Neuropathic pain following sagittal split ramus osteotomy of the mandible: prevalence, risk factors, and clinical course.

PURPOSE: To estimate the prevalence of, risk factors for, and clinical course of neuropathic pain (NPP) after sagittal split ramus osteotomy (SSRO) of the mandible in a large cohort of patients. MATERIALS AND METHODS: A retrospective cohort of all patients who underwent SSRO at 2 medical centers within Kaiser Permanente Northern California from January 2007 through September 2012 was assembled. Demographic, clinical, and surgical factors were abstracted from medical records and relevant comorbidities were identified. The prevalence of NPP in the cohort was calculated and the clinical signs, symptoms, temporal characteristics, and treatment response in affected patients were noted. RESULTS: The authors identified 1,778 patients who underwent SSRO and excluded 107 patients according to predefined criteria. The remaining 1,671 patients had a median age of 24 years (interquartile range, 19 to 35 yr) and 62.4% were women. Seven patients developed NPP after SSRO, which was an overall prevalence of 0.42%. All patients with NPP in this cohort were women and had a median age of 49 years. The risk factors for developing NPP after this surgery were older age (P = .0098), depression (P = .0100), and female gender. NPP developed an average of 30 days postoperatively (range, 18 to 56 days) and persisted for a median duration of 52 days (range, 30 to 69.5 days). All patients responded favorably to anticonvulsant (n = 6) or tricyclic (n = 1) medications, and no patients developed chronic postsurgical pain. CONCLUSIONS: NPP was an infrequent complication after SSRO, occurring in 1 of 238 patients in this cohort. The short duration and positive response to medication are reassuring findings. The results of this investigation highlight the need for prospective studies to further understand the spectrum of postoperative NPP.

Nasal airway function after maxillary surgery: a prospective cohort study using the nasal obstruction symptom evaluation scale.

PURPOSE: To examine nasal airway function using a disease-specific quality-of-life survey instrument in subjects undergoing Le Fort I osteotomy without simultaneous rhinosurgical procedures. MATERIALS AND METHODS: We conducted a prospective cohort study of nasal airway function in consecutive Le Fort I osteotomy patients, who had not received simultaneous rhinosurgical procedures, between 2007 and 2008 at Kaiser Permanente Oakland Medical Center. We administered the Nasal Obstruction Symptom Evaluation (NOSE) survey before and 3 months after surgery. Clinical and radiographic examinations were performed, and the relevant medical and demographic factors were analyzed. RESULTS: The initial study sample comprised 55 patients, of whom 5 were excluded. Of the remaining 50 patients (median age 21 years, 60% women), the maxilla was advanced (median 4 mm, interquartile range 3 to 5) with minimal vertical change. During the follow-up period (median 5.5 months), significant improvement was seen in the NOSE scores for the cohort, with a median decrease of 10 units (P = .0005). Patients with moderate nasal obstruction (preoperative NOSE score >25) had the greatest improvement (P < .001). Those with severe nasal obstruction (preoperative NOSE score >50) improved, however, this did not reach statistical significance (P < .0625). The NOSE scores worsened in 10 patients; of these, 6 had minimal change. However, 4 had significant worsening, with 2 having symptomatic complaints. No predictor variables were identified in this small subgroup; however, individual case analyses revealed 1 subject with postoperative turbinate inflammation on the side of maxillary segmentalization and 1 had nasal septal buckling. CONCLUSIONS: Our overall findings have suggested that nasal airway function improved after maxillary advancement and that subjects with greater preoperative NOSE scores (>25) were more likely to experience relief of nasal obstructive symptoms.

Atypical femur fractures among breast cancer and multiple myeloma patients receiving intravenous bisphosphonate therapy.

PURPOSE: Atypical femur fractures represent a potential complication of chronic oral bisphosphonate therapy in women with osteoporosis, but the risk of atypical femur fractures among cancer patients receiving intravenous bisphosphonates at higher cumulative doses remains unclear. We examined femur fractures occurring in cancer patients treated with intravenous bisphosphonates (IVBP) to determine whether a subset may be atypical fractures. METHODS: Between 2005 and 2010, we identified patients with known IVBP therapy for multiple myeloma or metastatic breast cancer, who subsequently sustained a femur fracture based on hospitalization, oncology, pharmacy and chemotherapy visit records. Radiographs were examined by an orthopedic surgeon to determine anatomic fracture site and pattern. An atypical fracture was defined as a transverse or short oblique fracture occurring below the lesser trochanter with evidence of focal hypertrophy of the lateral cortex and absence of biopsy-proven malignancy or radiation therapy at the fracture site. RESULTS: A total of 62 patients with breast cancer (N=39) or multiple myeloma (N=23) with femur fracture and prior IVBP treatment for bone malignancy were identified. There were 30 proximal hip, 18 subtrochanteric and 14 femoral shaft fractures. Intraoperative bone samples were sent in 29 of 58 fracture cases undergoing operative repair, with 76% positive for malignancy. Six cases (4 breast cancer, 2 multiple myeloma) of atypical femur fracture were identified, two with negative intraoperative pathology and four with no bone biopsy samples sent. Five of the six patients with atypical fracture had bilateral femur findings, including two with transverse fracture in the contralateral femur and three with focal hypertrophy of the contralateral cortex. Two atypical fracture cases also experienced osteonecrosis of the jaw compared to 3 in the remaining cohort (33% vs. 5%, p=0.07). Patients with atypical fracture received more IVBP (median 55 vs. 15 doses) and zoledronic acid (32 vs. 12 doses) and had longer treatment duration (median 5.9 vs. 1.6 years) compared to patients without atypical fracture (all p≤0.01). CONCLUSIONS: Among 62 patients who received IVBP for skeletal malignancy and experienced a femur fracture, we identified six cases of atypical fracture. While fractures in this population are often assumed to be pathologic, prospective studies investigating fracture pattern, microscopic bone pathology and pharmacologic exposures should be conducted to further examine the association of IVBP and atypical femur fractures.

