Tratamento cirúrgico da osteomielite dos maxilares: relato de caso / Surgical treatment of osteomyelitis of the jaws: Case report / Tratamento quirúrgico de la osteomielitis de los maxilares: reporte de um caso

A Osteomielite dos Maxilares (OM) é uma inflamação óssea, de origem na maioria infecciosa, podendo atingir a porção medular e cortical dos ossos maxilares. Apresenta-se em maior extensão na mandíbula, devido ao pobre suprimento sanguíneo que essa possui, sendo mais prevalente em homens entre a faixa etária de 40 a 60 anos. Sua etiologia está relacionada principalmente às infecções odontogênicas, infecções secundárias e corpos estranhos ocasionais, como os implantes dentários. Tem-se por objetivo apresentar um relato de caso clínico sobre OM na região posterior da mandíbula, bem como sua associação a uma insatisfatória implantação dentária onde houve desenvolvimento de lesão peri-implantar. Paciente do gênero feminino, 53 anos, melanoderma, apresentou dor crônica, abaulamento ósseo sem outros sinais significativos na região de molares inferiores no lado direito, radiograficamente visualizava-se imagem mista sendo sugestiva de sequestro ósseo. Na história pregressa relatou ter realizado explantação na referida região após ser diagnosticada com peri implantite. Ao final do estudo concluiu-se que a afecção teve como causa a infecção bacteriana proveniente de contaminação durante a inserção de implante dentário. Optou-se por remoção cirúrgica do osso necrótico e inflamado... (AU)

Osteomyelitis of the Jaws (OM) is a bone inflammation, of mostly infectious origin, which can affect the medullary and cortical portion of the maxillary bones. It presents itself to a greater extent in the mandible, due to the poor blood supply that it has, being more prevalent in men between the age group of 40 to 60 years. Its etiology is mainly related to odontogenic infections, secondary infections and occasional foreign bodies, such as dental implants. The objective is to present a clinical case report on OM in the posterior region of the mandible, as well as its association with an unsatisfactory dental implantation, where there was development of a peri-implant lesion. Female patient, 53 years old, melanoderma, presented chronic pain, bone bulging without other significant signs in the region of lower molars on the right side, radiographically a mixed image was visualized, suggesting bone sequestration. In her previous history, she reported having performed explantation in that region after being diagnosed with peri-implantitis. At the end of the study, it was concluded that the disease was caused by bacterial infection from contamination during dental implant insertion. We opted for surgical removal of the necrotic and inflamed bone... (AU)

La osteomielitis de los maxilares (OM) es una inflamación de los huesos, en su mayoría de origen infeccioso, que puede afectar la porción medular y cortical de los huesos maxilares. Se presenta en mayor medida en la mandíbula, debido a la escasa irrigación sanguínea que tiene, siendo más prevalente en hombres entre el grupo de edad de 40 a 60 años. Su etiología se relaciona principalmente con infecciones odontogénicas, infecciones secundarias y cuerpos extraños ocasionales, como los implantes dentales. El objetivo es presentar un reporte de caso de OM en la región posterior de la mandíbula, así como su asociación con una implantación dentaria insatisfactoria a partir de la cual desarrollamos una lesión periimplantaria. Paciente femenina, 53 años, melanodermia, presenta dolor crónico, tumefacción ósea con otros signos significativos en región molar inferior del lado derecho, radiográficamente se visualiza imagen mixta sugestiva de pérdida ósea. En su historia previa menciona haber realizado una explantación en esa región tras ser diagnosticada de periimplantitis. Al final del estudio, se concluyó que la enfermedad fue causada por una infección bacteriana provocada por la contaminación durante la inserción del implante dental. Se optó por la extirpación quirúrgica de la piel necrótica e inflamada... (AU)

Marsupialização de cisto dentígero após traumatismo / Marsupialization of dentigerous cyst after traumatism

Objetivo: as causas mais comuns das alterações na dentição permanente são os traumatismos alvéolo-dentários (TAD) na dentição decídua, ultrapassando, inclusive, as incidências de cárie ou doença periodontal. Estes podem levar a hipoplasia de esmalte, alterações na morfologia dentária e desenvolvimento de cistos, como o cisto dentígero, considerando ainda que o tratamento desta ocorrência diverge ao tratar da dentição decídua e não da permanente. O objetivo deste trabalho é ilustrar essas características e como elas podem ser manejadas através de um relato de caso. Relato de caso: no caso em questão, ocorreu o desenvolvimento de um cisto dentígero de grandes dimensões após traumatismo alvéolo-dentário em dentição decídua na região anterior da maxila com retenção de três dentes permanentes. Foram discutidas as formas terapêuticas para tal situação clínica, bem como a possibilidade de uma abordagem multidisciplinar da cirurgia-ortodontia. Considerações finais: os TADs na dentição decídua devem ser bem diagnosticados e tratados, visando a prevenção de sequelas na dentição permanente.(AU)

