Anatomical aspects and technical note of a modified retropharyngeal approach and reconstruction of the anterior occipitocervical junction.

Surgery to expose the anterior occiptocervical junction (OCJ) is exacting, and optimal approaches are debatable. The close proximity of vital structures and difficult surgical access present a unique challenge to treat lesions in this area. Routine access to the upper anterior cervical spine remains limited. The authors present a modified retropharyngeal approach and instrumentation in order to resect an exceptionally rare atypical rhabdoid teratoid tumor involving the craniovertebral junction. The technical aspects of this approach in anatomical perspectives are discussed in this article.

Facial Nerve Palsy Associated With Orthognathic Surgery.

The authors report a 25-year-old female who presented facial palsy after undergoing bimaxillary orthognathic surgery for retrognathism correction. Orthognathic surgery is a procedure used to treat dentofacial deformities which aims to achieve an adequate relationship between dental archs, improving function (such as chewing, breathing, and speaking) and facial aesthetics. Even though there are some complications that can occur during the intraoperative and postoperative periods like bleeding, tooth, soft-tissue damage, nerve damage, bad split, infection, and nonunion, facial nerve injuries are considered rare complications after this kind of surgical procedure. Despite being uncommon, rarely described, transient, and spontaneously resolved in almost all patients, facial nerve palsy is one of the most serious complications because it directly affects patient's quality of life and social interaction.

Metastasis of Prostate Adenocarcinoma in the Mandible: Rare Occurrence in Maxillary Bones.

OBJECTIVE: This article describes the case report of a prostate adenocarcinoma in the mandible. BACKGROUND: Prostate adenocarcinoma is a malignant tumor common in men from the fourth decade of life. The occurrence of oral metastatic lesions is rare. CASE REPORT: A 78-year-old male patient was referred to the oral and maxillofacial surgery service of the Pontifical Catholic University of Rio Grande do Sul for complaints of painless volume increase in the mandible. The diagnosis through the association of clinical, radiographic, and histopathological examination with the patient's health history determined that the lesion was prostatic adenocarcinoma metastasis. CONCLUSION: Despite the rare occurrence of metastases in the oral region, the dental surgeon should be aware of the possibility for correct diagnostic conduction and, subsequently, the institution of treatment in the early stages of disease.

Postural Assessment in Class III Patients Before Orthognathic Surgery.

PURPOSE: To determine the postural characteristics of patients with Class III dentofacial deformities before orthognathic surgery by photogrammetry using SAPO postural assessment software. MATERIALS AND METHODS: This was a cross-sectional study. Eligible participants were adult patients who had an indication for orthognathic surgery to correct skeletal Class III dentofacial deformities and were undergoing orthodontic preparation for surgery. Patients were recruited at the outpatient clinic for dentofacial deformities of the authors' institution from March to November 2015. Postural assessment was performed by photogrammetry based on anterior, posterior, and lateral images, which were analyzed using SAPO software. RESULTS: The sample consisted of 40 patients with a mean age of 28.7 years; 55% were men. Postural changes were found in most anatomic structures, and the main changes were anterior displacement of the center of gravity (sagittal plane asymmetry, 43.77%) and a tendency to left lateral deviation (frontal plane asymmetry, -3.89%). The anterior view showed a pattern of head tilt to the left (measured value minus reference value [Δ], -0.22), elevation of the left acromion (Δ, 2.31), elevation of the right anterior superior iliac spine (Δ, -0.56), right knee with genu varum (Δ, 1.25), and left knee with genu valgum (Δ, -1.55). The posterior view displayed scapular asymmetry with abduction of the right scapula (Δ, 7.54) and valgus foot deformity (Δright, 8.35; Δleft, 11.60). The lateral view depicted decreased cervical lordosis (Δright, 22.63; Δleft, 19.98), pelvic anteversion (Δright, -0.56; Δleft, -0.26), and genu flexum at the right (Δ, 6.85) and left (Δ, 4.40) knees. Twenty-seven patients (67.5%) reported temporomandibular joint pain. CONCLUSIONS: Postural assessment by photogrammetry showed that most anatomic structures were outside the normal range in patients with skeletal Class III dentofacial deformities before orthognathic surgery. These results suggest that dentofacial abnormalities can lead to postural disorders in this population.

Use of Recombinant Human Bone Morphogenetic Protein-2 Associated With Lyophilized Bovine Bone in Reconstruction of Atrophic Maxilla.

