Infecção orbitária: experiência no manejo de seis casos / Orbital infeccion: experience on the management of six cases

Infecções orbitárias são enfermidades, que requerem atenção e cuidados especiais. Os principais fatores etiológicos associados são sinusites paranasais e o trauma local. Essas infecções classificam-se em pré-septal e pós-septal e distinguem-se clinicamente, de acordo com a manutenção da acuidade visual e motilidade do globo ocular. O curso da infecção pode agravar com disfunção da motilidade ocular extrínseca, perda de visão e trombose do seio cavernoso. A tomografia computadorizada (TC) é o principal exame imaginológico para a classificação do abscesso, investigação etiológica, determinação da gravidade e a relação do processo com o sistema nervoso central. Este trabalho apresenta e discute o manejo de seis pacientes admitidos com infecção orbitária pelo serviço de Cirurgia e Traumatologia Bucomaxilofacial do Hospital Geral Roberto Santos e em Salvador, Bahia. A TC mostrou não haver disseminação do processo inflamatório para o sistema nervoso central em nenhum dos casos tendo esse achado sido fundamental para determinar que a conduta estivesse restrita à drenagem, sem necessidade de craniotomia. As intervenções cirúrgicas e a antibioticoterapia estavam indicadas devido à importante congestão tecidual e intensa sintomatologia dolorosa. Todos os pacientes apresentaram remissão da infecção e acuidade visual preservada... (AU)

Orbital infections are diseases that require special attention and care. The main risk factors are associated with paranasal sinusitis and local trauma. These infections are classified into pre-septal and post-septal and distinguished clinically according to the maintenance of visual acuity and eye motility. The course of the infection may worsen with extrinsic ocular motility dysfunction, loss of vision and cavernous sinus thrombosis. Computed tomography (CT) is the primary imaging examination for the classification of the abscess, etiologic investigation, determining the severity of the process and the relationship with the central nervous system. This paper presents and discusses the management of six patients admitted with orbital infection by service Oral and Maxillofacial Surgery General Hospital Roberto Santos in Salvador, Bahia. A CT scan showed no spread of the inflammatory process in the central nervous system and in any case this finding was important to determine that the drainage duct was confined without requiring craniotomy. Surgical interventions and antibiotics were given because of the important tissue congestion and intense painful symptoms. All patients had remission of infection and preserved visual acuity... (AU)

Angiogenesis and osteogenesis at incorporation process of onlay bone graft.

PURPOSE: The roles of angiogenesis and osteogenesis in autologous and allogenic bone grafts and the use of platelet-rich plasma (PRP) as a modifier were investigated. MATERIALS AND METHODS: Forty rabbit mandibles received onlay grafts of fresh autologous and frozen allogeneic bone. PRP was added on the right side. After intervals of 3, 7, 14, 28, and 56 days, the animals were euthanized. Hematoxylin and eosin staining was used to measure the quantity and area of osteoblasts. Sections stained with toluidine blue showed newly formed bone area. In sections with Weigert-van Gieson staining, the number of vessels and their lumens was quantified. The quantity and area of cellular arrangements expressing CD31 and the area of vessels were obtained. RESULTS: Quantities of osteoblasts and their areas, newly formed matrices, and vessels and their lumen areas were obtained and identified by immunomarking with CD31. In general, values for these were higher in rabbits with allogeneic bone grafts and on the sides where PRP had been added. There was a variable significance between categories and days. It was confirmed that osteogenesis was intensified when angiogenesis was consolidated. CONCLUSIONS: Angiogenesis was important for greater osteoblast differentiation and bone matrix synthesis, ensuring consolidation of onlay grafts with the receptor bed. Allogeneic grafts and PRP intensified these processes.

Conservative treatment of the dentigerous cyst: report of two cases

The purpose of this paper is to present two cases of dentigerous cyst associated to permanent teeth in children treated by conservative techniques. Dentigerous cyst is the most common developmental cysts of the jaws. Conservative treatment is very effective to this entity and aims at eliminating the cystic tissue and preserving the permanent tooth involved in the pathology. Two techniques are described as conservative treatment for these cysts, marsupialization and the decompression. Two children presented with dentigerous cysts. A female child was affected by a large lesion at the right side of the mandible associated to tooth 45. The other lesion arose at the left maxilla associated to tooth 21 of a male child. Each dentigerous cyst promoted severe tooth displacement. The first patient was treated with decompression and the second with marsupialization.