Objective: the most common causes of changes in permanent dentition are alveolar-dental trauma (TAD) in deciduous dentition, with occurrence rates even higher than decays or periodontal disease, which can lead to enamel hypoplasia, changes in dental morphology and the development of cysts such as the dentigerous cyst, considering treatment differs when dealing with deciduous dentition instead of permanent dentition. The objective of this work is to illustrate these characteristics and propose a possible treatment, through a case report. Case report: in the case at hand occurred a development of a large dentigerous cyst occurred after TAD in primary dentition, in the anterior region of the maxilla with retention of three permanent teeth, discussing the therapeutic forms for such clinical situation, as well as the possibility of a multidisciplinary approach to surgery-orthodontics. Final considerations: TAD in deciduous teeth should be well diagnosed and treated aiming to prevent sequelae in permanent dentition.(AU)

Challenges in the Successful Reconstruction of Cleft Lip and Palate: Managing the Nasomaxillary Deformity in Adolescence.

The surgical techniques and execution of primary cleft lip and palate repair are no longer the greatest challenge to achieving successful rehabilitation for those born with facial clefting (i.e., bilateral and unilateral cleft lip and palate). Despite a surgeon's best efforts, when cleft palate repair is carried out during infancy, by the mixed dentition, a majority will demonstrate nasomaxillary deficiency. The cleft team's commitment to a family under their care is to ensure that the newborn reaches adulthood reconstructed without need for special regard to their original birth malformation. Guiding principles are provided for the accurate diagnosis and reliable reconstruction of the bilateral and unilateral cleft lip and palate adolescent/adult who presents with nasomaxillary deficiency and any residual oronasal fistula, bony defects, cleft dental gap(s), nasal obstructions, and associated facial dysmorphology. Successful orthognathic surgery provides a stable foundation on which any remaining soft-tissue cleft lip or cleft nasal deformities can be accurately assessed and then reconstructed.

Evaluation of photobiomodulation effects on pain, edema, paresthesia, and bone regeneration after surgically assisted rapid maxillary expansion: Study protocol for a randomized, controlled, and double blind clinical trial.

BACKGROUND: Surgically assisted rapid maxillary expansion (SARME) generates an uncomfortable postoperative period accompanied by pain, edema, and paresthesia. There are few studies on the effect of photobiomodulation (PBM) after SARME and it was not possible to find studies on the efficacy of light emitted by diode (LED) after this type of intervention. The main objective of the study will be to evaluate the efficacy of PBM with LED in the control of pain, facial edema, paresthesia, and bone repair after SARME. METHODS: A randomized, double-blind, placebo-controlled clinical trial involving 72 participants aged from 18 to 45 years, who search the Department of Buccomaxillofacial Surgery and Traumatology of Mandaqui Hospital Complex, will be conducted. Immediately after surgeries, the participant will be inserted into the placebo or LED group. In the LED group, the participants will receive PBM with an extraoral device (660 and 850 nm with 6 J per point) and an intraoral device (660 nm with 2 J per point) and in the control group the person in charge of the application will simulate the irradiation with the devices kept off. The applications will be in the immediate postoperative period, 1, 2, 7, 14, 30, 60, 90, and 120 days after the end of the surgeries, when the evaluations will also be performed. Facial measurements, extra and intraoral sensitivity, pain and bone repair will be evaluated. Secondarily, data regarding the occurrence of headache; otalgia; nausea; bruising; nasolacrimation; epistaxis; dysphagia; systemic and superficial temperature in the operated region; use of analgesics and anti-inflammatories; anxiety and impact of oral health on the participants' quality of life will be computed. DISCUSSION: Since PBM has shown positive effects on postoperative complications of other types of oral surgery and also has a positive effect on bone repair after maxillary disjunction, surgically assisted or not, it seems clear the need to evaluate its performance regarding pain, edema, and paresthesia after these surgeries. TRIAL REGISTRATION: This protocol was registered in Clinical Trials platform (https://clinicaltrials.gov/) with the number NCT03814525, first published and last updated on January 24, 2019.

