brazilian journal of craniomaxillofacial surgery

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brazilian journal of craniomaxillofacial surgery
BRAZILIAN JOURNAL
OF
CRANIOMAXILLOFACIAL
SURGERY
ISSN 151 6-4187
Official publication of the Brazilian Society of Craniomaxillofacial Surgery
-
P
-
Volume 5 Number 1 June 2002
*di
*- @*
Sociedade Brasileira
de Cirurgia
Craniomaxilofacial
Brazilian Society of Craniomaxillofacial Surgery
President
Vice President
Nivaldo Alonso (SP!
Ricardo Lopes da Cruz (RJ)
Secretary
Treasurer
Marcus Vinicius Martins Collares (RS)
Max Domingues Pereira (SP)
Please s e n d correspondence t o t h e Editor a t t h e f o l l o w i n g address:
Rua HilArio Ribeiro 2021406. CEP 9 0 5 1 0-040, P o r t o Alegre, RS, Brazil
E-mail: [email protected]
Editorial office1
Consultoria editorial:
Scientific Linguagem Ltda.
Publishing/EditoracGo:
Scientific Linguagem Ltda.
Phoneifax: +55-51-3388.5000
E-mail: [email protected]
http://www.scientific.com.br
Arte&ComposicSo
Phone:
+ 55-51 -3338.601 9
E-mail: [email protected]
DesignlPrograma~GoVisual:
Claudia Koch
55-51-9103.6565
+
i t i c a lrnpressora
Phone: +55-51-3337.4322
E-mail: [email protected]~ressora.com.br
BrazilianJournal of CraniomaxillofacialSurgery1Sociedade Brasileira
de Cirurgia Craniomaxilofacial. - Vo1.5, n.1 (Jun.2002). - Porto
Alegre : SBCC, 1998
.
v. : il. : 30cm.
-
Dois n h e r o s por ano, em ingles.
ISSN 1516-4187
1. Cirurgia Bucal I. Brazilian Journal of Craniornaxillofacial Surgery.
II. Sociedade Brasileira de Cirurgia Craniomaxilofacial.
CDD: 61 7.522
CDU: 616.31-089
BRAZILIAN JOURNAL
OF CRANIOMAXILLOFACIAL SURGERY
Official publication of the Brazilian Society of Craniomaxillofacial Surgery
EDITOR
ASSOCIATE EDITOR
Marcus Vinicius Martins Collares, MD, PhD
Sflvio AntBnio Zanini, MD
Hospital de Clinicas de Pono Alegre
Hospital de Reabilitacso de Anomalias Craniofaciais
Universidade Federal do Rio Grande do Sul
Universidade de SBo Paulo
Brazil
Brazil
SCIENTIFIC COUNCIL
Nivaldo Alonso, MD, PhD (Brazil)
Elisa Altmann, MD (Brazil)
Cassio Raposo do Amaral, MD (Brazil)
Carlos Alberto Ballin, MD (Brazil)
Vera Nocchi Cardim, MD (Brazil)
Roberto Corrga Chem, MD, PhD (Brazil)
Edgard Alves Costa, MD (Brazil)
S6rgio Moreira da Costa, MD (Brazil)
Ricardo Lopes da Cruz, MD (Brazil)
Pedro Dogliotti, MD (Argentina)
Jose Carlos Ferreira, MD, PhD (Brazil)
Luis Francisco Fontoura, MD (Brazil)
Omar Gabriel, DDS (Brazil)
Eduardo Grossmann, DDS, PhD (Brazil)
Paulo Hvenegaard, MD (Brazil)
Ian Thomas Jackson, MD (United States of America)
Lufs Paulo Kovalski, MD (Brazil)
Jose Alberto Landeiro, MD (Brazil)
Luis Tresserra Llauradd, MD, PhD (Spain)
Michael T. Longaker, MD (United States o f America)
Gilvani Azor de Oliveira e Cruz, MD (Brazil)
Antonio Richieri-Costa, MD, PhD (Brazil)
Diogenes Lakrcio Rocha, MD (Brazil)
Flavio M. Sturla, MD (Argentina)
Fausto Viterbo, MD, PhD (Brazil)
RETROSPECTIVE,
DESCRIPTIVE
EPIDEMIOLOGIC
ASSESSMENT
OF FACIAL
BONEFRACTURES
IN GROWING
PATIENTS,
FROM 1992 TO 2001,
AT HOSPITAL
CRISTO
REDENTOR,
PORTOALEGRE,RS ..................................... 11
Eduardo Seixas Cardoso, Renata Pittella Canqado, Marilia Gehardt Oliveira, Salete Maria Pretto
USEOF VIDEOENDOSCOPY
IN THE DIAGNOSIS
OF ORBITAL
FLOOR
FRACTURES
...... 11
Fernando Cesar A. Lima, Weber Leo Cavalcante, Ricardo Lopes da Cruz
VIDEO-ASSISTED
TREATMENT
OF FACIAL
FRACTURES:
INDICATIONS,
TECHNICAL
ASPECTS,
AND INITIAL
EXPERIENCE
.............................
Dov C. Goldenberg, Nivaldo Alonso, Luiz Gustavo B. Cruz, Claudio E. P. de Souza,
Daniel S.C. Lima, Marcus C. Ferreira
COMPLEX
FACIAL
FRACTURES:
TREATMENT
ALGORITHM
.......................
ClAudio Eduardo Pereira de Souza, Dov Charles Goldenberg, Mauro Leonardis,
Daniel Santos Correa Lima, Nivaldo Alonso, Marcus C. Ferreira
EFFICACY
OF THE CONVENTIONAL
TREATMENT
OF MANDIBULAR
FRACTURES
CAUSED
BY GUNSHOTS
................................................................................
Thiago de Almeida Furtado, Adriano do Valle Fernandes, Marcelo Drummond Naves,
Gustavo Bellozi de Araujo, Evandro Magalhges Nunes
VESTIBULAR
ACCESSROUTES
AND THE TREATMENT
OF COMPLEX
MANDIBULAR
FRACTURES
.................................
Belini Freire Maia, Bruno Ramos Chcanovic, Leandro Napier de Souza
HYPERTELEORBITISM:
ORBITAL
MEDIALIZATION
WITH THE FIXED
CENTRAL
T TECHNIQUE
AND NO FLOOR
MOBILIZATION
........
Sergio Pablo Pimentel Vela, Felipe Hund, Vera LLicia Nocchi Cardim
BECKWITH-WIEDEMANN'S
SYNDROME:
REPORT
OF A CASE
WITH AN 18-YEAR
SEQUENTIAL
FOLLOW-UP
....
Lidia D'Agostino, Rolf Rode, Paulo Clrnara
FREEMAN-SHELDON'S
SYNDROME:
MULTIDISCIPLINARY
MANAGEMENT
(A CASEREPORT)....................
Fabiana Correia Monteiro, Lidia D'Agostino, Marcia Andre, Fabiana Rufino.
Margareth Torrecillas Lopez
14
FOLLOWING
CRANIOFACIAL
DISJUNCTION
IN OSTEOGENIC
DISTRACTION
PROCEDURES
.................................
Rodrigo de Faria Valle Dornelles, Rolf Lucas Salomons, Vera Lucia Nocchi Cardim
THEUSEOF OSTEOGENIC
MANDIBULAR
DISTRACTION
IN NEONATES
WITH THE PIERRE-ROBIN
SEQUENCE
........................
Marcus Vinicius Martins Collares, Rinaldo de Angeli Pinto, Roberto Correia Chem,
Ant6nio Carlos Pinto Oliveira, Gustavo Berlim, Ciro Paz Portinho
ORTHODONTICS
AND FACIAL
ORTHOPEDICS
ASSOCIATED
WITH
OSTEOGENIC
DISTRACTION
IN CASES
OF CONGENITAL
MICROGNATHIA
..........
Daniela Franco Bueno, Nelson Bardella Filho, Marcelo P. Vaccari Mazzetti,
Lucy Dalva Lopes
APPLICATIONS
OF OSTEOGENIC
DISTRACTION
IN THE TREATMENT
OF CRANIOMAXILLOFACIAL
DYSPLASIAS
.......
Nelson Bardella Filho, Ana Lucia C. Bardella, Lucy Dalva Lopes,
Dulce M. F. Soares Martins, Lydia Masako Ferreira
INCIDENCE
OF PATIENTS
WITH CLEFTLIPAND PALATE
AT INSTITUTO
DE CIRURGIA
PLASTICA
CRAN~OFACIAL
(SOBRAPAR)
..........
Celso Luiz Buzzo, Cassio Raposo Menezes do Amaral, Rita Mancebo Bianco,
Cinthia Regina Seraphim, Clariane Viero Vargas, Eliane Teixeira Caixeta Maiello
COLUMELLAR
RECONSTRUCTION
WITH NASOGENIAN
FLAPS
.............
Celso Luiz Buzzo, Cassio Raposo Menezes do Amaral, Rita Mancebo Blanco,
Clariane Viero Vargas, Cinthia Regina Seraphim. Eliane Teixeira Caixeta Maiello
THEUSEOF LABIORH~NOPLASTY
IN CASES
OF UNILATERAL
FISSURES
.................. 20
Celso Luiz Buzzo, Cassio Raposo Menezes do Amaral, Jcpiter Neewler Lopes Duarte
ACRYLIC
CONDYLE
AFTER RESECTION
OF A SOLID
AMELOBLASTOMA:
CASEREPORT
.......................................................................................... ,
AND AN
A
Christian Barros Ferreira, Jan Peter llg, Andre Caroli Rocha,
Araldo Ayres Monteiro Junior
TREATMENT
OF AMELOBLASTOMA
WITH MARGINAL
MANDIBULECTOMY,
INFERIOR
ALVEOLAR
NERVE
DISSECTION
AND PRESERVATION,
AND IMMEDIATE
BONE
RECONSTRUCTION
.....................................
