Epidemiological Study of Frontal Sinus Fractures: Evaluation of 16 Years of Care at the Faculty of Dentistry of Ribeirão Preto/Brazil.

Purpose: Aiming to evaluate and study the epidemiological profile of frontal sinus fractures treated in the region of Ribeirão Preto-Brazil. Methods: Sixteen years of activity in the Oral and Maxillofacial service of the Faculty of Dentistry of Ribeirão Preto/SP (FORP/USP), totaling 9,736 consultations, 4,524 with facial fractures, those diagnosed with frontal sinus fracture (113) were evaluated and selected for the study. Results: Frontal sinus fractures accounted for 2.5% of facial fractures, the majority occurring in men (89.4%), concentrated in the age group 21-30 years old, with 52.2% of cases being caused by road traffic accidents (RTA). Associations with other facial fractures are common and appeared in 75.2% of cases. Treatment was followed either surgically, by open reduction internal fixation (52.2%) or conservatively (35.4%). Analyzing only the 28 isolated frontal sinus fractures, the most common treatment was conservative (46.4%). surgical treatment dropped to 25%. The most common postoperative complications were temporal branch paralysis and supraorbital nerve paresthesia, both occurring in 30.5% of surgical cases. Conclusion: The frequency of frontal sinus fractures may be decreasing, but the pattern of occurrence in young men due to road traffic accidents does not seem to change, fortunately the appearance of serious complications is not common and it is usually associated with more severe trauma.

Pseudocarcinomatous Squamous Hyperplasia After Surgical Management Of Pediatric Ameloblastoma: An Immunohistochemical Study.

Pseudocarcinomatous squamous hyperplasia (PSH) affecting the jaws is uncommon. The mandible is the most common location, usually as a complication associated with osteomyelitis, medication-related osteonecrosis or osteoradionecrosis. Herein, we report an 8-year-old male patient presenting a solid ameloblastoma, plexiform type, who was treated by segmental mandibulectomy with bone grafting. Three months later, on the underlying graft, a sinus tract was observed, and a small bone fragment was resected which was diagnosed as bone sequestration associated with PSH. After 7-year follow-up, the patient is well, without alterations. To our knowledge, for the first time, we report in detail the immunohistochemical features of PSH which, in addition to epithelial component profile and chronic inflammatory cells, revealed a diffuse infiltration by dendritic cells, suggesting that epithelial cell-immune cell interactions in PSH pathogenesis should also be considered.

Retrospective analysis of the predictability of using three-dimensional models for preoperative planning of the length of zygomatic implants.

PURPOSE: This present study aimed to retrospectively evaluate the predictability of using three-dimensional models (TDMs) to plan the preoperative lengths of zygomatic implants (ZIs). METHODS: The records of all patients that received such implants between March 2007 and March 2019 were evaluated. The ZI lengths predicted on the TDMs were compared to the lengths of the implants the patients received. RESULTS: In total, the records of 74 patients were evaluated, of which 37 records met the criteria of inclusion, and were included in the study. Twenty-seven (73%) of the patients were female and 10 (27%) were male, ranging from 34 to 80 years of age, with the average age being 55.7 years. Seventeen (43.2%) of these patients were classified as ASA I and 21 (56.8%) as ASA II. A total of 142 ZIs were planned and installed in the time frame mentioned. Without distinguishing the region of the maxilla, the implants used were, on average, 1.1 mm larger in length than those initially planned. CONCLUSION: Overall, the data indicates moderate agreement between the planned and surgical lengths of the ZIs and indicates that using TDMs is a predictable and reliable preoperative planning technique of the length of posterior ZIs.

Laboratorial Comparative Study of the Accuracy Between Virtual Planning and Erickson's Platform.

