvita (losartan), atenolol, cilostazol, amlodipine, glibenclamide, sertraline and lorazepam, with persistence of smoking and alcoholism habits after antineoplastic therapy. For this therapy, the patient was submitted to surgery for tumor removal and received 38 sessions of conventional radiotherapy, adding up to a total radiation dose of 6,480 cGy. On general physical examination, the patient presented disturbed gait due to strong pain in the lower limbs, edema on the right mandibular region, signals of surgery involving the cervical lymphatic chain and fibrosis of masticatory and cervical muscles. Local clinical examination revealed an area of bone exposure on the mandibular right alveolar ridge, mobility on manual examination of the proximal and distal mandibular regions, presence of ulcer in the mucosa and orocutaneous fistula, with purulent secretion on the right submandibular region (Fig 1). Imaging examination by CBCT revealed simple mandibular fracture affecting the mandibular body. A hyperdense area was also observed on the posterior region of the right mandibular body in lingual direction, with hypodense areas in the mandibular cortical base, disorganization and thickening of bone trabeculae and presence of bone sequestra (Fig 2).

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):25-30

Castro Junior RC, Soares MQS, Santos PSS, Rubira CMF, Santâ€™Ana E

Figure 1: Clinical aspect of extraoral fistula and intraoral bone exposure.

Figure 2: Clinical and imaging aspect before treatment: A) extraoral fistula involving the right submandibular space; B) 3D reconstruction of CBCT; C) panoramic reconstruction exhibiting areas with mandibular osteoradionecrosis on the right side and fracture line.

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J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):25-30

Conservative treatment of mandibular fracture in patient with osteoradionecrosis

with 0.12% aqueous chlorhexidine solution 3 times a day. The patient was again submitted to the OHIP-14 questionnaire, which revealed significant improvement from the treatment, since the impact of oral status was strong to moderate, when related with the quality of life (Fig 3). The general clinical condition of the patient – hepatopathy, congestive heart failure and severe blood hypertension – precluded the accomplishment of general anesthesia to remove the sequestra and place a mandibular reconstruction plate, thus the medical staff suggested only clinical follow-up, considering the possibility to maintain the patient in this condition. Despite all management efforts, the patient persisted with smoking and daily alcohol ingestion, which impaired the effectiveness of the proposed therapy.

Treatment planning involved a multidisciplinary team comprising dental and medical doctors, speech pathologists, nutritionist and physical therapist. Initially the patient was submitted to general medical evaluation, aiming to stabilize and adapt the clinical condition of the patient to receive dental management by a conservative treatment protocol for patients submitted to radiotherapy. The questionnaire Oral Health Impact Profile (OHIP-14) was applied, which revealed that oral status had a strong impact on the quality of life. The patient was then submitted to treatment sessions at every 15 days comprising local anesthesia, curettage of necrotic bone, removal of residues, irrigation with 0.12% chlorhexidine digluconate on the exposed bone region and revival of lesion borders for 12 months after diagnosis of osteoradionecrosis – when mandibular fracture was then diagnosed, with complaint of intense pain on the region and presence of purulent exudate. Despite this therapeutic approach, the patient had systemic complications that led to hospitalization and, after three months without dental follow-up, the patient presented increased volume on the right hemimandible, pain and extraoral fistula. For treatment of infection, the patient was prescribed amoxicillin 500mg associated with metronidazole 500mg orally at every 8 hours, for 21 days, and pain was controlled with Tylex® 30mg. After a 7-day period the patient returned with greater purulent secretion in the fistula tract and was then referred to the hospital for intravenous antimicrobial therapy. After hospitalization, there was resolution of infection without purulent secretion. The patient was again submitted to weekly dental follow-up with new curettages and irrigation with 0.12% chlorhexidine, avoiding new infection foci on the exposed bone so far. The patient was informed to discontinue the utilization of dentures and avoid smoking and alcoholism habits. The physical therapist prescribed exercises to enhance the masticatory and cervical muscles. Additionally, the nutritionist indicated liquid-paste diet, followed weekly, with adequate calorie ingestion, besides speech pathology investigation and management to improve the swallowing. Currently the patient is being followed for the simple mandibular fracture, without displacements, pain or infections, yet with presence of exposed bone, on which daily local antisepsis is performed

Figure 3: Clinical and imaging aspect after conservative treatment: A) clinical aspect of extraoral fistula after conservative treatment of mandibular osteoradionecrosis; B) panoramic radiographic aspect after conservative treatment.

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):25-30

Castro Junior RC, Soares MQS, Santos PSS, Rubira CMF, Sant’Ana E

DISCUSSION Local trauma is an important risk factor for ORN and is associated with its development in 89% of diagnosed cases.2 The mean period of occurrence of ORN after radiotherapy is 18 months; however, cases have been diagnosed in up to 192 months of follow-up. Curi et al2 identified two periods of peak occurrence of ORN: the first 12 months after radiotherapy, associated with tumor size and surgical resection for treatment, without difference in prevalence between patients submitted to pre-treatment dental care; and a second peak between 24 and 60 months, in which 60% of cases had involvement of dental factors, especially tooth extractions.2 In the present case, ORN occurred after multiple tooth extractions and placement of complete dentures, more than 50 months after radiotherapy. This emphasizes the need of careful evaluation to indicate tooth extractions in patients with previous history of radiotherapy; if absolutely necessary, extractions should be performed with little trauma and strict criteria of handling and management. Adjutant therapeutic maneuvers, such as prophylaxis and antibiotic therapy, are indicated to avoid infections secondary to the surgical procedure. Hyperbaric therapy may also be used to improve the repair after surgical handling, yet never as a single option for ORN treatment. Additionally, the patient should be carefully followed and instructed about the risk of ORN after tooth extraction, as well as on the essential postoperative care to minimize the risk of infection.2,6 The treatment of ORN is challenging and several therapies have been reported. However, a universally accepted approach has not yet been established. The main objectives of ORN treatment are to restore the blood supply and establish the homeostasis of normal tissues. Removal of non-viable tissues and providing conditions for self-healing, as well as suppression of secondary infections, are important. Treatment success is achieved when the lesion is asymptomatic and stable and, if surgically removed, reconstruction should provide functional and esthetically favorable results1. For that purpose, surgical or conservative approaches may be employed.1 The clinical conditions, surgeon’s experience and patient’s interests (complaints, preferences, socioeconomic status, and others) influence the selection of adequate treatment for each patient, besides prevention of facial bone fractures1.

Conservative treatment of osteoradionecrosis is indicated for elderly individuals presenting severe systemic impairment who are unable to receive radical surgical treatment.8 The conservative treatment includes local debridement of the lesion with 0.12% chlorhexidine digluconate (aqueous solution), besides daily mouthrinses with antiseptic solution and counseling about oral hygiene care. Decortication with burs may be performed if needed. Local factors that contribute to maintenance of secondary infection, such as plates and screws, should be removed. Sequestrectomy is indicated when bone sequestra are diagnosed, and the entire removed specimen should be submitted to histopathological examination to rule out any residual or recurrent malignant neoplasia.1,8 Opioid analgesics and anti-inflammatory drugs may be prescribed in case of pain and/or discomfort.2,7,8 Hyperbaric oxygen therapy, when available, may be employed; however, if residual or recurrent neoplasia is suspected, its use is contraindicated.1 Antibiotic therapy based on the bacterial culture and sensitivity tests is indicated for secondary infection control. Ampicillin/sulbactam may be used for prophylaxis, and suspected secondary infection may require amoxicillin/clavulanic acid and fluoroquinolone. Oral bacteria and Candida spp. are the primary causes of infected ORN; however, infection by Actinomyces in individuals with chronic refractory ORN is associated with bone destruction, purulent secretion and fistula formation.1 In the present case, conservative treatment was indicated because the patient was elderly and presented impaired general health, which would contraindicate extensive surgery. Therefore, the management comprised antibiotics, analgesics, local and general care, as suggested by Chrcanovic et al.8 A study evaluating 505 cases of facial fractures caused by falls in elderly individuals reported that the mandible was the most affected area, especially simple mandibular condyle fractures, followed by mandibular body fractures. In individuals older than 60 years, the most affected region is usually the mandibular body9 — as observed in the present case, in which mandibular body fracture was caused by a fall, yet with previous ORN. Some possible treatments for mandibular fracture with osteoradionecrosis include hyperbaric oxygen therapy, sequestrectomy and bone resection, and

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):25-30

Conservative treatment of mandibular fracture in patient with osteoradionecrosis

CONCLUDING REMARKS Due to the limited general health conditions of the patient and unhealthy habits, conservative treatment of ORN and mandibular fracture was the most indicated in this case, achieving a favorable outcome so far, without pain or infection.

reconstruction using plates, screws and microvascular grafts.10 However, conservative treatments are best indicated, because they are acceptable for maintenance of asymptomatic lesions, especially in older patients, in whom surgeries with greater morbidity should be avoided.8 This may be observed in the present case, in which the patient, besides being older, presented highrisk systemic involvement, which would contraindicate a greater and more invasive surgical procedure.

References:

1. Pitak-Arnnop P, Sader R, Dhanuthai K, Masaratana P, Bertolus C, Chaine A, et al. Management of osteoradionecrosis of the jaws: an analysis of evidence. Eur J Surg Oncol. 2008 Oct;34(10):1123-34. 2. Curi MM, Dib LL. Osteoradionecrosis of the jaws: a retrospective study of the background factors and treatment in 104 cases. J Oral Maxillofac Surg. 1997 June;55(6):540-4; discussion 545-6. 3. Lyons A, Ghazali N. Osteoradionecrosis of the jaws: current understanding of its pathophysiology and treatment. Br J Oral Maxillofac Surg. 2008 Dec;46(8):653-60. 4. Ang E, Black C, Irish J, Brown DH, Gullane P, O’Sullivan B, et al. Reconstructive options in the treatment of osteoradionecrosis of the craniomaxillofacial skeleton. Br J Plast Surg. 2003 Mar;56(2):92-9.

5. Rice N, Polyzois I, Ekanayake K, Omer O, Stassen LF. The management of osteoradionecrosis of the jaws--a review. Surgeon. 2015 Apr;13(2):101-9. 6. Deshpande SS, Thakur MH, Dholam K, Mahajan A, Arya S, Juvekar S. Osteoradionecrosis of the mandible: through a radiologist’s eyes. Clin Radiol. 2015 Feb;70(2):197-205. 7. Koga DH, Salvajoli JV, Alves FA. Dental extractions and radiotherapy in head and neck oncology: review of the literature. Oral Dis. 2008 Jan;14(1):40-4. 8. Chrcanovic BR, Reher P, Sousa AA, Harris M. Osteoradionecrosis of the jaws--a current overview--Part 2: dental management and therapeutic options for treatment. Oral Maxillofac Surg. 2010 June;14(2):81-95.

