Actinomycosis in the maxilla of a young asymptomatic patient: unusual case report / Actinomicose em maxila de um paciente jovem assintomático: relato de caso incomum

ABSTRACT The aim of this study is to report an unusual case of actinomycosis in the maxilla region of an asymptomatic patient. A 21-year-old white man was referred for the analysis of panoramic radiography and cone beam computed tomography, where it was observed the presence of a hypodense lesion on the left side of the maxilla, which extended from the maxillary left central incisor to the region of the maxillary left second premolar. During intraoral examination, a depression was observed in the hard palate mucosa, as well as a fistula in the alveolar mucosa close to maxillary left central incisor, which had pulp vitality confirmed by thermal tests. A fistulography was performed, with periapical radiography, where it was found that the fistulous path did not originate from the tooth mentioned above. An incisional biopsy was performed for diagnostic purposes. However, given the inconclusive microscopic findings, four months later, a new biopsy was performed. The histopathological examination revealed the presence of a colony of microoganisms with filamentous pattern of radiated rosette, surrounded by polymorphonuclear inflammatory cells. Based on the morphological characteristics, the diagnosis of actinomycosis was established. The treatment was based on antibiotic therapy. Six months after treatment of the infection, no signs of recurrence were observed, and the patient remains in follow-up. Actinomycosis in the maxilla is an uncommon infection with a predilection for males between the ages of 20 and 60, whose treatment is antibiotic therapy associated or not with surgical excision.

RESUMO O objetivo deste estudo é relatar um caso incomum de actinomicose em região de maxila de um paciente assintomático. Um homem de 21 anos, branco, foi encaminhado para análise de radiografia panorâmica e tomografia computadorizada de feixe cônico, onde foi observada a presença de lesão hipodensa do lado esquerdo da maxila, que se estendia da região do incisivo central superior esquerdo ao segundo pré-molar superior esquerdo. Ao exame intrabucal, observou-se depressão na mucosa do palato duro, bem como fístula na mucosa alveolar próxima ao incisivo central superior esquerdo, no qual tinha vitalidade pulpar confirmada pelos testes térmicos. Uma fistulografia com radiografia periapical foi realizada, onde foi observado que o trajeto fistuloso não era originado do dente mencionado anteriormente. Foi realizada biópsia incisional para fins diagnósticos. Porém, diante dos achados microscópicos inconclusivos, quatro meses depois, uma nova biópsia foi realizada. O exame histopatológico revelou a presença de colônia de microrganismos com padrão filamentoso de roseta irradiada, circundado por células inflamatórias polimorfonucleares. Com base nas características morfológicas, foi estabelecido o diagnóstico de actinomicose. O tratamento foi baseado em antibioticoterapia. Seis meses após o tratamento da infecção, não foram observados sinais de recidiva e o paciente permanece em acompanhamento. A actinomicose da maxila é uma infecção incomum, com predileção por pacientes do sexo masculino com idade entre 20 e 60 anos, cujo tratamento é antibioticoterapia associada ou não à excisão cirúrgica.

Jaffe-Lichtenstein syndrome associated with a simple bone cyst: unprecedented rare case report

Abstract Lesions denominated fibro-osseous lesions of the jaw constitute a diversified group of disorders, in which the normal bone architecture is replaced by fibroblasts, collagen fibers and immature bone. At present, the World Health Organization recognizes four variants of these lesions, namely: bone-cement dysplasia, fibrous dysplasia, ossifying fibroma and Familial gigantiform cementoma. Fibrous dysplasia may present in the monostotic form, affecting one single bone or an isolated craniofacial region; and in the Polyostotic form, involving two or more bones of the skeleton, and eventual association with syndromic conditions. The patient, C.P.G., 43 years old, sought attendance due to symptomatic increase in the region of the mandibular body on the right side. Imaging exams revealed craniofacial areas with ground-glass aspect, beyond the extensive mandibular radiolucent lesion. During the physical exam, spots of the Café au lait type disposed on the right side of the body were identified, in addition to uncoordinated gait with distinct shortening of the right leg. Additional radiographic exams showed evidence of skeletal dissemination of the disease. The patient denied any sexual precocity, and the final diagnosis was fibrous dysplasia, expressed by means of the Jaffe-Lichtenstein syndrome, in association with a simple bone cyst.

