Complications and Management of Implants Migrated into the Maxillary Sinus.

The article describes complications following dental implant dislocation into the maxillary sinus and their management and attempts to elucidate the reasons for these complications and their prevention. This retrospective study presents 55 cases of dental implant migration into the maxillary sinus. Patients were 30 men and 25 women with average age of 58 years. Oroantral communication was found in 46 cases, primarily in cases without prior bone augmentation, in patients aged older than 60 years (mean), and medically compromised patients (ASA > 1). The dislocated implant and the infected tissue were removed from the sinus in most cases by Caldwell-luc intervention. The oroantral communication was closed by local and regional flaps. In most of the cases, the oroantral communication was closed by a single intervention. The conclusion was that oroantral communication and maxillary sinusitis are common findings following dental implant migration and dislocation into the maxillary sinus. The risk factors for these complications were dental implantation in the posterior maxilla without sufficient alveolar bone, implantation without prior maxillary sinus augmentation, and older and medically compromised patients. Successful closure of the communication is usually performed with local or regional flaps.

Decompression as a treatment of odontogenic cystic lesions in children.

PURPOSE: To evaluate the efficiency of decompression in treating odontogenic cystic lesions of the jaws in children. MATERIALS AND METHODS: All consecutive odontogenic cysts occurring in children and treated by decompression from 1994 to 2009 at 1 maxillofacial center were included in the present study. Clinical data included age, gender, jaw, histopathologic diagnosis, and decompression time. Radiologic data from panoramic radiographs before and after decompression included tooth involvement, locularity, location, involvement of adjacent vital anatomic structures, and cyst area. RESULTS: Thirty-two odontogenic cystic lesions from 26 children (14 boys [53.8%] and 12 girls [46.2%]) treated with decompression were included. The average age at the time of presentation was 11.6 ± 3.3 years (range, 7 to 18 yr). The mandible was involved in 13 cases (40.6%) and the maxilla in 19 (59.4%). All cysts were unilocular at presentation. Twenty-seven cysts (84.4%) showed tooth involvement. The diagnoses consisted of dentigerous cysts (20 [62.5%]), keratocysts (9 [28.1%]), and radicular cysts (3 [9.4%]). The mean decompression period was 7.45 ± 2.6 months (2 to 14 months). The mean standard lesion area index changed from 12.7 ± 0.9 mm(2) (3.6 to 44 mm(2)) before compression to 2.3 ± 4.3 mm(2) (0 to 22.3 mm(2)) after decompression. The mean percentage of reduction (POR) was 82 ± 16% (49 to 100%). The POR was ranked as good in 22 lesions (69%), moderate in 9 lesions (28%), and poor in 1 lesion (3%). Surgery was performed for 15 lesions (47%). CONCLUSION: Decompression results in good regeneration potential of the bone in the developing craniofacial skeleton of children. Children might benefit from a less invasive surgical protocol.

Topical simvastatin improves the pro-angiogenic and pro-osteogenic properties of bioglass putty in the rat calvaria critical-size model.

Objective was to describe the effect of bioactive glass putty with and without topical simvastatin on new bone formation in critical-sized defects of rat calvaria. A calvarial bone defect was created in 20 male Wistar rats and filled with bioactive glass alone (n = 10) or combined with simvastatin (n = 10). After 4 weeks, the defects were histomorphometrically evaluated for volume fraction (Vv) of woven bone, vessel density, bioglass quantity, and inflammation. Compared to the bioglass-only group, rats treated with simvastatin had greater Vv of blood vessels (3.3% ± 0.7 vs 1.6% ± 0.1, P = .0002) and new bone (2.3% ± 0.2 vs 1.8% ± 2.5, P = .003). The Vv of the bioglass remnants in the bioglass-only group was higher than in the group treated with simvastatin (2.4% ± 0.08 vs 1.7% ± 0.3, P < .0004). Chronic inflammation was noted in 1 rat from each group. Topical simvastatin seems to improve the pro-angiogenic and pro-osteogenic properties of bioglass putty in rat calvaria critical-size defects without significant inflammation.

Re-evaluation of common paradigms regarding the clinical appearance of oral mucosal malignancies.