Purpose: The goal was to perform an orthognathic surgery laboratorial study to evaluate the reproducibility of the resulting movements from virtual surgical planning (VSP), by comparing the measurements obtained from VSP to those obtained from Erickson's platform using the 3D printed surgical guide. Methods: Eight patients who had undergone orthognathic surgery were screened and grouped according to maxillary movement and the patient's dentofacial deformity. Three-D virtual surgery simulations were performed, and surgical guides were obtained using Dolphin Imaging 11.9® software. In a semi-adjustable articulator (SAA), the maxilla model was separated from the SAA mounting platform, and the surgical guide was used to reassemble it. Then, the maxilla model was fixed and transferred to Erickson's platform to verify the planned movement. The data were submitted for statistical analysis. Results: The agreement between the methods was excellent, regardless of direction, landmark analyzed, or the amount of movement. The most considerable variation was 0.42 mm in the movement amplitude of 6 mm, and the highest mean was 0.07 mm in the region of the superior right first molar (16). Conclusion: Therefore, regardless the movement of the maxilla, no statistically significant difference was observed between the measurements obtained through VSP and Erickson's platform, demonstrating that both methods are equally accurate and reliable.

Reproducibility of a three-dimensional skeletal-based craniofacial orientation method for virtual surgical planning.

Inadequate craniofacial orientation of computed tomography (CT) scans can have significant implications in all three planes of space. The purpose of this study was to present the reproducibility of a 3-dimensional skeletal-based method of craniofacial orientation for virtual surgical planning. The protocol was defined by landmarks commonly used for cephalometry, and required identification of basion, nasion, right porion, and right orbitale, and navigation in all CT views (coronal, sagittal, and axial) for correction of yaw, roll, and pitch. Reproducibility of the method was assessed using eight CT scans that were randomly selected and anonymised. The observer group consisted of six oral and maxillofacial surgeons with varying levels of experience (resident or faculty) who performed craniofacial orientation according to the proposed method. Results were expected to be below 2° of variation, when overall accuracy as well as the influence of the academic level of the observers and symmetry of the evaluated anatomy, were considered as independent variables. Overall accuracy for all cases and for yaw, roll, and pitch were always below 2° of variation, without influence of level of experience and symmetry. Interobserver assessment was categorised as excellent in all instances, and intraobserver evaluation demonstrated consistency in the orientation of all axes. The proposed craniofacial orientation protocol presented in this study is easy to learn, applicable to computer-aided surgical planning, and can be performed by the non-technical clinician, resulting in excellent reproducibility and consistency.

Surgically assisted rapid palatal expansion (SARPE): three-dimensional superimposition on cranial base.

OBJECTIVES: To evaluate dental and skeletal changes caused by surgically assisted rapid palatal expansion (SARPE) using the superimposition of three-dimensional cone-beam computed tomography (CBCT) images on the cranial base. MATERIAL AND METHODS: This is a retrospective quasi-experiment before-and-after study using a convenience sample. Twenty-four adult patients (13 male and 11 female) were evaluated before SARPE (T0), immediately after expansion (T1), and after 6 months of retention (T2). CBCT scans were superimposed on the anterior cranial base using voxel-based registration. Measurements from different reference points were used for comparisons between times. RESULTS: At T1, all teeth had significant buccal tipping. At T2, most teeth remained in the same position as at T1, except the first premolar and the first molar, whose buccal roots moved slightly. The amount of bony expansion was 65 to 70% of the amount of tooth movement. The A point and maxillary incisors moved anteriorly from T0 to T1 and T2 (p < 0.0001). Inter-nasal distance had increased significantly at T1 (p < 0.0001) and remained stable at T2 (p = 0.478). No expansion was achieved at the zygomatic arch (p = 0.114). CONCLUSION: SARPE promoted substantial buccal tipping of posterior teeth and some bone displacement; it also moved the maxilla and teeth forward and increased nasal width. CLINICAL RELEVANCE: No other clinical studies have evaluated dental and skeletal changes caused by SARPE using superimposition of 3D CBCT images on the cranial base. This study findings may help clinical dentists plan treatments using safe and reliable information.

