Surgical management of bisphosphonate-related osteonecrosis of the jaw stages II and III.

OBJECTIVE: The value of surgery in advanced stages of bisphosphonate-related osteonecrosis of the jaw (BRONJ) is still controversial. Hence, we evaluated the effect of surgical therapy in BRONJ stages II and III in combination with a standardized perioperative adjuvant treatment. STUDY DESIGN: We included 39 patients who presented with BRONJ in a total of 47 locations and stages II (n = 23) and III (n = 24). All patients had exclusively received a monthly intravenous application of zoledronic acid. Surgical therapy consisted of complete removal of the necrotic jaw, accompanied by a standardized perioperative adjuvant treatment including intravenous antibiotic prophylaxis, gastric feeding, and an antimicrobiologic mouth rinsing. RESULTS: Overall, 35 (74.5%) of the 47 BRONJ sites were treated successfully, with success defined as complete mucosal healing of the exposed jaw (n = 24) or as relative healing when surgical therapy downscaled BRONJ II or III to asymptomatic BRONJ stage I (n = 11). Interestingly, perioperative adjuvant treatment or bisphosphonate therapy parameters showed no statistical effect on the treatment outcome. CONCLUSIONS: The results of the present study prove the effectiveness of surgical therapy for BRONJ stage II or III.

Value of nonsurgical therapeutic management of stage I bisphosphonate-related osteonecrosis of the jaw.

There is still controversy about the best treatment strategy for patients with bisphosphonate-related osteonecrosis of the jaw (BRONJ) stage I. Therefore, the aim of the present study was to analyse the effect of a nonsurgical treatment protocol in patients with BRONJ stage I. During the study period we included 17 patients (11 male; 6 female) who presented with a total of 24 separate areas of BRONJ, stage I. All patients were exclusively treated with a monthly intravenous regime of zoledronic acid due to an underlying malignant disease. All patients were treated using a standardized nonsurgical protocol consisting of antimicrobial mouth rinsing with chlorhexidine (CHX) (0.12%) three times a day, and daily CHX gel application. In 11 patients (45.8%) the surface area of the exposed jawbone was completely healed by nonsurgical treatment. In seven patients (29.2%), nonsurgical treatment reduced the size of the exposed bone area by a mean of 64.7% (range 20.0-96.8%). None of the patients showed an increase in size of the area of exposed jawbone, or a worsening of the BRONJ from stage I to stages II or III. However, the duration of nonsurgical treatment or the duration of intravenous bisphosphonate therapy did not significantly influence the treatment outcome (p = 0.6628, p = 0.6077, respectively). The results of the present study support the beneficial role of nonsurgical treatment in patients presenting with BRONJ stage I. Surgical therapy of BRONJ should be restricted to patients with advanced stages with clinical symptoms and local signs of infection.

Incidence of bisphosphonate-related osteonecrosis of the jaw in high-risk patients undergoing surgical tooth extraction.

As the most suitable approach for preventing bisphosphonate-related osteonecrosis of the jaw (BRONJ) in patients undergoing surgical tooth extraction is still under discussion, the present study evaluates the incidence of BRONJ after surgical tooth extraction using a standardized surgical protocol in combination with an adjuvant perioperative treatment setting in patients who are at high-risk for developing BRONJ. High-risk patients were defined as patients who received intravenous bisphosphonate (BP) due to a malignant disease. All teeth were removed using a standardized surgical protocol. The perioperative adjuvant treatment included intravenous antibiotic prophylaxis starting at least 24 h before surgery, a gastric feeding tube and mouth rinses with chlorhexidine (0.12%) three times a day. In the follow-up period patients were examined every 4 weeks for the development of BRONJ. Minimum follow-up was 12 weeks. In 61 patients a total number of 184 teeth were removed from 102 separate extraction sites. In eight patients (13.1%) BRONJ developed during the follow-up. A higher risk for developing BRONJ was found in patients where an additional osteotomy was necessary (21.4% vs. 8.0%; p = 0.0577), especially for an osteotomy of the mandible (33.3% vs. 7.3%; p = 0.0268). Parameters including duration of intravenous antibiotic prophylaxis, the use of a gastric feeding tube and the duration of intravenous BP therapy showed no statistical impact on the development of BRONJ. Furthermore, patients currently undergoing intravenous BP therapy showed no higher risk for BRONJ compared with patients who have paused or completed their intravenous BP therapy (p = 0.4232). This study presents a protocol for surgical tooth extraction in high-risk BP patients in combination with a perioperative adjuvant treatment setting, which reduced the risk for postoperative BRONJ to a minimum. However, the risk for BRONJ increases significantly if an additional osteotomy is necessary, especially in the mandible.

Mandibular reconstruction with a prefabricated free vascularized fibula and implant-supported prosthesis based on fully three-dimensional virtual planning.

Because optimal reconstruction of maxillofacial defects requires functional rehabilitation, the current study demonstrates the successful secondary reconstruction of a large mandibular continuity defect using a fully digitally planned prefabricated free vascularized fibula with immediate implant-supported prosthodontic restoration. A 56-year-old man presented with a large mandibular continuity defect after resection of an enlarged squamous cell carcinoma arising from the floor of the mouth. For secondary reconstruction, the shape of the neomandible and implant position for support of the lower prosthesis were planned virtually. The combined cutting and drilling guide was printed in 3 dimensions. In a 2-step surgical approach, first, the implants were inserted into the fibula and covered with a split-thickness skin graft to form a neogingiva. In a second operation, the fibula was harvested, osteotomized, and fixed with the denture on the preinserted implants. The fibula was placed to its final position guided by the occlusion. Using three-dimensional virtual backward planning, it was feasible to perform a mandibular reconstruction with immediate prosthetic rehabilitation.

Role of neck dissection in the treatment of melanoma of the head and neck.

Despite numerous studies, specific guidelines for cervical lymph node surgery in cutaneous malignant melanoma of the head and neck are still missing.In a retrospective study, the modalities of neck dissection (ND), the histologic results, and the outcome in 59 patients with cutaneous malignant melanoma of the head and neck were evaluated to verify the benefit of this therapy.Patients with proven lymph node metastasis often benefit from complete ND because about 50% of the patients showed more metastases in their ND specimen than before surgery. In addition, suspicious but not surely malignant lymph nodes often proved to be benign.This study reveals that patients with proven lymph node metastasis often benefit from complete ND because the number of infiltrated nodes is often higher than suspected; nevertheless, when planning the surgical therapy, the overall prognosis has to be kept in mind.

Reconstruction of a near-total nasal defect using a precontoured titanium mesh with a converse scalping flap.

The reconstruction in case of large nasal defects, especially affecting the cartilaginous portion, is a surgical and aesthetic challenge. The result has to fulfill functional and aesthetic aspects concerning shape, texture, and nasal breathing, which requires accurate reproduction of nasal lining, support, and coverage. Here, we describe nasal reconstruction in a 36-year-old woman after near-total nasal resection due to a malignant peripheral nerve sheath tumor in the glabellar and nasal regions. After tumor resection, the cartilaginous and bone structures were reconstructed using a dynamic titanium mesh, which was precontoured on a three-dimensional-print model of the preoperative situation. Soft tissue defects were covered as a 2-stage procedure using a Converse scalp flap. We achieved an adequate long-term functional and aesthetic and oncological result. Titanium mesh in combination with Converse flap proved to be an alternative in extensive composite midfacial defects.