Resumo As denominadas lesões fibro-ósseas dos maxilares constituem um grupo diversificado de desordens nas quais a arquitetura óssea normal é substituída por fibroblastos, fibras colágenas e osso imaturo. Atualmente a Organização Mundial de Saúde reconhece quatro variantes destas lesões, sendo elas: a displasia cemento-óssea, a displasia fibrosa, o fibroma ossificante e cementoma gigantiforme familiar. A displasia fibrosa pode ser apresentar na forma monostótica, acometendo um único osso ou a região craniofacial isoladamente, e a forma poliostótica, envolvendo dois ou mais ossos do esqueleto, com eventual associação com condições sindrômicas. Paciente C.P.G., 43 anos, procurou atendimento devido aumento volumétrico sintomático na região de corpo mandibular do lado direito. Exames imaginológicos revelaram áreas craniofaciais com aspecto de vidro fosco ou despolido, além de extensa lesão radiolúcida mandibular. Durante o exame físico foram identificadas manchas do tipo café com leite dispostas do lado direito do corpo, além de marcha descoordenada com nítido encurtamento da perna direita. Novos exames radiográficos evidenciaram a disseminação esquelética da doença. O paciente negou qualquer precocidade sexual e o diagnóstico final foi de displasia fibrosa, expressa por meio da síndrome de Jaffe-Linchtenstein, em associação com um cisto ósseo simples.

Reversible Endoscopic Medial Maxillectomy: Endonasal Approach to Diseases of the Maxillary Sinus

Abstract Introduction The endoscopic access has reduced the morbidity associated with external approaches in diseases of themaxillary sinus. A reversible endoscopic medialmaxillectomy (REMM) is presented as an alternative for treatment of benign maxillary diseases. Objective To describe the REMM technique and report four cases of patients with benign maxillary sinus conditions treated through this approach. Methods The present study was divided into two parts: anatomical and case series. Two cadaveric dissections confirmed the feasibility of the REMMapproach. The same technique was performed on four consecutive patients with benign maxillary sinus disease. Results The cadaveric dissections confirmed wide exposure to the maxillary cavity, preserving the anatomy of the maxillary sinus. In the patient series, one patient presented with an antrochoanal polyp, one had a silent sinus syndrome, one had a chronic maxillary sinusitis secondary to a gunshot, and the last one had an inverted papilloma in the maxillary sinus. In all of the cases, the REMM approach provided excellent access and adequate resection, as well as preservation of the inferior turbinate, nasolacrimal duct, and lateral wall of the nose (including its osteomucosal component). Finally, all of the patients had an uneventful postoperative course. Conclusion The REMM technique is an excellent surgical approach to benign conditions of the maxillary sinus. It has few limitations and appears to be associated with less morbidity than conventional techniques.

Quality of Life and Maxillary Defects: A Cross-Sectional Study / Calidad de Vida y Defectos Maxilares: Un Estudio Transversal

ABSTRACT: There has been little discussion about the quality of life of patients with maxillary defects. This article evaluates the issues related to the condition. We performed a cross-sectional study of patients with maxillary defects from referral centers in Brazil. To avoid subject burden, a questionnaire was developed, based on questions from seven instruments, which dealt with domains and conclusions that were similar to those from other studies. The predictor variable was the patients' score for each question. The outcome measure was the presence of the best-ranked items on the questionnaire as the impact factor. Six experts assessed these items and suggested which questions to include or exclude. Patients scored each item according to its occurrence and importance. Descriptive statistics and the items' rank according to the impact factor were computed to determine whether there is a comprehensive instrument available. Thirteen patients and six professionals were included in this study. The patients' age ranged from 24 to 72 years (mean (standard deviation, SD), 50.41 (14.46) years). We obtained a 60-item instrument from the selected questionnaires and subject interviews. Only 12 (37.5 %) out of the 32 best-rated items were verified by the existing instruments, two (6.25 %) were suggested by professionals and 18 (56.25 %) were conclusions from other studies. To the best of our knowledge, this is the first study to provide many features related to the quality of life in patients with maxillary defects.

