Imaging findings of bisphosphonate-associated osteonecrosis of the jaws.

BACKGROUND AND PURPOSE: Bisphosphonates are drugs that decrease bone turnover by inhibiting osteoclast activity. An association between the use of bisphosphonates and osteonecrosis of the maxilla and mandible has recently been described. This study describes the imaging findings of bisphosphonate-associated osteonecrosis of the jaws. MATERIALS AND METHODS: This is a retrospective series of 15 clinically diagnosed patients, identified at 3 centers. Eleven patients were women, of whom 6 had breast cancer, 3 had osteoporosis, and 2 had multiple myeloma. Of the 4 male patients, 2 had prostate cancer, 1 had multiple myeloma, and 1 had osteoporosis. The age range of the patients was 52-85 years (average, 68 years). The mandible was the clinical site of involvement in 11 patients, and the maxilla was involved in 4 patients. Imaging consisted of orthopantomograms in 14 patients, CT scans in 5 patients, and radionuclide bone scan in 1 patient. Nine patients had sequential imaging. Two radiologists reviewed the images. RESULTS: All of the patients had a degree of osseous sclerosis, most commonly involving the alveolar margin, but lamina dura thickening and full-thickness sclerosis were also observed. The sclerotic change encroached on the mandibular canal in 3 patients. Less commonly encountered findings included poorly healing or nonhealing extraction sockets, periapical lucencies, widening of the periodontal ligament space, osteolysis, sequestra, oroantral fistula, soft tissue thickening, and periosteal new bone formation. CONCLUSIONS: The most common finding in bisphosphonate-associated osteonecrosis was osseous sclerosis. This varied from subtle thickening of the lamina dura and alveolar crest to attenuated osteopetrosis-like sclerosis.

Orofacial rhabdomyosarcoma in neonates and young children: a review of literature and management of four cases.

Rhabdomyosarcoma (RMS) is an aggressive malignant skeletal muscle neoplasm arising from embryonal mesenchyme. It accounts for over 50% of all pediatric soft tissue sarcomas. The head and neck region is the most common site for this tumor in children. Neonatal presentation of this tumor is rare. We present the management of one neonatal case and three additional cases of orofacial RMS in children under the age of 7 years. All four patients were seen in the department of oral and maxillofacial surgery at Children's Hospital and Regional Medical Center (CHRMC) in Seattle between 1992-2000. Three of the four cases were alveolar RMS and one was botryoid sub-type of embryonal RMS. Three patients were treated with a combination of surgery, chemotherapy and radiation, while the patient with botryoid RMS was treated with surgery and chemotherapy only. The patient with congenital RMS died at 2.5 years of age due to recurrent metastatic disease. The other three patients are alive without evidence of recurrent with a mean follow up was 5.5 years (range 2.5-8.5 years). We discuss the current management, diagnosis, biological behavior, histopathology, prognosis and survival of head and neck RMS in neonates and young children.

Congenital bony syngnathia: a proposed classification.

Congenital bony syngnathia is an extremely rare condition characterized by bony fusion of the jaws. Five new cases are described and the existent literature is reviewed. A classification system is proposed and treatment recommendations based on this classification are presented.

Conservative management of recurrent keratocysts in Basal-cell naevus syndrome.

Basal-cell naevus syndrome is characterized by multiple odontogenic keratocysts as well as skeletal, ophthalmologic and neurologic features. It is important that the dental practitioner be aware of this syndrome as it has important ramifications for the developing dentition. A case of Basal-cell naevus syndrome is presented along with a review of the literature regarding the management of this disorder. An argument for conservative surgical management of this syndrome is made.

Unusual presentations of injuries associated with the mandibular condyle in children.

Condylar fractures are sustained commonly by children and are readily diagnosed in the main. Three case histories serve to illustrate the intricate anatomy of the area and how damage to it can produce unusual signs and symptoms which can mislead the unwary. Supplemental images, in particular coronal CTs, can be instrumental in arriving at the correct diagnosis and treatment.