Cases of severely atrophic edentulous maxilla require reconstruction techniques employing bone grafts to promote adequate bone dimension for the successful placement of dental implants for prosthetic rehabilitation that reestablishes the patient's function and aesthetics. This study aims to present a severely atrophic edentulous maxilla reconstruction with the off-label use of recombinant human bone morphogenetic protein type 2 (rhBMP-2) associated with lyophilized particulate bovine bone xenograft for the prosthetic rehabilitation with osseointegrable dental implants. The paper describes a case of severely atrophic edentulous maxilla in a 42-year-old woman referred to the dental school with complaint of failure in adaptating to the dentures. The patient reported 27 years of maxilla edentulism and consecutive treatment failures, so the proposed therapy was the reconstruction of the maxilla with an association of rhBMP-2 and lyophilized bovine bone xenograft for increasing bone volume and further prosthetic rehabilitation with osseointegrated dental implants. The present report illustrates a case of atrophic edentulous maxilla in which the off-label use of rhBMP-2 was successful and the patient's prosthetic rehabilitation could be concluded. The 8 dental implants received prosthetic functional load during 1 year of follow-up with no complications. Based on the case presented, the association between rhBMP-2 and a bovine bone xenograft could be considered a viable option for the reconstruction of atrophic edentulous maxilla. After a year of functional prosthetic load follow-up, the patient is asymptomatic and satisfactorily adaptated to the prosthesis, which restored her functional and aesthetic demands.

Changes in Cervical Lordosis After Orthognathic Surgery in Skeletal Class III Patients.

The purpose of this study was to evaluate cervical lordosis and head posture changes using lateral cephalographs after bimaxillary orthognathic surgery for mandibular prognatism by null hypothesis. Twenty-five patients with skeletal class III dentofacial deformities (10 men, 15 women; mean age, 29.28 ±â€Š8.23 years; range 18-48 years) were included in this prospective clinical study. Lateral cephalographs were taken in natural head position (NHP) 2 weeks before and 6 months after orthognathic surgery. The reproducibility of the radiographer's technique of taking radiographs in NHP was investigated using a photographic method and found to be acceptable. All measurements for cervical lordosis (CV1/CV2; CV3/CV7; CV1/CV7), head posture (NSL/OPT; NSL/VER), and other cephalometric values (NSL/Go-Gn; NSL/OCL; Overjet) were repeated 3 times by the same blinded investigator at 2-week intervals and the average values of the 3 measurements were calculated to use in statistical analysis. Intraclass correlation coefficients (ICC) ranged between 0.996 and 1.000, demonstrating a high reliability of the measures. Statistically significant differences were found for CV3/CV7 (P = 0.006) and CV1/CV7 (P = 0.005) and no significant differences were identified in head posture for both cranio-cervical and cranio-vertical angles. The null hypothesis was rejected. Orthognathic surgery resulted in significant cervical lordosis extension, and a tendency for head extension could also be observed.

Bone Substitutes in Le Fort I Osteotomy to Promote Bone Union and Skeletal Stability.

Maxillary advancement by Le Fort I osteotomy has become the standard procedure to restore function and facial esthetics, correct skeletal and occlusal discrepancies, and treat obstructive sleep apnea in patients with facial deformities. Incomplete ossification between the bone segments at the jaw osteotomy site has proven to be a major problem in these patients. There are several studies in the literature that address orthognathic surgery, but only a limited number that discuss the use of graft materials in maxillary osteotomy. Bone grafts were introduced in recent decades in order to promote and improve bone union and prevent the formation of gaps. This study will discuss the results obtained using bone substitutes in orthognathic surgery for maxillary advancement and maxillary repositioning with Le Fort I osteotomy, in a clinical report and a literature review, covering the main indications and specifying the type of material used and the stability of the surgical procedure postoperatively.

Low-level laser therapy on bone repair: is there any effect outside the irradiated field?

The biological effects of local therapy with laser on bone repair have been well demonstrated; however, this possible effect on bone repair outside the irradiated field has not been evaluated. The aim of this study was to investigate the effect of low-level laser therapy (LLLT) (λ = 830 nm) on repair of surgical bone defects outside the irradiated field, in rats. Sixty Wistar rats were submitted to osteotomy on the left femur and randomly separated into four groups (n = 15): group I, control, bone defect only; group II, laser applied on the right femur (distant dose); group III, laser applied locally on the bone defect and also on the right femur (local and distant doses); and group IV, laser applied locally on the left femur (local dose). Laser groups received applications within a 48-h interval in one point per session of density energy (DE) = 210 J/cm(2), P = 50 mW, t = 120 s, and beam diameter of 0.028 cm. Five animals of each group were euthanized 7, 15, and 21 days after surgery. Histologic analysis in all groups showed new bone formation in the region of interest (ROI) at 7 days. After 15 days, bone remodeling with a decrease of bone neoformation in the marrow area was observed in all groups. After 21 days, advanced bone remodeling with new bone mostly located in the cortical area was observed. The histomorphometric analysis showed at 7 days a significant increase of bone formation in groups III and IV compared to groups I and II. At days 15 and 21, histomorphometric analysis showed no significant differences between them. Laser therapy presented a positive local biostimulative effect in the early stage of bone healing, but the LLLT effect was not observed a long distance from the evaluated area.