Mandibular Implant-Retained Overdentures: Potential Accelerator of Bone Loss in the Anterior Maxilla?

PURPOSE: To compare the residual ridge resorption (RRR) of the anterior maxillary bone beneath complete dentures when opposed by mandibular complete dentures (CD) and implant-retained overdentures (IRO). MATERIALS AND METHODS: 18 patients were rehabilitated with maxillary CD opposing mandibular IRO, and 4 patients were prescribed with conventional CD. Cone beam computed tomography (CBCT) scans of the maxilla were acquired before and 1 year post-treatment and converted into 3D models using Mimics research software. RRR was quantified by measuring the changes in bone volume following superimpositioning and sectioning of these models at the anterior maxillary region. Subsequently, the sectioned 3D models of the anterior maxilla were exported to 3-Matic software to reveal the predominant region and depth of RRR. RESULTS: The mean reduction in bone volume of the anterior maxilla in the CD group was 2.60% (SD = 1.71%, range = -4.89 % to -0.92%, median = -2.30%), while the mean reduction in the IRO group was almost three times higher at 7.25% (SD = 3.16%, range = -13.25 to -1.50, median = -7.15%). The predominant areas of RRR were on the buccal and occlusal ridge of the anterior maxilla. CONCLUSION: Within the limits of this study, it may be concluded that an IRO caused significantly higher RRR of the anterior maxilla than a CD.

Recurrence of nonsyndromic odontogenic keratocyst after marsupialization and delayed enucleation vs. enucleation alone: a systematic review and meta-analysis.

PURPOSE: This study was conducted in order to determine whether marsupialization before definitive enucleation of nonsyndromic odontogenic keratocysts (OKCs) is capable of decreasing the recurrence rate more effectively than just enucleation. METHODS: We searched MEDLINE, Web of Science, Scopus, and Cochrane Library, until August 5th of 2017 for original studies reporting on the treatment of OKCs with and without previous marsupialization and the related recurrence rate. All records and data were independently assessed, meta-analysis was performed, and the odds ratio of recurrence was the effect measure; P value for the summary effect of < 0.05 was considered statistically significant. RESULTS: The 748 records retrieved were reduced to 6 studies to be qualitatively assessed and 5 studies were included in the meta-analysis. The overall odds ratio of 0.57 [0.25-1.28] of the pooled values pointed that marsupialization reduced the recurrence rate in comparison to just enucleation; however, the P value showed that there is no strong evidence to support this statement. CONCLUSIONS: Marsupialization followed by enucleation after 12 to 18 months reduces the recurrence rate, but more studies are necessary to support this statement.

Maxillary osteomyelitis associated with osteopetrosis: Systematic review.

Osteopetrosis is a rare condition which presents increased bone density and deficient bone remodeling. The consequential complications include cranial nerve impairment due compression, bone fractures, and osteomyelitis. Maxillary osteomyelitis is uncommon even in osteopetrosis patients. This is a systematic review of the literature regarding the management and outcomes of maxillary osteomyelitis in patients with autosomal dominant osteopetrosis (ADO) type II. A case of this specific pathology is reported. There are 18 cases of maxillary osteomyelitis associated with ADO type II reported in the literature. The mean age of the patients reported was 33.5 (SD 15.9) years, and the male:female ratio was 1:1. Antibiotic therapy was variable, and amoxicillin with clavulanic acid was the main choice (33.33%). Surgery or sequestrectomy was performed in 88.89% of the studies. Complete healing was achieved in only 44.4% of cases. The treatment protocols remain controversial and often do not lead to complete healing. In the case that we report, complete healing was achieved after prolonged antibiotic therapy, hyperbaric oxygen therapy, and partial resection. In conclusion, the management of maxillary osteomyelitis in ADO type II patients is challenging, and complete resolution of the process is dependent on multiple interventions.

Maxillary sinus floor pneumatization and alveolar ridge resorption after tooth loss: a cross-sectional study.

