A SERM increasing the expression of the osteoblastogenesis and mineralization-related proteins and improving quality of bone tissue in an experimental model of osteoporosis.

Raloxifene is an antiresorptive drug, selective estrogen receptor modulator (SERM) used in the treatment of osteoporosis. Objective To evaluate proteins related to bone repair at the peri-implant bone in a rat model of osteoporosis treated with raloxifene. Material and Methods 72 rats were divided into three groups: SHAM (healthy animals), OVX (ovariectomized animals), and RLX (ovariectomized animals treated with raloxifene). Raloxifene was administered by gavage (1 mg/kg/day). Tibial implantation was performed 30 days after ovariectomy, and animals were euthanized at 14, 42, and 60 days postoperatively. Samples were collected and analyzed by immunohistochemical reactions, molecular analysis, and microtomographic parameters. Results RLX showed intense staining of all investigated proteins at both time points except for RUNX2. These results were similar to SHAM and opposite to OVX, showing mild staining. The PCR gene expression of OC and ALP values for RLX (P<0.05) followed by SHAM and OVX groups. For BSP data, the highest expression was observed in the RLX groups and the lowest expression was observed in the OVX groups (P<0.05). For RUNX2 data, RLX and SHAM groups showed greater values compared to OVX (P<0.05). At 60 days postoperatively, microtomography parameters, related to closed porosity, showed higher values for (Po.N), (Po.V), and (Po) in RLX and SHAM groups, whereas OVX groups showed lower results (P<0.05); (BV) values (P=0.009); regarding total porosity (Po.tot), RLX group had statistically significant lower values than OVX and SHAM groups (P=0.009). Regarding the open porosity (Po.V and Po), the SHAM group presented the highest values, followed by OVX and RLX groups (P<0.05). The Structural Model Index (SMI), RLX group showed a value closer to zero than SHAM group (P<0.05). Conclusions Raloxifene had a positive effect on the expression of osteoblastogenesis/mineralization-related proteins and on micro-CT parameters related to peri-implant bone healing.

Raloxifene but not alendronate can compensate the impaired osseointegration in osteoporotic rats.

OBJECTIVES: Alendronate and raloxifene, a bisphosphonate and a selective estrogen modulator, respectively, are established osteoporosis therapies. Current evidence suggests that simultaneous application of osteoporosis therapies modulates osseointegration. However, alendronate shows inconsistent findings and raloxifene has not been studied comprehensively. This study aimed to evaluate the bone dynamics and molecular and microstructural features at the peri-implant bone interface in osteoporotic rats. MATERIALS AND METHODS: Thirty female rats underwent ovariectomy and were fed a diet low in calcium and phosphate and treated with alendronate or raloxifene for 30 days or underwent fictional ovariectomy surgery (SHAM) prior to implant insertion in the tibia; osteoporosis therapies continued thereafter. After 42 days, peri-implant bone was evaluated by histometric and micro-CT analysis. Fluorochrome incorporation and gene expression was determined to evaluate bone turnover. RESULTS: We report here that alendronate had no impact on bone-to-implant contacts and the mineral apposition rate. The RANKL/OPG ratio and local bone volume, however, were increased compared to the untreated osteoporotic rats. Even though signaling to bone resorption activity through RANKL production was observed in the alendronate group, the blockade of bone resorption activity that occurs in decorrence to alendronate activity took place and resulted in an increase in bone volume. Raloxifene significantly increased osseointegration in osteoporotic rats, as indicated by bone-to-implant contacts, mineral apposition, and local bone volume. Raloxifene, however, had no considerable impact on the RANKL/OPG ratio compared to untreated osteoporotic rats. As expected, the SH group showed higher bone-to-implant contacts and mineral apposition rates than the untreated osteoporotic rats. CONCLUSIONS: These findings suggest that raloxifene but not alendronate can compensate for the impaired osseointegration in osteoporotic rats. CLINICAL RELEVANCE: Regarding the superiority of raloxifene observed in the improvement of bone dynamics response, this statement suggests that raloxifene could be a good option for osteoporosis patients in oral rehabilitation procedures.