Dentes retidos: novas perspectivas de localização / Impacted teeth: new diagnostic perspectives

As radiografias convencionais são úteis e fáceis de usar para o diagnóstico de dentes retidos, porém, pela característica de fornecerem imagens bidimensionais e sobrepostas, dificultam o planejamento da cirurgia. O uso da tomografia computadorizada tem se difundido por permitir a visualização de pequenas estruturas anatômicas maxilofaciais relevantes para intervenções cirúrgicas e por possibilitar a visualização das suas relações espaciais em três dimensões. Objetivo e relato dos casos: Relatar os casos de dois pacientes que apresentavam dentes retidos na região anterior da maxila, os quais foram avaliados por tomografia computadorizada. Discutem-se especificidades deste moderno método de diagnóstico por imagem e as vantagens clínicas advindas dessas imagens, pois foi possível identificar a localização precisa dos dentes retidos, a distância das corticais, de acidentes anatômicos e de outros dentes. Considerações finais: A tomografia computadorizada mostrou ser um exame complementar muito importante e preciso para o diagnóstico planejamento cirúrgico e controle pós-operatório de dentes retidos.

Prevalência de complicações oftalmológicas em portadores de fraturas do complexo zigomático / Prevalence of ophthalmic complications in individuals with fractures of the zygomatic complex

OBJETIVO: Realizar estudo observacional e retrospectivo da prevalência de complicações oftalmológicas em indivíduos portadores de fratura de complexo zigomático. MATERIAL E MÉTODO: Foi realizada a análise retrospectiva por consulta a prontuários dos pacientes atendidos no ambulatório de Cirurgia Buco-Maxilo-Facial do Hospital Geral Roberto Santos, no período de janeiro de 2005 a junho de 2009. RESULTADOS: Este estudo mostrou uma maior incidência de fraturas no sexo masculino, sendo a amostra composta por 70 homens (92,2%) e 6 mulheres (7,8%) com idade média de 20 a 39 anos. Dentre as causas, destacaram-se os acidentes de trânsito, envolvendo, motocicleta, carros e bicicleta que foram os agentes etiológicos mais comuns em ambos os sexos, perfazendo um total de 41 casos (54,0%). As complicações oftalmológicas observadas podem ser classificadas em menores (transitórias) e maiores (que necessitam de tratamento adicional). CONCLUSÃO: Pacientes portadores de fraturas 67 do complexo zigomático apresentam incidência elevada de complicações oftalmológicas, o que justifica o atendimento multidisciplinar desses pacientes.

OBJECTIVES: To conduct an observational and retrospective study of the prevalence of ophthalmic complications in individuals with fractures of the zygomatic complex. MATERIAL AND METHODS: This retrospective analysis was carried out by consulting the records of the patients treated at the Oral and Maxillofacial Surgery Clinic of the Roberto Santos General Hospital from January 2005 to June 2009. RESULTS: The study, comprising 70 men (92.2%) and 6 women (7.8%) aged between 20 and 39 years, showed a higher incidence of fractures in males. Road accidents involving motorcycles, cars and bicycles were the most common etiological agent in both sexes, accounting for a total of 41 cases. The ophthalmic complications observed can be classified as minor (transitory) and major (requiring further treatment). CONCLUSIONS: Patients with fractures of the zygomatic complex present a high incidence of ophthalmic complications, which justifies their treatment in a multidisciplinary fashion.

Pattern of osteogenesis during onlay bone graft healing.

OBJECTIVE: The aim of this paper was to analyze how healing occurs between onlay bone graft and the mandible cortex. STUDY DESIGN: Autologous and allogeneic corticocancellous bones, harvested from the ilium wing, were grafted at each mandible side of 40 rabbits. One side received platelet-rich plasma (PRP). Killings occurred at 3, 7, 14, 28, and 56 days. Tissues were stained by hematoxylin-eosin and toluidine blue. New bone area was measured at different regions of sections stained with toluidine blue. Wilcoxon test was used to analyze differences among regions and Bonferroni test to analyze the influence of PRP, graft nature, and days. RESULTS: Osteogenesis was higher at the lateral region (P < .05). PRP tended to improve bone neoformation, which was higher at the allogeneic graft. Statistical significance among the different categories of variables-grafts, use of PRP, and days of observation-did not have a linear behavior. A linear behavior of statistical tests was not detected. Bone new formation increased until the 14th day (P < .05). CONCLUSIONS: Onlay grafts heal due to osteogenesis which occurs at the lateral region and between the cortex and host mandible. Allogeneic grafts and PRP tend to improve bone formation.