Does the type of sagittal split ramus osteotomy influence fixation strength? Evaluation of the mechanical behavior of two types of fixation used in three types of sagittal split ramus osteotomy.

PURPOSE: This study compared the mechanical behavior of two fixation techniques used in three sections representing the sagittal split ramus osteotomy (SSRO) in polyurethane replicas that were divided into groups, according to type of section, and sub-groups according to type of fixation, simulating 11-mm advancement and 6º clockwise mandibular rotation. METHODS: Loads were applied in two regions, aiming at progressive application and consequent strength value, measured in kilogram-force in displacements of 1, 3, 5, and 7 mm, from the load application tip. Shapiro-Wilk test was performed, followed by two-way analysis of variance (ANOVA-2 way), and Bonferroni's multiple comparison. RESULTS: The results showed no statistically significant difference in the type of section and type of fixation used when load was applied to the inter-incisor region. However, when load was applied to the first molar region, statistically significant difference was observed in 1-mm displacement, in which section described by Epker with two modifications showed greater strength, regardless of type of fixation used (p = 0.007). CONCLUSION: In the application of load in the inter-incisor region, there was no statistical difference between the type of osteotomy and the type of fixation used. When applying loads to molars, there was a difference for the type of osteotomy, where the Epker osteotomy with 2 modifications presented greater resistance, regardless of the type of fixation used.

Effect of vomer position following surgically assisted rapid palatal expansion.

PURPOSE: To evaluate the effect of vomer position and prevalence of periodontal dehiscence in patients who underwent surgically assisted rapid palatal expansion (SARPE). The null hypotheses were the following: (1) vomer position in the coronal plane does not influence the degree of skeletal and dental expansion; and (2) there is no association between expansion, periodontal dehiscence and vomer position. METHODS: Twenty-one patients were evaluated before treatment (T0) and immediately after SARPE expansion (T1). After SARPE, the vomer was in the right side in 11 patients and in the left in 10 patients. Skeletal and dental effects were evaluated using CBCT, landmarks and measurements. RESULTS: The maxilla and the nasal cavity expanded asymmetrically. The side containing the vomer had less skeletal expansion but more dental tipping. Dehiscence increased significantly from T0 to T1 and was associated with the amount of skeletal displacement, especially when greater than 3.20 mm. In the first premolars region, there was more than 2 mm of asymmetric expansion observed in 38.5% of the patients. CONCLUSION: The null hypotheses were rejected. The side containing the vomer had less skeletal expansion of the maxilla and nasal cavity but more dental tipping. Dehiscence increased after expansion, but there were no differences between sides.

Complex odontoma restricting mouth opening: an unusual clinical presentation and surgical management.

Odontomas are common benign odontogenic tumors, being often detected on routine radiographs during the first two decades of life. Rarely, odontoma can interfere with jaw movements, causing mouth opening limitation. A 28-year-old male patient was referred complaining of restriction of mouth opening and mandibular movements, which started 6 months ago. Clinical examination revealed a painless increase of volume on the right maxilla, which interfered the mandibular movements, being associated with pain in these attempts. A well-defined, oval radiopaque lesion in close relationship with the impacted maxillary right third molar was detected in tomographic reconstructions. A surgical excision of the lesion was performed, and microscopy revealed complex odontoma. After 4 months of follow-up, the patient achieved adequate mouth opening and recovered mandibular movements. In the current case, the lesion was placed in a difficult access site, which directly interfered with the displacement of coronoid process. Odontoma should be included in the differential diagnosis when assessing causes of restricted mouth opening.

Body postural realignment in the first 2 months after orthognathic surgery.