Adalberto Novaes Silva, Paulo Cesar de Jesus Dias
ASSESSMENT
OF SEPTAL
DEFORMITIES
USINGNASAL
VIDEOFIBROSCOPY
IN ADULTPATIENTS
WITH TRANSVERSAL
MAXILLARY
ATRESIA
......................
Adalberto Novaes Silva, Wilma T. Anselmo Lima
ESTHETIC
AND FUNCTIONAL
REHABILITATION
OF THE MAXILLA
AND ALVEOLAR
RIDGESWITH CALVARIAL
BONEGRAFTS
.................
Wilson Cintra Junior, Nivaldo Alonso
THEUSEOF TITANIUM
MICROANCHORS
IN THE TREATMENT
OF DISPLACEMENT
OF MEDIAL
CANTHI
..................................
Dov Charles Goldenberg, Nivaldo Alonso, Marcus Castro Ferraira
MANDIBULAR
FIBROSARCOMA
...................................
Marcela Azevedo Brito, SBrgio Luiz de Miranda
COMPLICATIONS
OF PROCEDURES
USEDIN THE TREATMENT
OF SLEEP-RELATED
RESPIRATORY
DISORDERS
.......................
Nelson E. P. Colombini, Jose A. Pinto, Gustavo J. Faller
OBSTRUCTIVE
SLEEPAPNEA- A NEWOPTION
FOR THE CRANIOMAXILLOFACIAL
SURGEON
(CONCEPTION
AND BASIC
SURGICAL
PROTOCOL)
............................... 26
Nelson E. P. Colombini, Gustavo J. Faller, Wolney B. D'Azevedo
AN ALTERNATIVE
IN FACIAL
RECONSTRUCTION
PROCEDURES
.....
Sonja Ellen Lobo
IDIOPATHIC
BONECAVITYIN THE MANDIBULAR
CONDYLE
............................
Adriano do Valle Fernandes, Evandro Nunes Magalhaes, Gustavo Bellozi de Aralijo,
Marcelo Drummond Naves, M6nica Vieira Salgado, Wagner Rodrigues dos Santos
A SURGICAL
APPROACH
TO CRANIOFACIAL
NEUROFIBROMATOSIS
- A CASE
REPORT
..................................................................................................... 27
Clarissa Leite Turrer, Ricardo Lopes Cruz
MAXILLARY
SINUSLIR. USINGMANDIBULAR
RAMUS
........................................
BONEGRAFTS
- TECHNICAL
CONSIDERATIONS
Davidson Rodarte Feliz de Oliveira, Ant6nio Albuquerque de Brito, Aloisio Borges Coelho
ZYGOMATIC
FIXATION
- AN ALTERNATIVE
PROCEDURE
FOR THE REHABILITATION
OF SEVERELY
ATROPHIED
MAXILLA
.........
Waldemar Daut Polido, Eduardo Marini
SEQUELAE
- A CASEREPORT
.........................................................
Blas Antonio F. Santander, Mayra Cristina Kimura, Patricia de Paula Shimabuku,
Rejane Aparecida de Lima, Vera Lljcia Nocchi Cardim
MULTIDISCIPLINARY
TREATMENT
OF A PROGNATHIC
PATIENT
WITH HYPOMAXILLISM
...................................................
Rejane Aparecida de Lima, Mayra C. Kimura, Rodrigo Dornelles,
Rolf L. Salomons. Vera L. N. Cardim
ZYGOMATICOPLASTY:
AN ESTHETIC
COMPLEMENT
TO ORTHOGNATIC
SURGERY
(TECHNIQUES AND ALTERNATIVES)
......
Nelson E. Colombini, Wolney B. D'Azevedo, Einar F. Oquendo
PALATINE
DISJUNCTION
THROUGH
ENDONASAL
MICROSURGERY
.................
Nelson E. P. Colombini, Wolney B. D'Azevedo, Gustavo J. Faller
FUNCTIONAL
GENIOPLASTY
.......................................................
Rodrigo 0. M. Marinho, David S. Precious
-
OF A
-
CLINICAL
CASE.........................................................................
Paulo Roberto Pelucio CBmara
TREATMENT
OF THE ANTEROPOSTERIOR
MAXILLARY
EXCESS
WITH LE FORT
I OSTEOTOMY:
REPORT
OF TWO CASES
AND DISCUSSION
......................................................................
AntBnio Albuquerque de Brito, Davidson Rodaite Felix de Oliveira,
Yumara Siqueira de Castro
A f t e r the first biennial Brazilian Congress on Craniomaxillofacial Surgery is held, we will
be able to make a preliminary evaluation of the changes in the fields of education and research
regarding craniomaxillofacial surgery.
The downside of holding these meetings every two years is the restricted dissemination of
knowledge outside the Si3o PauloIRio de Janeiro route, in addition to the difficulty in having scientific
studies for ~ublication.
The advantages include the strengthening of extension courses in SBo Paulo (coached by
Nivaldo Alonso) and in Rio de Janeiro (led by Ricardo Cruz), and an expected increase in the
number of papers submitted for presentation.
These facts led us to the decision to publish the abstracts of the papers presented at the
Congress as volume 5 , issue 1 of the Brazilian Journal of CraniomaxillofacialSurgery.
As we can see, the current issue of the journal features interesting studies. They comprise
all fields of craniomaxillofacial surgery. We wish to have their extended version, not only on oral
presentation, in the near future.
Hopefully, we will have a better view of the matter after the next meeting, to be held in
Rio de Janeirol2004. Moreover, we expect to have fulfilled the requests to have the journal
indexed by then.
We also strongly suggest that new measures should be taken by the board of the Brazilian
Society of Craniomaxillofacial Surgery to improve the scientific quality of our journal.
Marcus Wcius Mattins Collares, MD, PhD
Editor
We welcome
Original research
Clinical reports
Case reports
Letters t o the editor
Book reviews
Announcements
Please submit to:
Marcus Vinicius Martins Collares, MD, PhD
Editor
Brazilian Journal of Craniomaxillofacial Surgery
Rua Hilario Ribeiro, 2021406
CEP 905 10-040 Porto Alegre, RS
Brazil
VII Congresso Brasileiro de Cirurgia Craniomaxilofaciai - Abstracts
RETROSPECTIVE, DESCRIPTIVE EPIDEMIOLOGIC ASSESSMENT
QF FACIAL BONE FRACTURES IN GROWING PATIENTS, FROM 1992 TO 2001,
AT HOSPITAL CRISTO REDENTOR, PORT0 ALEGRE, RS
Eduardo Seixas Cardoso, Renata Pittella Canqado, Marilia Gehardt Oliveira, Salete Maria Pretto
Pontificia Universidade Catolica d o Rio Grande d o Sul (PUCRS) Porto Alegre, Brazil
-
OBJECTIVE
To assess the prevalence and epidemiologic characteristics of facial bone fractures occurred in growing
patients.
MATERIALS AND METHODS
Paradigm: quantitative; study model: retrospective,descriptive; statistical analysis: parametric, descriptive,
non-inferential;data collection: manual and computer-based;data base: medical records; variables: age, gender,
fracture etiology, fracture location, mode of treatment, presence of associated lesions, and period of the year.
RESULTS
From 1992 to 2001,2,410 trauma patients were hospitalized at Hospital Cristo Redentor, Potto Alegre,
state of Rio Grande do Sul, southern Brazil. Of this total, only 60 individuals (2.49%) presented facial bone
fractures and had up to 12 years of age. Excluding nasal and dento-alveolar fractures, the prevalence
observed corresponds to 1.95%, i.e., 47 patients and 61 fractures. Most of these affected the mandibular
bone, more precisely the parasymphysis and articular process regions, followed by the zygoma and the
arch. Female patients were more common than males, and children from 6 to 12 years of age were the most
prevalent group. The most frequent etiologic factor was runover accidents, followed by car accidents and
falls. Most hospitalizations took place in the summer quarter, and lasted 7 to 12 days, on average. In relation
to modes of treatment, mandibular bone fractures were usually treated with non-surgical options, while
fractures of the middle third of the face were usually treated with surgery. Finally, in the assessment of
associated facial lesions, of the 47 patients included in the study, 15 showed associated lesions cranioencephalic trauma was the most common one.
USE OF VIDEOENDOSCOPY IN THE DIAGNOSIS
OF ORBITAL FLOOR FRACTURES
Fernando Cesar A. Lima, Weber Leo Cavalcante, Ricardo Lopes da Cruz
Hospital Geral de lpanema Rio de Janeiro, Brazil
-
BACKGROUND
Orbital floor fracture is a relatively common consequence of facial traumas, and it often remains undiagnosed.
The fracture can be easily diagnosed with computed tomography, but not with conventional radiography. The
present study was developed to show how videoendoscopy, when well indicated, can help in the precise
diagnosis of orbital floor fracture.
Braz J Craniomaxiilofac Surg 2002;5(1) 11
VII Congress0 Brasileiro de Cirurgia Craniomaxilofacial- Abstracts
OBJECTIVE
To demonstrate the use of videoendoscopy in the diagnosis of orbital floor fracture
MATERIALS AND METHODS
Clinical case reports in which a precise diagnosis of orbital floor fracture was not possible were selected to
undergo a videoendoscopic test for confirmation of the clinical status.