9. Iida S, Hassfeld S, Reuther T, Schweigert HG, Haag C, Klein J, et al. Maxillofacial fractures resulting from falls. J Craniomaxillofac Surg. 2003 Oct;31(5):278-83. 10. Sawhney R, Ducic Y. Management of pathologic fractures of the mandible secondary to osteoradionecrosis. Otolaryngol Head Neck Surg. 2013 Jan;148(1):54-8.

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OriginalArticle

Wilkes self-retaining TMJ retractor:

ABSTRACT Introduction: the indication of arthrotomy, also known as open joint surgery, in the temporomandibular joint (TMJ) is associated with previous requirements and clinical protocols, being necessary when conservative treatment options have failed. Clyde H. Wilkes proposed a classification for staging of joint pathologies and also developed a self-retaining retractor for open TMJ surgeries, which increases the joint space when activated. Due to the technical difficulty for transoperative placement in its original design, utilization of this tool has been discontinued. Methods: after fabrication of two prototypes, we achieved a final design that was effective for clinical application. We performed open TMJ procedures with and without utilization of the modified Wilkes retractor, to compare the operative time and postoperative outcomes. Results: it was observed that surgical arthrotomy procedures of the TMJ using the modified Wilkes retractor presented reduced total time and allowed better visualization of joint structures. Conclusion: the technical modification presently proposed reduced the duration of arthrotomy procedures of the TMJ, with reduced risk of injury to the patients, and providing more predictable outcomes. Keywords: Temporomandibular joint. Temporomandibular joint disorders. Oral surgical procedures. Operative time.

Irmandade da Santa Casa de Piracicaba (Piracicaba/SP, Brazil).

How to cite: Oliveira Jr PA, Barros A, Faber PA, Dressano D, Franck FC, Oliveira FA. Afastador autoestático de Wilkes: modificação técnica. J Braz Coll Oral Maxillofac Surg. 2017 maio-ago;3(2):31-4. DOI: https://doi.org/10.14436/2358-2782.3.2.031-034.oar

Universidade Estadual Paulista, Faculdade de Odontologia (Araraquara/SP, Brazil).

» The authors report no commercial, proprietary or financial interest in the products or companies

Submitted: July 22, 2015 - Revised and accepted: May 02, 2017

described in this article.

Contact address: Paulo Afonso de Oliveira Jr Av. Independência, 953 – Bairro Alto, Piracicaba/SP E-mail: pauloafj@terra.com.br

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

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):31-4

Wilkes self-retaining TMJ retractor: technical modification

INTRODUCTION The treatment of myofascial pain and dysfunction (MPD) is multiprofessional. Even though analysis of the causal factors of MPD evidences several pathologies associated with temporomandibular joint (TMJ) disorders, it reveals greater prevalence of muscle disorders, for which surgical treatment is not indicated. Aware of this fact, professionals should be very careful when indicating invasive procedures in the TMJ, following strict therapeutic protocols, such as the clinical and radiographic staging system suggested by Wilkes.1 This classification and utilization of protocols allows standardized use of surgical techniques, making them more predictable and effective, as proposed by Bronstein and Merril,2 who related the Wilkes stages with arthroscopic findings. Minimally invasive procedures as arthroscopy and arthrocentesis of the TMJ present very encouraging results;3-6 however, pathologies in more advanced stages require more radical approaches. Arthrotomy of the TMJ is indicated in cases of advanced pathologies, such as disc displacement without reduction, whose success rate is 80 to 95%7, evidencing the efficacy of the procedure. Mechanical disorders as crepitation and limited movement are also considered in the surgical indication.8 Imaging examinations as computed tomography and magnetic resonance are fundamental for diagnosis and indication of invasive procedures, as well as previous arthroscopic evaluations. TMJ surgery is usually successful when care is taken to avoid further damage to the joint, making this procedure delicate and careful. The surgical procedures most employed are disc repositioning (which may be associated with osteoplasty of the fossa or eminoplasty), procedures to stabilize the mechanics of movement of the condyle-disc complex, removal of excess tissues at the retrodiscal region and cauterization of the area, to create a metaplastic tissue with most appropriate mechanical characteristics to stabilize the condyle-disc complex.8 The staging of joint disorders plays an important

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

role to indicate the most adequate procedure, as well as for long-term follow-up of the evolution of joint pathologies, always highlighting the importance of multidisciplinary management in these cases. The utilization of proper instruments enhances the access to the region and contributes to a successful procedure, since it allows adequate visualization, facilitating the delicate procedures in the joint compartment, whose space is very restricted. DESCRIPTION OF TECHNIQUE AND INSTRUMENTS The Wilkes self-retaining TMJ retractor allows gradual displacement of the condyle in the mandibular fossa, allowing intraarticular surgical procedures by increasing the joint space. For that purpose, the original Wilkes instrument required placement of Kirschner wires using rotary instruments, followed by adaptation on their end, which demanded longer operative time. By the proposed modification, this stage was replaced, facilitating the adaptation of instruments. The differential adaptation of new instruments comprises transformation of these fittings into unpolished Cr-Ni or Widia posts soldered on its edges, with diameters compatible with bur #702 (Fig 1 and 2), allowing fixation by bur perforations of this size at the upper region of the subcondylar fossa (Fig 3). In these perforations, they are easily placed by manual pressure. The instrument is activated by fine adjustment (Fig 4), which provides distraction or increase of intraarticular space, capsule and ligaments (Fig 5 and 6). Posts fixated to retractor edges are very resistant, allowing application of pressure and retraction of the region without deflections or displacements, due to retentions in its active tips, which prevents material loosening. This instrument allows procedures in the joint space (by dilation) without the need of alternate access, such as submandibular access (Risdom), thereby minimizing additional efforts from the auxiliary staff or utilization of intraoral devices. After completion of surgery, the retractor is gradually deactivated and gently removed.

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):31-4

Oliveira Jr PA, Barros A, Faber PA, Dressano D, Franck FC, Oliveira FA

Figure 1: Modified self-retaining Wilkes retractor.

Figure 2: Edge of Cr-Ni fitting with same diameter as bur #702.

Figure 3: Perforations performed with bur #702 on the articular fossa and subcondylar region.

Figure 4: Introduction of instrument after delicate adjustment allowed by the screw.

Figure 5: Activation of self-retaining retractor, increasing the joint space.

Figure 6: Stability of space provided by the retractor, facilitating surgical procedures as discopexy, arthroplasty and joint eminoplasty.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):31-4

Wilkes self-retaining TMJ retractor: technical modification

DISCUSSION Invasive procedures in the TMJ are still widely discussed in the specialized scientific community, yet there is consensus about the utilization of minimally invasive procedures with greater maintenance of joint components.3-6 However, surgeons should be familiar with the benefits of TMJ surgeries,8 when properly indicated and accomplished. The literature reports an extensive number of complications related with open TMJ surgery, among which the most common is facial nerve injury, which occurs in 18 to 30% of cases.9 Besides access to the TMJ and surgeon’s skill, this is also often related with excessive handling of surrounding tissues. Utilization of this instrument in open TMJ surgeries provides several advantages, since it allows broader visualization transoperatively, facilitates discopexy and arthroplasty procedures, and promotes distension of joint structures, facilitating mobilization of the articular disc.

This self-retaining retractor is also useful in temporomandibular ankylosis surgeries, especially when the gap osteotomy technique is used. In this case, the retractor is introduced at the final region of osteotomy and activated to maintain the instrument tense and activated, so as, when bone is released, the instrument itself will distend, maintaining the gap and facilitating posterior complementary osteoplasty. The main objective of this instrument is to widen the joint space, facilitating surgical maneuvers within the joint space by exclusive preauricular access. CONCLUSION The changes to the original design of this instrument aim to facilitate its application and utilization in joint surgeries, since they widen the joint space in a simple and fast manner, both for placement and removal. Its application in our service has become routine and we have noticed that this allows faster procedures with lower risk of injuries to our patients.

References:

1. Wilkes CH. Internal derangements of the temporomandibular joint. Pathological variations. Arch Otolaryngol Head Neck Surg. 1989 Apr;115(4):469-77. 2. Bronstein SL, Merrill RG. Clinical staging for TMJ internal derangement: application to arthroscopy. J Craniomand Disord. 1992;6(1):7-16. 3. Murakami K, Moriya Y, Goto K, Segami N. Four-year follow-up study of temporomandibular joint arthroscopic surgery for advanced stage internal derangements. J Oral Maxillofac Surg. 1996 Mar;54(3):285-90; discussion 291. 4. Dimitroulis G. A review of 56 cases of chronic closed lock treated with temporomandibular joint arthroscopy. J Oral Maxillofac Surg. 2002 May;60(5):519-24; discussion 525.

5. González-García R, Rodríguez-Campo FJ. Arthroscopic lysis and lavage versus operative arthroscopy in the outcome of temporomandibular joint internal derangement: a comparative study based on Wilkes stages. J Oral Maxillofac Surg. 2011 Oct;69(10):2513-24. 6. Ahmed N, Sidebottom A, O’Connor M, Kerr HL. Prospective outcome assessment of the therapeutic benefits of arthroscopy and arthrocentesis of the temporomandibular joint. Br J Oral Maxillofac Surg. 2012 Dec;50(8):745-8. 7. Dolwick MF, Nitzan DW. TMJ disk surgery: 8-year follow-up evaluation. Fortschr Kiefer Gesichtschir. 1990;35:162-3.

8. Fonseca RJ, Marciani R, Turvey TA. Oral and Maxillofacial Surgery. 2nd ed. Philadelphia: Saunders; 2009. v. 3 9. Belli E, Mici E, Mazzone N, Catalfamo L, Fini G, Liberatore GM. A monolateral TMJ replacement under intraoral endoscopic assistance for jaw osteomielitis: a modified approach. G Chir. 2015 Jan-Feb;36(1):36-9.

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):31-4

OriginalArticle

Segmental maxillary osteotomy for simultaneous

correction of Class III and malpositioned implants LEONARDO MATOS SANTOLIM ZANETTINI1 | ALEXANDRE ABREU2 | RODRIGO SOFIA DA ROCHA2 | BRUNA RODRIGUES FRONZA2 | WALDEMAR DAUDT POLIDO3

ABSTRACT This paper reports a case of simultaneous correction of horizontal and transverse maxillary deficiency and malpositioned implants by segmental maxillary osteotomy, combined with maxillary advancement. The results achieved by three-segment orthognathic surgery demonstrate that the esthetic problem of previous implants was solved, and simultaneously the facial harmony and adequate occlusal relationship were established. By careful interdisciplinary planning between Prosthodontics, Orthodontics and Oral and Maxillofacial Surgery, a predictable and safe outcome was achieved. Keywords: Orthognathic surgery. Segmental osteotomy. Complications. Esthetic failure. Interdisciplinary treatment.