This is a cross-sectional study that aimed to estimate maxillary sinus floor (MSF) pneumatization in single missing tooth of posterior maxilla, by using cone-beam computed tomography (CBCT). CBCT images were analyzed bilaterally and divided into 2 groups: edentulous site (EdS) - edentulous single region of upper second premolar, first or second molars; Tooth site (TS) - contralateral region homologous to the EdS region, with tooth present. Variables evaluated were: sinus height (SH), estimated sinus pneumatization (eSP: ∆ EdS - TS), healed ridge height (HR) and presence of localized sinus pneumatization (LSP) in molars teeth at TS. HR were categorized according to therapeutic option for posterior maxilla. 183 CBCT scans were included and it was observed that EdS presented a higher SH than the TS (p < 0.001) showing an eSP of 0.9 ± 2.93 mm. First molars presented the highest SH for both sides, although significant differences were detected when compared to second molars. First molars were mostly affected by LSP at TS (36 out of 43). Individuals with LSP at TS presented lower HR than the ones without LSP (p < 0.05). 54% of the cases presenting LSP obtained HR < 5 mm, which indicates sinus lift surgery. The present study showed that tooth loss in posterior maxilla favors sinus pneumatization and the identification of LSP at molar roots seems to indicate a greater necessity for sinus lift surgeries.

Expansive renal osteitis fibrosa: a case report.

Hyperparathyroidism (HPT) is an endocrine metabolic disorder characterized by increased secretion of parathyroid hormone. Untreated secondary HPT leads to renal osteodystrophy (ROD). Facial skeletal abnormalities in patients with ROD are rare. The purpose of this paper is to report a conservative surgical approach of exuberant osteitis fibrosa lesions in patient with chronic kidney disease. A 24-year-old female was referred to maxillofacial surgery department with giants ROD affecting palate, maxilla, and mandible, resulting in esthetic and functional impairment. The pathogeneses and multidisciplinary management of ROD are discussed with a brief literature review. Eight years after the conservative treatment of exuberant jaw lesions, no noticeable bone changes were observed in the patient. A multidisciplinary therapy is essential for correct diagnosis of ROD and optimal multimodality treatment. The conservative management was an efficient alternative for the success of the case reported.

Incisor malalignment and the risk of periodontal disease progression.

INTRODUCTION: The objective of this study was to investigate the association between incisor crowding, irregularity, and periodontal disease progression in the anterior teeth. METHODS: Data collected over 35 years from men enrolled in the Veterans Affairs Dental Longitudinal Study included information concerning pocket depth and alveolar bone loss. Plaster casts of the maxillary (n = 400) and mandibular (n = 408) arches were available for baseline measurements. Periodontal disease in the anterior teeth was defined as per arch sum of pathologic pocket depth and sum of teeth with any alveolar bone loss in the anterior sextants. Incisor malalignment status was defined by the anterior tooth size-arch length discrepancy index and Little's Irregularity Index. Adjusted mixed effects linear models computed the beta (ß) estimates and 95% confidence intervals (95% CI) of the amounts of change in periodontal disease outcomes by the level of malalignment. RESULTS: In the anterior maxillary arch, crowding and spacing were significantly associated with an increased per-arch sum of pathologic pocket depth (ß, 0.70 mm; 95% CI, 0.20-1.21, and ß, 0.49 mm; 95% CI, 0.06-0.91, respectively). In the anterior mandibular arch, incisor crowding and irregularity were significantly associated with an increased per-arch sum of pathologic pocket depth (mild crowding: ß, 0.47 mm; 95% CI, 0.01-0.93; severe irregularity: ß, 0.94 mm; 95% CI, 0.50-1.38), and the sum number of teeth with alveolar bone loss (mild and moderate-to-severe crowding: ß, 0.45 teeth; 95% CI, 0.08-0.82; and ß, 0.45 teeth; 95% CI, 0.13-0.83, respectively; moderate irregularity: ß, 0.34 teeth; 95% CI, 0.06-0.62). CONCLUSIONS: Certain incisor malalignment traits (ie, maxillary incisor crowding, maxillary incisor spacing, mandibular incisor mild crowding, mandibular incisor moderate-to-severe crowding, mandibular incisor moderate irregularity, and mandibular incisor severe irregularity) are associated with significant periodontal disease progression.

Infraorbital Nerve Located Medially to Postoperative Maxillary Cysts: A Risk of Endonasal Surgery.

BACKGROUND/AIMS: This study aimed to examine variations in the location of the infraorbital nerve relative to postoperative maxillary cysts to assess the potential risk of nerve injury during endonasal marsupialization. METHODS: Coronal computed tomography images of 130 patients (162 sides) with postoperative maxillary cysts who visited our clinic between 2003 and 2014 were reviewed from the viewpoint of the anatomical relationship between the infraorbital nerves and cysts. RESULTS: The proportions of the six locations were as follows: upside 45.1% (n = 73), separate 13.0% (n = 21), medial 5.6% (n = 9), lateral 14.2% (n = 23), in-between 7.4% (n = 12), and unevaluable 14.8% (n = 24). The proportion of the cases with a potential risk of infraorbital nerve damage during endoscopic marsupialization, including medial, in-between, and unevaluable locations, was 27.8%. Retrospective chart review revealed that 2 patients with a postoperative maxillary cyst that were unevaluable complained of persistent postoperative hypoesthesia of the cheek. CONCLUSION: The anatomical relationship between the infraorbital nerve and postoperative maxillary cysts varied among patients, with approximately one-fourth of the patients being at risk of infraorbital nerve injury even during endoscopic procedures.