Root healing after horizontal fracture: a case report with a 13-year follow up.

Although horizontal root fractures connote a serious trauma to the tooth, they present a favorable prognosis, as the vitality of the pulp remains. Small displacements of the fragments minimize the failure of the healing process; however, even when they occur, the reduction of the diastasis between root fragments is always necessary. A majority of cases are asymptomatic and heal spontaneously even though no therapeutic measures have been adopted. A case of root fracture that was discovered only 1 year after the trauma is presented. Thirteen years later, the tooth is well positioned in the maxillary arch and has kept its pulp vitality despite the obliteration of the root conduct. Expectant management was adopted at the moment of the first examination, and the follow-up of the patient showed it to have been the best choice.

Osteoimunologia aplicada às reconstruções maxilofaciais: [revisão] / Osteoimmunology applied to maxillofacial reconstruction: [review]

Esta revisão de literatura teve por objetivo discutir os aspectos atuais da osteoimunologia aplicada às reconstruções maxilofaciais. As reabilitações maxilares por implantes podem demandar enxertia óssea para prévia adequação do rebordo à colocação do implante. Os enxertos ósseos alógenos têm sido introduzidos nesse protocolo para evitar cirurgia numa segunda área. A criopreservação figura como um método importante para diminuir a antigenicidade do tecido, mas outras técnicas podem ser exemplificadas como a esterilização por radiação gama ou óxido de etileno. A imunologia participa do processo de incorporação ou de rejeição dos enxertos ósseos incrementando sua absorção. Diversas moléculas, como as interleucinas, o ligante do receptor ativador do fator nuclear-κβ (RANKL), o fator nuclear de células T ativadas (NFAT), o fator estimulador de colônias de macrófagos (M-CSF), o fator de células B jovens (EBF-2) e a osteoprotegerina estabelecem a relação entre as células imunológicas e o metabolismo do osso enxertado. As evidências obtidas da literatura permitem inferir que o osso alógeno congelado é um bom material para aposição dos maxilares por não induzir rejeição imunológica.

This literature review aimed to discuss some current aspects related to osteoimmunology applied to maxillofacial reconstruction. Maxillary rehabilitation with implants may demand bone grafting before implant placement in the alveolar ridge. Allografts have been introduced to prevent surgery in a secondary area. Cryopreservation is an important method to decrease tissue antigenicity, but other techniques can also be used such as sterilization by gamma radiation or ethylene oxide. Immunology may participate in the incorporation or rejection process of bone grafts by increasing bone resorption. Several molecules, such as interleukins, receptor activators of nuclear factor κβ ligand RANKL, nuclear factor of activated T cells (NFAT), macrophage-colony stimulating factor (M-CSF), early B cell factor (EBF-2), and osteopontegrin establish the relation between immunological cells and bone graft metabolism. Evidences from the literature suggest that frozen allogenic bone may be a good material for jaw onlay grafts since they do not induce immunological rejection.

Osteoimunologia aplicada às reconstruções maxilofaciais / Osteoimmunology applied to maxillofacial reconstruction

Esta revisão de literatura teve por objetivo discutir os aspectos atuais da osteoimunologia aplicada às reconstruções maxilofaciais. As reabilitações maxilares por implantes podem demandar enxertia óssea para prévia adequação do rebordo à colocação do implante. Os enxertos ósseos alógenos têm sido introduzidos nesse protocolo para evitar cirurgia numa segunda área. A criopreservação figura como um método importante para diminuir a antigenicidade do tecido, mas outras técnicas podem ser exemplificadas como a esterilização por radiação gama ou óxido de etileno. A imunologia participa do processo de incorporação ou de rejeição dos enxertos ósseos incrementando sua absorção. Diversas moléculas, como as interleucinas, o ligante do receptor ativador do fator nuclear-κβ (RANKL), o fator nuclear de células T ativadas (NFAT), o fator estimulador de colônias de macrófagos (M-CSF), o fator de células B jovens (EBF-2) e a osteoprotegerina estabelecem a relação entre as células imunológicas e o metabolismo do osso enxertado. As evidências obtidas da literatura permitem inferir que o osso alógeno congelado é um bom material para aposição dos maxilares por não induzir rejeição imunológica.