INTRODUCTION: This study aimed to assess the static posture in patients with Angle Class II and III malocclusions in the first 2 months after orthognathic surgery. METHODS: This was a longitudinal observational study. Eligible participants were adult patients who had an indication of orthognathic surgery (bilateral sagittal split osteotomy of the maxilla and/or mandible, can be associated or not with genioplasty). Thirty-five patients were evaluated from the orthognathic surgery group (OSG) and control group (CG). Measurements in OSG were performed at 3 time points: preoperative orthognathic surgery (P0), first postoperative month (P1), and second postoperative month (P2). Static posture was evaluated using the PostureScreen Mobile (PostureCo Inc, Trinity, Fla) application in 4 views. RESULTS: Patients with Angle Class II malocclusion in the OSG evidenced a tendency to a left hip translation at P1 with a significant difference at P2 in the anterior view (P = 0.052). In the right lateral view, patients with Angle Class II malocclusion in the OSG at P1 presented an accentuated anterior shoulder translation when compared with CG (P <0.001). At P1, patients with Angle Class II malocclusion in the OSG showed a significant anterior knee translation compared with the CG and OSG at P0 and P2 (P <0.001 for all). Patients in the OSG with Angle Class III malocclusion presented an average posterior head translation in the right lateral view at P1 when compared with those in the CG and OSG at P0, who presented an anterior translation (P = 0.0008). CONCLUSIONS: These findings suggest a realignment of static posture in the first 2 months after orthognathic surgery.

Linear analysis of the nasal septum in patients treated with surgically assisted rapid maxillary expansion.

INTRODUCTION: Surgically assisted rapid maxillary expansion is a widely used surgical procedure for resolving transverse maxillary occlusal changes in patients with bone maturity. However, few studies about the postoperative morphologic alterations in the nasal cavity in its inferior portion and the nasal septum positioning exist. METHODS: The linear nasal septum measurements of 26 adult patients treated with surgically assisted rapid maxillary expansion from 2009 to 2013 were assessed through a retrospective analysis of cone-beam computed tomographies, in Digital Imaging and Communications in Medicine files, through the Dolphin Imaging program (Dolphin Imaging and Management Solutions, Chatsworth, Calif), aimed to identify significant changes during 3 time periods of the treatment: preoperative, immediately after the palatal expansion device locking (immediate postoperative), and 6-months postoperative (late postoperative). The analyses were performed in the inferior third of the nasal septum, from 4 equidistant points in anteroposterior position and height, using fixed cranial references for lateral measures of displacement. RESULTS: No significant difference was found between preoperative, immediate postoperative, and late postoperative measurements in the 4 fixed nasal septum measurements, applying the analysis of variance test with a significance level of 5%. Comparing the surgical times alone, we found no statistically significant difference between the right and left sides applying the Student t test, which also showed symmetry in the nasal septum. CONCLUSIONS: The measurements of the nasal septum did not change in the different surgical times throughout their inferior extension, and they remained symmetrical throughout patients' follow-up period.

Which type of method shows the best mechanical behavior for internal fixation of bilateral sagittal split osteotomy in major advancements with clockwise rotation? Comparison of four methods.

PURPOSE: The aim of the present study was to evaluate the four methods for bilateral sagittal osteotomy fixation. METHODS: In this study, 56 replicas of whole mandibles made of rigid polyurethane were used. After simulation of major advancement (11 mm) with clockwise rotation of the mandible (6o) in relation to the occlusal plane, the bone segments were fixed with plates and screws of the 2.0-mm system on both the right and left sides: group I, double "H" plate; group II, two mini-plates; group III, "hybrid technique"; and group IV, three bicortical screws in the "inverted L" pattern. The mandibles were submitted to load on the central incisors and right first molar. RESULTS: The mean value of group I was higher than those of groups IV and II in the displacement of 1 mm (F = 4.705; p = 0.010) with load on the incisor. The mean value of group III was higher than those of groups I and II in the displacement of 1 mm (F = 5.166; p = 0.007) and 3 mm (F = 5.166; p = 0.007). The mean value of group IV was higher than that of group II (F = 3.142; p = 0.044) with load on the molar. CONCLUSION: Therefore, after the analyses, the hybrid technique was the one that showed the best results.

Primary intraosseous CD9-positive B-cell lymphoblastic lymphoma of the maxilla affecting a pediatric patient: Immunohistochemical and in situ hybridization analysis.

