Two Cases of COVID-Related Osteonecrosis of the Jaws: A New and Worrying Entity Is Emerging.

Many people were affected by COVID-19 in its severe form. Some intercurrences are still emerging. We here report two cases of COVID-related osteonecrosis of the jaws (CRONJ). Two retrospective cases were admitted into Imam Reza Hospital, Mashhad, Iran with suspected CRONJ. One patient escaped from hospital while the other showed a positive result after our proposed treatment. A new aftermath to COVID-19 infections is emerging. Maxillofacial and orthopedic surgeons should be aware of this situation. CRONJ should be on the suspect list in patients with COVID-19. Measures that are useful in the treatment carried out, as well as some measures recommended in the literature, were discussed. Surgical treatment of CRONJ appears to be an effective alternative, especially in the more aggressive cases.

Postoperative nausea and vomiting in orthognathic surgery: systematic review and meta-analysis.

PURPOSE: Postoperative nausea and vomiting (PONV) is a frequently reported adverse event following orthognathic surgery. The aim of this work is to conduct a systematic review of the literature on the subject, and to discuss the role of maxillofacial surgeons and the steps that can be taken to prevent or control PONV in orthognathic surgery. METHODS: A systematic review was conducted according to the PRISMA guidelines, using the search strategy: (orthognathic AND (nausea OR vomiting)). The authors searched PubMed, Embase, Dimensions, Web of Science and Google Scholar databases, without any language restrictions. RevMan 5.4 was used to create a risk of bias graph and a forest plot. RESULTS: The included articles were classified as having a low risk of bias, despite the limited literature on the subject. Various measures have been reported to be beneficial in preventing or managing PONV, such as the use of dexamethasone, antiemetic drugs, gastric aspiration, and anesthetic blocks. Effective bleeding control and faster surgeries can also be helpful. CONCLUSIONS: Throat packs have not been found to be effective in preventing PONV. Although no definitive protocol has been established in the literature, the Enhanced Recovery After Surgery (ERAS) protocol could be a useful approach. Overall, a multimodal approach may be taken to prevent PONV, and further research is needed to establish definitive protocols.

Exploring the relationship between the number of systematic reviews and quality of evidence: an orthognathic surgery-based study.

OBJECTIVE: We analyzed the quality and quantity of systematic reviews (SRs) of orthognathic surgery, the most frequently published topic in maxillofacial surgery. STUDY DESIGN: We searched the PubMed database for SRs of orthognathic surgery with no restriction on the language of publication date. We assessed the certainty of evidence presented according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol and the Leiden Manifesto using the Grading of Recommendations Assessment, Development, and Evaluation approach. We analyzed the data using descriptive statistics, Pearson´s correlation test, and linear regression. RESULTS: Of the 171 SRs evaluated, approximately one fifth presented evidence with a high level of certainty. The number of orthognathic surgery SRs has been increasing, and many SRs were published after very similar topics had already been published. There is no relationship between the impact factor and the certainty of evidence. CONCLUSIONS: An excessive number of SRs of orthognathic surgery are published, and many SRs are superfluous, simply reporting previous findings. Clinicians should not base treatment decisions solely on the evidence presented in SRs, and journal editors and reviewers should evaluate these SRs more critically, particularly when they address topics that have already been covered in the literature.

The importance of written informed consent in facial cosmetic surgery litigation.

It is the aim of the study to discuss litigation related to facial cosmetic surgery with a particular focus on written consent, in order to prevent unfortunate outcomes for the surgeon and patient alike. A 10-year online search for facial cosmetic surgery litigation in Brazil was conducted from 2012 to 2022. Statistical analyzes were performed using RStudio, and the results were considered significant with a 95% confidence interval. A total of 992 litigations were identified through the search. Of these, 122 articles met our inclusion criteria. The number of legal disputes on this subject has been increasing for years. Female patients are more prone to litigation. Financial damage ranged from $75 to $500,000 (mean: $59,536). Many of the lawsuits that had appropriate written consent have had a favorable outcome for the defendant. The primary specialty was the most common plastic surgery (67%), followed by maxillofacial surgery (9%). Surgeons engaged in facial cosmetic surgery should protect themselves legally from litigation. Written consent significantly reduces both litigation losses and financial damage. Some details on the preparation of this consent form have been discussed.