RESULTSICONCLUSION
Videoendoscopy is a rapid and easy method to be used in the diagnosis of orbital floor fractures, and it
should be indicated whenever a precise diagnosis cannot be obtained via physical examination and computed
tomography.
VIDEO-ASSISTED TREATMENT OF FACIAL FRACTURES: INDICATIONS,
TECHNICAL ASPECTS, AND INITIAL EXPERIENCE
Dov C. Goldenberg, Nivaldo Alonso, Luiz Gustavo B. Cruz,
Claudio E.P. de Souza, Daniel S. C. Lima, Marcus C. Ferreira
Hospital das Clhicas da Faculdade de Medicina
da Universidade de S6o Paulo - SHo Paulo, Brazil
INTRODUCTION
The conventional access routes used in the treatment of facial fractures may result in unesthetic scars and
operative complications, in addition to interfering with the adequate visualization of the fracture focus and the
positioning of bone grafts, in some cases. The introductionof video-assistedsurgical methods in plastic surgery
has helped in the treatment of several conditions. In the case of facial fractures, it has shown to be useful as a
diagnostic tool, as a treatment complement, and also as a method of treatment in itself. Fractures affecting the
frontal region, orbital floor and mandibular condyle have been the most common indications for video-assisted
surgeries.
OBJECTIVES
This study aimed at assessing the indications and technical aspects of the video-assisted performanceof
access routes in cases of fractures affectingthe frontal bone, orbital floor, and mandibular condyle, based on
the initial experience of the authors.
PATIENTS AND METHODS
Between March 2001 and March 2002, 14 patients presentingwith facial bone fractures were submitted to
video-assisted treatment. Six of the fractures were condylar, 5 were orbital, and 3 affected the frontal bones.
Access routes and the associated advantages, disadvantages, and contraindications were assessed.
RESULTS
in the cases of frontal fracture, 3 incisions made into the scalp allowed for adequate instrumentation and
focus reduction; a small superciliary incision also had to be performed, for the placement of plates and screws.
In the orbital fractures, the transmaxillary access route allowed the diagnosis of floor fractures, the visualization
12 Braz J Craniomaxillofac Surg 2002;5111
ViI Congresso Brasileiro de Cirurgia Craniornaxiiofacial - Abstracts
of hernia and its reduction, and also helped in the placement of bone grafls and their adequate positioning. In
condylar fractures, the intraoral access route, associatedwith two extraoral, punctiform incisions for the passage
of transcutaneous screws and with the traction applied on the ramus, ensured an adequate visualization. All
these aspects reinforcedthe indicationof the method for the treatment of lower condylar and subcondylar fractures.
CONCLUSIONS
The video-assisted performance of access routes showed to be useful in the treatment of facial fractures,
and constitutes an additional alternative method, with potential advantages in terms of reduction of external
scars, improved visualization and consequent reduction of the fracture focus.
COMPLEX FACIAL FRACTURES: TREATMENT ALGORITHM
Claudio Eduardo Pereira de Souza, Dov Charles Goldenberg, Mauro Leonardis,
Daniel Santos Correa Lima, Nivaldo Alonso, Marcus C. Ferreira
Hospital das Clinicas da Faculdade de Medicina
da Universidade de SSio Paulo Sfio Paulo. Brazil
-
OBJECTIVES
This study aimed at showing the most frequent etiologies that are present in complex facial traumas and at
assessing the association of facial fractures with othertraumas, in addition to clinical and complementarydiagnoses,
time and planning of the surgical treatment.
MATERIALS AND METHODS
From February 1999 to April 2001,112 patients submitted to surgery for facial fractures were selected. Of
these, 16 presented complex fractures, which affected several bones (extremely severe traumas). Fourteen
patients were males, and two were females, with a mean age of 24 years. Surgery was performed as early as
possible, and the approach was chosen taking into consideration aspects such as exposure of the fracture
focus, standard incisions, and rigid fixation. Afler the performance of initial measures and image diagnosis,
treatment was definedaccordingto the presencelabsence of neurosurgicaltraumaand of concomitant mandibular
and upperlmiddle third fractures.
RESULTS
The most frequent cause of trauma was car accident (13 cases), followed by physical violence. Complex
fractures usually affected the orbits, naso-orbito-ethmoidal bone, maxilla, and frontal bone fractures. Multiple
fractures affecting both the upper and middle thirds of the face and the mandible occurred in only 4 cases.
Neurologic impairment was observed in 8 of the 16 cases, and the eyes were affected in 9 (partial loss of sight
in 7 cases, and total loss in 2). Late complications, such as enophthalmus and telecanthus, were observed in 5
and 6 cases, respectively.
CONCLUSIONS
Complex facial traumas still represent a significant portion of cases seen at a tertiary hospital. The
involvement of the upper and middle thirds of the face, more common when compared to the lower third, seems
to be related to the mechanism of trauma. The standard, sequential approach used in the study helped in the
management of conditions and was associated with improved results.
Braz J Craniomaxiilofac Surg 2002;5/11 1 3
Vii Congress0 Brasileiro de Cimrgia Craniornaxilofaciai - Abstracts
EFFICACY OF THE CONVENTIONAL TREATMENT
OF MANDIBULAR FRACTURES CAUSED BY GUNSHOTS
Thiago de Almeida Furtado, Adriano do Valle Fernandes, Marcelo Drummond Naves,
Gustavo Bellozi de Araujo, Evandro Magalhies Nunes
Hospital Maria Amelia Links (FHEMIG), Faculdade de Odontologia,
Universidade Federal de Minas Gerais Belo Horizonte, Brazil
-
OBJECTIVE
To analyze the efficacy of the conventional treatment of mandibularfracturescaused by gunshots, namely,
the non-surgical approach.
MATERIALS AND METHODS
The conventional treatment was applied to 23 patients diagnosed with mandibular fractures caused by
gunshots at the Service of Bucomaxillofacial Surgery at Hospital Maria Amelia Lins. Patients were followed and
assessed in the pre- and trans-operativeperiods and for up to 180 days immediately afler surgery. Clinical and
radiographic data were observed, and data were recorded in a descriptive data sheet.
RESULTS
In our study, 21 patients were males, and most were 21 to 25 years old (21%) and 31 to 35 years old
(30%). A total of 30 mandibular fractures were diagnosed, predominantly at the corpus (46.5%) and the angle
(23%). Of all fractures, 52% were caused by 38 caliber guns. Fractures were usually compound (73%) and
comminuted (84%). On examination, clinical signs such as bone mobility and crackling (87%), absence of
infection signs (82%), and limited mouth opening (82%) were common. Treatment was successful in 53% of
cases and unsuccessful in 13%; in addition, 34% of patients left the study prior to completing the postoperative
follow-up period.
CONCLUSIONS
Mandibular fractures caused by gunshots were mostly compound and comminuted, and the conventional
treatment showed to be effective in these cases. In view of the social origin and difficulties faced by the group of
patients studied, an adequate postoperativefollow-up and consequent assessment of results is often impossible.
VESTIBULAR ACCESS ROUTES AND THE TREATMENT
OF COMPLEX MANDIBULAR FRACTURES
Belini Freire Maia, Bruno Ramos Chcanovic, Leandro Napier de Souza
Mandibular fractures have been treated with wire osteosynthesis associated with intermaxillary blocking
for several years. With the introduction of rigid internal fixation, in the end of the 60s, extremely rigid systems
employing plates and screws started to be used for the treatment of these fractures, and several innovations
have already been made to the method since then. Finally, in the 70s, asa result of studies carried out in France
by Michelet (1971) and Champy (1975), a new system was developed, in which miniature plates and screws
were used via an intraoral access route. This new procedure was soon known all over the world, and since then
it is the treatment of choice for cases of mandibular fractures, independently of complexity. The present study
will present the case of a complex mandibularfracturesurgically treated via a wide vestibular access route, with
exposure of the whole symphysis and mandibular corpus bilaterally, and the following application of miniplates
and screws according to the model preconized by Champy.
14 Braz J Craniomaxillofac Surg 2002;5/1/
VII Congress0 Brasileiro de Cirurgia Craniomawilofacial- Abstracts
HYPERTELEORBITISM: ORBITAL MEDlALlZATlON
WlTH THE FIXED CENTRAL T TECHNIQUE AND NO FLOOR MOBILIZATION
Sergio Pablo Pimentel Vela, Felipe Hund, Vera Lucia Nocchi Cardim
Hospital SBo Joaquim da Real e Benemerita Sociedade Portuguesa
de Beneficiencia SIio Paulo, Brazil
-
OBJECTIVES
To show the result of the fixed central T technique with orbital medialization and without floor mobilization,
as used in the treatment of hyperteleorbitism.
MATERIALS AND METHODS
We report the case of M.A.F.F., a 16-year old patient submitted to surgery for the treatment of Tessier's
hyperteleorbitism level Ill. The patient did not present dysraphia, and middle third of the face was normal. Due
to the presenceof primary frontonasal dysplasia, the orbital medialization technique was employed (fixed central
T) with no mobilizationof the floor. Surgery was carried out intracranially,via acoronal and longitudinal transnasal
access route, as in the form of an horizontal Z, whosecentral axis was positioned in parallel with internal ligaments.
RESULTS
Tomographic control showed a variation in the angle of oculomotor nelve axes from 82 to 72 *, and in the
internal interorbital distance from 40 to 33 mm.
CONCLUSION
The technique herein described is an alternative mode of treatment with effective results (from a esthetic
and functional point of view) and low morbidity.