Pontifícia Universidade Católica do Rio Grande do Sul (Porto Alegre/ RS, Brazil). Private practice (Porto Alegre/RS, Brazil). Indiana University, School of Dentistry (Indianapolis, USA).

How to cite: Zanettini LMS, Abreu A, Rocha RS, Fronza BR, Polido WD. Osteotomia segmentar de maxila para correção simultânea de Classe III e implantes malposicionados. J Braz Coll Oral Maxillofac Surg. 2017 maio-ago;3(2):35-40. DOI: https://doi.org/10.14436/2358-2782.3.2.035-040.oar

» The authors report no commercial, proprietary or financial interest in the products or companies

Submitted: June 30, 2016 - Revised and accepted: February 06, 2017

described in this article. Contact address: Waldemar D. Polido 1121 W. Michigan Street - RM DS126 Indianapolis, IN - 46202 - USA - E-mail: wdpolido@iu.edu

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

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):35-40

Segmental maxillary osteotomy for simultaneous correction of Class III and malpositioned implants

INTRODUCTION Orthognathic surgery is often used for correction of Angle Class II and III skeletal facial deformities, dentofacial deformities, mandibular laterognathism and maxillofacial asymmetries.1,2,3 The interaction between orthodontist and oral and maxillofacial surgeon is paramount for the success and accomplishment of treatment planning with predictable outcomes. The key principles of surgical care and general patient care include psychological preparation of the patient, good pre- and postoperative nourishment, protection of bone and neurovascular structures, appropriate postoperative management, fixation of bone segments and control of occlusion postoperatively.4 Transverse maxillary deficiencies are frequent dentofacial deformities that may be associated with other maxillary disorders. In adult patients with transverse deficiencies, dental arch expansion may be achieved by maxillary segmentation during Le Fort I osteotomy.5 Segmental maxillary osteotomy is also indicated and may be used for correction of malpositioned endosseous implants that may hinder prosthetic rehabilitation. Implant removal may cause great alveolar bone loss, often requiring reconstruction of the lost area with grafts and other procedures.6 The segmental technique has been proposed as an alternative to correct implant positioning in the basal bone, especially in vertical direction. Some criteria should be followed for its utilization, such as availability of space for accomplishment of osteotomies between implants and teeth, sufficient quantity of bone for osteosynthesis and peri-implant tissue stability, and gingival tissue with adequate thickness around the implants.7,8 This paper reports a case in which the combination of three-segment Le Fort I osteotomy was performed for simultaneous correction of Angle Class III and anterior implants malpositioned in vertical direction.

anteroposterior deficiency of the patient were related to an existing maxillary deficiency (Fig 1). Currently, this type of planning is conducted using digital tools and Cone Beam Computed Tomography. Clinical examination revealed exposure of metallic abutments of provisional restorations and implantsâ€™ heads. The possible cause for such exposure could be considered as implants of coinciding platforms very close to each other, positioned deeply in vertical direction. This caused bone remodeling (described as saucerization) with consequent soft tissue retraction. The treatment stages included: a) new provisional dentures placed directly on the implant head, with adequate emergence profile and correct tooth length; this caused an anterior open bite aspect, which would be corrected by segmental surgery; b) assembly of surgical arches in segments, with adequate distance for cervical leveling of anterior teeth with the natural posterior teeth; c) orthognathic surgery for advancement, expansion and downward repositioning of the anterior segment; d) orthodontic finalization; E) new definitive dentures (Fig 2A). Surgical planning was based on segmental orthognathic surgery, aiming to simultaneously correct the anteroposterior maxillary deficiency and malpositioning of maxillary anterior implants. It was indicated to replace the abutments and fabricate provisional dentures directly on the implantsâ€™ heads, maintaining the ideal cervical-incisal dimension of restorations, leading to anterior open bite due to cervical and incisal unleveling of incisors in relation to posterior teeth. Brackets were bonded on the unleveled restorations, considering the leveling to be achieved during surgery (Fig 2B). Correction was conducted by three-segment Le Fort I osteotomy. Interdental vertical osteotomy was performed between maxillary lateral incisors and canines, as well as horizontal osteotomy parallel to the maxillary suture for transverse maxillary expansion. The maxillary segment was repositioned as planned for maxillary advancement, posterior intrusion and anterior extrusion, thus leveling the occlusal plane while simultaneously correcting the Class III (Fig 2). Postoperative recovery was uneventful and, after orthodontic finalization, the patient returned to the prosthodontist for fabrication of definitive dentures. All-ceramic crowns were applied on direct abutment on the implant head, aiming to reduce the metallic components, which could impair the final esthetic outcome (Fig 3).

CASE REPORT A 50-year-old male patient attended the clinic with complaint of function and esthetics. Upon clinical examination, he presented maxillary anterior dental implants with skeletal, facial and occlusal Class III relationship. The esthetic appearance was inadequate due to vertical malpositioning of endosseous implants. Radiographic analysis by panoramic radiograph and lateral cephalogram confirmed that the Class III profile and

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):35-40

Zanettini LMS, Abreu A, Rocha RS, Fronza BR, Polido WD

Figure 1: A) Preoperative frontal image. B) Frontal image during smile. C) Lateral image evidencing the Angle Class III. D) Preoperative panoramic radiograph. E) Preoperative lateral cephalogram evidencing the anteroposterior maxillary deficiency.

Figure 2: A) Initial intraoral clinical aspect. B, C) Maxillary segments fixated with miniplates and titanium miniscrews.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):35-40

Segmental maxillary osteotomy for simultaneous correction of Class III and malpositioned implants

Figure 3: Images at posttreatment 5-year follow-up. A) Frontal image. B) Frontal image during smile. C) Postoperative facial profile. D) Intraoral clinical aspect exhibiting the reestablished final occlusion. E, F) Follow-up lateral cephalogram and panoramic radiograph, exhibiting good maxillomandibular relationship and stability of tissues.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):35-40

Zanettini LMS, Abreu A, Rocha RS, Fronza BR, Polido WD

DISCUSSION Malpositioned implants cause significant functional and esthetic disorders. Implant removal or repositioning are two viable treatment options. Implant removal promotes significant alveolar bone loss, which can impair rehabilitation, besides being more expensive and unpredictable. However, this is the only option in many cases. According to the literature, implant repositioning may be an option to be considered, especially if the problem exists only in vertical direction.6 In cases with previous multiple losses in esthetic region, the utilization of several adjacent implants may lead to inadequate results. The first indication in case of loss of four maxillary incisors would be the use of two implants and a four-element fixed partial denture. This approach allows more predictable and long-lasting outcomes, from both esthetic and functional standpoints.10 In the present case, implant malpositioning was associated with anteroposterior and transverse maxillary deficiency. Correct planning of dental esthetics would lead the patient to correction of the emergence profile, improving the aspect in the transition area (cervical) of implants, with adequate size of anterior teeth. However, this would also lead to anterior open bite. Anterior open bite has been routinely corrected by segmental maxillary osteotomies, with intrusion of posterior segments and rotation of anterior segment. Correction of maxillary deficiency is one of the orthodontic-surgical procedures most used in orthognathic surgery.5 Besides the esthetic benefit to correct the anteroposterior discrepancy, there are remarkable esthetic, functional and respiratory improvements. Thus, planning comprised the fabrication of new provisional dentures with correct dimension, causing an anterior open bite. Correction was performed by a traditional procedure in orthognathic surgery, namely three-segment Le Fort I osteotomy

for maxillary advancement, transverse correction and anterior open bite closure. Detailed restorative planning is fundamental. Analysis of dental dimensions, emergence profile of the denture, relationship of peri-implant soft tissues and correct accomplishment of provisional and definitive dentures are fundamental for the result achieved. Surgery had the main objective to correct the natural malocclusion of the patient, combined with correction of the problem caused by failure of the previous treatment with implants. According to Janson et al,5 segmental osteotomies present difficulties and risks. By technique modifications and modern equipment, high success rate has been achieved in segmental osteotomies for the treatment of malpositioned implants.9 The present case report evidences that correct diagnosis, interaction between oral and maxillofacial surgeon, orthodontist and prosthodontist, and surgeon’s skill during surgical intervention are important requirements for treatment success and predictable outcomes. The change of abutments and utilization of all-ceramic crowns with correct emergence profile also facilitated the stability of peri-implant tissues, as observed in the 5-year post-treatment follow-up. By proper planning and sequential accomplishment of procedures, acceptable and stable outcomes were achieved. CONCLUDING REMARKS Case selection, planning, sequence and interdisciplinary management are fundamental to allow careful analysis and discussion of all parameters before treatment accomplishment. The integration and team work between Surgery, Prosthodontics, Orthodontics and Periodontology are increasingly necessary to achieve the best outcomes in advanced and complex treatments.

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):35-40

Segmental maxillary osteotomy for simultaneous correction of Class III and malpositioned implants

References:

1. Ow A, Cheung LK. Skeletal stability and complications of bilateral sagittal split osteotomies and mandibular distraction osteogenesis: an evidence-based review. J Oral Maxillofac Surg. 2009 Nov;67(11):2344-53. 2. Ruiz LP, Lara JC. Facial nerve palsy following bilateral sagittal split ramus osteotomy for setback of the mandible. Int J Oral Maxillofac Surg. 2011 Aug;40(8):884-6. 3. Chrcanovic BR, Custódio AL. Optic, oculomotor, abducens, and facial nerve palsies after combined maxillary and mandibular osteotomy: case report. J Oral Maxillofac Surg. 2011 June;69(6):e234-41. 4. Khechoyan DY. Orthognathic surgery: general considerations. Semin Plast Surg. 2013 Aug;27(3):133-6. 5. Janson M, Janson G, Sant’ana E, Nakamura A, Freitas MR. Segmental Le Fort I osteotomy for treatment of a Class III malocclusion with temporomandibular disorder. J Appl Oral Sci. 2008;16(4):302-9.