Global network mapping research findings on orthognathic surgery and temporomandibular disorder.

OBJECTIVES: The objective of this work is to assess the relationship between orthognathic surgery and temporomandibular disorders literature through a bibliometric analysis. METHODS: A bibliographic search in line with the STROBE guidelines and the concepts of the Leiden Manifesto was performed on the Web of Science using the terms orthognathic surgery AND temporomandibular. A citation analysis and establishment of the more cited articles were performed. A graphical representation of the keywords was created with VOSviewer. RESULTS: A total of 810 articles were analyzed in this study. The research revealed a significant increase in publications on this topic, particularly in English language articles and a high H-index. The publications represented 55 nations, with the highest number of articles coming from the USA. The discussion of highly cited articles covered various aspects such as the relationship between orthognathic surgery and TMD, including condylar resorption or displacement, predisposing factors, dentoskeletal and occlusion patterns, anatomical factors, osteotomy techniques, condylar positioning techniques, and emerging technologies for improved TMJ stability. CONCLUSION: The analysis reveals an increasing research interest in this field, with a significant number of publications in English and a high citation rate per article, indicating the impact of the research. Various factors associated with TMD in orthognathic surgery are explored, including condylar alterations, predisposing factors, occlusion patterns, and surgical techniques. The study underscores the importance of thorough assessment, treatment, and monitoring of TMD in orthognathic surgery patients, while acknowledging the need for further research and consensus in management strategies.

A global science mapping analysis on odontogenic infections.

OBJECTIVES: Odontogenic infections are common and a topic of core interest for dentists, and maxillofacial surgeons. The aim of this study was to conduct a bibliometric analysis of the global literature on odontogenic infection and explore the top 100 most cited papers to identify the common causes, sequelae and management trends. METHODS: Following a comprehensive literature search, a list of top 100 most cited papers was created. The VOSviewer software (Leiden University, The Netherlands) was used to create a graphical representation of the data, and statistical analyses were performed to analyze the characteristics of the top 100 most cited papers. RESULTS: A total of 1,661 articles were retrieved with the first article published in 1947. There is an exponential upward trend on the number of publications (R2 = 0.919) and a majority of papers are in English language (n = 1,577, 94.94%). A total of 22,041 citations were found with a mean of 13.27 per article. The highest number of publications were recorded from developed countries. There was a male predilection in the reported cases and the most common sites included the submandibular and parapharyngeal spaces. Diabetes mellitus was identified as the commonest co-morbidity. Surgical drainage was ascertained to be the preferred method of management. CONCLUSIONS: Odontogenic infections remain prevalent and have a global distribution. Although prevention of odontogenic infection through meticulous dental care is ideal, early diagnosis and prompt management of established odontogenic infections is important to avoid morbidities and mortality. Surgical drainage is the most effective management strategy. There is lack of consensus regarding the role of antibiotics in the management of odontogenic infections.

The importance of a local cleft mission and its spread.

OBJECTIVES: Cleft lip or palate are very usual birth defects. This study aims to discuss a local cleft mission performed in Angola and some specifics on the topic. METHODS: This retrospective study assessed the main features of a local cleft mission conducted in September 2022. The mission was carried out at the Hospital Josina Machel in Luanda, Angola. Data was retrieved and analyzed. The Shapiro-Wilkes test and Pearson correlation were used and considered significant only at 95% confidence interval. RESULTS: Cleft missions are a difficult task. Logistical and financial problems are exacerbated by the extreme difficulty of recruiting patients, particularly in remote regions, far from major centers. Despite successful widespread, some surgeries have been postponed due to comorbidities, common in Africa. CONCLUSION: The organizers of the mission must be aware of the difficulty of attracting patients and must use different media such as television and radio. The internet needs to be used to the maximum and could reach a higher number of prospects.

Which sports have a higher risk of maxillofacial injuries?

