Fibrous Dysplasia treated with virtual planning – report of two cases

Fibrous dysplasia (FD) is part of a rare group of bone dysplasia. It exhibits benign behavior and can lead to osteolytic lesions, deformities, and fractures. The treatment is challenging, and accurate removal of the lesion is necessary to restore function and esthetics. Here we present two cases of FD where virtual planning with presurgical computed tomography (CT) was used for the production of a surgical guide for bone contouring. First, CT image reconstruction was performed to mirror the patient’s original anatomy. Then, three surgical guides that determined the area and depth of bone wear were prepared and used in the relevant sequence during the actual surgeries, which were successfully performed in both patients. This technique is termed the template guide holes (TGH) technique. The findings from this report suggest that presurgical virtual planning and guide preparation allows direct and objective measurement of the level of bone wear and improves the functional and esthetic outcomes of surgery for FD. In particular, the TGH technique is safe and allows adequate preoperative surgical simulation, reduces the surgical duration, and increases the predictability of the final result

Two- or three-dimensional evaluations of the position and center of rotation of the mandibular condyle in joint, occlusal, and orthognathic surgery planning: a systematic review

Apresentamos uma revisão sistemática que buscou determinar o eixo de rotação e a posição condilar nas avaliações articulares, oclusais e no planejamento virtual e tradicional de cirurgias ortognáticas por meio da síntese dos resultados de estudos de avaliações 2D ou 3D. Foi realizada um revisão sistemática por dois investigadores independentes nas bases de dados PubMed, SCOPUS, Embase e Cochrane. Foram considerados elegíveis para a presente revisão: apenas artigos completos que incluíssem avaliação bi ou tridimensional da posição condilar da mandíbula em relação a sua fossa e seu eixo rotacional usado para o planejamento da cirurgia ortognática; qualquer tipo de avaliação em humanos ou biomodelos humanos; acesso qualitativo ou quantitativo da posição condilar da mandíbula em relação a sua fossa e a posição do eixo rotacional mandibular. Revisões críticas, relatos de caso individuais, revisões sistemáticas ou não, estudos em animais ou in vitro, foram excluidos. Foram recuperados inicialmente um total de 1.110 estudos. Dez artigos foram eleitos na amostra final. Seis em análise bidimensional e quatro em análise tridimensional. Realizou-se síntese dos dados obtidos em cada estudo incluído, considerando as características metodológicas da seleção dos participantes; das intervenções e métodos de avaliação; além dos principais desfechos quanto a posição e a localização do centro de rotação condilar. Verificamos não haver consenso quanto à posição condilar em relação à fossa, contudo o eixo de rotação mais relatado era póstero inferior. Apesar disso, os estudos apresentaram grande heterogeneidade, sem padronização, com incertezas e vieses metodológicos. Isso não nos permitiu identificar superioridade de algum método, 2D ou 3D, na determinação do eixo rotacional nas avaliações articulares, oclusais e no planejamento tradicional ou virtual da cirurgia ortognática. Observamos a existência de duas relações oclusais no planejamento e execução da cirurgia ortognática. A primeira é obtida pela manipulação clínica e reproduzida no transoperatório; tendo a relação côndilo-fossa como referência. A segunda, diferente dessa, é a oclusão final cirúrgica, obtida em máxima intercuspidação habitual, com o côndilo em relação cêntrica. Também observamos a individualização condilar como critério essencial para realização de um planejamento mais acurado. Portanto, metodologias de planejamento que não permitem essa individualização, são mais imprecisas. Existe muita subjetividade e divergência na definição de relações oclusais nas especialidades odontológicas o que pode confundir as avaliações e a padronização de reporte nos estudos. Concluímos que os achados evidenciam a necessidade de estudos clínicos que utilizem delineamentos metodológicos mais acurados e transparentes para uniformizar conceitos e análises nos planejamentos virtuais em cirurgia bucomaxilofacial.We present a systematic review that sought to determine the axis of rotation and the condylar position in joint, occlusal evaluations and in the virtual and traditional planning of orthognathic surgeries through the synthesis of the results of studies of 2D or 3D evaluations. The survey was conducted by two independent reviewers in PubMed, SCOPUS, Embase and Cochrane databases. Were considered eligible for this review: only complete articles that included bi or three-dimensional evaluation of the condylar position of the mandible in relation to its fossa and its rotational axis used for orthognathic surgery planning were considered eligible for this review; any type of evaluation in humans or human biomodels; qualitative or quantitative access of the condylar position of the mandible in relation to its fossa and the position of the mandibular rotational axis. While critical reviews, individual case reports, systematic reviews or not, animal or in vitro studies were not included. A total of 1,110 studies were retrieved initially; 10 articles were included in the review, after reviewer\'s analysis. Six in two-dimensional analysis and four in three-dimensional analysis. The synthesis of the data obtained in each study included was performed, considering the methodological characteristics of the selection of participants; of the interventions and evaluation methods; in addition to the main outcomes regarding the position and location of the center of condylar rotation. We found that there was no consensus regarding the condylar position in relation to the fossa, however the most reported axis of rotation is posterior inferior. Nevertheless, the studies showed great heterogeneity, without standardization, with uncertainties and methodological bias. This did not allow us to identify the superiority of any method, 2D or 3D, in the determination of the rotational axis in joint, occlusal evaluations and in the traditional or virtual planning of orthognathic surgery. We observed the existence of two occlusal relationships in the planning and execution of orthognathic surgery. The first is obtained by clinical manipulation and reproduced during surgery; having the condyle-fossa relation as a reference. The second is the final surgical occlusion, obtained at maximal intercuspal position, with the condyle in centric relation. We also observed individualization as an essential criterion for performing a more accurate planning. Therefore, planning methodologies that do not allow this individualization are more imprecise. There is a lot of subjectivity and divergence in the definition of occlusal relations between dental specialties, which can confuse evaluations and standardization of reports in studies. We conclude that the findings show the need for clinical studies that use more accurate and transparent methodological design to standardize concepts and analyses in virtual planning in maxillofacial surgery

Surgical treatment of a rare bilateral synovial chondromatosis

Synovial chondromatosis (SC) in the temporomandibular joint (TMJ) is an uncommon entity, mostly when the involvement is bilateral. The authors report a rare case of bilateral SC, with a follow-up of 13 months, and a literature review. A 60-year-old Caucasian woman, with the chief complaint of pain for 6 years in the bilateral pre-auricular region, had a progressive clacking and discomfort on the left side during mouth opening. The panoramic image was suggestive of SC. The bilateral lesion was surgically removed by direct access. Histopathological examination confirmed the clinical diagnosis of bilateral SC. This article shows the importance of a multidisciplinary approach for the early diagnosis and appropriate treatment. Also, it encourages the referral of such cases to professionals with a greater familiarity with this entity