Pain following iliac crest bone grafting of alveolar clefts.

The purpose of this study was to investigate pain following iliac crest bone grafting of alveolar clefts. The study involved 34 consecutive patients requiring secondary alveolar bone grafting. The study population consisted of 21 males and 13 females with a mean age of 11 years (SD = 3.4). Twenty-three patients had unilateral and 11 patients bilateral clefts. The patients were treated in a like manner with harvesting of an iliac crest cortico-cancellous block concurrently with the raising of flaps and cleft closure. All surgery was performed by combinations of the authors. Eighteen patients were placed on postoperative intravenous ketorolac and the remainder were not. All patients received patient controlled analgesia at a dose of 0.015 mg/kg of morphine with an 8 min exclusion period before re-dosing. Total narcotic usage averaged 0.18 mg/kg (SD = 0.19) with 31 patients using less than 0.4 mg/kg. Regular ketorolac did not influence narcotic usage, nor did sex, age or nature of the cleft. Thirty-one patients began ambulating on the first postoperative day and 27 were discharged within 2 days of surgery. No long-term donor site morbidity was observed. Our results suggest that pain following iliac crest bone grafting of alveolar clefts is not severe and is readily alleviated with small quantities of analgesic drugs. It would appear that short-term morbidity following these procedures is frequently overstated and is in itself not a valid reason to change to calvarial or mandibular donor sites.

Septic arthritis of the temporomandibular joint: review of the literature and report of two cases in children.

Septic arthritis of the temporomandibular joint (TMJ) has a high morbidity, is infrequently reported, and has been described almost exclusively in adults. We present two cases of septic arthritis of the TMJ that occurred in children after minor blunt trauma. Literature related to septic arthritis of the TMJ was reviewed, and a composite list of cases was constructed. The most common causes were various infections of the head and neck, rheumatic joint disease, and iatrogenesis. Pathogens may gain access to the TMJ by several routes. Patients typically present with an acute, tender, monarticular arthritis with associated swelling and erythema. Malaise, nausea, and vomiting may also be present. Traumatic effusions, fractures, and neoplasms may present in a similar fashion, and mimic TMJ septic arthritis. Staphylococcus aureus is the most commonly reported pathogen and often causes permanent joint damage. Aspiration and analysis of joint fluid, as well as blood chemistry, imaging studies, and clinical impression, may assist in the diagnosis. Timely diagnosis and treatment are essential for a successful outcome; therapy should include antimicrobial agents, adequate drainage, and resting of the joint. Complications include spread of infection, postinfectious bony changes, and fibrous (or bony) ankylosis of the temporomandibular joint.

Intraoral infantile hemangiopericytoma: literature review and addition of a case.

A rapidly growing neoplasm in the buccal mucosa of a 4-month-old baby was excised. By light and electron microscopy the neoplasm had features that were similar to those described in infantile hemangiopericytoma, a rare neoplasm of vascular origin. By light microscopy the neoplasm was multilobular with highly proliferating round to spindle-shaped cells interspersed with numerous vascular spaces. Ultrastructurally, round to elongated cells with short processes, pinocytotic vesicles, reduplicated basal lamina, and basal lamina-like material were identified. Immunohistochemically the cells were weakly positive with antibodies to vimentin, focally positive with HHF-35, a smooth-muscle cell antibody, negative with antibodies to S-100 protein, T-200, neuron-specific enolase, neurofilaments, desmin, and cytokeratins 35BH11 and 34BE12. Blood vessels were positive with Ulexeuropaeuslectin, but tumor cells were negative. Reticulin stain decorated a delicate network of fibrils surrounding tumor cells and vascular spaces. Clinically the neoplasm did not recur and the baby has been disease free for more than 26 months. The difficulty of the histologic diagnosis of this neoplasm is discussed and the literature is reviewed, with special emphasis on lesions occurring in the oral cavity.