6. Cunha HA, Nary Filho H, Batista JG, Matsumoto MA. Segmental osteotomy for the correction of a malpositioned single implant: an 8-year follow-up. Quintessence Int. 2011 Nov-Dec;42(10):817-22. 7. Kassolis JD, Baer ML, Reynolds MA. The segmental osteotomy in the management of malposed implants: a case report and literature review. J Periodontol. 2003 Apr;74(4):529-36. 8. Martin RJ, Goupil MT, Goldschmidt M. Single-implant segmental osteotomy: a case report. Int J Oral Maxillofac Implants. 1998 Sept-Oct;13(5):710-2. 9. Toscano N, Sabol J, Holtzclaw D, Scott T. Implant repositioning by segmental osteotomy: a case series and review. Int J Periodontics Restorative Dent. 2011 Nov-Dec;31(6):e102-8.

10. Siadat H, Arshad M, Shirani G, Alikhasi M. New method for fabrication of gunning splint in orthognathic surgery for edentulous patients. J Dent. 2012;9(3):262-6. 11. Nóia CF, Lopes RO, Andrade VC, Chaves Netto HDM. Otimização da reabilitação implantodôntica por meio de cirurgia ortognática. J Braz Coll Oral Maxillofac Surg. 2015;1(1):40-5.

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):35-40

OriginalArticle

Epidemiological study of two modalities

ABSTRACT This study evaluated the treatment of frontal fractures treated at the Oral and Maxillofacial Surgery and Traumatology Service of Hospital Universitário do Oeste do Paraná. The study analyzed 46 records of patients with frontal bone fractures, treated between June 2008 and December 2015. Among these, 86.95% of patients were males and 39.13% were within the age range 20-29 years. The most prevalent etiology was traffic accidents (motorcycles, cars, bikes and running overs), adding up to 56.52% of cases; further 26.08% of cases were due to physical aggression. In 74.46% of cases the patient had other fractures associated with frontal bone fracture, mainly affecting the orbit and zygomatic bone. Nonsurgical treatment was performed in 71.73%. Based on the present results, it may be stated that there was no statistically significant difference between surgical and non-surgical groups concerning the complications. There is no contraindication to any therapeutic option, provided the selected option is well indicated, as explained in the present paper. Keywords: Bone fractures. Frontal bone. Epidemiology.

Universidade Estadual do Oeste do Paraná, Cirurgia and Traumatologia Bucomaxilofacial (Cascavel/PR, Brazil).

How to cite: Marins BR, Érnica NM, Garbin Jr EA, Griza GL, Conci RA, Pavelski MD. Estudo epidemiológico de duas modalidades para tratamento de fraturas de frontal: análise retrospectiva de 46 casos. J Braz Coll Oral Maxillofac Surg. 2017 maio-ago;3(2):41-6. DOI: https://doi.org/10.14436/2358-2782.3.2.041-046.oar

Universidade Estadual do Oeste do Paraná, Hospital Universitário do Oeste do Paraná (Cascavel/PR, Brazil).

Submitted: July 18, 2016 - Revised and accepted: March 21, 2017 Contact address: Bruna de Rezende Marins

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

Rua Universitária, 2.069 – Jardim Universitário, Cascavel/PR – CEP: 85.819-110 E-mail: brunamarins_15@hotmail.com

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):41-6

Epidemiological study of two modalities for treatment of frontal fractures: retrospective analysis of 46 cases

INTRODUCTION The prevalence of frontal bone fractures is 5 to 15% of all facial traumas.1-6 Most frontal bone fractures are caused by high-speed impacts, such as traffic accidents, aggressions and sports lesion. 7 Patients presenting frontal sinus fractures often have associated facial fractures and systemic lesions 6. Nearly 0.7 to 2.1% of these cases present severe comminuted fractures, involving the posterior wall of the frontal sinus.4,8 Frontal bone fracture is not an immediate concern during initial patient attendance. However, it should be rapidly addressed in the management of craniofacial trauma, due to the possible complications that may occur in case of delayed or improper management, such as persistent outflow of cerebrospinal fluid (CSF), mucocele or mucopyocele, encephalitis or cerebral abscess.4,5,9,10 The main signs and symptoms are anesthesia of the supraorbital nerves, outflow of cerebrospinal fluid, subconjunctival and periorbital ecchymosis, depression (with loss of projection, irregularities and crepitus in the frontal bone), edema, lacerations (with possible exposure of fragments), local pain and headache.9 The main objectives of treatment of frontal bone fractures are to isolate the neurocranium and stop any cerebrospinal fluid leakage, prevent the possible immediate or late complications and restore the facial esthetics and function.6,10,11 Several treatment options are available for frontal bone fractures, according to their classification and literature reviewed. The most accepted classification divides the frontal bone fractures into: Type 1 – simple fracture of anterior wall; Type 2 – comminuted fracture of anterior wall; Type 3 – fracture of anterior and posterior walls; Type 4 – fracture of anterior and posterior walls, with involvement of nasofrontal duct; and Type 5 – fracture of anterior and posterior walls, with severe injury to the brain and/or soft tissues.5,6,10,11 The treatment of these fractures may be surgical or non-surgical, with or without obliteration of the nasofrontal duct or cranialization.5,9,10 The possible complications related to treatment of these fractures include postoperative deformity in bone contour, acute or chronic sinusitis, mucocele or mucopyocele, osteomyelitis, meningitis or even cerebral abscess.4,5,9

Thus, this paper reports the experience of management of patients with frontal sinus fractures at the Oral and Maxillofacial Surgery and Traumatology Service of Hospital Universitário do Oeste do Paraná, discussing data in the literature and comparing with the approaches adopted at this service. MATERIAL AND METHODS This epidemiological study comprised analysis of records of patients treated at the Oral and Maxillofacial Surgery and Traumatology Residency Service of Hospital Universitário do Oeste do Paraná, between June 2008 and December 2015. The study was approved by the Institutional Review Board under n. 1.591.012 on June 15th 2016. Data collection comprised information on patients’ age and gender, fractured side, associated fractures, signs and symptoms, treatment selected, management of nasofrontal duct and postoperative complications. The inclusion criteria comprised patients with frontal fracture assisted by the Oral and Maxillofacial Surgery and Traumatology Team of HUOP/UNIOESTE. Incomplete forms or without 6-month postoperative follow-up were excluded. The patients were submitted to one of the two following treatment options: Group I received non-surgical treatment; Group II was submitted to surgical treatment, which was further subdivided as closed or open. According to the criteria of Paza et al,12 treatment success is defined as the absence of interfragmentary movement, stability of the fixation system, absence of infection and osteolysis or nonunion of bone fragments. The records were evaluated considering the complications reported in 6-month follow-up. Analysis was performed by descriptive statistics and percentages. The Fisher exact test was applied for comparison of the variable complications between surgical and non-surgical groups, using the software BioEstat 5.3 (Instituto Mamirauá, Tefé/AM, Brazil). RESULTS Between June 2008 and December 2015, 49 patients were assisted at the service; however, 3 were excluded because the follow-up period was shorter than 6 months, leading to a sample of 46 patients. The sample included 40 males (86.95%) and only 6 females (13.04%) (Table 1).

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):41-6

Marins BR, Érnica NM, Garbin Jr EA, Griza GL, Conci RA, Pavelski MD

Table 1: Sample distribution according to gender.

At the moment of trauma, 4 (8.69%) patients were aged less than 19 years; 18 (39.13%) between 20 and 29 years; 12 (26.08%) between 30 and 39 years; 9 (19.56%) between 40 and 49 years; and 3 (6.52%) older than 50 years (Table 2). The etiology was diverse. The main cause of trauma was 26 (56.52%) cases of traffic accident (11 motorcycles, 9 cars, 4 bikes and 2 running overs), followed by 12 (26.08%) cases of physical aggression, 4 (8.69%) cases of fall, 4 (8.69%) cases of work accident and 1 (2.17%) sports accident (Table 3). Concerning the site of fracture, in 30 (65.21%) patients only the anterior wall was affected, while 16 (34.78%) had fracture of anterior and posterior walls. Four cases exhibited rhinorrhea. Exposed fracture was observed in 2 patients. Concerning the concomitant occurrence of other associated facial fracture, there were 35 (74.46%) cases of frontal bone fracture associated with other facial bone fractures, as follows: 13 cases involving only one facial bone associated with frontal fracture, 12 involving two other facial bones and 8 cases involving three or more facial bones. Among these fractures, there were 19 (40.42%) orbital fractures, 30 (63.82%) fractures of zygomatic complex, 7 (14.89%) maxillary fractures, 10 (21.27%) nasal fractures, 5 (10.63%) cases of nasoorbitoethmoidal complex (NOE) fractures, 13 (27.65%) mandibular fractures and 3 (6.38%) cranial bone fractures. Concerning the treatment, in 13 (28.26%) there was surgical intervention and 33 (71.73%) cases were treated without surgery (Table 4). Nine (69.23%) surgically treated cases received bicoronal access; in 2 (15.38%) cases the preexisting laceration was used, 1 (7.69%) was submitted to eyebrow access and 1 (7.69%) was reduced using Carrol-Girard screw (Tab. 5). Fixation of bone fragments was performed in 3 cases with titanium miniplates and fixation screws; in 9 cases with titanium mesh and fixation screw, and 1 case did not receive fixation. In 12 cases the surgical treatment comprised reconstruction of the frontal sinus anterior wall; cranialization was performed in 1 case. In 12 (92.30%) cases the nasofrontal duct was maintained and was patent, and in 1 (7.69%) case it was obliterated. Complications occurred in three patients and evolved with loss of projection; in one of these indi-

Gender

Female Male

6 40

Table 2: Sample distribution according to age range. Age range

up to 19 years 20 to 29 years 30 to 39 years 40 to 49 years above 50 years

4 18 12 9 3

Table 3: Sample distribution according to etiology. Etiology

Traffic accident Physical aggression Fall Work accident Sports accident

26 12 4 4 1

Table 4: Sample distribution according to treatment. Treatment

Surgical Non-surgical

13 33

Table 5: Sample distribution according to the access employed. Access

Bicoronal access Preexisting laceration Eyebrow access Transcutaneous access - Carrol-Girard screw

9 2 1 1

Table 6: Comparison of the variable complications between surgical and conservative groups.