OBJECTIVES: Sports etiology is one of the most common causes of maxillofacial injuries. This work aimed to provide an up-to-date review of sports-related maxillofacial injuries. METHODS: An updated review was conducted on Pubmed and Google Scholar. No publication year and language restrictions were applied. Two different search strategies were performed, the first addressed which sports, generally associated with maxillofacial injuries, and the second search was conducted to determine the frequency of maxillofacial injuries associated with each sport individually. RESULTS: The first search returned 26 articles distributed across different sports, from different countries, and with varied age distribution. The second search displayed 85 articles on individual sports group. Papers were rated and categorized according by the sport associated to the reported injury. A useful sports risk scale for maxillofacial injuries has been developed. Peculiar themes from all participating sports were evaluated. The use of protective equipment and other preventive measures were highlighted. CONCLUSIONS: Some sports with ball and cycling can be considered riskier sports for maxillofacial injuries. Athlete education and the mandatory use of mouthguards, helmets, and eye protection, among other things, are crucial to prevent these injuries. Tailor-made mouthguards and protective masks, which are becoming cheaper, are in vogue. The Sports-related Maxillofacial Injuries Risk scale can be useful for athletes, athletic coaches, and maxillofacial surgeons.

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

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

Three-Dimensional Analysis of the Skull Base of Individuals With Cleft Lip and Palate.

AIMS: Identify variations of skull base measurements in individuals with dentofacial deformities associated or not with cleft lip and palate and compare the results with individuals without dentofacial deformities. METHODS AND RESULTS: The individuals were categorized into three different groups: dentofacial deformity without cleft malformation, dentofacial deformity associated with cleft lip and palate, and without facial deformity. The inclusion criteria were individuals over 18 years of age, without any intervention involving facial bones or structures of interest for the study and field of view encompassing from the glabella to the hyoid bone. Poor quality CT scans or lack of adequate medical records were considered exclusion criteria. In the analysis by computerized tomography using the Dolphin Imaging Software, the length determined by the Ba-S and S-N lines was evaluated, as well as the Ba-S-N angle formed by landmarks. RESULTS: The length of S-N was not statistically different between the groups, the Ba-S length and the Ba-S-N angle demonstrated statistical difference. CONCLUSION: There was statistically significant difference in the morphometry of the (Ba-S) between groups (FS) and (C). This suggests that the standard values for cephalometric analyzes involving these structures, especially to determine the treatment planning, should be used with caution.

Analgesia and side effects of codeine phosphate associated with paracetamol vs. paracetamol after the extraction of mandibular third molars: a randomized double-blind clinical trial using the split-mouth model.

PURPOSE: To assess the analgesia and side effects of codeine phosphate associated with paracetamol (test medication) as compared to paracetamol (control medication) after the extraction of impacted mandibular third molars. MATERIALS AND METHODS: Forty-seven patients removed the right and left impacted mandibular third molars. After one surgery, patients took the test medication and after the other surgery, they took the control medication. Patients with exacerbated pain were prescribed to use the rescue medication instead of the medication initially administered and were included in the rescue group. They were evaluated for 7 days postoperatively, and the mean score of the visual analogue scale (VAS) of pain between test and control medications was assessed by the Poisson distribution. The side effects of these medications were assessed by the patient's complaints. A P value of < .05 was considered to be statistically significant. RESULTS: The mean score of the VAS of pain was not statistically different between test and control medications in the non-rescue group, but it was significantly greater in patients previously using paracetamol in the rescue group. The most common side effects reported in both groups, predominantly in patients using the test medication, were drowsiness, dizziness, and nausea. CONCLUSION: The use of codeine phosphate associated with paracetamol after the extraction of impacted mandibular third molars is a better choice to control the postoperative pain rather than paracetamol, but with more side effects, which are clinically acceptable.

A systematic review on the expression of bcl-2 in the nonsyndromic odontogenic keratocyst: should it be considered a cyst or a tumor?