Orbital abscess of odontogenic origin. Case report and review of the literature.

A case is discussed of a patient with an orbital cellulitis and a post septal abscess secondary to infection from an upper molar tooth. Spread of infection was to the maxillary sinus and thence to the orbit via a defect in the orbital floor. The clinical presentation, differential diagnosis, value of CT scanning, treatment and possible complications are reviewed.

Jaw deformity caused by juvenile rheumatoid arthritis and its correction.

An underdeveloped mandible and resulting micrognathia and malocclusion may occur in some children with juvenile rheumatoid arthritis. Combined orthodontic and surgical procedures can now greatly improve esthetics and function in such children. We describe corrective treatment and followup of 7 patients.

Are you overlooking fractures of the mandibular condyle?

Fractures of mandibular condyle may be overlooked because attention is often focused on readily apparent soft tissue injury such as lacerations and abrasions. Clinical and radiographic signs are often subtle, but the injuries caused by rapid deceleration and listed in Table 2 will serve to alert the pediatrician to the possibility of such fractures. All children in these circumstances should be carefully examined for dental occlusion and the preauricular area palpated to help formulate a clinical diagnosis. Additional evidence is gained from the finding of deviation or limitation of the jaw upon opening or edema in the preauricular area. If any of these yield abnormal findings, a good quality series of mandibular radiographs will be needed to confirm the diagnosis. Overlooking a condylar fracture may commit a child to unsightly facial asymmetry, marked malocclusion, or ankylosis requiring invasive surgery for correction. Consultation with an oral and maxillofacial surgeon or other interested specialist should be sought while the patient is still in the emergency room.

Chronic factitious illness: recognition and management of deception.

Factitious disease is often manifested in the head and neck region. It is only when the oral and maxillofacial surgeon is aware of the existence of this syndrome and has been unable to correlate a patient's history and signs and symptoms with known diseases that factitious illness may be suspected as the diagnosis. Three case histories that help to demonstrate the variety of ruses used by patients to feign illness are presented. The expertise of a psychiatrist will often help to substantiate the diagnosis, but in many instances the main aspects of treatment will remain in the hands of the original clinician. It is important for clinicians to realize that patients with chronic factitious illness are extremely manipulative and unwilling to admit to their fabrications.

Patients with long Q-T syndrome: a caveat for the oral surgeon.

Three children with long Q-T syndrome were admitted to the hospital for elective minor oral surgery. Patients afflicted with this syndrome often have a family history of recurrent syncope, prolongation of the Q-T interval on the electrocardiogram, sometimes deaf mutism, and occasionally sudden death. Their cardiac dysrhythmias are controlled by a variety of medications, all of which must be understood before the oral surgical procedure is undertaken, so that potentially lethal events can be recognized and dealt with appropriately. The management of two of the three patients was further complicated by juvenile-onset diabetes mellitus.

Melanoma metastatic to the mandible. Report of a case.

Metastasis of a tumor to the jaws can simulate an infection, but the presence of paraesthesia and loose teeth or inadequate response to treatment should alert the clinician to a more serious cause. A malignant melanoma metastatic to the jaws illustrates these points.

A review of Burkitt's lymphoma. Importance of radiographic diagnosis.

Burkitt's lymphoma is a malignant proliferation of undifferentiated B lymphocytes that most often affects children. In endemic areas of Africa, the jaws are the sites most frequently involved. In non-endemic areas of North America, the jaws are involved in only 15-18 per cent of the cases. The oral and maxillofacial surgeon can play an important role in the early diagnosis of Burkitt's lymphoma by recognizing the clinical signs of multiple loose teeth and jaw tenderness coupled with the radiographic signs of generalized destruction of tooth crypts and diffuse disruption of jaw trabeculation. Successful treatment results from a combination of early diagnosis and controlled chemotherapy.