RESUMEN: Existe escasa discusión en la literatura sobre la calidad de vida de los pacientes con defectos maxilares. Este artículo evalúa los problemas relacionados con esta condición. Realizamos un estudio transversal de pacientes con defectos maxilares de centros de referencia en Brasil. Se desarrolló un cuestionario basado en preguntas de siete instrumentos, que trataba sobre dominios y conclusiones similares a las de otros estudios. La variable de estimación fue la puntuación de los pacientes para cada pregunta. La medida de resultado fue la presencia de los elementos mejor clasificados en el cuestionario como factor de impacto. Seis expertos evaluaron estos ítems y sugirieron qué preguntas incluir o excluir. Los pacientes puntuaron cada ítem según su ocurrencia e importancia. Se calcularon las estadísticas descriptivas y la clasificación de los ítems según el factor de impacto, para determinar si existe un instrumento completo. Trece pacientes y seis profesionales fueron incluidos en este estudio. La edad de los pacientes osciló entre 24 y 72 años [media (desviación estándar), 50,41 (14,46) años]. Obtuvimos un instrumento de 60 ítems de los cuestionarios y entrevistas de temas seleccionados. Solo 12 (37,5 %) de los 32 ítems mejor calificados se verificaron de acuerdo a los instrumentos existentes, dos (6,25 %) fueron sugeridos por profesionales y 18 (56,25 %) fueron conclusiones de otros estudios. De acuerdo a nuestro conocimiento, este es el primer estudio que proporciona características relacionadas con la calidad de vida en pacientes con defectos maxilares.

Tumor central de células gigantes em paciente pediátrico: exérese, reabordagem e homeopatia / Tumor central de células gigantes en paciente pediátrico: exéresis, reabordaje y homeopatía / Pediatric central giant cell granuloma: exeresis, second-management and homeopathy

RESUMO Introdução: A lesão central de células gigantes é própria dos ossos gnáticos, sendo um tumor benigno não odontogênico. É uma lesão de crescimento predominantemente lento, bem circunscrito e assintomático, geralmente diagnosticada através de algum exame de rotina ou, em casos mais avançados, quando se começa a visualizar alguma alteração estético-anatômica ou através da queixa do paciente de algum desconforto localizado na região. Objetivo: Ilustrar um caso clínico de lesão central de células gigantes e sua resolução envolvendo momento cirúrgico e reabordagem que inclui a homeopatia na proposta terapêutica. Apresentação do caso: Paciente do sexo feminino, inicialmente com 4 anos de idade com uma lesão na região de pré-maxila. Após avaliação radiográfica, tomográfica, exames sanguíneos e biópsia incisional, foi realizada, em primeiro momento, a exérese da lesão sob anestesia geral, por curetagem com aplicação de solução de carnoy. Após proservação e surgimento de imagem radiopaca nos exames, deu-se início ao tratamento não invasivo com homeopatia e injeções de corticoide visando à redução e neoformação óssea em área sugestiva de tecido cicatricial. Conclusões: Abordagens mais conservadoras podem ser, em muitos casos, uma opção plausível que acaba por livrar o paciente de cirurgias mutilantes(AU)

RESUMEN Introducción: La lesión central de células gigantes es propia de los huesos gnáticos, lo que constituye un tumor benigno no odontogénico. Es una lesión de crecimiento predominantemente lento, bien circunscrita y asintomática, generalmente diagnosticada a través de algún examen de rutina o en casos más avanzados cuando se empieza a visualizar alguna alteración estético-anatómica o el paciente que se queja de algún malestar localizado en la región. Objetivo: Presentar un caso clínico de lesión central de células gigantes y su resolución involucrando momento quirúrgico y reabordaje que incluye la homeopatía en la propuesta terapéutica. Presentación del caso: Paciente del sexo femenino, inicialmente con 4 años de edad con una lesión en la región de pre-maxila. Después de la evaluación radiográfica, tomográfica, exámenes sanguíneos y biópsia incisional con el diagnóstico, se realizó en un primer momento la exéresis de la lesión bajo anestesia general, por curetaje con aplicación de solución de carnoy. En los exámenes de acompañamiento, después de la aparición de imagen radiopaca, se inició el tratamiento no invasivo con homeopatía e inyecciones de corticoides para la reducción y neoformación ósea en el área sugestiva de tejido cicatricial. Conclusiones: Los enfoques más conservadores pueden ser, en muchos casos, una opción plausible que termina librando al paciente de cirugías de mutilación(AU)