Conservative Surgical

With complications

Without complications

3 1

30 12

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):41-6

Epidemiological study of two modalities for treatment of frontal fractures: retrospective analysis of 46 cases

tures, with emphasis to the classification of Doonquah, Brown and Mullings:15 Type 1 – anterior wall fracture with minimal comminution, without associated fractures of the nasoorbitoethmoidal complex (NOE) or orbit; Type 2 –comminuted fracture of the anterior wall with possible fracture of NOE and/or orbit; Type 3 – anterior and posterior wall fractures, without significant displacement of the posterior wall; Type 4 – anterior and posterior wall fractures with dura-mater lesion and cerebrospinal fluid outflow; and Type 5 – anterior and posterior wall fractures with dura-mater lesion, cerebrospinal fluid outflow, loss of hard and/or soft tissue and severe rupture of the anterior cranial fossa. Other simple classification is according to bone plates (anterior, posterior or both), situation of the nasofrontal duct, presence of associated intracranial lesions and presence of other facial fractures. Fractures of the frontal bone anterior wall are more common than of the posterior wall, since this region suffers the initial impact during trauma,16 in accordance with the present study, in which 65% of patients presented anterior wall fracture. The treatment modality to be adopted depends on the type of fracture. The best treatment modality for frontal fractures is controversial in the literature. Non-surgical treatment should be selected by consensus between the Oral and Maxillofacial Surgery team and the patient, and should be carefully performed. It is important to check whether the functions of the frontal sinus are normal and if the esthetic changes are significant.2,16,17 Open surgical reduction aims to protect the intracranial structures, prevent postoperative inflammation and reestablish the facial contour, restoring the symmetry and separation between nasosinusal tract and brain. Several accesses to fractures are described in the literature: gull wing incision, supraorbital incision, forehead/thin line incision, utilization of lacerations, coronal access or, alternatively, by endoscopy.2,10,17 In most surgically treated cases (71.42%), the bicoronal access was selected. This allows wide visualization of the surgical field, facilitating the management, reduction and fixation of frontal bone fractures, besides yielding esthetic scars in most patients, except for bald individuals.10,16 Fractures of the frontal sinus anterior wall without involvement of the posterior wall or injury to the nasofrontal duct may be reconstructed and rigidly fixated with miniplates, meshes and screws.10 This was

viduals, the general clinical condition contraindicated the surgical procedure and two patients did not present severe esthetic complaint and decided not to perform surgery, though indicated by the team. One patient submitted to surgical treatment presented frontal sinus sinusitis, which was treated with antibiotic therapy and local care. No patient presented chronic sinusitis, mucocele or mucopyocele, osteomyelitis, meningitis or cerebral abscess. The Fisher exact test for comparison of the variable complications between surgical and conservative groups, using the software BioEstat 5.3 (Instituto Mamirauá, Tefé/AM, Brazil), presented value of 1 for the null hypothesis, demonstrating no statistically significant difference between study groups. Thus, both surgical and non-surgical treatments can be performed, provided they are well indicated (Table 6). DISCUSSION Frontal bone fractures comprise 2 to 15% of facial fractures10. The results of epidemiological studies vary widely according to demographic data of the studied population. Factors as demographic region, socioeconomic status and seasonal aspects may also influence.13 The increased prevalence of facial bone lesions highlights the need of epidemiological studies to determine the ideal strategies for prevention and management of patients.13 The etiologies in this study agree with the world literature,2,10,13,14 with higher prevalence of traffic accidents (motorcycle, car and bike accidents and running overs), adding up to 56.52% of cases, and physical aggression, with 26.08% of cases. Thus, these are mainly high energy traumas. Frontal fractures are rare at extreme ages and present greater prevalence in the age range 20 to 30 years, mainly in males (91.4%), agreeing with the findings of Lopes10, Gonçalves et al.2 and Montovani et al14 Males are more prone to fractures in general, and the age group from 20 to 30 years is economically active and more prone to high energy trauma, due to their greater labor and social activity. The association with other facial and cranial fractures, especially affecting the zygomatic bone, maxilla and orbit, is common and often reported in the literature and agrees with the present study. There are several classifications of frontal frac-

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):41-6

Marins BR, Ă‰rnica NM, Garbin Jr EA, Griza GL, Conci RA, Pavelski MD

contour, acute or chronic sinusitis, mucocele or mucopyocele, osteomyelitis, encephalitis, meningitis or even cerebral abscess or cavernous sinus thrombosis, which may evolve to death4,5,9,17. The present study evidenced a low rate of complications, similar to reports in the world literature. However, the results did not present any statistical difference in complications between treatment modalities. There is consensus in the literature regarding the need of long-term follow-up of patients with frontal fracture; in this study, all patients were followed for at least 6 months.

performed in 12 surgically treated patients in whom only the anterior wall was affected and the nasofrontal duct was intact. Among these, fixation of bone fragments was performed in 3 cases with titanium miniplates and fixation screws; in 9 cases with titanium mesh and fixation screw, and in 1 case this was not necessary. Frontal sinus obliteration is usually performed when the nasofrontal duct is affected, which precludes cannulation. By this technique, the frontal sinus space may be filled with several materials, including autogenous bone, muscle fascia, muscle, fat, hydroxyapatite and cartilage. This technique is also used in cases of frontal sinus posterior wall fracture, in which there are no large displacements or comminutions,10 as in the present study, in which only 1 case (7.67%) presented nasofrontal duct obliteration. Severe complications may occur if treatment is inadequate, such as postoperative deformity in bone

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

CONCLUSION Based on the present results, it may be stated that there was no statistically significant difference between surgical and non-surgical groups concerning the complications. None of the therapeutic options is contraindicated, provided they are well recommended, as presented in this study.

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):41-6

Epidemiological study of two modalities for treatment of frontal fractures: retrospective analysis of 46 cases

References:

1. Bell RB. Management of frontal sinus fractures. Oral Maxillofac Surg Clin North Am. 2009 May;21(2):227-42. 2. Gonçalves CP, Farah GJ, Pava AJ, Camarine ET, Iwagi-Filho L, Iwagi LCV. Levantamento epidemiológico sobre fraturas de osso frontal atendidas pelo serviço de residência em cirurgia buco-maxilo da Universidade Estadual de Maringá, entre 2009 a 2012. FOL: Faculdade de Odontologia de Lins/Unimep. 2014 Jul-Dez;24(2):10-6. 3. Manson PN. Facial fractures. In: Mathes SJ, Hentz VR, editors. Plastic surgery. 2nd ed. Philadelphia: Saunders Elsevier; 2006. p. 338-44. 4. Garg RK, Afifi AM, Gassner J, Hartman MJ, Leverson G, King TW, et al. A novel classification of frontal bone fractures: The prognostic significance of vertical fracture trajectory and skull base extension. J Plast Reconstr Aesthet Surg. 2015 May;68(5):645-53. 5. Lee Y, Choi HG, Shin DH, Uhm KI, Kim SH, Kim CK, et al. Subbrow approach as a minimally invasive reduction technique in the management of frontal sinus fractures. Arch Plast Surg. 2014 Nov;41(6):679-85. 6. Febomfs MR, Pietra LD, Bertossi D, Albanese M, Fresku A. A simple method for the repair of frontal sinus fracture: the bone mesh pull-up technique. Craniomaxillofac Trauma Reconstr. 2014 Jan 9;7(1):79-84.

7. Asgharpour Z, Baumgartner D, Willinger R, Graw M, Peldschus S. The validation and application of a finite element human head model for frontal skull fracture analysis. J Mech Behav Biomed Mater. 2014 May;33:16-23. 8. Conci RA, Martins JRP, Tomazi FH, Sbardelotto BM, Sirena Neto L, Oliveira GR. Tratamento cirúrgico de fratura de seio frontal. Rev Cir Traumatol Buco-Maxilo-Fac. 2012;(12):31-6. 9. Dalla Torre D, Burtscher D, Kloss-Brandstätter A, Rasse M, Kloss F. Management of frontal sinus fractures--treatment decision based on metric dislocation extent. J Craniomaxillofac Surg. 2014 Oct;42(7):1515-9. 10. Lopes FS. Estudo epidemiológico retrospectivo de fraturas do seio frontal [monografia]. Araraquara (SP): Universidade Estadual Paulista; 2015. 11. Manolidis S, Hollier LH Jr. Management of frontal sinus fractures. Plast Reconstr Surg. 2007 Dec;120(7 Suppl 2):32S-48S. 12. Paza AO, Abuabara A, Passeri LA. Analysis of 115 mandibular angle fractures. J Oral Maxillofac Surg. 2008 Jan;66(1):73-6. 13. Hwang K, Song YB. Closed reduction of fractured anterior wall of the frontal bone. J Craniofac Surg. 2005 Jan;16(1):120-2.

14. Montovani JC, Nogueira EA, Ferreira FD, Lima Neto AC, Nakajima V. Cirurgia das fraturas do seio frontal: estudo epidemiológico e análise de técnicas. Rev Bras Otorrinolaringol 2006;72(2):204-9. 15. Doonquah L, Brown P, Mullings W. Management of frontal sinus fractures. Oral Maxillofac Surg Clin North Am. 2012 May;24(2):265-74, ix. 16. Bicalho ALR. Tratamento cirúrgico da fratura do osso frontal: revisão da literatura e relato de caso [monografia]. Belo Horizonte (MG): Universidade Federal de Minas Gerais; 2012. 17. Santos MBP, Cavalieri I, Araujo MM, Vale DS, Breda Junior MA. Tratamento de fratura do seio frontal seguido da obliteração do sistema de drenagem: relato de caso. Rev Portuguesa Estomatol Med Dent Cir Maxilofac. 2010;51(4):225-30.

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CaseReport

Pterygoid implants

for dental rehabilitation in an atrophic maxilla RAFAEL ZETEHAKU ARAUJO1 | CAMILA LOPES CARDOSO2 | CLÁUDIA CURRA2 | MARCOS MARTINS CURI2

ABSTRACT This paper presents a case of total rehabilitation of an atrophic maxilla using the pterygoid implant technique, discussing the surgical technique as well as the success rates, survival, peri-implant marginal bone loss and important clinical variables related to this type of treatment. The patient, aged 75 years, attended the clinic for rehabilitation of maxillary and mandibular dental arches. In the mandible, multiple tooth extractions were performed followed by immediate placement of six Nobel Biocare implants. Maxillary rehabilitation comprised placement of five Nobel Biocare implants at the anterior region, combined with two Bränemark pterygoid implants, bilaterally. There were no surgical or postoperative complications. The six-year follow-up evidenced the satisfactory esthetic and functional outcome. Dental rehabilitation with utilization of pterygoid implants is a treatment option with low morbidity, low cost and treatment time, associated with few surgical or prosthetic complications, both in short and long terms. They eliminate the need of reconstructive procedures and bone grafts, allowing immediate load due to their excellent primary stability, without the need of posterior cantilevers. The pterygoid implant technique is a viable and realistic treatment option for the rehabilitation of patients with atrophic posterior maxilla. Keywords: Prostheses and implants. Jaw fixation techniques. Mouth rehabilitation. Maxillary sinus. Reconstruction.

Unime/Facsul (Itabuna/BA, Brazil).