The purpose of this study is to find out if the biological behavior and the capacity of the odontogenic keratocyst (OKC) in maintaining pathologic cells alive are more similar to the dentigerous cyst or to the ameloblastoma by assessing bcl-2. We searched MEDLINE, Web of Science, and Scopus for immunohistochemical studies reporting OKCs, dentigerous cysts, and ameloblastomas. Risk difference between the lesions expressing bcl-2 was the effect measure and a P value < 0.05 was considered to provide evidence to the effect estimates. OKCs have an estimated difference of 91% in the probability to express the bcl-2 over dentigerous cysts, but there is no difference in the expression of bcl-2 between OKCs and ameloblastomas. The present study demonstrated a great risk difference in the expression of bcl-2 between OKCs and dentigerous cysts and no risk difference between OKCs and ameloblastomas. OKC's growth may indirectly be attributed to the anti-apoptotic effect of bcl-2 in the cystic epithelium and not only to the increase of its intraluminal pressure. Therefore, the classification of this lesion into keratocystic odontogenic tumor should be carefully reconsidered.

A clinical-based protocol of diagnosis of temporomandibular joint open lock and treatment with arthrocentesis.

PURPOSE: Arthrocentesis of the temporomandibular joint (TMJ) is a minimally invasive surgical procedure that provides good clinical results such as the improvement of jaw movements. It also helps to balance the synovial liquid viscosity and relieve TMJ pain by the washout of inflammatory components from the upper compartment. The purpose of this study is to report a case series of patients submitted to a clinical-based protocol of diagnosis of TMJ joint open lock and treatment with arthrocentesis. MATERIAL AND METHODS: Patients suffering from a recurrent unilateral open lock of the TMJ were submitted to one arthrocentesis of the affected TMJ and all of them reported that the open lock was caused by daily stomatognathic activities. To decide the arthrocentesis as the initial treatment of these patients, the authors followed a rational protocol of diagnosis. RESULTS: Ten patients were included in the present study. No complications occurred during arthrocentesis. Immediately, 1 week, 1 month, and 6 months after arthrocentesis, patients did not suffer from open lock or disc click anymore. They also reported no more pain because it was strictly related to the disc click. CONCLUSIONS: All patients of the present study improved from the open lock and disc click of the affected TMJ for 6 months after arthrocentesis. The clinical-based protocol of diagnosis of TMJ open lock reported in the present study, followed by the treatment with arthrocentesis is a reasonable, low-cost, and safe method to treat patients with the acute open lock.

Synergism between recombinant human bone morphogenetic protein 2/absorbable collagen sponge and bone substitutes favors vertical bone augmentation and the resorption rate of the biomaterials: Histomorphometric and 3D microcomputed tomography analysis.

BACKGROUND: Recombinant human bone morphogenetic protein 2 (rhBMP-2) is an osteoinductor frequently used for bone regeneration in oral and maxillofacial surgery. There is no consensus about the ideal carrier for this growth factor. The aim of this study was to compare the bone augmentation, bone microarchitecture, and biodegradation rate of additional carriers to rhBMP-2/absorbable collagen sponge (ACS) in a vertical guided bone regeneration model. METHODS: Four titanium cylinders were fixed onto the calvaria of rabbits (n = 20) that received (n = 10) or not (n = 10) rhBMP-2/ACS in conjunction with one of the carriers: beta-tricalcium phosphate (ß-TCP), biphasic calcium phosphate (BCP), bovine bone mineral (BBM) or blood clot. The samples were analyzed by means of microcomputed tomography and histomorphology after 14 weeks. RESULTS: All the materials with rhBMP-2/ACS exhibited improvement on bone augmentation, mainly BCP (P = 0.033) and ß-TCP (P = 0.038), in the upper portion of the cylinder. Although trabecular anisotropy was improved in all the materials groups, trabecular connectivity was diminished when the biomaterials received rhBMP-2/ACS. Resorption rate of the remaining biomaterial was improved by rhBMP-2/ACS, mainly in BBM (P <0.01) and ß-TCP (P <0.01). BBM exhibited the highest osteoclast density compared with the other materials groups. CONCLUSIONS: BCP and ß-TCP biomaterials exhibited a synergic effect with rhBMP-2/ACS, acting as suitable and viable carriers for vertical bone augmentation. The addition of rhBMP-2 significantly affected the biodegradation of ß-TCP and BBM, accelerating the resorption of these materials.

Myeloid sarcoma on the temporal region before the onset of the acute myeloid leukemia: an extremely rare case report.