A SERM increasing the expression of the osteoblastogenesis and mineralization-related proteins and improving quality of bone tissue in an experimental model of osteoporosis

Abstract Raloxifene is an antiresorptive drug, selective estrogen receptor modulator (SERM) used in the treatment of osteoporosis. Objective To evaluate proteins related to bone repair at the peri-implant bone in a rat model of osteoporosis treated with raloxifene. Material and Methods 72 rats were divided into three groups: SHAM (healthy animals), OVX (ovariectomized animals), and RLX (ovariectomized animals treated with raloxifene). Raloxifene was administered by gavage (1 mg/kg/day). Tibial implantation was performed 30 days after ovariectomy, and animals were euthanized at 14, 42, and 60 days postoperatively. Samples were collected and analyzed by immunohistochemical reactions, molecular analysis, and microtomographic parameters. Results RLX showed intense staining of all investigated proteins at both time points except for RUNX2. These results were similar to SHAM and opposite to OVX, showing mild staining. The PCR gene expression of OC and ALP values for RLX (P<0.05) followed by SHAM and OVX groups. For BSP data, the highest expression was observed in the RLX groups and the lowest expression was observed in the OVX groups (P<0.05). For RUNX2 data, RLX and SHAM groups showed greater values compared to OVX (P<0.05). At 60 days postoperatively, microtomography parameters, related to closed porosity, showed higher values for (Po.N), (Po.V), and (Po) in RLX and SHAM groups, whereas OVX groups showed lower results (P<0.05); (BV) values (P=0.009); regarding total porosity (Po.tot), RLX group had statistically significant lower values than OVX and SHAM groups (P=0.009). Regarding the open porosity (Po.V and Po), the SHAM group presented the highest values, followed by OVX and RLX groups (P<0.05). The Structural Model Index (SMI), RLX group showed a value closer to zero than SHAM group (P<0.05). Conclusions Raloxifene had a positive effect on the expression of osteoblastogenesis/mineralization-related proteins and on micro-CT parameters related to peri-implant bone healing.

An Uncommon Occurrence of Three-Fourth Molars Concomitant to Hypodontia in a Nonsyndromic Patient.

Bilaterally mandibular and maxillary fourth molars, concomitant to hypodontia, are uncommon. These dental anomalies, called hypohyperdontia, are rare and etiology is not well defined. Several complications may occur as a consequence of supernumerary teeth, such as teeth impaction, resorption of adjacent teeth, and development of cysts and tumors. The authors present an uncommon occurrence of three-fourth molars concomitant to hypodontia and dentigerous cyst associated with impacted mandibular second and third molars in a nonsyndromic patient. The authors attempt to discuss the occurrence of bilaterally fourth molars and reinforce the importance of clinical approach, considering risks and benefits for the patient.

Effect of antiresorptive drugs in the alveolar bone healing. A histometric and immunohistochemical study in ovariectomized rats.

OBJECTIVES: The aim of this study is to evaluate the alendronate and raloxifene influence in the alveolar healing process of osteoporotic rats. MATERIALS AND METHODS: Sixty-four female rats were divided in four groups: sham rats (SHAM), ovariectomized rats and no medical treatment (OVX NT), ovariectomized rats and submitted to alendronate treatment (OVX ALE), and ovariectomized and submitted to raloxifene treatment (OVX RAL). The histomorphometrical and immunohistochemical analysis was performed. The quantitative data were analyzed through Kruskal-Wallis and Dunn tests (α = 0.05). RESULTS: In the longest period, SHAM and OVX RAL groups showed the better bone formation responses (P < 0.05). The worst bone formation response was observed in the group OVX NT. OVX RAL group showed the better response at 42 days. OVX ALE group showed a favorable response at 14 days, in comparison with OVX RAL group, but a reduced response at 42 days. It was possible to observe a mature bone in SHAM group at 14 days and an immature bone in the OVX NT group. An intermediate quality bone was observed in the groups OVX ALE and OVX RAL. CONCLUSION: Alendronate and raloxifene treatment improved the alveolar healing process in osteoporotic rats, but not enough to achieve the histometrical and protein expression values that were observed in the SHAM group. CLINICAL RELEVANCE: Alendronate is largely used as a potent antiresorptive agent. Otherwise, considering the undesirable effects in relation to the alveolar healing, other antiosteoporosis medications should be studied. Raloxifene seems to be a good candidate once its action mechanism involves the activation of osteoblasts.

Misdiagnosis of Extensive Maxillofacial Infection and Its Relationship with Periodontal Problems and Hyperglycemia.