ABSTRACT Introduction: Giant cell central lesion is characteristic of the gnathic bones, being a non-odontogenic benign tumor. Classified as a predominantly slow grotwh, well-circumscribed and asymptomatic lesion usually diagnosed through routine examination or in some and more advanced cases once it begins to create some aesthetic-anatomical alteration or when the patient starts complaining of some located discomfort in the region. Objective: To present a clinical case of central giant cell lesion and its resolution involving surgical approach and second management, which includes homeopathy as a therapeutic proposal. Case presentation: central giant cell lesion located in the premaxilla region in a 4 years old female patient. After radiographic, tomographic and blood exams evaluation, followed by incisional biopsy and diagnostic, leading to surgical approach to remove the entire lesion by curettage with Carnoy's solution application under general anesthesia. After appearance of radiopaque imaging in the proservation examinations, the non-invasive treatment by corticoid injection and homeopathy got started aiming the reduction of cicatricial tissue's suggestive area and neoformation of the bone. Conclusions : approaches that are more conservative can be, in many cases, a plausible option that ends up ridding the patient of mutilating surgeries(AU)

Osteomielitis maxilar y mandibular en pacientes pediátricos / Pediatric maxillary and mandibular osteomyelitis

Introducción: La osteomielitis es un cuadro, de presentación ocasional, que resulta como complicación de diversas etiologías y requiere un tratamiento quirúrgico y médico inmediato. Objetivos: Evaluar los resultados de patología informados como osteomielitis a nivel de los maxilares en pacientes pediátricos, tanto de la mandíbula como del maxilar superior, los cuales requirieron tratamiento quirúrgico y cobertura antibiótica en el periodo del 2008 – 2013. Material y método: Estudio descriptivo y retrospectivo, realizado en el Instituto Nacional de Salud del Niño. Resultados: Se encontró predominio en el sexo masculino (64.7%) y mayor presentación en menores de 10 años de edad (91%), la mandíbula fue en mayor frecuencia afectada (92,1%); con predominio de osteomielitis crónica en 82,4% de los casos. La región del cuerpo y ángulo mandibular resultaron los más afectados con 75 y 62,5% respectivamente. A todos los pacientes se les realizó limpieza quirúrgica y remoción de secuestros óseos con exodoncias de las piezas comprometidas. Conclusión: La cirugía junto a la cobertura antibiótica son la base del tratamiento el cual se busca erradicar el foco infeccioso y al microorganismo patógeno. Proponemos como cobertura antibiótica clindamicina y penicilina resistente a betalactamasa durante 8 semanas, en forma parenteral por 2 semanas como mínimo y luego vía oral hasta completar el tratamiento.

Introduction: Osteomyelitis is a picture of casual presentation, resulting as a complication of various etiologies and requires immediate surgical and medical treatment. Objective: To evaluate the results of pathology-level reported as osteomyelitis of the jaws in pediatric patients , both the jaw and the upper jaw, which required surgical treatment and antibiotic coverage, for the period from 2008 to 2013. Material Methods: Study descriptive, retrospective , held at the National Institute of Child Health Results : predominance was found in males ( 64.7 %) and higher filing under 10 years of age (91%), the mandible was more frequently affected (92.1 %) with a predominance of chronic osteomyelitis in 82.4 % of cases . The region of the mandibular body and angle were the most affected with 75 and 62.5 % respectively. All patients were performed surgical cleaning and removal of sequestra with extractions of compromised parts. Conclusion: Surgery with antibiotic coverage are the mainstay of therapy , which seeks to eradicate the source of infection and the pathogen. We propose as clindamycin antibiotic coverage lactamase resistant penicillin for 8 weeks parenterally for at least 2 weeks and then orally until complete.

