Sclerotic bone: a sign of bone reaction in patients with medication related osteonecrosis of the jaw.

Medication-related osteonecrosis of the jaw (MRONJ) is a serious adverse reaction associated with antiresorptive drugs such as bisphosphonates and denosumab. When dealing with advanced and/or multiple MRONJ lesions undergoing surgical therapy, the extent of surgery is often a topic of discussion. The aim of this study was to identify the differences in bone density in and around the MRONJ lesion before and after surgical treatment to evaluate the needed surgical extend of the modelling osteotomy. In this retrospective study 26 patients with MRONJ lesions that were surgically treated in our department were observed. Length, width and bone density were measured in panoramic radiograph pre and postoperatively with the Imaging processing software Sidexis and ImageJ (Fiji). The necrotic area, the surrounding sclerotic area as well as the healthy contralateral side were observed. Measurements were performed by two independent observers. Pearson correlation was calculated to determine the interobserver variability. Bone density was significantly reduced in the necrotic bone area compared to the healthy unaffected contralateral reference side. The sclerotic bone area surrounding the necrosis showed increased bone density compared to the contralateral unaffected reference side. The density of the sclerotic bone area was increased in the previously affected MRONJ area in the postoperative panoramic radiograph. The pre and postoperative density showed no significant correlation to healing behaviour. The focus of the modelling osteotomy in surgical treatment of mature MRONJ lesions should be predominantly on the parts that appear necrotic and less dense in the panoramic radiograph as sclerotic areas might be an expression of bone reaction.

Clinical and Radiographic Outcomes of Dental Implants in Patients Treated With Antiresorptive Drugs: A Consecutive Case Series.

Medication-related osteonecrosis of the jaw (MRONJ) is a serious concern for dentists as well as maxillofacial surgeons. Therefore, the safety of dental implant placement in patient receiving antiresorptive drugs (ARDs) has been the subject of controversial debate for several years and remains a source of uncertainty for surgeons and patients. This consecutive case series assessed the clinical and radiographic outcomes of dental implants placed in patients under antiresorptive therapy. Patients who received at least one dental implant at the Department of Oral and Maxillofacial Surgery, Ludwig Maximilian University (LMU), Munich, Germany, between 2010 and 2019 with a history of current or past antiresorptive medication were included the study. The main outcomes were occurrence of MRONJ, implant success, and survival rate. A total of 16 patients were treated with 39 implants. No implant loss or MRONJ occurred in the respective patients. The reasons for antiresorptive intake were osteoporosis, malignancy, edema of bone marrow, or diffuse sclerosing osteomyelitis (DSO). MRONJ occurred neither around implants nor in other locations. Cumulative implant success was 92.6% (25 of 27). No subjective complaints or postoperative complications were documented. Mean bone loss was 0.60 ± 0.98 mm. The prevalence of peri-implantitis was 30% on patient level and 29.6% on implant level. None of the patients had failed implants. No major complications after implant placement under antiresorptives could be detected. As long as implant surgery follows a specific protocol, implant placement in patients treated with antiresorptive therapy seems to be safe and predictable.

Surgical treatment of medication-related osteonecrosis of the upper jaw: Case series.

PURPOSE: The management of maxillary medication-related osteonecrosis of the jaw (MRONJ) is challenging. Therefore, identifying the proper treatment is important. This study aimed to evaluate the surgical treatment of maxillary MRONJ using single-layer closure with mucoperiosteal flap and double-layer closure with buccal fat pad flap (BFPF) and mucoperiosteal flap and to find the outcomes after rehabilitation with obturators. METHODS: A retrospective analysis was conducted and included all surgically treated and followed-up maxillary MRONJ cases in a single center. Demographics and clinical data, stage of MRONJ, surgical treatment, and treatment outcome were collected. RESULTS: Seventy-nine lesions were included. Removal of necrotic bone was followed by coverage with mucoperiosteal flap in 60 lesions and BFPF in 14 lesions. Seven lesions (five primarily and two following unsuccessful treatment with BFPF) underwent necrectomy and were reconstructed with obturators. Complete mucosal healing was achieved in 76.7% of the lesions covered with mucoperiosteal flap. BFPF led to complete mucosal healing in 85.7% of the lesions. No complications were observed in the defects rehabilitated with obturators. CONCLUSION: Removal of necrotic bone followed by closure with mucoperiosteal flap is reliable for MRONJ treatment. BFPF is effective for closure of MRONJ-related oroantral communications (OACs).