PURPOSE: To evaluate the clinical appearance and rate of ulceration of oral mucosal malignancies, and to investigate the accuracy of clinical provisional diagnoses. METHODS: A 10-year retrospective analysis, which included diagnostic biopsies of malignant tumors of the oral mucosa. The clinical provisional diagnoses were compared with final diagnoses. RESULTS: Two hundred and twenty-seven oral mucosal malignant tumors were included. Squamous cell carcinoma and its variants accounted for the majority (78%) of all malignant tumors. The most common clinical presentations were non-ulcerated (59.7%) and ulcerated masses (20.4%). Only 11.9% presented as indurate ulcers. The highest ulceration rate of all malignancies was recorded for SCC, with only about half of SCC and its variants ulcerated at the time of biopsy. 31.1% of all malignancies were not clinically suspected to be malignant and did not even include a request to rule out malignancy. There was a better agreement between the clinical provisional diagnoses and microscopic diagnoses in the SCC group than in other types of malignancy (P < 0.001). CONCLUSION: Within this study sample, non-ulcerated masses rather than indurate ulcers are the most common clinical appearance of oral mucosal malignancies, and even for SCC, that showed the highest ulceration rate at presentation, half were non-ulcerated. Approximately, one-third of oral mucosal malignancies were not suspected to be malignant prior to biopsy. Thus, the level of suspicion currently reserved for mucosal ulcers and ulcerated masses should also be applied to non-ulcerated oral mucosal masses.

Bisphosphonate related osteonecrosis of the jaws: clinico-pathological investigation and histomorphometric analysis.

OBJECTIVES: Clinico-pathological evaluation of bisphosphonate (BP)-related osteonecrosis of jaws, comparison between oral (PO) and intravenous (IV) BPs and histomorphometric analysis of associated actinomyces. STUDY DESIGN: Retrospective clinical and histomorphometric analysis. Data on background, clinical, treatment and follow-up were analyzed. Actinomyces colonies were identified by typical filamentous colony morphology, Gram, and PAS stains. Colony density and relative colony surface area were measured. RESULTS: Fifty-two patients were included, 37 (71.2%) IV, 15 (28.8%) PO BPs. with a mean duration of 2.33 and, 4.33 years respectively. One hundred percent of cases exhibited actinomyces colonization. The relative colony surface area was significantly higher in PO treatment (P = .024), with no differences in density, healing time or antibiotic treatment periods. High frequency of diabetes mellitus (60% PO cases) and corticosteroid treatment (25% of cases) were recorded. CONCLUSION: Infection with actinomyces is a common denominator in BP-related osteonecrosis of the jaws (BRONJ), regardless of administration route. Diabetes and corticosteroid treatment seem to be important contributing factors for BRONJ.

Jaws features in Type 1 Gaucher disease.

PURPOSE: Our aims were to present 2 new cases of Gaucher disease involving the jaws and to review the literature. MATERIALS AND METHODS: Two new cases and the literature from 1982-2011 were reviewed. RESULTS: Ten articles describing 35 cases (for a total of 37 with 2 new cases presented) were analyzed. The mandible and maxilla were affected in 97.3% and 24.3% of the reported cases, respectively. Generalized rarefaction of bone (osteopenia) was present in 83.8%, and well-defined radiolucent lesions in 40.5%. The effects on the surrounding structures included loss of cortication of the mandibular canal (56.7%), cortical bone thinning (27%), expansion, root resorption (24.3%), mandibular canal displacement (18.9%), cortical perforation, maxillary sinus obliteration, and tooth displacement (10.8%). CONCLUSIONS: Two distinct bone abnormalities with separate pathophysiologies, radiographic presentation, and effects on the surrounding structures are suggested: 1) generalized mandibular/maxillary osteopenia and 2) a well-defined radiolucent lesion, which appears only in the mandible. This review refutes 2 accepted assumptions; according to the results, 1) the most common manifestation is generalized osteopenia (and the resulting mandibular canal changes), whereas the well-defined radiolucent lesion is the next most common, and 2) cortical bone thinning/perforations and lamina dura thinning are not uncommon in these patients.