BECKWITH-WIEDEMANN'S SYNDROME: REPORT OF A CASE
WlTH AN 18-YEAR SEQUENTIAL FOLLOW-UP
Lidia D'Agostino, Rolf Rode, Paulo CSmara
lnstituto de Cirurgia Plastlca Santa Cruz
The authors report the case of A.A.J., male, diagnosed with Beckwith-Wiedemann'ssyndrome, currently
with 22 years of age and followed since the chronological age of 4 years. The syndrome is characterized by
skeletal and dentofacial abnormalities, in addition to macroglossia. In this specific case, speech therapy was
used with the aim of improving muscle tonus and correcting tongue position so as to normalize stomatognatic
functions and prevent the need for partial giossectomy.Treatment plan included isometric and isotonic exercises
(carried out in weekly sessions) for adequacy of the muscle tonus of the tongue and lips. In view of difficulties
related to the maintenance of tongue position and lip sealing, caused by the patient's anterior cross and open
bite, a resin-made device aimed at limiting the tongue position was developed. The device was molded on the
patient's lower teeth and filled the sublingual space, simulating the postoperative position of the mandible. The
use of the device contributed to the proprioceptionof the tongue and consequently to the success of the speech
therapist's job. Tongue retroposition was successful, since it coapted to the palate. The authors conclude that
the diagnosis of macroglossia should be followed by a careful study of the patient's muscle tonus and facial
skeletal conditions, mainly in terms of the oral cavity, so as to establish a treatment plan that is able to eliminate
the effects of this problem on the patient's dento-osteo-mandibulargrowih,consequently minimizingfuture surgical
intewentions and preventing the need for invasive and unnecessary procedures, as is the case of partial
glossecomy.
Braz J Craniomaxillofac Surg 2002;5/11 15
VII Congresso Brasileiro de Cirurgia Craniomaxilofacial- Abstracts
FREEMAN-SHELDON'S SYNDROME:
MULTIDISCIPLINARY MANAGEMENT (A CASE REPORT)
Fabiana ~ o r r e i aMonteiro, Lidia D'Agostino, Marcia Andre,
Fabiana Rufino, Margareth Torrecillas Lopez
Hospital BeneficEncia Portuguesa, School of Dentistry, Universidade de SHo Paulo,
and lnstituto de Cirurgia PlAstica Santa Cruz Sgo Paulo, Brazil
-
The Freeman-Sheldonsyndrome is also known ascraniocarpotarsaldystrophy, distal type II arthrogryposis,
Windmiil-Vane-Hand's syndrome, or whistling face syndrome. Freeman-Sheldon'ssyndrome is a rare congenital
myopathy, characterized by three main signs: a whistling-likefacial expression; ulnar deviation of the hand, with
flexion contracture at the fingers; foot deformities.
Patients affected by this syndrome present multiple facial contractures, which are associated with
microstomy, micrognathia, and neck stiffness - these are the conditions that resul in the "whistling face".
Hypertelorism is also present, as well as narrow and antimongoloid eyelid folds, a saddle nose, and an ogival
palate. Finally, in addition to limb myopathy, several patients develop visible scoliosis and stature deficiency.
The case of R.A.S., a byear old male patient born to clinically normal and non-consanguineous parents, was
seen at the School of Dentistry at Universidadede Sao Paulo with adiagnosis of Freeman-Sheldon's syndrome.
On clinical examination, important manifestationsof the syndrome were observed: great difficulty in opening the
mouth, caries-relatedlesions, and dental malocclusion. Due to the complexity of the pathology,a multidisciplinary
treatment plan was developed so as to prioritize myofunctional aspects, followed by dental and orthodontic
treatment. The results obtained up to the present moment confirm the advantages of multidisciplinary
management.
ELASTIC TRACTION OF THE MIDDLE THIRD OF THE FACE FOLLOWING
CRANIOFACIAL DISJUNCTION IN OSTEOGENIC DISTRACTION PROCEDURES
Rodrigo de Faria Valle Dornelles, Rolf Lucas Salomons, Vera L ~ i c i aNocchi Cardim
Hospital S3o Joaquim da Real e Benemerita Sociedade Portuguesa
de Beneficiencia, SHo Paulo, Brazil
OBJECTIVES
Osteogenic distraction of the middle third of the face, carried out with elastics and Erich arch bars applied
to the teeth, allow the growth and maintenance of results obtained in advancement procedures in patients
presenting craniofaciostenoses.
MATERIALS AND METHODS
Between 1981 and 2001.42 patientswith craniofaciostenoses were operated using class Ill elastic traction
at the middle third of the face, after craniofacial disjunction, for advancement of the frontomaxillary monoblock.
Bone grafts were used only on the lateral walls of the orbits, with semi-rigidfixation, so that the maxilla remained
initially retropositioned.Afler a7-day latency period, elastic traction was applied to the maxilla,which was gradually
placed in a more anterior position, reaching a class II occlusion afler approximately 4 days. After this time, elastic
traction was decreased with the aim of maintaining the result obtained.
16 Braz J Craniomaxillofac Surg 2002;5(11
VII Congresso Brasileiro de Cirurgia Craniornaxilofacial-Abstracts
RESULTS
The pterigomaxillary area presented perfect ossification in all cases. In addition, the result was definitively
maintained in adult patients, and maintainedfor 1.5 year in children; of these, 52.6% maintained the result until
the adult age.
CONCLUSION
Elastic traction only requires the placement of Erich arch bars on the patients' teeth, making the procedure
more simple when compared to the use of distractors, with a similar osteogenic result.
THE USE OF OSTEOGENIC MANDIBULAR DISTRACTION
IN NEONATES WITH THE PIERRE-ROBIN SEQUENCE
Marcus Vinicius Martins Collares, Rinaldo de Angeli Pinto, Roberto Correia Chern,
AntBnio Carlos Pinto Oliveira, Gustavo Berlim, Ciro Paz Portinho
Hospital de Clinicas de Porto Alegre - Porto Alegre, Brazil
INTRODUCTION
The Pierre-Robin sequence (PRS) is characterizedby micrognathia,glossoptosis, palatal anomalies, and
severe respiratory and nutritional dysfunctions. Several techniques have been used to treat the condition, such
as positional therapy, labio-lingual suture, pelviplasty, and tracheostomy. Osteogenic distraction is a mandibular
lengthening technique based on the llizarov principle that has been used in children older than 2 years.
OBJECTIVES
To analyze the result of osteogenic mandibular distraction in the treatment respiratory and dietary
dysfunctions in neonates presenting PRS and to propose the systematization of the management of these
patients according to clinical classification.
METHODS
The study describes a series of 16 patients with PRS submitted to osteogenic mandibular distraction with
external distraction devices provided with four pins (using external approach and osteotomy).The applicationof
traction started on the 1st postoperative day at a rate of 0.5 mm twice a day. The consolidation period was either
equal to the duration of distraction or set at 2 weeks (minimum). The following aspects were assessed: age at
the beginning of treatment, distraction distance, duration of distraction, complications, time to extubation
(postoperatively)and oral nutrition during the postoperative period, presencelabsenceof apnea after distraction,
and mean oxygen saturation values before and after distraction.
RESULTS
Mandibular growth and bone consolidation were observed in all cases. The main respiratory parameters
analyzed (SaO,) and the nutritional pattern also showed improvement. There were no important complications
associatedwith the method.
Braz J Craniomaxillofac Surg 2002;5/11 17
1/11Congresso Brasileiro de Cirurgia Craniomaxilofacial - Abstracts
DISCUSSION
We propose the following classification for the management of patients with PSR: type I (no dysfunction),
clinical treatment; type II (no respiratory dysfunction,with nutritional dysfunction),clinical therapy, with surgeryon
the 15th to 30th day of life if no improvement is observed; type Ill (respiratory difficulty only while at rest, significant
nutritional impairment), clinical therapy, with surgeryon the 10th to 15th day of life if no improvement is observed;
type IV (sleep apnea, with our without nutritional impairment), same as type II; type V (unable to breathe without
mechanical help), surgery on the 5th day of life.
CONCLUSION
Osteogenic distraction is an effective (with low morbidity and high resolution rates) treatment for respiratory
and nutritional abnormalities resultingfrommicrognathia in PRS, even in less severe manifestations of the sequence.
ORTHODONTICS AND FACIAL ORTHOPEDICS ASSOCIATED
WITH OSTEOGENIC DISTRACTION IN CASES OF CONGENITAL MICROGNATHIA
Daniela Franco Bueno, Nelson Bardella Filho, Marcelo P. Vaccari Mauetti, Lucy Dalva Lopes
Centro de ReabilitaqHo das Deformidades Faciais S2o Paulo, Brazil
-
OBJECTIVES
To assess the importance of early multidisciplinary management of congenital mandibular deformities,
such as Pierre-Robin sequence, Treacher Collins'syndrome, and hemifacial microsomies, through the association
of orthodontics and facial orthopedics with craniofacial surgeries (osteogenic distraction). This is important
mainly in more severe cases, where the obtainment of good functional results contributes to the survival of
these patients.
MATERIALS AND METHODS
Patients (newborns up to 12-year old children) carrying severe congenital mandibular deformities and
referred to osteogenic distraction were seen at our rehabilitation center. In cases presenting risk of death,
distraction was performed prior to maxillary orthopedic intervention. In the other cases, early or preventive
orthopedic treatment was carried out prior to, during and after osteogenic distraction. Radiographs, models,
photos and tomographs were used to determine diagnosis and treatment plan. At the end of the treatment, new
radiographs, tomographs and models were obtained for the assessment of esthetic and functional results.