Background. Complex dental infections can reach distant areas of the alveolar process, invading the secondary fascial spaces. Objectives. This case report aims to show a misdiagnosis of odontogenic infection and a great need for dentist in the hospital environment. Case Report. A male patient presented facial asymmetry and trismus, while the facial CT examination showed a hyperdense mass involving the left masseteric, pterygomandibular, and superficial temporal regions. The patient was then referred to oral oncology center by emergency physician with cancer suspicion. After 15 days, the patient returned to the same emergency room and was attended by the surgical and maxillofacial trauma team, presenting tachycardia, tachypnea, dysphagia, and trismus. During anamnesis, the patient reported being an uncontrolled diabetic. In intraoral exam, a poor oral condition and generalized periodontitis were observed. Results. Correct diagnosis of odontogenic infection was established and adequately treated. Conclusions. Symptomatology bland may mask the severity of an infection; every increase in volume associated with trismus, poor oral hygiene with or without hyperglycemia should be heavily investigated for the presence of an infectious process. It emphasizes the importance of a dentist working with the physician in emergency room.

Alveolar bone dynamics in osteoporotic rats treated with raloxifene or alendronate: confocal microscopy analysis.

In this study, the characteristics of the alveolar bone of rats with induced osteoporosis were examined. Thirty-two rats were divided into four groups according to the induction of osteoporosis and drugs administered: OG, osteoporotic rats without treatment (negative control); SG, rats which underwent sham surgery ovariectomy (SHAM); alendronate (AG), osteoporotic rats treated with alendronate; and RG, osteoporotic rats treated with raloxifene (RG). On the 8th day after ovariectomy and SHAM surgeries, drug therapy was started with AG or RG. On the 52nd day, 20 mg/kg calcein was administered to all of the rats, and on the 80th day, 20 mg/kg alizarin red was administered. Euthanasia was performed on the 98th day. The bone area marked by fluorochromes was calculated and data were subjected to two-way ANOVA test and Tukey's post-hoc test (p < 0.05). The comparison of the induced osteoporosis groups showed no statistically significant differences in bone turnover only between RG and SG (p = 0.074) and AG and OG (p = 0.138). All other comparisons showed significant differences (p < 0.001). The largest bone turnover was observed in RG and SG groups. RG was the medication that improved the dynamics of the alveolar bone of rats with induced osteoporosis, resembling that of healthy rats.

Unerupted lower third molar extractions and their risks for mandibular fracture.

As every surgical procedure extraction of third molars can result in several complications, among them the mandibular angle fracture. Predisposing factors for fracture should be analyzed during and after the surgery. This paper aims to discuss the predisposing factors to the occurrence of mandibular angle fractures during and after the procedure for third molars extraction, as well as surgical principles to avoid this complication.

Surgical techniques for maxillary bone grafting - literature review / Técnicas cirúrgicas para a enxertia óssea dos maxilares - revisão da literatura

For oral rehabilitation with implant-supported prostheses, there are required procedures to create the bone volume needed for installation of the implants. Thus, bone grafts from intraoral or extraoral donor sites represent a very favorable opportunity. This study aimed to review the literature on the subject, seeking to discuss parameters for the indications, advantages and complications of techniques for autogenous bone grafts.

Para a reabilitação bucal com as próteses implantossuportadas é necessário a realização de procedimentos para criar o volume ósseo necessário para a instalação dos implantes. Com isso, os enxertos ósseos provenientes de áreas doadoras intrabucais ou extrabucais, representam uma possibilidade bastante favorável. O presente trabalho objetivou realizar uma revisão da literatura em que procurou discutir parâmetros para as indicações, as vantagens e complicações para as técnicas dos enxertos ósseos autógenos.

Intraoperative blood loss and blood transfusion requirements in patients undergoing orthognathic surgery.

Procedures for the surgical correction of dentofacial deformities may produce important complications, whether due to the potential for vascular injury or to prolonged surgery, both of which may lead to severe blood loss. Fluid replacement with crystalloid, colloid, or even blood products may be required. The aim of this study was to assess blood loss and transfusion requirements in 45 patients (18 males and 27 females; mean age 29.29 years, range 16-52 years) undergoing orthognathic surgery, assigned to one of two groups according to procedure type-rapid maxillary expansion or double-jaw orthognathic surgery. Preoperative hemoglobin and hematocrit levels and intraoperative blood loss were measured. There was a substantial individual variation in pre- and postoperative hemoglobin values (10.3-17 and 8.8-15.4 g/dL, respectively; p < 0.05). Mean hematocrit values were 41.53 % preoperatively (range 31.3-50.0 %) and 36.56 % postoperatively (range 25-43.8 %) (p < 0.05). Mean blood loss was 274.60 mL (range 45-855 mL). Only two patients required blood transfusion. Although blood loss and transfusion requirements were minimal in the present study, surgical teams should monitor the duration of surgery and follow meticulous protocols to minimize the risks.