PURPOSE: Myeloid sarcoma (MS) is a rare malignant tumor that arises outside the bone marrow and usually occurs concomitantly or after the acute myeloid leukemia (AML). The aim of the present study is to report an extremely rare case of a patient with an MS arising in the maxillofacial region before the onset of AML to serve as a guide on how to conduct the initial assessment and diagnosis of similar cases. MATERIALS AND METHODS: A 29-year-old healthy man complained of a "swelling on the head," which was rapidly increasing. He was asymptomatic and never had a previous AML. RESULTS: The patient presented a large mass on the left temporal region. The computed tomography showed a well-delimited lesion extending from the lateral pterygoid muscle and involving the zygomatic arch and lateral orbital rim. The mass was diagnosed as an MS arising before the onset of the AML. CONCLUSION: Masses of a rapid increase in the maxillofacial region should always raise suspicion of being an MS even in asymptomatic patients. Following a protocol of initial assessment and diagnosis will decrease the period between the initial appearance of the MS and effective treatment aimed to prevent or delay the manifestation of leukemia, improving the prognosis and survival of these patients.

Antimicrobial photodynamic and photobiomodulation adjuvant therapies for prevention and treatment of medication-related osteonecrosis of the jaws: Case series and long-term follow-up.

BACKGROUND: Medication-Related Osteonecrosis of the Jaws (MRONJ) incidence are increasing among elderly. Treatment can be challenging. Prevent or treatment protocols that control evolution of the lesion are warranted. OBJECTIVE: To observe long-term outcomes of two protocols based on photonics [antimicrobial photodynamic therapy (aPDT) and photobiomodulation (PBM)] for prevention and treatment of MRONJ lesions. METHODS: In a prospective study, patients who needed oral surgery and had been exposed to antiresorptive drugs were long-term followed-up. For MRONJ prevention, immediately after tooth extraction aPDT was applied. For aPDT a 0.01 % methylene blue solution was applied inside socket for 5 min followed by irradiation with a diode laser [660 nm, 0.028cm2, 0.1 W, 3.57 W/cm2, 90 s and 9 J per point, 321 J/cm2, at least at in 3 points (laser probe was placed at central, and two equidistant points) and total energy of 27J]. Irradiation was repeated weekly until total tissue repair. MRONJ treatment included preoperative aPDT sessions until signs and symptoms of infection had reduced. Then, after necrotic bone removal, aPDT was applied inside surgical wounds and re-applied weekly until healing. Antibiotics were administered pre or postoperatively for no longer than 7 days. PBM therapy was applied with 808 nm diode laser, 0.028cm2, 0.1 W, 3.57 W/cm2, 30 s, 107 J/cm², 3 J and total energy of 12 J until evidence of remission. RESULTS: Eighteen patients underwent preventive protocol, and none presented signs of MRONJ after a follow-up of at least 6 months. Seventeen patients presented with MRONJ underwent aPDT protocol and sixteen of them showed total regression of lesions. PRACTICAL IMPLICATIONS: aPDT and PBM therapy protocols appear to be effective as adjuvant approach not only for preventing MRONJ development due to tooth extraction but for treating MRONJ lesions at early stages with no adverse effects.

The presentation of odontogenic keratocysts in the jaws with an emphasis on the tooth-bearing area: a systematic review and meta-analysis.

PURPOSE: This study was conducted in order to gain insight in the actual ratio of odontogenic keratocysts occurring in the tooth-bearing area as compared to the posterior region of the jaws in order to come up with reliable data to base upon a rational treatment policy. METHODS: We searched MEDLINE, Web of Science, Scopus, and Cochrane databases for studies reporting on the location of mandibular and maxillary odontogenic keratocysts. All records were independently assessed and a meta-analysis was performed. Risk difference with a confidence interval of 95% of having the lesion in the posterior region versus the tooth-bearing area was the effect measure. P value for the summary effect of < 0.05 was considered statistically significant. RESULTS: The 2615 records retrieved were reduced to 34 studies to be qualitatively/quantitatively assessed. The pooled values showed that the difference in the clinical risk of having keratocysts in the posterior region of the mandible and in the tooth-bearing area of the maxilla is 21 and 43%, respectively (P < 0.02 and P < 0.00001). CONCLUSIONS: A substantial amount of keratocysts occur in the tooth-bearing area of the jaws, requiring attention.

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

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