Stage II Chronic Maxillary Atelectasis Associated with Subclinical Visual Field Defect

Chronic maxillary atelectasis (CMA) is characterized by a persistent decrease in the maxillary sinus volume due to inward bowing of its walls. According to its severity, it may be classified into three clinical-radiological stages. Objective: To report a case of stage II CMA associated with subclinical visual field defect. Case Report: A 34-year-old woman presented with a 15-year history of recurrent episodes of sinusitis and intermittent right facial discomfort for the past 5 years. She denied visual complaints, and no facial deformities were observed on physical examination. Paranasal sinus computed tomography (CT) demonstrated a completely opacified right maxillary sinus with inward bowing of its walls, suggesting the diagnosis of stage II CMA. A computerized campimetry (CC) disclosed a scotoma adjacent to the blind spot of the right eye, indicating a possible damage to the optic nerve. The patient was submitted to functional endoscopic sinus surgery, with drainage of a thick mucous fluid from the sinus. She did well after surgery and has been asymptomatic since then. Postoperative CT was satisfactory and CC was normal. Discussion: CMA occurs because of a persistent ostiomeatal obstruction, which creates negative pressure inside the sinus. It is associated with nasosinusal symptoms but had never been described in association with any visual field defect. It can be divided into stage I (membranous deformity), stage II (bony deformity), and stage III (clinical deformity). The silent sinus syndrome is a special form of CMA. This term should only be used to describe those cases with spontaneous enophthalmos, hypoglobus, and/or midfacial deformity in the absence of nasosinusal symptoms...

Importância do diagnóstico radiográfico de patologias dos maxilares em pacientes ortodônticos / Importance of radiographic diagnosis of pathologies of the jaws in orthodontic patients

Introdução: a Ortodontia como uma especialidade odontológica tem mostrado para a sociedade a sua grande relevância e seu impacto na promoção da saúde da população. Enquanto ciência, os avanços para tratamento e reabilitação de pacientes são incontestáveis,desde situações mais simples às mais complexas, proporcionando saúde e bem-estar a um número cada vez maior de pessoas. Por outro lado, o grande número de profissionais tem gerado preocupações e inquietações à medida que tratamentos podem ser conduzidos deforma inadequada. Objetivo: neste artigo será abordada a importância do diagnóstico de patologias dos maxilares por meio da descrição de quatro situações clínicas, nas quais pacientes sob tratamento ortodôntico, portadores de lesões visíveis ao exame radiográfico panorâmico,tiveram o diagnóstico destas lesões negligenciado ou desconsiderado.Conclusão: a radiografia panorâmica constitui importante meio de diagnóstico de patologias assintomáticas dos maxilares, devendo ser criteriosamente avaliada antes do início da terapia ortodôntica.A parceria com outras especialidades da Odontologia é fortemente aconselhada na rotina do ortodontista.

Introduction: orthodontics as a dental specialty has shown its relevance to society and a great impact on the promotion of public health. The advances in the treatment and rehabilitation of orthodontic patients, from mild to severe cases, provide health and wellness to a growing number of people. On the other hand, the growing number of orthodontic professionals has raised concems,as treatments can be conducted improperly Objective: in this articlewe discuss the importance of diagnosis of pathological changes of the jaws through the description of four clinical situations in which patients under went orthodontic treatment. Lesions which were visible on panoramic radiographs were overlooked or disregarded for these patients. Conclusion: the panoramic radiograph is an important modality of diagnosis of asymptomatic pathological changes of the jaws. The panoramic image must be carefully evaluated before the beginning of orthodontic treatment. Collaboration with other specialties of dentistry is strongly recommended for the orthodontist.