How to cite: Araujo RZ, Cardoso CL, Curra C, Curi MM. Implantes pterigóideos para reabilitação dentária de maxila atrófica. J Braz Coll Oral Maxillofac Surg. 2017 maio-ago;3(2):47-52. DOI: https://doi.org/10.14436/2358-2782.3.2.047-052.oar

Universidade Sagrado Coração (Bauru/SP, Brazil).

Submitted: October 15, 2016 - Revised and accepted: February 14, 2017

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

Contact address: Rafael Zetehaku Araujo Departamento de Cirurgia e Traumatologia Buco-Maxilo-Facial Secretaria da Pós-graduação em Biologia Bucal Rua Irmã Arminda, 10-50, Jardim Brasil, Bauru/SP – CEP: 17.011-160 E-mail: rafaelzaraujo@hotmail.com

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

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):47-52

Pterygoid implants for dental rehabilitation in an atrophic maxilla

INTRODUCTION Endosseous dental implants have been routinely used with success to treat completely or partially edentulous individuals. Dental rehabilitation in the posterior region of atrophic maxillae is difficult and challenging for professionals involved in this treatment. The anatomy of the region, maxillary sinus pneumatization, insufficient bone volume, poor bone quality (bone types III and IV, with large cancellous bone spaces), rare presence of cortical bone, besides difficult surgical and prosthetic access, are important aspects that should be considered in the dental rehabilitation of this region.1-3 Other important factor is the biomechanical aspect of intense mastication forces (especially in premolar and molar regions) as compared to the anterior maxillary region.2,3 To compensate for these difficulties, reconstructive procedures involving bone grafting, such as maxillary sinus lift and onlay grafts, have been indicated in these conditions. However, these surgical techniques require long healing periods, additional surgical stages, increased treatment costs, besides the evident risk of morbidity at the receptor and/or donor sites.2,3 Other rehabilitation options include the use of zygomatic, angulated and short implants – which also present individual advantages and disadvantages, concerning the biomechanics, morbidity, treatment time and cost.3-5 Rehabilitations of atrophic maxillae using implants only at the anterior maxillary region are often completed with long posterior cantilevers, which may lead to complications as screw and prosthesis fractures, marginal bone loss and loss of implant osseointegration in the long term.4-6 Tulasne7 suggested implant placement at the pterygoid region to solve these problems occurring in the rehabilitation of posterior atrophic maxilla. The pterygoid implant technique is characterized by implant placement in a bone pillar composed of the maxillary tuberosity, pyramidal process of palatine bone and pterygoid process of sphenoid bone. This compact bone pillar provides excellent bone anchorage, allowing implant-supported rehabilitation without the need of bone graft and/or posterior prosthetic cantilever. Implants placed at the pterygoid region have been reported in the literature as pterygomaxillary, pterygoid and maxillary tuberosity implants.2,9 However, they should not be confused with implants placed in the maxillary tuberosity with pterygoid implants. These

implants are not synonymous, and there are significant differences between them. Implants placed at the maxillary tuberosity region, also known as maxillary tuberosity implants, are inserted at the most distal portion of the maxillary alveolar process (bone type III and/or IV), in more vertical positioning and rarely above 10° of inclination. Pterygoid implants are placed across the maxillary tuberosity, passing through the pyramidal process of the palatine bone and reaching the pterygoid process of the sphenoid bone.2-8 These implants are placed with angulation between 30 and 70° in relation to the maxillary plane. The success and survival rates in short and long terms are very different between pterygoid implant and maxillary tuberosity implant techniques, especially considering the bone quality at the anatomical site of placement and biomechanical effects from axial prosthetic loads.2-8 Thus, this paper presents a case of dental rehabilitation using pterygoid implants and implant-supported complete denture in a patient with posterior atrophic maxilla bilaterally. The paper also discusses the surgical technique and correlates clinical variables with the success and survival rates of pterygoid implants. CASE REPORT Patient aged 75 years, of male gender, attended a private clinic for rehabilitation of edentulous maxillary and mandibular arches, using removable dentures and with complaint of masticatory difficulty, lack of comfort, nutritional and psychological deficit (Fig 1). Considering these aspects, dental rehabilitation was planned using implant-supported fixed dentures in both dental arches. In the mandible, surgery comprised multiple extractions (due to advanced periodontitis) and immediate placement of six implants (Nobel Replace Nobel Biocare, four 4.3 x 16 mm implants and two 4.3 x 10 mm implants). The fabrication and placement of mandibular metal-ceramic denture occurred three months after surgery for implant placement. Maxillary rehabilitation comprised the same surgical technique for placement of five implants (Replace, Nobel Biocare; 4.3 x 10 mm RP) at the anterior maxillary region, combined with two pterygoid implants (Branemark System, Nobel Biocare; 18 x 3.75mm) at the posterior region, bilaterally (Fig 3). Surgery was performed under local anesthesia, with administration of articaine with epinephrine 1:100,000. The implant-supported fixed denture was fabricated and placed four months after osseointegration (Fig 5, 6). 48

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):47-52

Araujo RZ, Cardoso CL, Curra C, Curi MM

Figure 1: Initial radiograph. Notice the bilateral pneumatization at the maxillary sinus region, precluding implant placement at the region.

Figure 2: Adequate angulation (posterosuperior) of pterygoid implant placement, using straight handpiece at the pterygomaxillary region.

Figure 3: Immediate postoperative panoramic radiograph after implant placement in the maxilla. Notice the implant length and adequate inclination for the pterygoid implant technique.

Figure 4: Pterygoid implant in place.

Figure 5, 6: Placed dentures. Notice the adequate space for hygiene and rehabilitation up to the second molar, bilaterally.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):47-52

Pterygoid implants for dental rehabilitation in an atrophic maxilla

SURGICAL PROTOCOL FOR PLACEMENT OF PTERYGOID IMPLANT The surgical technique for placement of pterygoid implant is an outpatient procedure performed under local anesthesia. Imaging examinations, including panoramic radiograph and cone beam computed tomography, aid the surgical planning for implant placement at the pterygomaxillary region. The procedure is initiated by an incision on the bone crest at the posterior maxillary region and detachment of buccal and palatal mucous flaps, exposing the entire bone crest at the maxillary tuberosity region. This is followed by bone instrumentation for placement of pterygoid implant, using burs to define the implant angulation and direction, until reaching the bone pillar composed of the maxillary tuberosity, palatine bone and pterygoid process of sphenoid bone. Bone instrumentation for placement of pterygoid implant should follow posterior and upper direction of approximately 45° and oblique direction in relation to the palate of nearly 15°. For that purpose, a straight handpiece is used for instrumentation to guide the direction and angulation of surgical burs (Fig 3). Instrumentation is initiated with a 1.5 x 20 mm helicoidal bur penetrating without resistance through the cancellous bone at the maxillary tuberosity, toward the tuberosity-palatine-pterygoid pillar. This bone pillar is a region of greater bone density (composed of compact bone) and this greater resistance to perforation may be noticed. At this moment, the perforation pressure must be increased and the rotation speed should be reduced (to control and avoid accidents) until the pterygoid process is reached. The utilization of tactile sensation during perforation aids to reduce the potential surgical risks, especially transoperative hemorrhage. Preparation of the implant site is continued with 2 x 20 mm bur and finalized with 3 x 20 mm bur, which are used in a stepwise manner to maintain the most apical 4 mm without total instrumentation, aiming to enhance the primary implant stability upon insertion. The dimensions of the pterygoid implant to be placed are checked at this moment. It is possible to observe adequate implant emergence on the bone crest center at the region between maxillary second and third molars (Fig 4). Final prosthetic rehabilitation occurs after three months of osseointegration, with reopening of implants and all prosthetic stages for fabrication of the implant-supported denture. At reopening, the need of angulated (17°) or straight prosthetic abutments is

analyzed for denture fabrication. The lengths of prosthetic abutments range from 3 to 5mm, because the mucosa at this region is usually thicker. DISCUSSION Implant placement at the pterygomaxillary region provides excellent bone anchorage at the posterior maxillary region for the support of fixed or removable dentures. This rehabilitation has some advantages, such as avoidance of reconstructive procedures (grafts), reduced treatment time (avoiding new surgeries), reduced final treatment costs, besides providing posterior support/anchorage, and avoiding the negative effects of intense masticatory loads on cantilever dentures, as compared to implants only at the anterior maxillary region.2-4 From a surgical standpoint, this technique requires operative skill and attention to tactile sensation, more specifically sensitivity that the cortical bone of the pterygoid plate was reached.10 This cortical locking is very important to increase the primary stability and long-term success. For that purpose, pterygoid implants must be long enough to cross the maxillary tuberosity and pyramidal process of palatine bone and then lock at the pterygoid process of sphenoid bone; therefore, the length of these implants varies from 15 to 20mm.7-10 For proper instrumentation and implant placement toward the pterygoid pillar, the adequate angulation is approximately 81° in buccopalatal direction and 45 to 70° in anteroposterior direction, both in relation to the Frankfurt plane.7-10 In 2011, Bidra and Huynh-Ba3 published a systematic review on the survival of pterygoid implants in both short and long terms. They concluded that there is lack of studies with adequate follow-up time and highlighted the importance to distinguish between implants placed at the maxillary tuberosity and pterygoid implants. In this review, the survival rate of pterygoid implants was 92% in the first year, yet the survival rates after one year are not yet known, due to the lack of long-term studies. The authors suggest adopting the definition from the Glossary of Oral and Maxillofacial Implants for pterygoid implants, such as “implants placed through the maxillary tuberosity and on the pterygoid plate”. In reviewed papers, concerning implant failures, 88% occurred before prosthetic loading of implants. Another literature review conducted by Candel and Peñarrocha4 on pterygoid implants, with minimum follow-up of 12 months, analyzed a total of 1,053 pterygoid implants in

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Araujo RZ, Cardoso CL, Curra C, Curi MM

Patient acceptance of distal prosthetic components is excellent, in agreement with previously reported studies.4,10 No problems related to speech or difficulties in maintenance or hygiene have been observed, since the emergence of implants/abutments occurs on the occlusal aspect of molars and allows local hygiene of this free end. In general, the gingival biotype around pterygoid implants is thick and keratinized, which is clinically advantageous for the peri-implant health and long-term success of implants.