Lymphoblastic lymphoma (LBL) is a clinically aggressive disease, representing approximately 2% of all non-Hodgkin lymphoma cases. In the oral and maxillofacial (OMF) region, approximately 39 cases, diagnosed as LBL, acute lymphoblastic leukemia (ALL) or ALL/LBL, have been reported to date. Noteworthy, the CD9 expression, which indicates a poor outcome in ALL, has not been reported in LBL and lymphoblastic neoplasms of the OMF region. Herein, we report an additional maxillary intraosseous B-cell LBL, affecting a 14-year-old girl, which also showed positivity for CD9, Bcl-6 and MUM1/IRF4. Aiming at diagnostic and prognostic criteria, further studies focusing CD9 expression in LBL is recommended.

Migration and surgical retrieval of a broken dental needle: a literature review and case report.

Although the incidence of broken needles in dental practice is minimal, needle breakage can occur as a result of manufacturing defects, inadequate patient management, or poor practitioner technique. Retrieval of a broken needle is justified not only because of the potential for needle migration but also because of psychological and medicolegal considerations. This case report describes the surgical removal of a dental needle that fractured during an attempt at local anesthesia. Identifying the precise location of the broken needle fragment and its relationship with the surrounding bones, vessels, and nerves is essential to designing an adequate treatment plan. If surgical retrieval is indicated, it should be performed immediately, especially in cases in which the needle fragment has not been bent or deformed. In the present case, the use of C-arm fluoroscopy aided the surgical removal while saving time and reducing the cost of treatment.

Three-Dimensional Nasal Alterations in Le Fort I Advancement: Linear Measurements, Angles, Nasal Indices, and Volume Differences.

The maxillary advancement obtained by the Le Fort I osteotomy can also generate significant changes in the soft tissue of the nose and lips. The aim of this study was to compare the alterations in the soft tissue of the nose following the Le Fort I osteotomy maxillary advancement technique in a population of young adults submitted to orthognathic surgery. Seven men and 8 women aged between 23 and 45 underwent orthognathic surgery using the Le Fort I osteotomy and bilateral mandibular sagittal osteotomy. Sixty 3-dimensional images were analyzed (Vectra M3, Canfield, NJ) after labeling landmarks on the face and determining linear and angular measurements, proportion, and volume difference indices at the following intervals: preoperatively (baseline), then 2 months, 6 months, and 1 year after surgery. Following Le Fort I, there was an increase in the alar base, and reduction of nasal tip protrusion, nasal angles, and the nasal tip protrusion index (P < 0.05). There were no differences in the facial thirds, the nasal index, and angles of nasal and mentolabial convexity (P > 0.05). There was a difference in the volume of the nose only 2 months after surgery. The Le Fort I osteotomy caused significant alterations in linear, angular, and nasal proportion measurements. The volume differences were reversible in the early postoperative period and probably associated with edema. The possibility of variations in the size and shape of the nose should be presented to prospective patients preoperatively.

Removal of Implant and New Rehabilitation for Better Esthetics.

Tooth loss can result in loss of facial esthetics, in addition to its effect on mastication, swallowing, and speech. Adequate planning is required in order for the prosthetic treatment of the teeth and implants to be successful. Here, we present a clinical case demonstrating that improper positioning of an implant can make prosthetic rehabilitation unfeasible, necessitating new surgical and rehabilitation planning to achieve the desired esthetics. The patient had a missing right lateral incisor and cuspid, and a buccally directed implant. The preferred treatment regimen involved the removal of this implant and placement of another one more properly positioned distally and three dimensionally. The repositioning of the implant made rehabilitation treatment with a mesial cantilever possible. Due to esthetic considerations, gingival conditioning in the cantilever region was performed in the temporary prosthesis phase. The changes adopted in planning the surgery and rehabilitation resulted in good esthetics as well as functional outcomes.

Resistance of four fixation techniques used to treat subcondylar fractures.