Bone Regeneration using Silk Hydroxyapatite Hybrid Composite in a Rat Alveolar Defect Model.

Background: To overcome the limited source of autogenous bone in bone grafting, many efforts have been made to find bone substitutes. The use of hybrid composites of silk and hydroxyapatite to simulate natural bone tissue can overcome the softness and brittleness of the individual components. Methods: Critical-sized, 7 x 4 x 1.5 mm alveolar defects were created surgically in 36 Sprague-Dawley rats. Three treatment groups were tested: an empty defect group (group I), a silk fibrin scaffold group (group II), and a hydroxyapatite-conjugated silk fibrin scaffold group (group III). New bone formation was assessed using computed tomography and histology at 4, 8, and 12 weeks, and semi-quantitative western blot analysis was done to confirm bone protein formation at 12weeks. Statistical analysis of new bone formation was done using the Kruskal-Wallis test. Results: Radiomorphometric volume analysis revealed that new bone formation was 64.5% in group I, 77.4% in group II, and 84.8% in group III (p=0.027) at 12 weeks. Histologically, the osteoid tissues were surrounded by osteoblasts not only at the border of the bone defect but in the center of the scaffold implanted area in group III from week 8 on. Semi-quantitative western blotting revealed that osteocalcin expression in group III was 1.8 times higher than group II and 2.6 times higher than group I. Conclusions: New bone formation was higher in hybrid scaffolds. Both osteoconduction at the defect margin and osteoinduction at the center of the defect were confirmed. There were no detected complications related to foreign body implantation.

Maxillary deformity following CPAP treatment in myasthenia gravis.

OBJECTIVE: Patients with Myasthenia gravis (MG) are characterized by muscle weakness that may cause obstructive sleep apnea (OSA). The use of a continuous positive airway pressure (CPAP) device is often needed in order to maintain free breathing during the night and sometimes even during the day. CLINICAL PRESENTATION: A 29-year-old MG patient is presented who used a CPAP continuously since the age of 12. Tight fitting of a nasal mask applied enough force to cause severe maxillary deformity. CLINICAL RELEVANCE: Masks with additional forehead and chin support or a regular full face mask are recommended for patients with muscle weakness, in order to spread forces more evenly.

Maxillary sinus floor pneumatization and alveolar ridge resorption after tooth loss: a cross-sectional study

Abstract This is a cross-sectional study that aimed to estimate maxillary sinus floor (MSF) pneumatization in single missing tooth of posterior maxilla, by using cone-beam computed tomography (CBCT). CBCT images were analyzed bilaterally and divided into 2 groups: edentulous site (EdS) - edentulous single region of upper second premolar, first or second molars; Tooth site (TS) - contralateral region homologous to the EdS region, with tooth present. Variables evaluated were: sinus height (SH), estimated sinus pneumatization (eSP: ∆ EdS - TS), healed ridge height (HR) and presence of localized sinus pneumatization (LSP) in molars teeth at TS. HR were categorized according to therapeutic option for posterior maxilla. 183 CBCT scans were included and it was observed that EdS presented a higher SH than the TS (p < 0.001) showing an eSP of 0.9 ± 2.93 mm. First molars presented the highest SH for both sides, although significant differences were detected when compared to second molars. First molars were mostly affected by LSP at TS (36 out of 43). Individuals with LSP at TS presented lower HR than the ones without LSP (p < 0.05). 54% of the cases presenting LSP obtained HR < 5 mm, which indicates sinus lift surgery. The present study showed that tooth loss in posterior maxilla favors sinus pneumatization and the identification of LSP at molar roots seems to indicate a greater necessity for sinus lift surgeries.

[Maxillary, buccal and dental expressions of hyperparathyroidisms]. / Manifestations maxillo-buccodentaires des hyperparathyroïdies.