This literature review aimed to discuss some current aspects related to osteoimmunology applied to maxillofacial reconstruction. Maxillary rehabilitation with implants may demand bone grafting before implant placement in the alveolar ridge. Allografts have been introduced to prevent surgery in a secondary area. Cryopreservation is an important method to decrease tissue antigenicity, but other techniques can also be used such as sterilization by gamma radiation or ethylene oxide. Immunology may participate in the incorporation or rejection process of bone grafts by increasing bone resorption. Several molecules, such as interleukins, receptor activators of nuclear factor κβ ligand RANKL, nuclear factor of activated T cells (NFAT), macrophage-colony stimulating factor (M-CSF), early B cell factor (EBF-2), and osteopontegrin establish the relation between immunological cells and bone graft metabolism. Evidences from the literature suggest that frozen allogenic bone may be a good material for jaw onlay grafts since they do not induce immunological rejection.

Effects of freezing on bone histological morphology.

Allograft bone has been widely used for reconstruction of different portions of the skeleton. The fragment of bone harvested must be kept under low temperatures. The cryopreservation also contributes to decrease the antigenic potential of the tissue. Although this technique is considered safe, there is little information about the morphological modifications that the medullary and cortical portions of bone suffer after freezing. Hence, the aim of this study was to investigate the morphology of bone tissue after freezing under different temperatures and periods. Twelve rabbits were used to analyze the effects of two temperatures, -20 degrees C and -70 degrees C, during four periods of time: 30, 60, 90, 120 days. Tissues were analyzed by HE, picro-sirius stains and also by Feulgen's reaction, through qualitative and morphometric ways, considering the area occupied by cells and nuclei, medullary and cortical portions, as well as by collagen expression at cortical. The differences among the treatments were analyzed by Tukey s test, at 5% significance level. Bone freezing increased cellular and nuclear areas at cancellous bone and diminished nuclear area at the cortical bone. Cortical bone collagen suffered denaturation proportionally to temperature decrease and to freezing duration. These alterations compromised the morphology of tissues after 90 or 120 days of freezing at the temperature of -70 degrees C. Cells necrosed during freezing, contributing to reduce bone antigenicity.

Evaluation of factors that can modify platelet-rich plasma properties.

OBJECTIVE: The aim of this article is to discuss a protocol for obtaining platelet-rich plasma (PRP) and evaluate which factors, derived from its preparation method and from whole blood, modify PRP cytometry and coagulation time. STUDY DESIGN: Whole blood, harvested from 50 rabbits, was centrifuged at 300g for 10 minutes. Supernatant was recentrifuged at 5000g for 5 minutes. PRP was clotted with calcium chloride. Whole blood and PRP cytometry were obtained through automatic measurement. The amount of erythrocyte- and platelet-poor plasma drawn from whole blood was measured. Hematocrit, platelet and leukocyte count, mean corpuscular volume (MCV) and mean platelet volume (MPV), mean, standard deviation, and median were also calculated at whole blood and PRP. PRP coagulation time was also analyzed. Mean values between groups were analyzed using Student t test. Correlations were evaluated using Pearson's correlation coefficient. The significance level was set at P < .05. A linear regression was performed to investigate the relationship among the correlated variables. RESULTS: From whole blood, 2.68 mL of erythrocytes and 5.72 mL of platelet-poor plasma (PPP) were removed. PRP platelet count was 2,324,080 cells/microL. Whole blood hematocrit influenced the amount of cells and PPP removed, as well as PRP platelet count. PRP platelet count was dependent on whole blood hematocrit and platelet count, and does not interfere in PRP coagulation time. A linear interaction was confirmed between the variables that presented significant Pearson correlation. CONCLUSIONS: The protocol evaluated produces a good PRP. Whole-blood parameters can predict PRP features. Whole-blood hematocrit is an important variable for PRP preparation and PRP cytometry characterization. PRP platelet count is dependent upon whole-blood platelet count.