Osteonecrose dos maxilares associada ao uso de bisfosfonatos / Bisphosphonate-related osteonecrosis of the jaws

Os bisfosfonatos são potentes inibidores da reabsorção óssea e são utilizados no tratamento da osteoporose e de outras doenças que causam a perda de massa óssea, como doença de Paget, metástases ósseas e mieloma múltiplo, prevenindo fraturas patológicas. Desde 2003, estudos associam osteonecrose avascular dos ossos maxilares a seu uso, principalmente intravenoso. Na literatura, há relatos de ocorrência variando de 0,8 por cento a 12 por cento, dos pacientes, na sua maioria em uso prolongado. Médicos e dentistas devem estar cientes dessa potencial complicação no tratamento odontológico.

Bisphosphonates are potent inhibitors of bone resorption, and are used in the treatment of osteoporosis and other diseases that cause bone mass loss, such as Paget's disease, bone metastases, and multiple myeloma, to prevent pathological fractures. Since 2003, avascular osteonecrosis of the jaw has been associated with the use of bisphosphonates, mainly intravenous. According to the literature, the occurrence of osteonecrosis of the jaw has ranged from 0.8 percent to 12 percent of the patients on bisphosphonates, most of them on prolonged use. Physicians and odontologists should be aware of that potential complication in dental treatment.

Osteonecrose maxilar em pacientes portadores de doenças neoplásicas sob uso de bisfosfonatos / Jaw osteonecrosis in patients with neoplastic diseases taking bisphosphonates

A osteonecrose induzida por bisfosfonatos é uma complicação que pode ocorrer em pacientes acometidos por doença osteolítica tais como mieloma múltiplo, portadores de metástases tumorais em tecido ósseo, osteoporose e que fizeram uso de droga do grupo dos bisfosfonatos. A despeito dos benefícios do uso destes fármacos, a osteonecrose maxilar é uma importante complicação. Seu mecanismo de ação reduz a reabsorção óssea, o estímulo à atividade osteoblástica, a inibição do recrutamento e promoção da apoptose de osteoclastos. Até o presente momento, não há na literatura um protocolo de tratamento para a osteonecrose por bisfosfonatos. No presente trabalho, os autores fazem uma revisão da literatura e descrevem dois casos clínicos em pacientes do sexo feminino, com diferentes doenças, mieloma múltiplo e metástases ósseas por carcinoma de mama, acometidas por osteonecrose em mandíbula induzida por bisfosfonatos.

The use of bisphosphonates among patients affected by osteolytic diseases, such as multiple myeloma, metastatic bone lesions and osteoporosis has been associated with the risk of osteonecrosis of the jaws. Bisphosphonates are found in areas of the bone that are undergoing inflammation or resorption. They are phagocytosed and internalized by osteoclasts. Once in the bone, these bisphosphonates cause apoptosis or cell death of the osteoclasts and as a result they may inhibit osteoclast-mediated bone resorption. Bisphosphonates seem to affect osteoclasts when it comes to both numbers and function. Although bisphosphonates are potent and valuable inhibitors of osteoclastic bone lesions, several unanswered questions exist regarding the risk of developing osteonecrosis and the management of this complication. This study reports two clinical cases of osteonecrosis of the jaws associated with the use of bisphosphonates. According to the findings, the two patients (women) with different neoplasms: multiple myeloma and breast cancer with metastatic bone lesions presented some signs and symptoms of osteonecrosis.

Granulomatosis de células de Langerhans: Presentación de un caso

Se reporta un inusual caso de granulomatosis de células de Langerhans localizado en maxilares en un paciente de 30 meses de edad, quien presentaba además de las lesiones líticas óseas, lesiones de aspecto tumoral en encía palatina y lingual de ambas arcadas dentarias. El examen óseo no arrojaba compromiso de otros huesos. El diagnóstico histológico fue corroborado por el Centro Nacional de Referencia en Anatomía Patológica.

A unusual case of Langerhans´ cells is reported, located in maxillae of a 30 months old patients, who, apart from bone lithic injuries, showed injuries of tumoral type in lingual and palatine gingiva of both dental archs. According to bone examination, there weren´t involvement of other bones. Histologic diagnosis was corroborated by National Reference Center in Pathologic Anatomy.