The significance of surface ulceration as a sign of malignancy in exophytic oral mucosal lesions: myth or fact?

To compare the spectrum of pathologies in ulcerated versus non-ulcerated exophytic oral mucosal lesions and explore the significance of surface ulceration as an indication of malignancy. Retrospective analysis of exophytic lesions of the oral mucosa, 2009-2011. 713 biopsies of exophytic lesions of oral mucosa were included, of which 9.4% were ulcerated. Significant differences were found between ulcerated and non-ulcerated lesions. Of the ulcerated lesions 67.2% were reactive, 31.3% malignant and 1.5% benign, compared to 86, 8.4 and 5.6% respectively in non-ulcerated lesions (p < 0.0001). Malignancies were most prevalent in ulcerated lesions, in patients over 50. Malignancies presented the highest ulceration rate (36.8%, p < 0.001), compared to reactive (7.5%) and benign neoplasia (1.8%), however, the majority of oral mucosal malignancies (63.2%) presented as non-ulcerated masses. Squamous cell carcinoma presented the highest ulceration rate among malignancies, but even these were only ulcerated in 50% of cases. Non-epithelial malignancies were non-ulcerated in all cases. One-third of all malignancies were not suspected as such clinically, however, there was a better agreement between the clinical and microscopic diagnosis of malignancy in ulcerated lesions. Although the statistical likelihood of ulcerated masses to represent malignancy was higher than non-ulcerated lesions, especially in patients over 50, the majority of malignancies presented as non-ulcerated masses. Thus, all exophytic lesions should be submitted for microscopic analysis, and the status of ulceration should not be regarded neither as a factor in the decision to biopsy, nor a reliable indicator for malignancy.

The dynamics of oral lichen planus: a retrospective clinicopathological study.

To evaluate disease dynamics, treatment results, and frequency of malignant transformation. Ten-year single center retrospective study. The study included 171 patients, 28-99 years old. Follow-up was 1-16 years. 49.5% exhibited changes in clinical presentation, with 19% yearly increase of probability for type shift. Index of extent (number of oral locations) showed a mean 40% decrease and 94.1% reported improvement. There were significant differences between treated and untreated patients (P=0.012). Patients with or without systemic diseases had identical treatment requirements for oral lesions. The prevalence of SCC was 5.8%. Oral lichen planus constantly changes presentation and extent of involvement. The effect of systemic diseases was insignificant in the present study. There is a clear value for treatment to reduce the extent of lesions. The results indicate that all clinical forms of the disease need to be equally followed since the clinical presentation typically changes over time, while malignant transformation can occur in all forms.

Decompression of odontogenic cystic lesions: clinical long-term study of 73 cases.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of decompression as the initial treatment for odontogenic cysts. STUDY DESIGN: Pre- and postdecompression panoramic radiographs of 57 patients treated for 73 odontogenic cysts were reviewed for reduction parameters. Findings were evaluated against time of decompression and clinical and histopathologic data. RESULTS: Decompression reduced lesion area by a mean of 79.3%. The reaction was good in 60% of cysts, moderate in 29%, and poor in 11%. Mean decompression time was 9.2 ± 5.2 months; it was 7.6 months in patients ≤18 years old and 10.2 months in older patients (P < .0001). Mean rate of reduction was 0.14 in cysts <10 cm(2) and 0.10 in cysts >20 cm(2) (P = .0884); by age, values were 0.14 in patients ≤18 years old and 0.09 in older patients (P < .05). CONCLUSIONS: Decompression is effective in reducing odontogenic cysts. A shorter decompression period is needed for young patients. For aggressive lesions, secondary definitive surgery is recommended.

Bone remodeling in onlay beta-tricalcium phosphate and coral grafts to rat calvaria: microcomputerized tomography analysis.