States of chronic parathyroid hypersecretion, related to a primitive parathyroid abnormality (adenoma, hyperplasia), or to a cause of chronic calcipenia (renal failure, vitamin D deficiency…) have a major impact on bone remodeling, alveolodental structures. Thinning of the lamina dura, maxillary or mandibular brown tumors, giant cell epulis are the most emblematic signs of the primary hyperparathyroidism. Other expressions are related to genetic factors such as fibrous tumors of the jaw in conjunction with mutations in the gene coding for parafibromin.

Case of disseminated histoplasmosis in a HIV-infected patient revealed by nasal involvement with maxillary osteolysis.

BACKGROUND: Disseminated Histoplasmosis (DH) is a rare manifestation of Acquired Immune Deficiency Syndrome (AIDS) in European countries. Naso-maxillar osteolysis due to Histoplasma capsulatum var. capsulatum (Hcc) is unusual in endemic countries and has never been reported in European countries. Differential diagnoses such as malignant tumors, cocaine use, granulomatosis, vasculitis and infections are more frequently observed and could delay and/or bias the final diagnosis. CASE PRESENTATION: We report the case of an immunocompromised patient infected by Human Immunodeficiency Virus (HIV) with naso-maxillar histoplasmosis in a non-endemic country. Our aim is to describe the clinical presentation, the diagnostic and therapeutic issues. A 53-year-old woman, originated from Haiti, was admitted in 2016 for nasal deformation with alteration of general condition evolving for at least 6 months. HIV infection was diagnosed in 2006 and classified at AIDS stage in 2008 due to cytomegalovirus infection associated with pulmonary histoplasmosis. At admission, CD4 cell count was 9/mm3. Surgical biopsies were performed and ruled out differential or associated diagnoses. Mycological cultures identified Hcc and Blood Polymerase Chain Reaction (PCR) for Hcc was positive. The patient was given daily Amphothericin B liposomal infusion during 1 month. Hcc PCR became negative in the blood under treatment, and then oral switch by itraconazole was introduced. Antiretroviral treatment was reintroduced after a 3-week histoplasmosis treatment. Normalization of naso-maxillar mucosa enabled a palatal prosthesis. CONCLUSION: Naso-maxillar histoplasmosis is extremely rare; this is the first case ever reported in a non-endemic country. Differential diagnoses must be ruled out by conducting microbiologic tools and histological examinations on surgical biopsies. Early antifungal treatment should be initiated in order to prevent DH severe outcomes.

Brown tumor: clinical findings of secondary hyperparathyroidism in patients with renal osteodystrophy.

A brown tumor, or osteoclastoma, is a nonneoplastic bony lesion associated with hyperparathyroidism and directly related to increased levels of parathyroid hormone. These tumors result from excessive osteoclastic activity. This article presents 3 cases of brown tumor localized in facial bones. The lesions were the result of secondary hyperparathyroidism associated with chronic renal failure. The patients were two 42-year-old men and a 39-year-old woman. All patients had been treated systemically by hemodialysis for more than 10 years. This article highlights the importance of proper diagnosis and management of dental patients presenting with a brown tumor.

Miniplate With a Bendable C-Tube Head Allows the Clinician to Alter Biomechanical Advantage in Extremely Complicated Anatomic Structure.

BACKGROUNDS: This article reports C-tube miniplates as a practical temporary anchorage device choice to treat open bite patients with maxillary sinus pneumatization. METHODS: The C-tube components are titanium anchor plates and monocortical screws that are basically similar to any other miniplate systems, but it has the unique characteristic of the tube head to be malleable. The manipulation of the head part is easy due to the composition of pure titanium. The I-shaped C-tube with 3 holes and T-shaped C-tube miniplates were placed above the apices of maxillary molars as an absolute anchorage system to intrude the posterior maxilla. The bending of the tube heads assisted in reduction of severe open bite patient with maxillary sinus pneumatization. RESULTS: Sinus perforation during placement of skeletal anchorage system weakens stability of the anchorage and further cause complications. Placement of titanium C-tube miniplates allowed reliable skeletal anchorage and avoided maxillary sinus perforation in patients with extreme pneumatizations. Simple bending of C-tube miniplates ensured increased orthodontic intrusion force without having to replace them, and eliminated consequences such as perforation of maxillary sinus, sinusitis, soft tissue irritation, or infection. CONCLUSIONS: Anatomic difficulties in the placement of temporary anchorage device can be easily managed by using the bendable C-tube miniplate. It can serve as a great alternative over miniscrews or regular miniplates with reduced risk of sinus perforation and ability to bend the head portion to control orthodontic vectors and forces.