Bisphosphonate-related osteonecrosis of the jaw in patients with oral bisphosphonate exposure: clinical course and outcomes.

PURPOSE: To characterize the spectrum and outcomes of bisphosphonate-related osteonecrosis of the jaw (BRONJ) occurring with oral bisphosphonate therapy. MATERIALS AND METHODS: We assembled a retrospective cohort of patients who had developed oral BRONJ according to the 2009 American Association of Oral and Maxillofacial Surgeons criteria and received care within Kaiser Permanente, Northern California, during 2004 to 2011. Patients with intravenous bisphosphonate exposure were excluded. The demographic factors, comorbidities, pharmacologic exposure, maxillofacial findings, and outcomes were ascertained from the clinical and radiologic records. RESULTS: We identified 30 cases of oral BRONJ (median age 77 years, 87% women). All had received oral bisphosphonate for osteoporosis/osteopenia (median duration 4.4 years, interquartile range 1.9 to 6.6). More than one half (57%) had comorbidities or relevant drug exposure, including rheumatoid arthritis, diabetes, glucocorticoid therapy, and disease-modifying antirheumatic medications. Extractions preceded BRONJ in 17 patients and trauma in 3; 10 developed BRONJ spontaneously. Overall, 83% had healed within 3 to 52 months, although the relative rate of healing varied by antecedent factor and/or the presence of comorbid conditions/exposures. Nearly all patients with trauma-related and spontaneous BRONJ healed within 1 year (median 7.0 and 7.5 months, respectively) compared with those developing BRONJ after extraction, in whom the median time to healing was 18 months (P < .0001). Patients with relevant comorbidities had a lower probability of healing (P = .0002) and a longer median time to healing (20 months) than patients without comorbidities (7.5 months). CONCLUSIONS: We found that postextraction patients and those with comorbid conditions/exposures showed refractory BRONJ with prolonged healing times. Practitioners should be aware that the BRONJ clinical course and outcome varies depending on the antecedent factor and comorbidity status.

Complications following surgically assisted rapid palatal expansion: a retrospective cohort study.

PURPOSE: To examine the prevalence of complications and characterize the associated clinical findings in patients undergoing surgically assisted rapid palatal expansion (SARPE). MATERIALS AND METHODS: A retrospective evaluation was conducted of all patients who underwent SARPE from January 2004 through December 2008 at Kaiser Permanente Oakland Medical Center. Medical records were abstracted, and demographic factors and relevant comorbidities were identified. Clinical features of patients with complications (surgical and/or dental) after SARPE were characterized. RESULTS: One hundred thirty-one patients comprised the study sample and 11 patients were excluded. Of the remaining 120 patients (median age, 29.5 yrs; interquartile range, 22.0 to 39.0 yrs), 51.7% were women, 41 developed at least 1 complication, 33 had surgical complications, 18 had dental and/or periodontal problems, and 10 developed both surgical and dental or periodontal problems. Asymmetric and/or inadequate expansion was the most frequent surgical complication, found in 13.3% of the study cohort, and gingival recession (8.3%) was the most common dental complication. Two patients developed catastrophic periodontal bone defects resulting in loss of the central incisors; these patients had eccentric interdental osteotomies that caused separation of the bone from the root surface of the central incisors followed by postoperative osteotomy site infections. CONCLUSIONS: Overall, the present findings suggest that, although major complications after SARPE were rare, asymmetric or inadequate expansion and dental and/or periodontal problems primarily involving the central incisors accounted for most complications. Future prospective and long-term follow-up studies are needed to identify individual risk factors that may predispose patients to adverse outcomes after SARPE.

Characteristics of implant failures in patients with a history of oral bisphosphonate therapy.