Osteonecrosis of the jaw in patients treated with denosumab: A multicenter case series.

PURPOSE: Osteonecrosis of the jaw has been recently reported in patients receiving denosumab for the treatment of metastatic bone disease and osteoporosis. It is essential to investigate this disease as a new osteonecrosis entity in order to recognize its optimal management strategies. MATERIALS AND METHODS: A total of 63 cases of denosumab-related osteonecrosis of the jaw (DRONJ) diagnosed at two clinical centres were retrospectively reviewed. Demographics, comorbidities, antiresorptive medication use, local preceding event, location, DRONJ stage, treatment and treatment outcomes were analyzed. RESULTS: In all, 69 MRONJ lesions in 63 patients were diagnosed. The mean patient age was 70 ± 9 years. Denosumab was the only received antiresorptive medication in 50.8% of the patients. Discontinuation of denosumab prior to treatment was recorded for 66.7% of the patients, with a mean period of 6 ± 3.4 months. Stage 2 was the most common stage of the disease (71%). The lesions were predominantly located in the mandible (63.5%). The most common preceding local event was extraction (55.6%). Surgical treatment was performed in 95.7% of the cases, while purely conservative treatment was performed in 4.3%. DRONJ healed after surgical treatment in 71.7% of the treated lesions. Complete mucosal healing was achieved in 77.2% of the lesions treated with fluorescence-guided surgery (17/22). Clinical characteristics and treatment outcomes were not significantly different between patients with and without previous intake of bisphosphonates. CONCLUSION: DRONJ is more prevalent at extraction and local infection sites in cancer patients. Within the limitation of this study, surgical treatment, particularly fluorescence-guided surgery, appears to be effective for the management of DRONJ. The prior use of bisphosphonates does not seem to affect severity nor the treatment success rate of DRONJ.

Denosumab as a potential treatment alternative for patients suffering from diffuse sclerosing osteomyelitis of the mandible-A rapid communication.

PURPOSE: Diffuse sclerosing osteomyelitis (DSO) is a rare disease of the jaw bone. Its treatment is challenging. Different medical and surgical treatment protocols have been proposed; however, none of these treatment protocols produce reliable results. Recently, ibandronate administration has been attempted as a treatment alternative in acute cases of DSO. Due to the similar antiresorptive effect, we sought to explore the application of the human monoclonal antibody to the receptor activator of nuclear factor kappaB ligand (RANKL), denosumab, in the treatment of DSO. MATERIALS AND METHODS: One female patient with histologically verified DSO received subcutaneous injections of denosumab (Prolia® 60 mg). The further course of the disease was followed clinically and by radiography and scintigraphy. RESULTS: In this case, the use of denosumab displayed promising results in aiding pain relief and reducing inflammatory activity. CONCLUSION: We suggest that antiresorptive treatment with denosumab can be considered as an alternative treatment for patients suffering from DSO. However further studies, with respect to clarifying the mechanisms of action and defining the necessary medication dose as well as application intervals, have to be conducted.

Clinical features of peri-implant medication-related osteonecrosis of the jaw: Is there an association to peri-implantitis?

The purpose of this study was to examine the behavior of dental implants in patients diagnosed with MRONJ and to analyze the characteristics of peri-implant MRONJ. It was hypothesized that peri-implant parameters are not associated with peri-implant MRONJ. A retrospective study design was selected to address the research purpose. Patients with confirmed MRONJ and the simultaneous presence of dental implants who presented between 2010 and 2016 served as the study cohort. Predefined inclusion and exclusion criteria were applied. Demographic, clinical and radiological data were collected and analyzed statistically with respect to the variable scale (significance level p ≤ 0.05). The study sample was composed of 34 patients (female: 16; male: 18; average age: 70.6 years) with a total of 117 dental implants the majority of whom had received antiresorptive drug therapy within oncologic treatment protocols. Peri-implant MRONJ occurred in 15 patients (44%). Signs of peri-implantitis (present around 46/117 implants; 39%) appeared to be associated with the occurrence of peri-implant MRONJ. Patients receiving antiresorptive drugs in high doses seem to be at risk of developing MRONJ in the vicinity of dental implants. Peri-implantitis may be associated with the etiology of peri-implant MRONJ.