This study was conducted to establish the efficiency of microcomputerized tomography (micro-CT) in detection of trabecular bone remodeling of onlay grafts in a rodent calvaria model, and to compare bone remodeling after onlay grafts with beta-tricalcium phosphate (TCP) or coral calcium carbonate. Ten rats received calvarial onlay blocks-5 with TCP and 5 with coral calcium carbonate. The grafts were fixed with a titanium miniplate screw and were covered with a collagen resorbable membrane. Three months after surgery, the calvaria were segmented, and a serial 3-dimensional micro-CT scan of the calvarium and grafted bone block at 16-micrometer resolution was performed. Image analysis software was used to calculate the percentage of newly formed bone from the total block size. Newly formed bone was present adjacent to the calvarium and screw in all specimens. The mean area of newly formed bone of the total block size ranged from 34.67%-38.34% in the TCP blocks, and from 32.41%-34.72% in the coral blocks. In the TCP blocks, bone remodeling was found to be slightly higher than in the coral blocks. Micro-CT appears to be a precise, reproducible, specimen-nondestructive method of analysis of bone formation in onlay block grafts to rat calvaria.

The clinical spectrum of Actinomyces-associated lesions of the oral mucosa and jawbones: correlations with histomorphometric analysis.

OBJECTIVES: To characterize the clinical manifestations of Actinomyces-associated lesions of the oral mucosa and jawbones, and to correlate the clinical course and treatment requirements with the findings of histomorphometric analysis. STUDY DESIGN: The study was a 10-year retrospective analysis of archived cases with microscopic identification of Actinomyces infection. Actinomyces colonies were identified, using hematoxylin-eosin, Gram, and periodic acid-Schiff stains, exhibiting filamentous morphology with color variation between center and periphery. Only colonies with adjacent tissue reaction (inflammation, fibrosis) were analyzed. Actinomyces density (AD) was calculated by dividing total number of colonies by tissue surface, Actinomyces relative surface (ARS) was calculated by dividing total bacterial surface by tissue surface. RESULTS: The study included 106 cases (48 male, 58 female; aged 13-84 years, mean 50.5 years). Cases presented a wide clinical spectrum, involving jawbone and/or oral soft tissues. Cases included osteomyelitis associated with bisphosphonates, osteoradionecrosis, osteomyelitis unrelated to radiation or bisphosphonates, periapical lesions, odontogenic cysts, periimplantitis, and lesion mimicking periodontal disease. The AD correlated with median length of antibiotic treatment (R = 0.284; P = .028). CONCLUSIONS: Because we were able to identify 106 such cases, the results indicate that Actinomyces-associated lesions may not be as rare as would be expected from the relatively low number of cases in the literature. Actinomyces-associated lesions presented in a wide spectrum of clinical settings and a variety of contributing factors. Quantitative analysis of the number of bacterial colonies (representing bacterial load) could help in evaluating the aggressive potential of the lesion and help in treatment planning.

Central giant cell lesion of the jaw: nonsurgical treatment with calcitonin nasal spray.

OBJECTIVES: The aim was to evaluate the effectiveness of the long-term administration of intranasal calcitonin spray for the treatment of central giant cell granuloma (CGCG) in a retrospective case study. STUDY DESIGN: The medical files of 5 patients (4 male, 1 female; ages 8-66 years) with CGCG of the jaws treated with calcitonin nasal spray 200 U/spray once or twice daily were reviewed for lesion-related parameters, outcome, and adverse effects of therapy. RESULTS: Three lesions were located in the mandibular body and ramus region and 2 in the anterior maxilla. Mean lesion size on radiography was 3.2 x 2.3 cm. The duration of calcitonin treatment was 9-60 months (mean 28 months). All the lesions considerably decreased in size with a high degree of calcification. There were no recurrences. CONCLUSIONS: Calcitonin nasal spray appears to be safe and effective for the treatment of CGCG and might be considered an alternative to surgery. Further controlled studies are needed to corroborate these findings.

Complications of maxillary sinus augmentations in a selective series of patients.