RESULTS
Esthetic and functional results were satisfactory. Improvement was observed in respiration and suction in
newborns, and in respiration, mastication and deglutition in children (due to the mandibular increase resulting
from the association of osteogenic distraction and orthopedicslorthodontics).
CONCLUSION
In severe cases of congenital micrognathia, maxillary orthopedics and orthodontics, associated with
osteogenic distraction, allowed for mandibular and facial growth within normal standards, reestablishing these
patients' vital functions and providing a satisfactory estheticlfunctional result in view of the limitations of these
pathologies.
18 Braz J Craniomaxillofac Surg 2002;5/11
VII Congress0 Brasileiro de Cirurgia Craniomaxilofacial - Abstracts
APPLICATIONS OF OSTEOGENIC DISTRACTION
IN THE TREATMENT OF CRANIOMAXILLOFACIAL DYSPLASIAS
Nelson Bardella Filho, Ana Lucia C. Bardella, Lucy Dalva Lopes,
Dulce M. F. Soares Martins, Lydia Masako Ferreira
Universidade Federal de SLo Paulo - SBo Paulo, Brazil
Bone deficiency is a very common characteristic of craniomaxillofacial anomalies, and its treatment has
always been challenging to health practitionersthat act in this field. One of the main concerns in the treatment of
this condition is related to the acquisition of an organic materialthat is identicalto that of the patient to be treated.
Along the past few years, osteogenic distraction has become an alternative technique in the treatment of
craniomaxillofacial dysplasias, minimizing the need for the use of bone grafts. The aim of this study was to
present some alternativeapplications of osteogenic distraction that have been successfully used in the treatment
of patients carrying craniomaxillofacialanomalies. The study was carried out based on the history of osteogenic
distractionfound in the literature produced by the national and internationalscientific communities, and aimed at
comparing the benefits brought by these techniques with those of conventional procedures.
INCIDENCE OF PATIENTS WITH CLEFT LIP AND PALATE AT INSTITUTO DE
CIRURGIA PLASTICA CRANIOFACIAL (SOBRAPAR)
celso Luiz Buzzo, Cassio Raposo Menezes do Amaral, Rita Mancebo Blanco, Cinthia Regina
Seraphim, Clariane Viero Vargas, Eliane Teixeira Caixeta Maiello
lnstituto de Cirurgia Plastica Craniofacial (Sobrapar) Campinas, Brazil
-
OBJECTIVES
To assess the incidence and predisposing factors associated with cleft lip and palate in a period of 2 years.
MATERIALS AND METHODS
The authors performed a retrospective evaluation of 86 patients presenting cleft lip and palate who were
admitted to the hospital of our institution (Sobrapar) between March 2000 and March 2002, and who had not
been submitted to any previous treatment. The following data were analyzed: origin, sex, age, skin color, birth
weight and stature, type of fissure, associated pathologies, family history, as well as data referring to maternal
habits during gestation.
RESULTS
Most patientscamefromthecountlyside of thestateof SBo Paulo, more preciselyfrom the region of Campinas.
Most children were admitted during the 1st month of life. No prevalence was observed in terms of age, and most
patientswere whites. Mean birthweight was 3108 g, and mean stature at birth was 46.7 cm. Among cleft lip cases,
unilateral fissures were the most common ones, and they were more prevalent in males. Cases of posterior cleft
palate also predominated, but there was no predominance of sex. Unilateral cleft lip and palate occurred more
frequently in females, and bilateralcases in males. In 32.55% (28) of the patients assessed,there were intercurrences
during gestation. In addition, 19.76% (17) presented family history of cleft lip and palate. A total of 18 mothers
(20.93%) were tobacco smokers, while 12 (13.95%) consumed alcohol during pregnancy.
CONCLUSIONS
Afler assessment of the data obtained, it was possible to outline the current incidence and predisposing
factors associated with cleft lip and palate at our service. We conclude that, with some minor exceptions, our
results confirmed those found in the literature.
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VN Congresso Brasileiro de Cirurgia Craniomaxilofacial - Abstracts
COLUMELLAR RECONSTRUCTION WITH NASOGENIAN FLAPS
Celso Luiz Buuo, Cassio Raposo Menezes do Amaral, Rita Mancebo Blanco, Clariane Viero
Vargas, Cinthia Regina Seraphim, Eliane Teixeira Caixeta Maiello
lnstituto de Cirurgia Plastica Craniofacial (Sobrapar) Campinas, Brazil
-
OBJECTIVES
To report the case of a patient presenting nasal deformity (at the columeila and anterior portion of the
cartilaginous septum) caused by an infectious process. The deformity was repaired with a nasogenian flap,
aiming at restoring the patient's facial appearance as well as anatomical, functional, and esthetic functions.
MATERIALS AND METHODS
Surgical treatment was carried out with a nasogenianflap (left side), preserving local vascuiarization,followed
by the rotation of the flap and its passage through a subcutaneous tunnel directed to the midline of the nasal
base. The flap was fixed to the middle third of the nasal base and tip with simple 5.0 mononyion sutures, and oral
mucosa was grafted into the posterior portion.
RESULT
The nasogenian flap showed to be adequate and provided a satisfactory esthetic result at the donor site
(imperceptible scar).
CONCLUSIONS
The nasogenian flap showed to be a reliable method for wlumellar reconstruction. In addition, it has
advantages related to scars and to the color and texture of skin, as well as with the reestablishment of functional
and esthetic functions.
THE USE OF LABIORHINOPLASTY IN CASES OF UNILATERAL FISSURES
Celso Luiz B u u o , Cassio Raposo Menezes do Amaral, Jupiter Neewler Lopes Duarte
lnstituto de Cirurgia Plastica Craniofacial (Sobrapar) - Campinas, Brazil
OBJECTIVES
This study aimed at presenting a new technique for iabiorhinoplasty, which was developed in our service in
association with the University of Goteborg (Sweden).
MATERIALS AND METHODS
Labiohinoplasties were carried out in 53 patients presenting cleft lip and palate. Age ranged from 0 to 2
years, and patients were followed for approximately 7 years.
RESULTS
Excellent esthetic and functional results were observed.
CONCLUSION
In afollow-up period of 7 years, the alternative technique showed to result in more symmetric nostrils, and
scars were well positioned, with no retractions or level differences in the mucocutaneous line.
20 Braz J Craniomaxillofac Surg 2002;5/11
VII Congress0 Brasileiro de Cirugia Craniomaxilofacial- Abstracts
MANDIBULAR RECONSTRUCTION WlTH A RECONSTRUCTIVE PLATE
AND AN ACRYLIC CONDYLE AFTER RESECTION
OF A SOLID AMELOBLASTOMA: A CASE REPORT
Christian Barros Ferreira, Jan Peter Ilg, Andre Caroli Rocha, Araldo Ayres Monteiro Jlinior
Hospital das Clinicas da Faculdade de Medicina da Universidade de S5o Paulo - SSo Paulo, Brazil
OBJECTIVES
To present a case of resection of mandibular solid ameloblastoma followed by reconstruction using an
acrylic condyle and a reconstructive plate, and to discuss the characteristics of the tumor and its therapeutic
aspects.
MATERIALS AND METHODS
Report of the case of a male, 19-yearold patient (light brown skin), who presentedwith asymptomaticvolume
increase in the left hemiface lasting for 1Oyears. Panoramic radiographof the mandible and computed tomography
of the face were requested. The initially predictive diagnosis of solid ameloblastoma was later confirmed by an
incisionalbiopsy. Surgerywasplanned to becaniedoutviaasubmandibularaccessroute (goingfrom the symphysis
to the left mandibular angle), and consisted of segmental mandibulectomy followed by disarticulation and posterior
reconstructionof the defect with an endoprosthesis (reconstructiveplate and acrylic condyle),
RESULTS
Postoperative radiographic examinations showed that the endoprosthesis was well positioned, and no
relapse was obsewed along a 4-year follow-up. The patient developed skin and mucosa anesthesia at the left
hemimandible,as a result of the resection of the inferior alveolar nerve. The extraoral scar presented a satisfactory
aspect, the patient's face was symmetric, and mouth opening had no deviations, with normal lateral movements
to the left and right. In addition, the patient showed no signs of motor deficit.
CONCLUSIONS
Ameloblastorna is the most significant odontogenic neoplasia found in the clinical practice due to its
prevalenceand treatment difficulties that result from its locally aggressive behavior. Diagnosis should be based
on incisional biopsy. Treatment of thecase herein described was based on tumor extension, which did not allow
the use of less invasive methods. Reconstructionwith the reconstructive plate and the acrylic condyle showed
adequate esthetic, functional, and biological results.
TREATMENT OF AMELOBLASTOMA WlTH MARGINAL MANDIBULECTOMY,
INFERIOR ALVEOLAR NERVE DISSECTION AND PRESERVATION,
AND IMMEDIATE BONE RECONSTRUCTION
Adalberto Novaes Silva, Paulo Cesar de Jesus Dias
Hospital Unlversitario da Universidade Federal de Mato Grosso Cuiaba, Brazil
-
INTRODUCTION
Amelobiastoma is a benign neopiasia with great clinical importance, due to its invasive behavior and
potential relapse after conventional surgical treatment.
Braz J Craniomaxillofac Surg 2002;5/1) 21
VII Congress0 Brasileiro de Cirurgia Craniornaxilofacial - Abstracts
OBJECTIVES
To discuss the therapeutic management of ameloblastomas affecting the mandibles of young patients
(adolescents).