PURPOSE: This study examines the pattern of implant failures reported in a large cohort of patients who received oral bisphosphonate therapy. MATERIALS AND METHODS: A total of 8,572 individuals who received oral bisphosphonate drugs returned a dental survey that obtained information pertaining to implant placement and related complications. Among the 589 individuals reporting dental implants, 16 reported implant failures that were verified by dental records. Implant placement, timing of failure, and bisphosphonate duration were ascertained to determine the characteristics of implant loss in the setting of oral bisphosphonate exposure. RESULTS: Among the 16 patients (all women, aged 70.2 +/- 7.6 yrs) there were 26 implant failures; 8 had failure of 12 implants in the maxilla and 9 had failure of 14 implants in the mandible. Early failure (1 yr after placement) occurred in 10 patients (18 implants); 2 patients had both early and late failures. CONCLUSIONS: Overall, few patients reported implant failures. However, among these, there were more late than early failures and a slightly higher proportion of failures in the mandible versus the maxilla. Further studies should investigate the role of chronic bisphosphonate therapy in implant survival and long-term implant osseointegration.

Prevalence of osteonecrosis of the jaw in patients with oral bisphosphonate exposure.

PURPOSE: Osteonecrosis of the jaw (ONJ) is a serious complication associated with bisphosphonate therapy, but its epidemiology in the setting of oral bisphosphonate therapy is poorly understood. The present study examined the prevalence of ONJ in patients receiving chronic oral bisphosphonate therapy. MATERIALS AND METHODS: We mailed a survey to 13,946 members who had received chronic oral bisphosphonate therapy as of 2006 within a large integrated health care delivery system in Northern California. Respondents who reported ONJ, exposed bone or gingival sores, moderate periodontal disease, persistent symptoms, or complications after dental procedures were invited for examination or to have their dental records reviewed. ONJ was defined as exposed bone (of >8 weeks' duration) in the maxillofacial region in the absence of previous radiotherapy. RESULTS: Of the 8,572 survey respondents (71 +/- 9 years, 93% women), 2,159 (25%) reported pertinent dental symptoms. Of these 2,159 patients, 1,005 were examined and an additional 536 provided dental records. Nine ONJ cases were identified, representing a prevalence of 0.10% (95% confidence interval 0.05% to 0.20%) among the survey respondents. Of the 9 cases, 5 had occurred spontaneously (3 in palatal tori) and 4 occurred in previous extraction sites. An additional 3 patients had mandibular osteomyelitis (2 after extraction and 1 with implant failure) but without exposed bone. Finally, 7 other patients had bone exposure that did not fulfill the criteria for ONJ. CONCLUSIONS: ONJ occurred in 1 of 952 survey respondents with oral bisphosphonate exposure (minimum prevalence of 1 in 1,537 of the entire mailed cohort). A similar number had select features concerning for ONJ that did not meet the criteria. The results of the present study provide important data on the spectrum of jaw complications among patients with oral bisphosphonate exposure.

Intravenous bisphosphonate-related osteonecrosis of the jaw: bone scintigraphy as an early indicator.

PURPOSE: Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is recognized as a serious complication among patients receiving bisphosphonate therapy. However, methods for early detection and identification of patients at risk for osteonecrosis of the jaw (ONJ) need further investigation. The purpose of this study was to characterize BRONJ among patients receiving intravenous bisphosphonates and to examine bone scintigraphy findings that preceded manifestation of frank ONJ. MATERIALS AND METHODS: We identified all known cases of BRONJ (defined according to 2006 American Association of Oral and Maxillofacial Surgeons criteria) diagnosed between January 2004 and September 2008 among patients who received intravenous bisphosphonate therapy (IVBP). The medical records were abstracted, and the clinical and radiographic features of BRONJ and relevant comorbidities were characterized. Technetium Tc 99 bone scintigrams were systematically reviewed among the subset of patients who received these imaging studies for oncologic care and imaging findings were correlated with the temporal development of ONJ. RESULTS: We identified 59 cases of intravenous BRONJ (median age, 61.4 +/- 10.7 years; 57.6% female), of whom 44.1% had breast cancer, 33.9% had multiple myeloma, and the remainder had metastatic prostate cancer (15.3%) or other cancers (6.8%). One third (32.2%) of the cohort was diabetic. In addition to IVBP, the vast majority (86.4%) had also received prior systemic glucocorticoid therapy. The median cumulative number of IVBP doses was 25 (interquartile range, 16-39) at the time of BRONJ diagnosis. Half of the patients had prior invasive dental procedures; ONJ developed spontaneously in 27.1%, and in the remainder ONJ developed in the setting of periodontal disease (10.1%) or local trauma (8.4%). Most patients presented with painful stage 2 disease involving the mandible (75%), and Actinomyces was present in more than 77% of available histologic specimens. During the median follow-up of 1.5 years, 15 patients (25.4%) regressed to a less severe stage, with healing in 6 patients; 16 (27.1%) worsened; and the remainder stayed within the same stage, but in almost half of these patients, the extent of involvement progressed. Of the 38 patients who had 99Tc bone scintigraphy, 35 had bone scans before development of BRONJ, and among these patients, 23 (67.5%) had positive tracer uptake in areas that subsequently developed BRONJ. CONCLUSIONS: In this study bone scintigraphy showed positive tracer uptake before the development of BRONJ in almost 66% of patients who had these scans before clinical evidence of frank osteonecrosis. BRONJ subsequently developed in the areas identified on scintigraphy in these patients. Further studies should explore the role of bone scintigraphy in the detection of early subclinical BRONJ.