Neurosensory recovery of inferior alveolar nerve gap reconstruction: a systematic review.

Numerous procedures can potentially injure the inferior alveolar nerve during oral and maxillofacial surgery, eventually causing loss or alteration of local sensitivity. When its total rupture occurs, a conduit, such as an autogenous graft, can be used to join it. Due to the morbidity resulting from this technique, alternative forms of sensorineural repair have been investigated. This systematic review includes an electronic search of PubMed, Embase, LILACS, and Web of Science databases, in addition to a grey literature and manual search. Article selection was performed by two independent researchers following a predetermined inclusion criterion: human studies evaluating the regression of sensorineural disorders after any form of grafting (autogenous, allogeneic, and synthetic). Of the 789 studies, 648 were analysed. Only 11 articles met the eligibility criteria. After analysing the results, it was noted that regaining normal sensitivity was uncommon, but the majority of reconstructed nerves recovered their protective abilities. Allografts showed success rates similar to autogenous grafts, making them a viable alternative. However, clinical trials are still needed to provide solid evidence. Prognosis for sensory recovery was impacted by grafting time and patient age.

Effect of low-level laser therapy on incorporation of block allografts.

OBJECTIVE: To assess the effect of low-level laser therapy (LLLT) on the incorporation of deep-frozen block allografts in a rabbit model. BACKGROUND DATA: Studies have shown that LLLT has beneficial effects on tissue repair and new bone formation. METHODS: Bone tissue was harvested from two rabbits, processed by deep-freezing and grafted into the calvaria of 12 animals, which were then randomly allocated into two groups: experimental (L) and control (C). Rabbits in group L were irradiated with an aluminum gallium arsenide diode laser (AlGaAs; wavelength 830 nm, 4 J/cm(2)), applied to four sites on the calvaria, for a total dose of 16 J/cm(2) per session. The total treatment dose after eight sessions was 128 J/cm(2). Animals were euthanized at 35 (n = 6) or 70 days (n = 6) postoperatively. RESULTS: Deep-freeze-processed block allografts followed by LLLT showed incorporation at the graft-host interface, moderate bone remodeling, partial filling of osteocyte lacunae, less inflammatory infiltrate in the early postoperative period, and higher collagen deposition than the control group. CONCLUSION: Optical microscopy and scanning electron microscopy showed that allograft bone processed by deep-freezing plus LLLT is suitable as an alternative for the treatment of bone defects. Use of the deep-freezing method for processing of bone grafts preserves the structural and osteoconductive characteristics of bone tissue.

Computed tomography imaging superimposition protocols to assess outcomes in orthognathic surgery: a systematic review with comprehensive recommendations.

OBJECTIVES: A systematic review was performed to analyze the current evidence on three-dimensional (3D) computed tomography (CT) superimposition protocols used to assess dentomaxillofacial changes after orthognathic and orthofacial surgery. Accuracy, reproducibility, and efficiency were evaluated. METHODS: The search was divided into Main Search (PubMed, EMBASE, Cochrane Library, LILACS, and SciELO), Grey Literature search (Google Scholar and Open Grey), and Manual search. Thirteen studies were included. Of these, 10 reported data on accuracy, 10 on reproducibility and five on efficiency. Seven proposed or evaluated methods of voxel-based superimposition, three focused on the surface-based technique, one compared surface- and voxel-based superimposition protocols, one used the maximum mutual information algorithm, and one described a landmark-based superimposition method. Cone-beam computed tomography (CBCT) was the most common imaging technique, being used in 10 studies. RESULTS: The accuracy of most methods was high, showing mean differences smaller than voxels' dimensions, ranging between 0.05 and 1.76 mm for translational accuracy, and 0.10-1.09° for rotational accuracy. The overall reproducibility was considered good as demonstrated by the small mean error (range: 0.01-0.26 mm) and high correlation coefficients (range: 0.53-1.00). Timing to complete virtual superimposition techniques ranged between a few seconds up to 40 min. CONCLUSIONS: Voxel-based superimposition protocols presented the highest accuracy and reproducibility. Moreover, superimposition protocols that used automated processes and involved only one software were the most efficient.