OBJECTIVE: This study aimed to evaluate the resistance of four fixation techniques used to treat subcondylar fractures. The following techniques were evaluated: fixation with one 4-hole single straight plate; fixation with one 2-mm 4-hole system plate and one 1.5-mm 3-hole system plate; fixation with two 2-mm plates with a 3-hole anterior plate; and fixation with two 2-mm plates with four holes each. STUDY DESIGN: Each fixation technique was subjected to a resistance test. The load values were measured when displacement of 1, 2, and 5 mm was reached. Load values were compared for statistically significant differences using analysis of variance (ANOVA; p < 0.5) and Tukey's test. RESULTS: Statistically significant differences were observed, when the load was applied to the first molar on the side of the fracture. The group treated with a 4-hole, 2-mm, one plate system showed resistance to lower load values than the groups treated with two plates in any combination. CONCLUSIONS: When the fracture was fixed using two plates, regardless of the kind of plates used, no statistically significant difference between the groups was observed. However, two plate systems showed better resistance than one plate systems.

Intraoral Pigmented Low-Grade Adenocarcinoma, Not Otherwise Specified: Case Report and Immunohistochemical Study.

Salivary adenocarcinoma, not otherwise specified (AdCaNOS) is a rare malignant tumor with potential diagnostic challenge, which mainly affects the parotid glands; however, the minor salivary glands can also be involved by AdCaNOS. This paper reports a case of a 45-year-old Afro-descendant woman complaining of a slow-growing mass with 6 months of evolution in the left superior vestibular fornix. Microscopic examination revealed an infiltrative epithelial neoplasm composed of predominantly solid growth pattern, arranged in a lobular configuration, admixed with glandular or ductal structures. Perineural invasion was evident. The tumor cells were polygonal or oval showing focally mild nuclear pleomorphism, and eosinophilic or clear cytoplasm. Notably, some areas exhibited intracytoplasmic pigment granules mainly in non-luminal cells, as well as sebaceous-like cells, discrete hyaline material deposition and foci of infiltration of residual salivary gland parenchyma. Tumor cells were negative for PAS, mucicarmine and Alcian blue stains. By immunohistochemistry, the tumor cells were diffuse and strongly positive for pan-cytokeratin (CK) AE1/AE3, 34betaE12 CK, vimentin, p63 and S100. CK7 and EMA strongly highlighted the ductal structures. Solid areas also showed diffuse and moderate expression of CD56. Podoplanin (D2-40), GFAP and Calponin, followed by DOG-1, were focally positive; whereas CK20, α-SMA, h-Caldesmon, CD57, ERBB2/HER2 and p53 were negative. Ki-67 was < 2%. Consecutive serial tissue sections using CD57 confirmed the perineural invasion. Positivity for HMB-45 and MART-1/Melan-A, as well as Fontana-Masson stain (and potassium permanganate bleaching-sensitive), identified the pigment granules as melanin. To the best of our knowledge, this is the first case of intraoral low-grade AdCaNOS with intracytoplasmic melanin granules.

Failure of Osseointegrated Dental Implant After Alveolar Nerve Transposition: A Report of an Unusual Complication and Surgical Management.

PURPOSE: To describe an unusual case of mandibular fracture after osseointegrated dental implant removal placed after inferior alveolar nerve transposition. REPORT OF CASE: The patient underwent inferior nerve transposition for implant placement due to lack of interarch space. Two months after metal-ceramic crowns installation, the patient began to complain of pain in the region of the implant. In an attempt to remove the implant, there was a fracture of the implant, and only two third of it was removed, leaving only the apical portion of the implant in the mandible. The patient opted for the total removal of implant. At 15 days of follow-up, the patient returned with mandibular fracture, which was treated through an internal fixation with a titanium reconstruction plate of 2.0-mm thickness with locking screws. CONCLUSION: The inferior alveolar nerve transposition may represent the only rehabilitation option, especially in cases where there is insufficient bone remaining for installation of short implants with reduced interarch space.