MATERIALS AND METHODS
Two cases of ameloblastoma in adolescents, with involvement of the mandibular corpus and angle, will be
described and discussed. Treatment was similar in both cases, with the use of an intraoral access route. First,
marginal resection of the mandible was carried out, aimed at providing a safety margin and maintaining the
mandibular base. The inferior alveolar nerve was dissected and preserved. Then, immediate bone reconstruction
was carried out with the use of a block graft taken from the anterior iliac bone and fixed to the receptor site with
titanium plate and screws. Teeth affected by the neoplasia were temporarily replaced with a partially removable
prosthesis in order to prevent extrusion of the corresponding superior dentoalveolar segment.
RESULTS
Along 2 years of follow-up, no evidence of clinicallradiological relapse has been observed, and the
reconstructed area presents the necessary conditions to undergo rehabilitation with osteointegrated implants.
Complaints of paresthesia in the mentonian region (at the operated side) are present in both patients, but are
not significant.
CONCLUSIONS
The surgical treatment of ameloblastomas with preservation of the mandibular base and inferior alveolar
bone was carried out taking into consideration the patients' age. The use of the intraoral access route favored
the obtainment of adequate esthetic results. The follow-up of the present cases was too short to assure the
impossibility of relapse. However, the technique described in this study should be considered in some specific
circumstances.
ASSESSMENT OF SEPTAL DEFORMITIES
USING NASAL VIDEOFIBROSCOPY IN ADULT PATIENTS
WITH TRANSVERSAL MAXILLARY ATRESIA
Adalberto Novaes Silva, Wilma T. Anselmo Lima
Hospital Universitario da Universidade Federal de Mato Grosso Cuiaba, Brazil
-
INTRODUCTION
The occurrence of maxillary deformities in associationwith respiratory problems, mainly nasal obstruction,
has called the attention of several investigators for the possibility of an interrelation betweenthese two conditions.
The objectives of the present study were to assess the co-occurrenceof nasal obstruction and septa1deformities
in adult patients presenting posterior cross bite and to discuss the performanceof an integratedsurgical treatment
(maxillary surgerylseptoplasty) in these patients.
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VII Congresso Brasileiro de Cirurgia Craniomaxilofacial- Abstracts
MATERIALS AND METHODS
Otorhinola~yngological
assessment with emphasis on the examination of the nasal cavity was carried out
through nasofibroswpy in 30 adult patients presenting posterior cross bite and an indication for orthodontic1
surgical treatment (surgically assisted maxillary advancement).
RESULTS
Of the patients studied, 56.7% reported nasal obstruction, and 43.3% has not complaints of respiratory
problems. Taking the nasofibroscopic results into consideration, septal deformities were present in 100% of the
cases, and their topographic classification, according to Cottle, were as follows: compromising of area I in
13.4%, area II in 83.3%, area Ill in 90%, area IV in 83.3%, and area V in 3.3%.
CONCLUSIONS
We observed that adult patients with posterior cross bite do not necessarily present nasal obstruction. The
nasofibroscopic examination showed to be of extreme importance for the diagnosis of septal deformities in
adult patientswith posterior cross bite. We emphasize the importance of the co-work of the maxillofacialsurgeon
and the otorhinolaryngologist, so as to carry out both surgeries (maxillary osteotomy and septoplasty)
simultaneously in cases where both procedures are necessary.
ESTHETIC AND FUNCTIONAL REHABILITATION OF THE MAXILLA
AND ALVEOLAR RIDGES WITH CALVARIAL BONE GRAFTS
Wilson Cintra Junior, Nivaldo Alonso
Hospital Professor Edmundo Vasconcelos SSo Paulo, Brazil
-
OBJECTIVE
Patients (mainly youngsters) with maxillary and alveolar ridge atrophy resulting from loss of teeth caused
by severe trauma or periodontal diseases should be submitted to a surgical procedure aiming at increasing
bone tissue height and thickness so as to allow the placement of osteointegratedimplants or dental prostheses.
The objective of the present study was to describe a cortical bone graft technique carried out in the maxillary
sinus floor and alveolar ridges with the aim of increasing bone density (both horizontally and vertically) and
consequently improving the esthetic and functional oral rehabilitation process.
PATIENTS AND METHODS
After clinical evaluation, maxillofacial physical examination, and radiological assessment (including face
radiograph, panoramic radiograph of the mandible, and thin-slice computed tomography or dental scan), 17
patients with ages ranging from 32 to 55 years were operated between July 1998 and June 2001,with the aim
of creating a bone site where osteointegrated implants or dental prostheses could posteriorly be placed.
Postoperative clinical and radiological assessments were also carried out.
RESULTS
All patients obtained sufficient bone thickness at the end of treatment and could start oral rehabilitation.
After a mean periodof 6 months postoperatively,14 patients started rehabilitationtreatment with osteointegranted
implants, and three patientsstattedto use a removabledental prosthesis, with satisfactory esthetic and functional
Braz J Craniomaxillofac Surg 2002;5(11 23
Vll Congress0 Brasileiro de Cirurgia Craniornaxilofacial - Abslracts
results in all cases. Two patients presented partial dehiscence of the mucosal sutures, but the performanceof
complementary surgeries and continuous aseptic routines assured synthesis completion - the rate of bone
absorption resulting from this complication was not significant and had no effects on final results.
CONCLUSIONS
In spite of the small size of our sample, the bone graft technique provided satisfactory esthetic and functional
results and allowed the beginning of rehabilitation in all operated patients, with the use of either osteointegrated
implants or removable prostheses. A small rate of cortical bone graft reabsorption was observed, which is in
accordance with data found in the literature.
THE USE OF TITANIUM MICROANCHORS
IN THE TREATMENT OF DISPLACEMENT OF MEDIAL CANTHl
Dov Charles Goldenberg, Nivaldo Alonso, Marcus Castro Ferraira
Hospital das Clinicas da Faculdade de Medicina da Universidade de SZio Paulo SZo Paulo, Brazil
-
OBJECTIVES
The treatment of deformities affecting the medial canthus of the orbit is still considered a challenge in the
field of craniofacial surgery. The classical techniques, namely transnasal canthoplasty and canthopexy, have
been associated with a high rate of relapse and inadequate positioning of the medial canthal tendon, in addition
to the risk for contralateral ocular lesion. On the other hand, ipsilateral techniques are associated with technical
difficulties, and results are not always satisfactory. The present study proposes a new treatment option for
cases of deformities of the medial canthus of the orbit, through the use of titanium microanchors.
PATIENTS AND METHODS
Six cases of patients presenting telecanthus and displacement of the medial canthi of posttraumatic,
tumoral and congenital etiology were submitted to medial canthoplasty with microanchors. Results were assessed
by means of anthropometric measurements of the orbital region prior to and right after surgery, and also 1
month, 6 months, and 1 year after surgery. The following measurements were included: intercanthal distance,
distance between the medial canthus and the midline, orbital width, and distance between the lateral canthus
and the midline.
RESULTS
At 6 months and 1 year after surgery, the technique presented satisfactory results in terms of clinical aspects
and method stability. In addition, it allowed for the safe and fast ipsilateral fixation of the medial canthal tendon.
CONCLUSIONS
The performance of ipsilateral canthoplasty with microanchors proved to be a safe, simple, and effective
method for the treatment of displacement of the medial canthi and posttraumatictelecanthus. Due to its recency,
the assessment of long-term results is necessary in order to certify this therapeutic option.
24 Braz J Craniomaxillofac Surg 2002;5/11
VII Congress0 Brasileiro de Cirurgia Craniomaxilofacial- Abstracts
MANDIBULAR FIBROSARCOMA
Marcela Azevedo Brito, Sergio Luiz de Miranda
Hospital lsraelita Albert Einsten and Universidade de Santo Amaro Santo Amaro, Brazil
-
OBJECTIVES
To describe an extremely rare clinical case of malign odontogenic tumor of mesenchymal origin.
MATERIALS AND METHODS
Diagnosis was based on anatomopathologicalexamination and was originally defined as arneloblastoma.
Once the tumor started to present an abnormal evolution, a new examination was carried out; this second test
yielded a diagnosis of ameloblastic fibrosarcoma. This change in diagnosis required the performanceof a more
radical form of treatment: partial hemimandibulectomy associated with radiotherapy.
RESULTS
First diagnosis consisted of ameloblastoma, and the condition was treated twice at another service with the
conventional method. After some time, the neoplasia evolved to an ameloblastic fibrosarcoma. The patient
sought medical assistance again, and this time surgery and radiotherapy were carried out. After treatment, no
local relapse was observed, but there were metastases in the pulmonary, hepatic, and abdominal areas, which
caused the patient's death.
CONCLUSIONS
Fibrosarcomais an odontogenic neoplasia whose mesenchymalcomponent makes it resemble a sarcoma,
while its epithelial component makes it take the appearance of a benign lesion. The tumor affects young adults
more frequently, and there is no predominance of sex. The mandible is the most commonly affected organ.
Frequent signs and symptoms include pain, edema, and rapid growth, leading to significant bone destNcti0n
and dental mobility in some cases. Conventional treatment is usually followed by relapses, which may or may
not be accompanied by local or distant metastases.
COMPLICATIONS OF PROCEDURES USED IN THE TREATMENT OF SLEEPRELATED RESPIRATORY DISORDERS
Nelson E. P. Colombini, Jose A. Pinto, Gustavo J. Faller
Clinica Medica Nelson Colombini SHo Paulo. Brazil
-
OBJECTIVES
To show the incidence of complications associated with the surgical treatment of sleep-related respiratoly
disorders. We report the spectrum of complications found in our case series, with a focus on anesthetic,
transoperative and postoperative complications.