Transference of virtual planning and planning over biomedical prototypes for dental implant placement using guided surgery.

OBJECTIVES: This study evaluated the transference of virtual planning and planning over biomedical prototypes for dental implant placement using guided surgery. MATERIAL AND METHODS: This experiment was conducted with 11 identical replicas of a human edentulous mandible. For each mandible, models and surgical guides were manufactured using stereolithography. Simulated surgeries were performed on the prototypes. Following this, the implants were placed in the mandible replicas. Superposition of the tridimensional pre- and postoperative models was used for virtual evaluation. The real evaluation was conducted by linear measurements directly on the models. RESULTS: The variations in angles and distances between the coronal, central and apical regions of the 22 implants evaluated in this study had mean values <1.45 degrees and 0.41 mm. The correlations between the positions of implant beds in each mandible were fair to very good, according to the distance analyzed and the interpretation guidelines used. CONCLUSIONS: According to the results of this study, the variations found in the transference of dental implant positioning to the operative field, determined during virtual planning and obtained in surgeries simulated with biomedical prototypes, confirm the reliability of guided surgery techniques in implantology.

Treatment of comminuted mandibular fractures: a critical review.

The treatment of comminuted fractures of the mandible is challenging due both to the severity of the injuries generally associated with this type of fracture, and the lack of consensus as to the most appropriate treatment method.There are two distinct approaches for treating comminuted fractures of the mandible: closed reduction with maxillomandibular fixation (MMF) - the oldest and classical treatment - and open operation and internal fixation. The morbidity rate of closed reduction is lower but, with the advent of modern anaesthesia and antibiotics, open surgery has become more frequent. Stable internal fixation (SIF) is acheived using plates, miniplates and/or screws. The advantage of this approach is that there is a more precise reduction of the fragments, with the possibility of early function by eliminating or reducing the time of MMF. This paper reviews the main advantages, disadvantages and differences between the two techniques.

The treatment of condylar fractures: to open or not to open? A critical review of this controversy.

The treatment of condylar process fractures has generated a great deal of discussion and controversy in oral and maxillofacial trauma and there are many different methods to treat this injury. For each type of condylar fracture, the techniques must be chosen taking into consideration the presence of teeth, fracture height, patient's adaptation, patient's masticatory system, disturbance of occlusal function, deviation of the mandible, internal derangements of the temporomandibular Joint (TMJ) and ankylosis of the joint with resultant inability to move the jaw, all of which are sequelae of this injury. Many surgeons seem to favor closed treatment with maxillomandibular fixation (MMF), but in recent years, open treatment of condylar fractures with rigid internal fixation (RIF) has become more common. The objective of this review was to evaluate the main variables that determine the choice of method for treatment of condylar fractures: open or closed, pointing out their indications, contra-indications, advantages and disadvantages.

Postural assessment in class III patients before and after orthognathic surgery.

PURPOSE: This study aimed to assess body posture before and after bimaxillary orthognathic surgery by photogrammetry in skeletal class III patients. METHODS: Thirty-one patients with skeletal class III dentofacial deformities (14 men, 17 women) who underwent orthodontic preparation for surgery were included in this non-randomized controlled trial. Of these, 15 who did not undergo orthognathic surgery during the period of this study served as controls. Postural assessment was performed by photogrammetry using SAPO® (Postural Assessment Software) based on anterior-, posterior-, and lateral-view images taken 1 month before and 4 months after bimaxillary orthognathic surgery with internal rigid fixation (or 4 months after the initial assessment, for the control group). The study was approved by PUCRS Research Ethics Committee, and written informed consent was obtained from all individual participants prior to their inclusion in the study. RESULTS: There was no significant difference between groups for age, gender, and GAP. In the intervention group, the right leg/hindfoot angle, which initially indicated a valgus deformity, normalized after intervention (P < 0.048). Posterior displacement of the head (P < 0.005) and trunk (P < 0.004) were observed after intervention. CONCLUSIONS: These results suggest that correction of class III dentofacial deformities by bimaxillary orthognathic surgery can produce systemic postural adjustments, especially posterior displacement of the head and trunk and knee and ankle valgus.

Effect of low-level laser therapy on inflammatory reactions during wound healing: comparison with meloxicam.