The Fresh Frozen Bone Allograft (FFBA) to Reconstruct the Atrophic Maxilla: Evaluation of the Clinical and Histological Viability at Six and Nine Months in the Maxillary Sinus / Aloinjerto Óseo Fresco Congelado (FFBA) en la Reconstrucción del Maxilar Atrófico: Evaluación de la Viabilidad Clínica e Histológica a los Seis y Nueve Meses en el Seno Maxilar

This work aimed to analyze clinically and histologically the allogen bone graft behavior at 6 and 9 months. A leukoderm, female, 55 years old patient sought dental care for oral rehabilitation with dental implants and implant supported fixed prosthesis in the maxilla. Bilateral sinus lifting procedure were performed in a same patient, the analysis were made after 6 and 9 months, respectively. At 6 months, there was lack of a better bone remodeling in the region, associated to the presence of fibrous connective tissue within the collected tissue, showing us that this is not the best stage of tissue maturation to place dental implants. The 9 months period showed an improvement, with a more organized bone tissue surrounding particles of homogenous bone, what possibly had increased implant stability at the time of surgery. There is no doubt about the increase of clinical applications of FFBA, but there are no studies available regarding the standardization of time to load implants inserted in allografts. So papers with long-term monitoring are necessary to eliminate questions that still remain to be answered.

El objetivo fue analizar clínica e histológicamente el injerto óseo alógeno a los 6 y 9 meses. Una paciente sexo femenino, leucoderma de 55 años de edad consultó por atención odontológica para la rehabilitación oral con implantes y prótesis fija implanto soportada en el maxilar. Procedimientos de elevación del seno maxilar bilateralmente fueron realizados en la misma paciente, y se hicieron los análisis después del sexto y noveno mes, respectivamente. Al sexto mes, se observó una remodelación ósea deficiente de la región asociada a la presencia de tejido conectivo fibroso en el tejido analizado, demostrando que no era la mejor etapa de maduración óseo para instalar los implantes. Al noveno mes se observo una mejora, con un tejido óseo mas organizado rodeando partículas de hueso homogéneo, el cual posiblemente incrementaría la estabilidad del implante en el momento de la cirugía. No hay dudas respecto del incremento de aplicaciones clínicas del FFBA, pero no hay estudios capaces de estandarizar el tiempo de carga de los implantes instalados sobre aloinjertos. Investigaciones con seguimientos a largo plazo son necesarios para eliminar las preguntas que aun se mantienen sin respuesta.

Short dental implants in posterior mandible.

The rehabilitation with oral implants is, without any doubt, a consecrated technique. But often we face situations of high bone atrophy where the conventional installation of dental implants is not possible. The posterior mandible, when severely resorbed, generally requires complex techniques to be rehabilitated with implants, such as the lateralization of the inferior alveolar nerve. As an option for these cases, this paper proposes the use of short implants for the rehabilitation of severely resorbed posterior mandible.

Endaural access to remove the projectile from a firearm.

BACKGROUND: Surgical approaches to temporomandibular region have been the subject of numerous controversies in the literature. Pre-auricular approaches have been used with the observance of high success rate, and during surgery history, various modifications of this approach were conducted in order to reduce irreversible sequelae. Thus, given the relevance of the study, this article proposes to alert the professionals that carry out these surgical approaches in relation to the anatomical structures involved and to describe and emphasise the benefits of endaural approach. CASE REPORT: A Caucasian male patient, victim of a firearm injury, sustained a wound on the right pre-auricular region, and at the time of assessment, he complained of pain, mouth opening difficulty and dysphagia. On physical examination, there was oedema and ecchymosis in the right periorbital region. In the radiological examination, a foreign body compatible with a firearm projectile was observed in the right pre-auricular region, being in accordance with the information collected. The endaural incision and divulsion by plans was then made until the projectile. DISCUSSION: For proper exposure of the region, several studies were designed to evaluate the patterns of branching and anastomosis of the facial nerve. As for the best cosmetic result with the different pre-auricular approaches, the endaural approach was described as an approach that offers great cosmetic results because the incision design guides the surgeon in the wound closure and causes a decrease in the tension of flap, unlike that observed by some authors.

Controversies in the satisfaction of surgeons and orthodontists on facial aesthetics after orthognathic surgery.