METHODS
Ourseriesof 785 patients diagnosed with sleep-related respiratory disorders was selected between F e b r u ~ n ~
1996 and January 2002.
Braz J Craniomaxillofac Surg 2002;5111 25
v,r
Congresso Brasileiro de Cirurgia Craniomaxilofacial- Abstracts
RESULTS
The rate and type of complications observed in a total of 945 procedures were assessed. The most commonly
observed were: hemorrhage, loco-regional hematomas, edema causing upper airway obstruction, infections, loss
of fixation in skeletal procedures, hypoesthesia of the lower dental nerve and loss of occlusion relation. These
complicationswere effectively controlled with either complementary surgical procedures or clinical treatment, and
did not result in death or in the need for blood transfusion in any case. Tracheostomy was required in 12 cases.
CONCLUSION
The rate of complicationsobserved in our series is not different from the data found in the medical literature.
However, we emphasizethe morbidity that is usually associatedwith surgical procedures carried out in the upper
airways, and which is significantly increased in patients presenting moderate and severe apnea.
OBSTRUCTIVE SLEEP APNEA - A NEW OPTION
FOR THE CRANIOMAXILLOFACIAL SURGEON
(CONCEPTION AND BASIC SURGICAL PROTOCOL)
Nelson E. P. Colombini, Gustavo J. Faller, Wolney B. D'Azevedo
Clinica Medica Nelson E. P. Colombini - SZo Paulo, Brazil
OBJECTIVES
To focus on the importance of the rnaxillofacialsurgeon in the treatment of patients with apnea, since the
procedures recommended for these cases belong to the field of this specialist.
MATERIALS AND METHODS
A multicenter assessment of 785 cases surgically treated between 1995 and 2000 was carried out, with
the subsequent establishment of a protocol aimed at guiding professionals interested in treating these cases.
RESULTS
The protocol showed to be effective in 70 to 98% of patients. In cases of mild apnea, results were positive
in about 90% (reduction of the apnealhypoapnea index); in cases of moderate apnea, treatment effectiveness
was more difficult to be achieved, due to the craniofacial alterations presented by patients and to associated
morbidities (in our series, the success rate ranged between 70 and 95%); severe apnea with a corporeal mass
index of up to 33 was controlled in 98% of cases, with the use of maxillomandibular advancement associated
with laser-assistedmidline glossectomy.
CONCLUSION
Significant improvement has been observed in the surgical procedures used to treat obstructive sleep
apnea, mainly in terms of evolution of surgical procedures and comprehension of the inter-relation between the
craniofacial and pharyngeal structures. Each case presents variables that should be taken into consideration in
the selection of surgical procedures. Some examples include: corporeal mass index, hypoapnea, and desaturation
during sleep. The comprehension of facial typology and its effect on the disease studied are the key factors for
the success of treatment.
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VII Congresso Brasiieiro de Cirurgia Craniomaxiiofaciai - Abstracts
TISSUE ENGINEERING:
AN ALTERNATIVE IN FACIAL RECONSTRUCTION PROCEDURES
Sonja Ellen Lobo
Several materiais have been studied and used in tissue reconstructionprocedures, including bioceramics
with calcium radicals. The respect fortissue engineering principles is a main factor forthe obtainment of effective
results, as is the respect for architectonic, surface topography, porosity, and biocompatibility characteristics, in
addition to the properties of osteoconductionand osteoinduction related to the material used. All these aspects
contribute to a compatible and adequate tissue neoformation. These aspects will be discussed in the present
study, and some clinical cases will be presented.
IDIOPATHIC BONE CAVITY IN THE MANDIBULAR CONDYLE
Adrlano do Valle Fernandes, Evandro Nunes MagalhBes, Gustavo Bellozi de Araujo,
Marceio Drummond Naves, M6nica Vieira Salgado, Wagner Rodrigues dos Santos
Hospital Maria Amelia Lins Belo Horizonte, Brazil
-
Report of the case of F.P.S., a female, leukodermic, 18-year old patient who was referredto the Service of
Bucomaxillofacial Surgery and Traumatology of our hospital by an orthodontist due to the asymptomatic
radiographic finding of an alteration at the right mandibular condyle region during a routine examination. The
patient presented no history of trauma. On clinical examination, the skin and mucosa of the surrounding areas
presented normal color and texture, with no volume increase, no limitation to mandibular movements, and no
other sign of articular dysfunction. On conventional and tomographic radiography, a well-defined radiolucid
area was detected at the region of the right mandibular condyle, measuring about 4 x 6 mm in diameter, with no
signs of cortical expansion or bone continuity solution. Aspiration punch biopsy was carried out, followed by the
preparation of cytological slides for histopathologicalexamination, which revealed the presence of sanguineous
cells. This finding, in association with the clinical and radiographicfindings above mentionedand the postoperative
evolution of the case, determinedthe diagnosis of idiopathic bone cavity. Radiographic follow-up every 3 months
along 1 year showed complete cicatrization of the bone.
A SURGICAL APPROACH TO CRANIOFACIAL NEUROFIBROMATOSIS
A CASE REPORT
-
Clarissa Leite Turrer, Ricardo Lopes Cruz
lnstituto Fernandes Figueiras (FIOCRUZ) Rio de Janeiro, Brazil
-
Neurofibromatosis was first described by Von Recklinghausen in 1882 as a syndrome characterized by
multiplefibromas, skin pigmentation, alterations in the central nelvous system and skeletal anomalies. It consists
of an autosomic dominant inherited disease, and the gene mutations associated with it result in a various range
of clinical statuses, of different severity. The most severe forms of neurofibromatosis are associatedwith deformities
that compromise the patient's life. The present study describes a clinical case of craniofacial neurofibromatosis
affecting the orbitopalpebralarea, as well as the steps of the transdisciplinarysurgical treatment carried out with
the aim of providing ocular rehabilitation.We also describe technical limitations and results of the treatment, as
well as the subsequent improvement of the patient's clinical status and life.
Braz J Craniomaxillofac Surg 2002;5(11 27
VII Congress0 Brasileiro de Cirurgia Craniornaxilofacial - Abstracts
MAXILLARY SINUS LIFT USING MANDIBULAR RAMUS BONE GRAFTS
TECHNICAL CONSIDERATIONS
-
Davidson Rodarte Feliz de Oliveira, AntBnio Albuquerque de Brito, Aloisio Borges Coelho
The height of the posterior regions of the maxilla represents a limiting factor to its rehabilitation with grafts
in a great part of the Brazilian population. This is partly due to early tooth extractions, very common in oursetting,
which lead to high rates of alveolar bone reabsorptionalong the patient's life, and consequently tothe pneurnatization
of the maxillary sinuses. The lift of maxillary sinuses using bone grafts constitutes an important surgical technique
in the viabilization of the use of osteointegrated implants in the posterior regions of the maxilla. Several grafl
donor sites have already been described in the literature. The present study proposes the use of mandibular
ramus bone grafts due to several advantages: easy access, low morbidity, availability of bone volume, and the
same origin (intramembranous) as that of the receptor site.
ZYGOMATIC FIXATION - A N ALTERNATIVE PROCEDURE
FOR THE REHABILITATION OF SEVERELY ATROPHIED MAXILLA
Waldemar Daut Polido, Eduardo Marini
M5e de Deus Center Porto Alegre, Brazil
-
Reconstruction of the atrophied maxilla usually requires the use of iliac crest bone graft. The techniques
most frequently used to treat this problem take grafts from other sites and therefore require hospitalization, a
long time without the use of total prostheses, and a long time of treatment. Although the success rate associated
with the use of bone grafts is relatively high, it rarely goes over 90%. Taking these data into consideration, and
due to the current need for solving severe cases of maxiilectomy, Professor Branemark and his team developed
a fixation technique aimed at providing efficient bone anchorage to allow rehabilitation with a fixed prosthesis,
thus discarding the need for longer and more invasive surgical procedures. In 1989, zygomatic fixation started
to be used as an alternative procedure for the rehabilitation of severely atrophied maxillas, and its indications
and contraindications, advantages and disadvantages started to be studied.
A MULTIDISCIPLINARY APPROACH TO THE ASSESSMENT
AND TREATMENT OF A PATIENT PRESENTING PROGNATHISM,
HYPOMAXILLISM, AND BURN SEQUELAE - A CASE REPORT
Blas Antonio F. Santander, Mayra Cristina Kimura, Patricia de Paula Shimabuku,
Rejane Aparecida de Lima, Vera Lucia Nocchi Cardim
Hospital da Real e Benemerita Sociedade Portuguesa de
Beneficencia de SSo Paulo - SSo Paulo. Brazil
OBJECTIVES
The authors describe the clinical case of a patient with maxillomandibular disproportion and the assessment
and therapeutic approach carried out in the case. Through the description of speech-related, orthodontic and
surgical aspects, the routine of the service is described, as well as the intercurrences observed in the specific
case herein described.
28 Braz J Craniomaxillofac Surg 2002;5(11
VII Congresso Brasileiro de Cirurgia Craniornaxilofacial- Abstracts
MATERIALS AND METHODS
A 42-year old male patient presenting progmathism, hypomaxillism and cicatricial retraction due to burn
sequelae was submitted to orthodontic and oral preparation for a combined surgery involving advancement of
the mid third of the face and mandibular retrusion, together with the filling of the pyriform fossa with a bone graft
taken from the mandibular external cortical bone. Due to the compromise of teeth (absence of upper molars),
transskeletal maxillary orthopedic treatment was carried out for the maintenance of results.