OBJECTIVE: This study evaluated the action of low-level laser therapy (LLLT) on the modulation of inflammatory reactions during wound healing in comparison with meloxicam. BACKGROUND DATA: LLLT has been recommended for the postoperative period because of its ability to speed healing of wounds. However, data in the literature are in disagreement about its anti-inflammatory action. METHODS: Standardized circular wounds were made on the backs of 64 Wistar rats. The animals were divided into four groups according to the selected postoperative therapy: group A-control; group B-administration of meloxicam; and groups C and D-irradiation with red (lambda = 685 nm) and infrared (lambda = 830 nm) laser energy, respectively. The animals were killed at 12, 36, and 72 h and 7 days after the procedure. RESULTS: Microscopic analysis revealed significant vascular activation of irradiated sites in the first 36 h. Only group B showed decreases in the intensity of polymorphonuclear infiltrates and edema. Group D showed a higher degree of organization and maturation of collagen fibers than the other groups at 72 h. The animals in group C showed the best healing pattern at 7 days. The anti-inflammatory action of meloxicam was confirmed by the results obtained in this research. The quantification of interleukin-1beta (IL-1beta) mRNA by real-time polymerase chain reaction (PCR) did not show any reduction in the inflammatory process in the irradiated groups when compared to the other groups. CONCLUSIONS: LLLT improves the quality of histologic repair and is useful during wound healing. However, with the methods used in this study the laser energy did not minimize tissue inflammatory reactions.

Assessment of Adhesion and Proliferation of Bone Marrow Mesenchymal Stem Cells in Polymer Matrices with rhGH.

PURPOSE: Biomaterials, as an alternative to autogenous bone and other biologic tissues, have been widely used in oral and maxillofacial surgery. In this context, a biomaterial that functions as a scaffold (osteoconductor), combined with a growth factor (osteoinductor), would be of great interest for clinical application. Biodegradable polymers used for slow drug release have been investigated, demonstrating good results and interesting potential. Growth hormone (GH) may be released by incorporating it into these polymers. This study aimed to evaluate cell adhesion and proliferation of a polymeric biomaterial for slow release of recombinant human GH (rhGH). MATERIALS AND METHODS: Poly(lactic-co-glycolic acid) (PLGA) and PLGA/polycaprolactone (PCL) (at a 70/30 ratio of PLGA to PCL) matrices were prepared by the solvent evaporation method, combined or not with GH. Biomaterials were tested for cell adhesion and proliferation by culture in mesenchymal stem cells derived from Wistar rat bone marrow, 4',6-diamidino-2-phenylindole (DAPI) staining, and subsequent cell counting, in addition to scanning electron microscopy. Cell adhesion and proliferation was assessed at 24 and 72 hours of biomaterial exposure to culture medium. RESULTS: All tested polymers exhibited cell adhesion and proliferation. However, PLGA-based biomaterials, especially when combined with GH, showed greater cell proliferation when the difference in growth from 24 to 72 hours was evaluated. GH appeared to modify the polymer surface, with increased roughness and microporosity. This feature was more evident in the PLGA + GH combination. CONCLUSION: The biomaterials tested showed pronounced cell adhesion in all test groups, and GH appeared to contribute to the increase in cell proliferation, especially when combined with PLGA as compared with pure PLGA. Further studies are required to clarify this potential for development of new biomaterials.

Resection of Gingival Fibromatosis with High-power Laser.

Hereditary gingival fibromatosis (HGF), also known as hereditary gingival hyperplasia, idiopathic gingival fibromatosis, and hereditary gingival overgrowth, is a rare condition but the most common form of gingival hyperplasia. Overgrowth of gingival tissue is usually slow and progressive and may delay or prevent tooth eruption, resulting in cosmetic and functional impairments. Hypertrichosis, epilepsy, and intellectual disability may be associated with HGF, which can occur in isolation or as part of a syndrome. The purpose of this case report is to describe a diode laser resection of gingival hyperplasia in a seven-year-old patient with nonsyndromic HGF and hypertrichosis. The diode laser enabled efficient removal of hypertrophic gingival tissue with good healing and minimal postoperative discomfort.

Treatment of lip hemangioma using forced dehydration with induced photocoagulation via diode laser: report of three cases.

Several vascular lesions are related to the lip area. There is no universally accepted protocol for the treatment of hemangiomas and vascular malformations. In the oral cavity, high-power lasers represent an excellent therapeutic option for this type of lesion. Their coagulative properties allow for the performance of procedures without the risk of bleeding, which promotes a better healing pattern and a differentiated postoperative appearance. This study describes three cases of lip hemangioma treated with forced dehydration with induced photocoagulation (FDIP) via diode laser. All the reported cases were followed up until complete healing of the operated area had total remission of lesions, with no complications or adverse effects. The findings of the present study suggest that FDIP is effective and useful in the treatment of hemangiomas in the oral cavity. Laser treatment of these lesions prevents their recurrence and is well tolerated by patients.