Investigação de fatores que limitam a autonomia de pacientes do SUS no processo de decisão de sua integridade bucal / Investigation of factors that limit the autonomy of SUS patients during the decision process of their mouth integrity

O principio da autonomia prevê que os pacientes tenham direito de aceitar ou recusar qualquer proposta de tratamento para seus problemas de saúde, desde que gozem de sua capacidade intelectual e que o consentimento informado esteja contemplado. Pelo principio da justiça, todos os pacientes têm acesso aos serviços públicos de saúde, e isso é uma suposição importante para que eles exerçam sua autonomia com plenitude. Nas clínicas de assistência odontológica do Sistema Único de Saúde que oferecem serviços de exodontia, a demanda de atendimento é grande, e não raro incidem pacientes que desejam se submeter insistentemente a uma extração sem que haja indicação biológica desse procedimento. Este trabalho objetivou avaliar, através de metodologia qualitativa, o processo de consentimento informado a que esses pacientes foram submetidos e ainda analisou, dessa forma, se eles estavam gozando de sua autonomia com a plenitude que está prevista pela Bioética durante esse processo de decisão. Observou-se que o principio da autonomia está profundamente prejudicado por um comprometimento prévio do principio da justiça. Os pacientes não tiveram opção na escolha de tratamentos, porque não existe oferta além da exodontia. Assim, eles optaram por uma solução mais radical, considerando, não que ela seja a mais correta, mas sim a que está disponível. Constatou-se, dessa forma, a necessidade de se reformatar o espírito de respeito ao paciente na sua plenitude na rede de atendimento do SUS, seguindo pressupostos fundamentais do Principialismo.

Tooth displacement and root dilaceration after trauma to primary predecessor: an evaluation by computed tomography.

This case report illustrates the relationship between trauma to a deciduous tooth and the consequences to the permanent dentition. The patient suffered an injury to the central incisors at the age of four with resultant pulpal necrosis. The permanent dentition was affected by displacement from its original position and a severe dilaceration at the crown/root junction.

Efeitos biológicos do plasma rico em plaquetas / Biological effect of the plateled rich plasma

Muitas pesquisas têm investigado variáveis que influenciam a velocidade de cicatrização, especialmente alguns biomateriais e suas propriedades frente ao processo de reparo tecidual. O plasma, rico em plaquetas, (PRP) é um adjuvante recentemente introduzido nesse contexto. Esse biomaterial, de acordo com as suas características, é também conhecido por outras denominações na literatura. Gel de plaquetas, fonte autógena de fator de crescimento, coquetel natural de fatores de crescimento, tecido rico em plaquetas e concentrado plaquetário são as sinônimos do PRP. Independentemente da denominação recebida, desde seu lançamento tem crescido a esperança de que ele intensifique a neoformação óssea. A sua vasta utilização em diversos segmentos da cirurgia foi revisada, com um enfoque maior nas pesquisas de reconstruções ósseas, enxertos, bioengenharia e osteointegração. Foram revisados e discutidos os achados de ensaios clínicos, pesquisas com animais e com cultura de células avaliando-se a eficácia do PRP como potencializador do reparo tecidual e as possibilidades do seu uso isolado e associado a outros biomateriais. A experiência dos autores com a utilização do PRP também foi apresentada e discutida.

Oral paracoccidioidomycosis: a case without lung manifestations.