RESULTS
After 6 months of treatment with myofunctionaltherapy and orthodonticcare, the patient started to use the
definitive prosthesis, with unequivocal esthetic and functional gains.
CONCLUSION
The use of a multidisciplinaryapproach in the care, treatment and follow-up of patients potentially submitted
to orthognatic surgery is of paramount importance in the detection of problems, in the management of cases and
in the posterior maintenance of surgically-obtained results.
MULTIDISCIPLINARY TREATMENT
O F A PROGNATHIC PATIENT WITH HYPOMAXILLISM
Rejane Aparecida de Lima, Mayra C. Kirnura, Rodrigo Dornelles,
Rolf L. Salornons, Vera L. N. Cardim
Hospital Beneficencia Portuguesa de Sao Paulo Silo Paulo, Brazil
-
OBJECTIVE
Patients presenting maxillomandibular disproportion require a multidisciplinary treatment, with the
participation of a speech therapist working in conjunction with plastic surgeons and dentists, among other
professionals, in order to contribute to the diagnosis, planning and pre- and postoperative management of
cases. In orthognatic surgery, inter-related structural and functional elements are involved, and speech therapy
aims at assessing the maxiilofacial complex in its dynamic form, thus associating functional problems with
structural elements that may negatively interfere with surgical results.
MATERIALS AND METHODS
The use if orofacial myotherapy, with isometric (focused on tonicity) and isotonic (focused on mobility)
exercises, was selected to correct functional and muscular alterations. The authors report the case of S.L.M.F,
34 years old, who presented with maxillomandibular disproportion and was treated by a multidisciplinary team,
with pre- and postoperative follow-up focused on speech-related aspects.
RESULTS
After 1.5 year of postoperative follow-up, the patient was rehabilitated, and surgicaVorthodontic results
were maintained.
CONCLUSION
The multidisciplinary management of patients presenting maxillornandibulardisproportion, with the help of
a speech therapist so as to adequately restore the speech function, promotes balance among functional and
structural elements, resulting in facial harmony and preventing relapse.
Braz J Craniomaxillofac Surg 2002;5/11 29
Vll Congresso Brasileiro de Cirurgia Craniomaxilofacial - Abstracts
ZYGOMATICOPLASTY:
AN ESTHETIC COMPLEMENT TO ORTHOGNATIC SURGERY
(TECHNIQUES AND ALTERNATIVES)
Nelson E. Colombini, Wolney B. D'Azevedo, Einar F. Oquendo
Clinica Medica Nelson Colombini SBo Paulo, Brazil
-
OBJECTIVES
In the present study, we describe the application of different zygomaticoplasty techniques in conjunction
with lower Le Fort I osteotomy in cases where correction of the nasogenian segment can be carried out with a
Z osteotomy and where the zygomatic component can be esthetically repaired with less complex techniques.
MATERIALS AND METHODS
Eight cases were submitted to osteotomy as suggested by Powell & Hilley, together or not with orthognatic
surgery. The procedure consists in the filling of a gap with lyophilized or autogenous bone grafts, followed or not
by fixation with miniplates and screws of with 1.5 mm in diameter. In women, procedures of zygomaticfeminilization
may still be improved by the inversion of the Bichat ball to cover the osteotomized region.
RESULTS
The esthetic results obtained with zygomaticoplasty are as good as or better than those obtained with
quadrangular osteotomy or upper Le Fort I osteotomy, as observed the cases herein described.
CONCLUSIONS
The use of Powell's technique in zygomaticopiasties is fast, efficient, associated with low morbidity and
satisfactory esthetic results. It may be performed in combination of lower Le Fort I osteotomy or alone. In
addition, its association with blepharoplasty is also advocated by the authors.
PALATINE DISJUNCTION THROUGH ENDONASAL MICROSURGERY
Nelson E. P. Colombini, Wolney B. D'Azevedo, Gustavo J. Faller
Clinica Medica Nelson Colombini SSo Paulo, Brazil
-
OBJECTIVES
To describe the petformance of palatine disjunction via an endonasal access route and to discuss the
advantages and observations made along a 6-year experience.
MATERIALS AND METHODS
We describe 6 cases operated between 1996 and 2001, and report its advantages and indications.
RESULTS
The use of an endonasai access route in the performance of palatine disjunction is totally adequate to the
patient concerning physiological aspects. In addition, in one only surgical procedure, it allows forthe correction of
nasal cavities and cornets and for the manipulation of the osteomeatal space (whenever necessary). Surgically30 Braz J Craniomaxillofac Surg 2002;5/11
VII Congresso Brasileiro de Cirurgia Craniornavilofacial- Abstracts
assisted palatine disjunction is of paramount importance in the treatment of two basic situations: cases of insufficient
upper maxilla (above 5 mm from one side to the other), where it can help both in the preparation for surgery (in
association with orthodontia) and during the orthognatic period (postorthodontia); and cases of lower septa1
deviations or problems in the valvular area or Cottle's area. None of our patients presented complications related
to the procedure.
CONCLUSION
We used the basic septoplasty technique, with amplification of Cottle's lower tunel, in order to make room
for the entry of the modified microsaw. The modified technique herein described showed to be a natural, little
aggressive, and equally effective procedure for the performance of palatine disjunction, and is likely to be widely
used in maxillofacial surgeries in the future.
FUNCTIONAL GENIOPLASTY
Rodrigo 0. M. Marinho, David S. Precious
Hospital Lifecenter - Belo Horizonte, Brazil, and Dalhousie University Halifax, Canada
-
INTRODUCTION
The term "genioplasty" has classically been used to name as a cosmetic surgical procedure. However,
it is known that changes in form (anatomy) lead to changes in function. Functional genioplasty is a typical
example of this principle, due to the alteration of the position and anatomical form of the menton and its
myocutaneous structures.
OBJECTIVES AND CASE REPORT
This study has the aim of defining clinical indications for the use of functional genioplasty. In addition,
differences between this surgical technique and the classical treatment are reported based on the presentation
of clinical cases.
RESULTS
In all cases submitted to this surgical technique, excellent functional and cosmetic results were obtained.
It is important to emphasize the simplicity of the technique, the low morbidity levels associated with it and
the extremely low incidence of functional alterations in the mentonian nerve.
CONCLUSION
Functional genioplasty is a simple surgical procedure that may be used to correct functional and
cosmetic problems in patients who carry dentofacial deformities. It allows for the anatomical and
functional improvement of the menton, once it restores bones, muscles and the skin of the anterior and
lower portions of the face.
Braz J Craniomaxillofac Surg 2002;5/11 31
VII Congresso Brasileiro de Cirurgia Cran~ornaxilofacial- Abstracts
SURGICALLY-ASSISTED RAPID MAXILLARY EXPANSION REPORT OF A CLINICAL CASE
Paulo Roberto Pelucio CBmara
Occlusion problems are assessed in antero-posterior, vertical, and transversal directions. The variables
that determine whether a case should receive orthodontic or orthosurgical treatment include the intensity of the
problem and the degree of esthetic and/or functional compromise associated with the lesion. Treatment of
transversal problems usually implies the performance of maxillary expansion and, depending on the patient's
age, either removable devices (higher effect on teeth) or fixed expanders, such as Haas's or Hyrax's models
(significant effect on the maxillary bone), may be used. However, when the growing phase is over, the palatine
suture closes, and the orthopedic results commonly obtained with this form of treatment are lost. In these cases,
it is recommended to use a surgical procedure, so that the effect of expansion over bone tissues may be effective
and so that the upper and lower dental arches obtain an adequate coordination. The objective of this study was
to describe a clinical case and to show the effects of expansion on the maxilla of an adult patients submitted to
surgery in association with use of Hyrax-type expanders.
TREATMENT OF THE ANTEROPOSTERIOR MAXILLARY EXCESS
WITH LE FORT I OSTEOTOMY:
REPORT OF TWO CASES AND DISCUSSION
AntBnio Albuquerque de Brito, Davidson Rodarte Felix de Ollvelra, Yumara Siqueira de Castro
INTRODUCTION
Le Fort I maxillary osteotomy, as proposed by Bell in 1975, gave origin to a wide range of surgical techniques
aimed at the treatment of maxillary deformities. However, some procedures present a higher morbidity rate, so
that extreme care must be taken in the planning of treatment, as is the case of maxillary anteroposterior retraction.
OBJECTIVE
To report two cases of dentofacial deformity with anteroposterior maxillary excess treated with horizontal
retraction. In addition, we aim at discussing, based on the literature and on the experience of the authors,
considerations on the surgical technique and treatment plan.
RESULTS
Surgeries were performed without intercurrences, and lasted 4 hours and 18 minutes on average;
hospitalizations lasted 33 hours, on average. Patients showed an adequate evolution in the postoperative
period, with dental and skeletal stability and no manifestations of respiratory, speech, sleep or deglutition
alterations.
CONCLUSIONS
1) versatility of Le Fort I osteotomy;
2) reliability of the osteotomized maxilla vascularization;
3) need for preoperative assessment of velo-pharyngeal competency;
4) versatility in the plan of treatment, focusing on esthetic results;
5) need for the presence of less conventional procedures among the therapeutic options;
6) attention to the treatment plan, in order not to confer an "old" appearance to the patient.
32 Braz J Craniornaxillofac Surg 2002;5(11
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36 Braz J Craniomaxillofac Surg 2002;5/11
'
-
0 trauma craniomaxilofacial associado ao
pod€ r ~ s u l t a rEm IESOES
trauma cranio~nc~falico
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do
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Para a T~chnicare nao basta aptznas trazcr
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n ~ c ~ s s a r i oas sua seguranga.
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