Aim Acceptable facial aesthetics is a common desire among patients presenting with dentofacial deformities planning to undergo orthognathic surgeries. Thus, professionals must be alert to their patients' complaints as well as their desires regarding facial morphology, because this is quite subjective and personal. This research aimed at evaluating the different views of orthodontists and oral maxillofacial surgeons regarding the facial analysis of patients who undergo orthognathic surgery. Methods Thirty individuals were selected with a minimum postoperative period of 6 months and photographed in the frontal and profile norm. Facial morphology characteristics were recorded to observe the agreement of the assessments of four professionals (two orthodontists and two surgeons). Results A significant agreement was seen between the orthodontists regarding the nasolabial angle (80%). In the frontal analysis, the agreement percentage (60%) between orthodontists and surgeons was considerable regarding facial asymmetry assessment. Conclusions Professionals must keep alert to facial analysis, especially in terms of tegumental harmony, for the orthognathic surgery to reestablish, satisfactorily, the facial aesthetics in all parameters set.

O impacto das próteses implantossuportadas na harmonia facial / The impact of implant-supported prostheses in facial harmony

Grande parte da população que procura atendimento odontológico deseja melhorar a estética facial e a do sorriso, para ser inserida na sociedade em que vive. Nos indivíduos usuários de próteses totais, a reabsorção fisiológica causa uma atrofia, principalmente da maxila, sendo necessária a realização de técnicas reconstrutoras e, às vezes, de movimentação das bases ósseas, para maior estabilidade oclusal e harmonia facial. O objetivo deste trabalho foi abordar as características relacionadas com a reabilitação dos pacientes edêntulos, com indicação para a reconstrução dos maxilares com enxerto ósseo e cirurgia ortognática, por meio de um caso clínico. Sendo que após a reabilitação com as próteses implantossuportadas, a paciente se mostrou amplamente satisfeita com o resultado estético-funcional alcançado e se recusou a submeter-se à cirurgia ortognática proposta no planejamento. Com isso, os profissionais devem apresentar as opções terapêuticas aos pacientes, porém, deve prevalecer a queixa principal dos mesmos, desde que seja uma modalidade de tratamento viável.

Many patients seeking dental care wish to improve facial and smile aesthetics to be accepted in modern day society. In denture wearers, the physiological resorption causes atrophy mainly in the maxilla, being necessary to carry out reconstruction techniques and sometimes orthognathic surgery to improve occlusal stability and facial harmony. The aim of this study is to discuss the features related to the rehabilitation of edentulous patients with indication for reconstruction of the maxilla using bone grafts and orthognathic surgery by means of a clinical case. In the present case, after the prosthetic rehabilitation, the patient was full satisfied with obtained results and dismissed the initially proposed surgical protocol. Therefore, professionals should provide therapeutic options but the patient’s opinion should prevail provided its clinical feasibility.

Reabilitação de maxila atrófica com enxerto de calota craniana e implantes / Atrophic maxilla rehabilitation with calvarial graft and implants

A utilização dos enxertos ósseos autógenos de calota craniana é uma das opções para as reconstruções de maxila atrófica. Possui diversas vantagens, sobretudo, devido a menor morbidade pós-operatória, quando comparado ao de crista ilíaca, além de apresentar o menor índice de reabsorção durante a incorporação. O presente trabalho teve como proposta discutir as vantagens da enxertia óssea autógena da calota craniana na reabilitação de maxila atrófica, por meio de um relato de caso clínico cirúrgico de uma paciente de 65 anos, pontuando todas as características envolvidas no planejamento, assim como da execução do tratamento proposto. Os resultados foram excelentes, com a obtenção de grande volume ósseo após o enxerto da maxila, o que proporcionou a instalação favorável dos implantes na maxila atrófica. As próteses protocolos trouxeram maior conforto para as funções mastigatórias e fonéticas, além de promoverem melhor assentamento dos tecidos moles da face.

The use of autogenous bone grafts for cranial vault is one of the options for the reconstruction of the atrophic maxilla. It has several advantages, mainly due to lower postoperative morbidity when compared to that obtained from the iliac crest, and lower resorption rate during graft incorporation. Thus, oral rehabilitation with dental implants has become a highly predictable treatment modality, particularly in large reconstructions. This work aims to discuss the advantages of autogenous bone graft from the skull in the rehabilitation of the atrophic maxilla by means of a clinical case report of a 65 years-old patient, detailing all the features involved in planning, as well as the execution of proposed treatment. The results showed an excellent prognosis for success, obtaining high bone volume after grafting of the maxilla, which provided a very favorable implant placement in the maxillary arch. The prostheses have brought greater comfort for mastication and phonetics, and promoted a better accomodation of the facial soft tissues