OBJECTIVES: The purpose of this case series was to describe late complications of maxillary sinus augmentation procedures, including paranasal sinusitis and oroantral fistula, and to discuss the definitive surgical methods of treatment. STUDY DESIGN: The case series included 13 patients hospitalized for a failed lateral-approach maxillary sinus augmentation, performed by a dental practitioner, with or without simultaneous implant placement. Data on patient gender and age, presenting signs and symptoms, radiographic appearance, method of repair, and follow-up were recorded. RESULTS: There were 7 female and 6 male patients aged 53-74 years. Twenty-six of the total 34 implants inserted failed, of which 7 were displaced into the sinus. All patients had maxillary sinusitis, and 2 also had an inflammation of other paranasal sinuses. Ten patients presented with an oroantral fistula. Review of the files of the referring practitioner revealed the preoperative presence of chronic maxillary sinusitis in 4 patients and an odontogenic cyst in 1. Caldwell-Luc operation served as the definitive surgical treatment. All fistulas were successfully closed by a palatal rotation advancement flap (8 patients) or a buccal flap (2 patients). CONCLUSIONS: Thorough clinical and radiographic evaluation is necessary before sinus procedures to minimize complications. Total elimination of sinusitis and other pathologic conditions is recommended before maxillary sinus augmentation and implant surgery.

Adenoid cystic carcinoma of the salivary glands: a 20-year review with long-term follow-up.

The behavior of adenoid cystic carcinoma (ACC) of the salivary glands has been shown to be unpredictable in terms of local and distant spread and mortality. We retrospectively studied 35 operations in 34 patients who had had a pathologic diagnosis of ACC of the salivary glands and who had been treated over a 20-year period and followed for a minimum of 10 years. We analyzed the effect that different factors had on outcomes. The site of origin appeared to be an important factor in survival rates; survival among patients with tumors that had originated in the parotid gland was fairly good, while survival among those with tumors that originated in the minor salivary glands was significantly worse. TNM staging was another significant factor in survival. Other poor prognostic indicators were local spread, nodal positivity, distant metastasis, and local and regional recurrence. Radiation and chemotherapy did not appear to be beneficial for patients with advanced disease. We recommend radical surgery with complete resection for all patients with ACC of the salivary glands and a careful assessment of the neck in patients with minor salivary gland tumors.

The use of molecular markers as an aid in the diagnosis of glandular odontogenic cyst.

UNLABELLED: (1) To investigate the use of p53, Ki67, and PCNA as an aid in the diagnosis of glandular odontogenic cyst (GOC); (2) To compare the expression of these markers in GOC, low-grade mucoepidermoid carcinoma (MEPCa), and radicular cyst with mucous metaplasia (RCM) as an aid in the differential diagnosis; (3) To establish guidelines for the diagnosis of GOC. STUDY GROUP: 35 patients: 10 GOC, 15 RCM, 9 MEPCa. Immunostaining of archival specimens for p53, Ki67, PCNA. Twenty-nine articles (1987-2004) with detailed histopathological descriptions of GOC, analyzed for frequency of histopathological characteristics. Mean p53 labeling index (LI) was higher in GOC (3.0+/-4.3%) and MEPCa (4.9+/-7.4%) than in RCM (0.4+/-1.2%, p=0.048). Ki67 LI was higher in GOC (4.4+/-4.7%) and RCM (3.7+/-6.7%) than in MEPCa (0.7+/-1.6%, p=0.03). There were no significant differences in the expression of PCNA. In the literature, the most consistent histopathological characteristics of GOC included epithelial spherules/"knobs"/whorls (82.8%), cuboidal eosinophilic cells (65.5%), goblet cells (65.5%), intraepithelial glandular/microcystic ducts (58.6%), variations in lining width (55.2%), ciliated cells (51.7%) and mucous pools/mucous-lined crypts (41.4%). These histopathological features were divided into major and minor signs. The diagnosis of GOC should be based on at least the focal presence of the major signs. Measurement of p53 and Ki67 may aid in the differential diagnosis of GOC.

Glandular odontogenic cyst: treatment and recurrence.