AIM: The aim of this article is to present a case of Paracoccidioidomycosis with involvement of the oral cavity but without pulmonary manifestations. BACKGROUND: Paracoccidioidomycosis is a fungal infection caused by Paracoccidioides brasiliensis. It is an endemic disease representing a serious health problem for Latin American countries, especially Brazil. This infection primarily affects the lungs of adult men and is acquired through inhalation or accidental inoculation of the fungus. It can spread to other organs and tissues, mainly the oral cavity. Administration of antifungal medication always resolves the disease. REPORT: A 58-year-old black male presented with three painless, ulcerated, mulberry-like granulomatous lesions located in the floor of the mouth, on the superior alveolar ridge, and on the hard palate, which had evolved over a period of two years. Facial asymmetry was observed due to edema in the lower lip and lymphadenopathy. He had smoked for more than six years but showed no evidence of lung alterations, productive cough, or fever. Panoramic radiography showed no signs of a bone lesion in the jaws. Both a radiograph and a CT scan of the thorax showed no areas of nodular infiltration. Fibrobronchoscopic examination of the entire respiratory tract was normal. Biopsies of the oral lesions were performed, and tissue sections exhibited oral mucosa coated with non-keratinized stratified squamous epithelium with acanthosis and focal areas of exocytosis. The underlying connective tissue showed an intense lymphocytic and polymorphonuclear infiltrate in addition to multinuclear giant cells and coagulation necrosis. A special stain used for fungus (the Grocott-Gomori method) was positive. Pulmonary biopsy exhibited aerial spaces containing macrophages, dark granular hemossiderin, and absence of fungus. This was considered normal. In agreement with the recommendation of pneumologists 400 mg/day of ketoconazole was prescribed for the patient. After two months of treatment, even though the oral lesions had resolved completely, the therapy was maintained for six months more. One year after following treatment the patient was in good health and free of any signs of a recurrent infection. SUMMARY: Based on clinical, radiographic, and histologic findings the differential diagnosis included paracoccidioidomycosis and squamous cell carcinoma. Following clinical and biopsy examinations of the oral lesions and the lungs a final diagnosis of paracoccidioidomycosis was made. This is a prime example of oral manifestations of a systemic disease in which the dentist is the initial health care professional to evaluate the patient due to the location of the lesions.

Utilização do intensificador de imagem na cirurguia bucomaxilofacial para remoção de corpos estranhos / Application of the image intensifier in maxillofacial surgery for removal of foreign bodies

Os métodos de diagnóstico por imagem são continuamente aperfeiçoados e alternativas, como o intensificador de imagem, representam um auxílio importante na remoção de corpos estranhos alojados na face. O objetivo deste trabalho foi discutir uma proposta de tratamento, baseada no relato de três pacientes, dos quais foram removidos corpos estranhos, como agulhas descartáveis e projéteis de arma e fogo.

Intranasal tooth in a patient with cleft lip and palate

A erupção dentária ectópica para a cavidade nasal é um fenômeno raro e mais raro ainda entre os pacientes com fissura lábiopalatina. Relata-se o caso de um dente intranasal associado à cacosmia numa paciente fissurada de 5 anos de idade. Diversas cirurgias prévias foram feitas para a correção da má formação. A paciente foi avaliada por tomografia computadorizada e o dente foi removido de sua narina A etiologia do fenômeno é discutida.

Mixoma odontogênico: avaliação imaginológica de um caso tratado com crioterapia / Odontogenic myxoma: imaginologic evaluation of a case treated with cryotherapy

O mixoma odontogênico é um tumor benigno de crescimento lento, que promove aumento de volume ósseo e deslocamento dentário. O seu comportamento infiltrativo, responsável pela recorrência, justifica-se pela abundante matriz extracelular e ausência de cápsula. O tratamento ideal é a ressecção com margem de segurança, porém, a enucleação associada à crioterapia é uma alternativa menos agressiva...

Cytologic alterations in the oral mucosa after chronic exposure to ethanol.

The effects of ethanol alone on the oral mucosa are still poorly understood, especially because there are few non-smoking chronic consumers of alcoholic beverages. The aim of this study was to evaluate the frequency of micronucleus, abnormal nucleus/cytoplasm ratio, pyknosis, karyorrhexis and karyolysis in exfoliated cells from the buccal mucosa and from the lateral border of the tongue in 36 non-smoker alcoholics (ethanol group) and 18 non-smokers and non-drinkers (control group). The Papanicolaou method was used. Since alcoholics generally have hepatobiliary involvement, the association between serum gamma-glutamyl transpeptidase (GGT) and some of the analyzed oral mucosa alterations was also investigated. The ethanol group showed a significant increase in the frequency of all alterations analyzed in the tongue cells when compared with the control group (p < 0.01; Mann-Whitney). However, the presence of these changes in buccal mucosa cells was not statistically significant (p > 0.05; Mann-Whitney). In the ethanol group, the correlation between serum GGT and the frequency of micronucleus and abnormal nucleus/cytoplasm ratio in oral mucosa cells was not significant (p > 0.05; Spearman). In conclusion, chronic exposure to ethanol may be associated with carcinogenic cytologic changes in the oral mucosa, even in the absence of tobacco smoking. These alterations were not correlated with hepatobiliary injury.