676 patients, and revealed a mean success rate of 90.7%. Also, these authors concluded that pterygoid implants did not present marked complications compared to conventional implants, and revealed high level of patient satisfaction with the dentures.4 Studies analyzing bone loss in pterygoid implants on panoramic radiographs obtained excellent results one year after prosthetic loading of implants, with mean marginal bone loss of 0.71 mm.3 Curi et al10 evaluated the marginal bone loss around pterygoid implants of 1.21 mm (1.31 mm mesial and 1.01 mm distal) at 36-month follow-up. Few complications have been related to the surgical procedure in this type of treatment, which usually include mild venous bleeding and edema.2-10 Bleeding in the region is related to vessels of pterygoid muscles and may be easily controlled when implants are placed in their final position. The low complication rate associated with this technique may be anatomically explained, considering that there are no vital anatomical structures at the region of implant placement, since the internal maxillary artery runs 1 cm above the pterygopalatine suture.5

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

CONCLUDING REMARKS The utilization of pterygoid implants associated with anterior implants is a realistic and predictable treatment option for rehabilitation of individuals with atrophic posterior maxillae. This rehabilitation reduces the treatment time and costs and allows fabrication of fixed dentures with easy local hygiene maintenance without the need of cantilevers. Oral and maxillofacial surgeons and prosthodontists should consider this rehabilitative technique for patients with atrophic posterior maxillae.

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Pterygoid implants for dental rehabilitation in an atrophic maxilla

Referências:

1. Bahat O. Osseointegrated implants in the maxillary tuberosity: report on 45 consecutive patients. Int J Oral Maxillofac Implants. 1992 Winter;7(4):459-67. 2. Balshi SF, Wolfinger GJ, Balshi TJ. Surgical planning and prosthesis construction using computer technology and medical imaging for immediate loading of implants in the pterygomaxillary region. Int J Periodontics Restorative Dent. 2006 June;26(3):239-47. 3. Bidra AS, Huynh-Ba G. Implants in the pterygoid region: a systematic review of the literature. Int J Oral Maxillofac Surg. 2011 Aug;40(8):773-81. 4. Candel E, Peñarrocha D, Peñarrocha M. Rehabilitation of the atrophic posterior maxilla with pterygoid implants: a review. J Oral Implantol. 2012 Sept;38 Spec No:461-6.

5. Graves SL. The pterygoid plate implant: a solution for restoring the posterior maxilla. Int J Periodontics Restorative Dent. 1994 Dec;14(6):512-23. 6. Peñarrocha M, Carrillo C, Boronat A, Peñarrocha M. Retrospective study of 68 implants placed in the pterygomaxillary region using drills and osteotomes. Int J Oral Maxillofac Implants. 2009 July-Aug;24(4):720-6. 7. Tulasne JF. Osseointegrated fixtures in the pterygoid region. In: Worthington P, Brånemark PI, editors. Advanced osseointegration surgery. Applications in the maxillofacial region. Chicago: Quintessence; 1992. p. 182-8.

8. Valerón JF, Valerón PF. Long-term results in placement of screw-type implants in the pterygomaxillarypyramidal region. Int J Oral Maxillofac Implants. 2007 Mar-Apr;22(2):195-200. 9. Laney WR, editor. Glossary of oral and maxillofacial implants. Hanover Park, IL: Quintessence; 2007. 10. Curi MM, Cardoso CL, Ribeiro Kde C. Retrospective study of pterygoid implants in the atrophic posterior maxilla: implant and prosthesis survival rates up to 3 years. Int J Oral Maxillofac Implants. 2015 MarApr;30(2):378-83.

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):47-52

CaseReport

Extensive craniofacial reconstruction using

polymethylmethacrylate prostheses EDUARDO DE LIMA ANDRADE1 | ANA CAROLINA LEMOS PIMENTEL1 | DEYVID SILVA REBOUÇAS1 | LIVIA PRATES SOARES ZERBINATI1 | ADRIANO FREITAS ASSIS1

ABSTRACT The reconstruction of acquired cranial defects is a challenge in reparative surgery. For craniofacial reconstruction, emphasis is given to autogenous bone grafts and alloplastic materials, such as titanium, silicone, high-density polyethylene and polymethylmethacrylate (PMMA). This paper presents the successful utilization of customized polymethylmethacrylate prostheses, describing a case of craniofacial reconstruction conducted at the Oral and Maxillofacial Surgery and Traumatology Service of Hospital Geral Roberto Santos. The prostheses were fabricated with PMMA based on a biomodel, mimicking the real patient condition, who was affected by trauma with sequelae of fracture of facial bones and tissue loss at the frontal region due to craniotomy. The patient has been followed for one year postoperatively without any reactions to the graft material or complaints about facial esthetics. The PMMA prosthesis may be fabricated preoperatively, using rapid prototyping biomodels, or during surgery by direct application on the tissues. Keywords: Polymethyl methacrylate. Reconstruction. Facial bones. Craniotomy.

Escola Bahiana de Medicina e Saúde Pública, Dental School, Department of Oral and Maxillofacial Surgery and Traumatology (Salvador/BA, Brazil).

How to cite: Andrade EL, Pimentel ACL, Rebouças DS, Zerbinati LPS, Assis AF. Extensa reconstrução craniofacial com próteses em polimetilmetacrilato. J Braz Coll Oral Maxillofac Surg. 2017 maio-ago;3(2):52-61. DOI: https://doi.org/10.14436/2358-2782.3.2.053-061.oar

Contact address: Ana Carolina Lemos Pimentel Av. Silveira Martins, 3386, Cabula – CEP: 41.150-100, Salvador/BA E-mail: anacarolinalemosp@gmail.com

Submitted: November 21, 2016 - Revised and accepted: March 05, 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.

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):52-61

Extensive craniofacial reconstruction using polymethylmethacrylate prostheses

INTRODUCTION The loss of a body part significantly affects a person’s life, as well as his or her physical and mental status.1 Craniofacial traumas, tumors and intracranial malignant hypertension are the main etiological factors leading to acquired cranial defects, due to the need of neurosurgical management.2 Cranioplasty is a surgical intervention that aims to restore the integrity affected by skull defects, protect the underlying neural tissue and improve the perfusion and local metabolism.3,4 This procedure is especially challenging for surgeons, due to difficult reconstruction of the facial region, which presents different curvatures and bone thicknesses, besides the difficult selection of materials that can be used and need of a specialized team for this approach.1 The reestablishment of esthetics and function in craniofacial reconstruction comprises several reconstructive methods: from conservative treatments – such as bone reduction with or without fixation, that provides good results in facial bone fractures – up to the use of autogenous grafts, as well as bone substitutes in cases with difficult reconstruction.2,5,6 Preservation of the autogenous bone removed during craniotomy in the abdominal region or by freezing has been successfully described by some authors.4,7 However, repositioning of removed bone fragments is not always possible, such as in individuals with previous trauma with comminuted fractures.1 The main donor areas for autologous grafts are the calvaria, ribs and iliac crest.3,6,8,9 They are considered gold standard and have biological properties as osteoconduction, osteogenesis and osteoinduction, as well as easy achievement, which is fundamental for success when grafts are needed for facial reconstruction. However, there are some disadvantages as morbidity, difficult fitting, risk of infection, graft reabsorption and available quantity. These aspects are extremely important and should be considered in craniofacial reconstructions.1 With the evolution of biomaterials, alloplastic grafts have been increasingly used. Several materials are used for that purpose, including polymethylmethacrylate (PMMA), which is currently the most employed; hydroxyapatite; porous polyethylene; silicone and titanium mesh.2,3,4,6,10,11 When handled transoperatively, they can lead to poor esthetic results, due to the difficulty to achieve the desirable contour and fitting4.

PMMA presents exothermic polymerization and releases toxic monomers; these characteristics may lead to focal tissue damage, which implies local and systemic reactions. These factors increase the surgical time and consequently the surgical morbidity.4,2 The fabrication of customized prostheses, with adequate dimensions and shapes for correction of each type of defect, allows an increasingly thorough use of alloplastic materials.4,1,10 Customization is aided by rapid prototyping, which consists of three-dimensional printing of a model compatible with the anatomical structure to be treated, obtained by information collected from imaging examination data (computed tomography). Customized prostheses are fabricated by these prototypes, which reproduce the defect accurately, enhancing the efficiency of the entire treatment process, reducing the surgical time, blood loss and risk of postoperative infection.4,1,10 Thus, this paper presents the results of customized polymethylmethacrylate prostheses used for reconstruction in oral and maxillofacial surgery, describing a case of craniofacial reconstruction performed at the Department of Oral and Maxillofacial Surgery and Traumatology of Hospital Geral Roberto Santos, with one-year follow-up. CASE REPORT Patient aged 40 years, victim of motorcycle accident in 2011, attended the Oral and Maxillofacial Surgery and Traumatology Service of Hospital Geral Roberto Santos in year 2012, with complaint of diplopia in infraversion and dissatisfaction with facial esthetics. The patient denied systemic diseases or chronic intake of medicines. Physical examination revealed extensive defect on the frontal region, loss of malar projection on the right side and preserved extrinsic eye mobility, with enophthalmos, hypophthalmos and lowered attachment of the right medial canthal ligament (Fig 1). Tomographic examination revealed extensive defect on the frontal region, sequelae of fracture of the zygomatic bone, mandible and nasal bones, besides defect on the right orbit region on the orbital floor, medial and upper walls (Fig 2). Prototypes were requested for analysis and fabrication of implantable PMMA prostheses, from Centro de Tecnologia e Informação Renato Archer (CTI), which allowed analysis of the actual bone condition of the patient (Fig 3).

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):52-61

Andrade EL, Pimentel ACL, RebouĂ§as DS, Zerbinati LPS, Assis AF

The postoperative follow-up tomography presented in images A and B, representing one-week postoperative follow-up, reveals intensive emphysema on the zygomatic and frontal regions, as well as a dead space created by the prosthesis on the frontal region. In images C, D and E, presenting the one-year postoperative follow-up, signs of emphysema and the dead space created by the prosthesis on the frontal region are no longer observed, and the images reveal excellent restoration of contour both in frontal and zygomatic-orbital regions (Fig 5). Wide-spectrum antibiotic therapy was prescribed postoperatively and the patient evolved without signs or symptoms of infections or rejection of prostheses. Images at one-year postoperative follow-up revealed good esthetic result in the frontal region, malar projections, absence of hypophthalmos and corrected enophthalmos, compared to the preoperative period (Fig 6).

The patient was submitted to surgery under general anesthesia for placement of prostheses on the frontal and zygomatic regions, aided by a neurosurgery team. Coronal access was performed with right preauricular extension to expose the region, right zygomatic arch, upper and medial walls of the right orbit, with detachment of the medial canthal ligament (Fig 4). Right subciliary access was performed to expose the infraorbital rim and orbit floor close to the medial and lateral walls, and right maxillary buccal access, communicating with the infraorbital access, for placement of zygomatic prosthesis. After prosthesis placement, canthopexy was performed with nylon sutures, and suture was performed on the frontal region (Fig 4). After placement of prostheses, the medial wall and orbital floor were reconstructed using titanium mesh.