Etiology and clinical characteristics of symptomatic unilateral maxillary sinusitis: A review of 174 cases.

The purpose of the study was to analyze the causative pathology associated with symptomatic unilateral maxillary sinusitis requiring surgical treatment. A retrospective review of all patients that have been treated surgically for unilateral symptomatic maxillary sinusitis between 2006 and 2013 at a single institution was performed. Demographic, anamnesis, clinical, radiological, microbiological and histological data were gathered and analyzed. The patients were allocated into groups depending on the underlying cause of the disease. Descriptive and inferential statistics were computed (level of significance: p ≤ 0.05). The study sample was composed of 174 patients (72 female; 102 male) with a mean age of 52.7 years (SD 16.9). Most cases (130; 75%) were triggered by odontogenic pathology following dentoalveolar surgical interventions (83/130 patients; 64%). Other etiological factors for odontogenic unilateral sinusitis were periapical (23/130 cases; 18%) and periodontal pathology (13/130 cases; 10%). Rhinogenic factors for sinusitis were detected in 13 patients (7.5%) and dental implant-associated unilateral maxillary sinusitis was diagnosed in nine patients (5.2%). Four patients (2.3%) had undergone previous sinus augmentation surgery. A leading cause for the sinus infection could not be identified in 18 patients (10%) who all had a history of midfacial surgery. Medication-related osteonecrosis of the jaw (8) and squamous cell carcinoma (2) were incidental findings. There were no differences in the clinical appearance of the disease with respect to its etiology. Odontogenic causes for maxillary sinusitis must be considered especially in unilateral cases. Maxillary dental implants may induce symptomatic unilateral maxillary sinusitis.

Diagnostic efficacy of cone-beam computed tomography for mandibular fractures.

OBJECTIVE: The aim of the study was to determine the clinical efficacy of maxillofacial cone-beam computed tomography (CBCT) for the diagnosis of suspected mandibular fractures and to evaluate whether findings would lead to a change in treatment. STUDY DESIGN: CBCT imaging was performed for 164 patients with suspected mandibular fractures (231 sites) but equivocal clinical and radiological findings (conventional radiography). Images were interpreted by oral and maxillofacial surgeons and treatment decisions based on pre and postimaging were compared. Linear regression analyses were performed. RESULTS: For 63.2% of sites (n = 146) the suspected diagnosis was confirmed by CBCT (P < .0001; R(2) = 0.93). For 4.33% of sites (n = 10) no fracture was identified. Additional fractures were identified in 17.75% (n = 41) and additional infractures in 14.72% (n = 34). The treatment plan was altered for 9.52% of sites (n = 22). CONCLUSIONS: CBCT imaging of suspected mandibular fractures resulted in a change in the treatment plan in 9.52%.

Applications of cone beam computed tomography in dental and oral medicine.

Cone beam computed tomography (CBCT) is a radiological technique available since 1998 in dental and oral medicine in which a cylindrical volume is acquired with a conical x-ray beam during one rotation around the head of the patient (cone beam computed tomography, cone beam CT). This technique is increasingly replacing conventional radiological procedures due to the possibility of arbitrary reconstructions and views free of superimposition. CBCT focuses on the display of the bones of the jaw, so that its use concentrates on problems in implantology, before surgical removal of impacted and displaced teeth, in traumatology, and in craniofacial malformations. The objective of this overview was to emphasize the advantages of cone beam computed tomography in the individual disciplines. However, schematization of examinations should be avoided for reasons of radiation protection and for avoiding forensic pressure. The limits of CBCT and thus an indication for computed tomography exist where there is suspicion of bone tumors with soft tissue participation as well as in extensive fractures with suspicion of craniocerebral trauma. In the case of tumors in the soft tissues and of functional temporomandibular joint symptoms, magnetic resonance tomography is preferable to CBCT.