Figure 1: A) Frontal photograph indicating loss of frontal projection. B) Caudocranial photograph revealing loss of frontal and right zygomatic projection. C) Preserved extrinsic eye mobility.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):52-61

Extensive craniofacial reconstruction using polymethylmethacrylate prostheses

Figure 2: Preoperative computed tomograms with coronal sections evidencing defect in orbital floor, medial and upper walls (A). Sequel of mandibular symphysis fracture (B). Defect in frontal region (C). Sequel of right zygoma fracture (D).

Figure 3: Prototype demonstrating the actual status of the patient in 3D (A). Customized PMMA prostheses on the prototype, in frontal and zygomatic regions (B and C).

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):52-61

Andrade EL, Pimentel ACL, RebouĂ§as DS, Zerbinati LPS, Assis AF

Figure 4: Surgical accesses performed, caudocranial image, with reconstruction of orbital medial wall with titanium mesh (A). Zygomatic PMMA prosthesis in place and mesh reconstructing the orbital floor through the subciliary access (B). Frontal prosthesis in PMMA, placed with nylon suture used for canthopexy, connected to the frontal region (C).

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):52-61

Extensive craniofacial reconstruction using polymethylmethacrylate prostheses

Figure 5: A, B) Axial images of computed tomography in immediate postoperative period. C, D) Axial images of computed tomography one-year postoperatively. E) Coronal image of computed tomography one-year postoperatively.

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):52-61

Andrade EL, Pimentel ACL, Rebouças DS, Zerbinati LPS, Assis AF

Figure 6: Pre- and postoperative photographs: A, B) frontal, C, D) lateral, E, F) caudocranial.

DISCUSSION Selection of a bone substitute for craniofacial reconstruction is a difficult task, since the array of materials and purpose of the graft are determinant for the desired goals, either esthetic, functional or both.10 The present treatment was performed by craniofacial reconstruction with PMMA prostheses, which met the esthetic and functional objectives of neural tissue protection. Utilization of the bone tissue removed during craniotomy – which was frozen, maintaining the graft viability – was described in the paper of Sundseth et

al.7 This procedure accurately restores the physiological skull configuration and allows revascularization and new bone formation in the region affected by craniotomy.7 This is similar to the report of Wang et al,9 who used myocutaneous graft to restore the facial function and esthetics in victims of firearm accidents. The disadvantages include postoperative infection and graft resorption, as reported by Sundseth et al7 Alloplastic graft was used in the present case, which eliminated the need of a donor area and did not allow resorption, besides being biocompatible, did not produce bacterial colonization and reduced the surgical morbidity.

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):52-61

Extensive craniofacial reconstruction using polymethylmethacrylate prostheses

other study, excellent outcomes were observed with the use of polyether ether ketone (PEEK), a semi-crystalline thermoplastic polymer derivative, which provides good resistance, biocompatibility and translucency on radiographs.1 In the present paper, alloplastic material was used for zygomatic complex reconstruction and titanium mesh for orbital reconstruction, which restored the malar projection and corrected the hypophthalmos, with excellent outcome in one-year follow-up. Cranialization or frontal sinus duct obliteration in patients with fractures at this region have been suggested to protect the neural tissue, reducing the risk of infection and preventing complications in craniofacial reconstructions, with consequent surgery loss.15 In the present case, the frontal sinus was affected and the ducts were exposed, yet they were obliterated with fat tissue. Postoperatively, there were no complaints of sinus pathology symptoms and the empty spaces created by the prosthesis were physiologically filled. Among filling materials for obliteration of the frontal region, the literature highlights particulate bone from the iliac crest. However, there have been high failure rates, with infections in the postoperative period.15 The scanning of 3D models of cranial defects is very helpful in reparative surgery, since it significantly reduces the surgical time, as well as blood loss, compared to procedures in which the prostheses are handled and molded transoperatively, when it is difficult to achieve the desirable contour and curvature. An advantage is the esthetic outcome similar to bone repositioning in cases with preservation of bone removed during craniotomy. The reported disadvantages include high cost and long time required for fabrication of prostheses.4 In the present case, the prototype was obtained at Centro de Tecnologia e InformaĂ§ĂŁo Renato Archer (CTI), which provides biomodels at no cost to patients assisted by the Brazilian Public Health System (SUS). The prostheses were customized by dental professionals experienced with the manipulation of PMMA, which aided to reduce the surgical time and consequent morbidity, besides the excellent postoperative result.

The manipulation of PMMA transoperatively offers the advantages of lower cost and time required for prosthesis fabrication. Tissue reactions were suggested as being caused by the release of residual monomer and heating during the PMMA polymerization period in the study conducted by Pikis et al,2 in which the brain activity was monitored during surgery for craniotomy and cranioplasty. Changes were only observed during PMMA polymerization and in the immediate postoperative period, during which the patients exhibited mental confusion and agitation, which was assigned to toxicity of the residual monomer of PMMA. Even though PMMA prostheses were used in the present case, no adverse reaction was observed as reported by the aforementioned author, probably because customized prostheses were used, which reduced the risk of tissue reaction by heat or monomer residues. The study of Staffa et al,10 who employed customization of hydroxyapatite prostheses, revealed implant osseointegration to the underlying bone; however, there were cases of prosthesis fracture. Another study employed silicone prostheses for craniofacial reconstruction, with good patient acceptance and without immunological or infectious reactions to the material. However, elastic properties were mentioned in prostheses that aim to protect the neural tissue,11 which is not observed in PMMA prostheses, since this is an inert material that does not induce bone formation, yet offers good functional properties.12 Another substitute is porous polyethylene, which is excellent for craniofacial reconstructions due to easy material adaptation to the bone defects and because it allows tissue growth around the prosthesis and presents good patient acceptance, as demonstrated in a study performing orbital-zygomatic reconstructions.6,13 This was also observed in the present study, in which the polymethylmethacrylate graft in the frontal and zygomatic regions promoted excellent result, restoring the facial projections and esthetics to the patient. Osteotomy in sequelae of fractures of the zygomatic complex is a favorable treatment option. However, the use of grafts aims to reestablish the lost bone, restore atrophic tissue and provide tissue support and protection,14 as presented in the paper of Ram et al,6 who used iliac crest graft or porous polyethylene for orbital reconstruction. In this paper, autogenous bone was indicated as having better results for more severe cases, due to iliac crest resistance to infection. In an-

ÂŠ Journal of the Brazilian College of Oral and Maxillofacial Surgery

CONCLUDING REMARKS Customized polymethylmethacrylate prostheses reduce the rates of material reaction and toxicity and provide excellent results, from both esthetic and functional standpoints. Therefore, they may be indicated for craniofacial reconstructions.

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):52-61

Andrade EL, Pimentel ACL, Rebouças DS, Zerbinati LPS, Assis AF

References:

1. Alonso-Rodriguez E, Cebrián JL, Nieto MJ, Del Castillo JL, Hernández-Godoy J, Burgueño M. Polyetheretherketone custom-made implants for craniofacial defects: Report of 14 cases and review of the literature. J Craniomaxillofac Surg. 2015 Sept;43(7):1232-8. 2. Pikis S, Goldstein J, Spektor S. Potential neurotoxic effects of polymethylmethacrylate during cranioplasty. J Clin Neurosci. 2015 Jan;22(1):139-43. 3. Sahoo N, Roy ID, Desai AP, Gupta V. Comparative evaluation of autogenous calvarial bone graft and alloplastic materials for secondary reconstruction of cranial defects. J Craniofac Surg. 2010 Jan;21(1):79-82. 4. Lee SC, Wu CT, Lee ST, Chen PJ. Cranioplasty using polymethyl methacrylate prostheses. J Clin Neurosci. 2009 Jan;16(1):56-63. 5. Adam AA, Zhi L, Bing LZ, Zhong Xing WU. Evaluation of treatment of zygomatic bone and zygomatic arch fractures: a retrospective study of 10 years. J Maxillofac Oral Surg. 2010 June;9(2):134-41. 6. Ram H, Singh RK, Mohammad S, Gupta AK. Efficacy of iliac crest vs. Medpor in orbital floor reconstruction. J Maxillofac Oral Surg. 2010 June;9(2):134-41.

7. Sundseth J, Sundseth A, Berg-Johnsen J, Sorteberg W, Lindegaard KF. Cranioplasty with autologous cryopreserved bone after decompressive craniectomy. Complications and risk factors for developing surgical site infection. Acta Neurochir (Wien). 2014;156(4):805-11. 8. Ahmad I, Choudhary R. Wide surgical excision with split rib graft reconstruction of mandible for ameloblastoma; our 10 year experience. Indian J Otolaryngol Head Neck Surg. 2013 Jan;65(1):40-3. 9. Wang W, Duan J, Wang Q, Kuang W. Complex reconstruction of facial deformity and function after severe gunshot injury: one case report. Int J Clin Exp Med. 2015;8(1):1427-33. 10. Staffa G, Barbanera A, Faiola A, Fricia M, Limoni P, Mottaran R, et al. Custom made bioceramic implants in complex and large cranial reconstruction: A two-year follow-up. J Craniomaxillofac Surg. 2012 Apr;40(3):e65-70. 11. Lăţcan E, Popescu CR. Endoprosthetic reconstructive surgery with medical grade long term implantable silicone in facial asymmetry. J Med Life. 2012 Dec 15;5(4):474-81.

12. Silva ALF, Borba AM, Simão NR, Pedro FLM, Borges AH, Miloro M. Customized polymethyl methacrylate implants for the reconstruction of craniofacial osseous defects. Case Rep Surg. 2014(2014): Article ID 358569, 8 pages. 13. Mohammadi S, Ghourchian S, Izadi F, Daneshi A, Ahmadi A. Porous high density polyethylene in facial reconstruction and revision rhinoplasty: a prospective cohort study. Head Face Med. 2012;8:17. 14. Ranganath K, Hemanth Kumar HR. The correction of post-traumatic pan facial residual deformity. J Maxillofac Oral Surg. 2011 Mar;10(1):20-4. 15. Monnazzi M, Gabrielli M, Pereira-Filho V, HochuliVieira E, Oliveira H, Gabrielli M. Frontal sinus obliteration with iliac crest bone grafts. Review of 8 cases. Craniomaxillofac Trauma Reconstr. 2014 Dec;7(4):263-70.

J Braz Coll Oral Maxillofac Surg. 2017 may-aug;3(2):52-61

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

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

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

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

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

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

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