PURPOSE: To investigate the correlation between clinical characteristics, radiologic features, treatment modalities, and treatment outcome of glandular odontogenic cyst, and to suggest a treatment protocol based on these results. PATIENTS AND METHODS: The study included a total of 56 cases, 49 from the literature and 7 new cases. Demographic data, locularity and radiographic extension, cortical plate integrity, treatment modalities, follow-up, and recurrence were analyzed. RESULTS: There were 34 male and 22 female patients aged 14 to 74 years (mean, 48 years). The mandible was involved in 41 cases (73.2%) and the maxilla in 15 (26.8%), predominantly in the anterior region; 53.6% of the lesions were unilocular and 46.4% multilocular. Large lesions were found in 78.5% of cases. Cortical integrity was compromised in 53.6% (cortical perforation in 39.3% and thinning or erosion of the cortical plate in 14.3%). Recurrence occurred at a rate of 29.2%, within 0.5 to 7 years (mean, 2.9 years). Mean follow-up was also 2.9 years. Two patients had 3 recurrences each. Recurrence was associated with minor surgery such as enucleation or curettage; none of the patients treated by peripheral ostectomy, marginal resection, or partial jaw resection had a recurrence. Compared with the patients without recurrence, the recurrence group had a higher frequency of multilocularity than the nonrecurrent group (64.3% vs 41.2%) and of compromised cortical integrity (71.4% vs 47.1%). CONCLUSION: Glandular odontogenic cyst is an aggressive lesion. Treatment by enucleation or curettage alone is associated with a high recurrence rate. Small unilocular lesions can be treated by enucleation. In large uni- or multilocular lesions, an initial biopsy is recommended. Surgical treatment of large lesions should include enucleation with peripheral ostectomy for unilocular cases and marginal resection or partial jaw resection in multilocular cases. Marsupialization followed by second phase surgery is an option for lesions approaching vital structures. Follow-up should continue for at least 3 years (up to 7 years in cases with features associated with increased risk).

Palatal rotation-advancement flap for delayed repair of oroantral fistula: a retrospective evaluation of 63 cases.

OBJECTIVE: To review our 17-year clinical experience with delayed oroantral fistula repair by palatal rotation-advancement flap, and to report its advantages, disadvantages, and complications. STUDY DESIGN: The records of 63 patients with late oroantral fistula treated by palatal rotation-advancement flap from 1984 to 2002 were reviewed. Eleven had undergone unsuccessful closure with a buccal flap. Data recorded were patient age and sex, cause of fistula, signs and symptoms, interval from appearance of fistula to repair, fistula size, radiographic appearance, method of repair, and immediate and late complications. RESULTS: There were 35 women and 28 men aged 21 to 71 years (mean 50.3 years). Surgery was performed 3 months to 20 years after injury (mean 1.8 years). Twenty-four patients had acute maxillary sinusitis and 39 had chronic sinusitis. The main causes of oroantral fistula were extraction of the second and first molars and pathological lesions within the sinus. Average fistula size was 2.3 cm x 1.6 cm. Fifty-one repairs were preceded by Caldwell-Luc operation. All fistulas were successfully closed with the palatal rotation-advancement flap, with minimal complications on long-term follow-up. CONCLUSION: The palatal rotation-advancement flap is recommended for the late repair of oroantral fistula owing to its good vascularization, excellent thickness and tissue bulk, and easy accessibility; it also allows for the maintenance of the vestibular-sulcus depth. It is particularly indicated in cases of unsuccessful buccal flap closure.

Clear-cell variant of calcifying epithelial odontogenic tumor: clinical and radiographic characteristics.

OBJECTIVES: Clear cells have been reported in approximately 8% of cases of calcifying epithelial odontogenic tumor (CEOT). The purpose of this study was to describe the clinical and radiographic features of clear-cell CEOT (CCEOT). STUDY DESIGN: Eighteen cases of CCEOT were identified by review of the literature from 1958 to 2001, and a new one was added (total 19; 12 central, 7 peripheral). RESULTS: Fourteen tumors (74%) were located in the mandible, with the central lesions favoring the posterior area and the peripheral lesions the anterior-bicuspid area. Radiographic features were as follows: 50% radiolucent, 50% mixed radiolucent-radiopaque; 92% unilocular; 64% well-defined noncorticated borders, 27% well-defined corticated borders, 9% irregular borders. Cortical perforation was common (67%) compared with CEOT without a clear-cell component (6.7%). Recurrence was reported in 17% of the central lesions and none of the peripheral ones. CONCLUSIONS: CCEOT is a distinct variant of CEOT; its high tendency for cortical perforation may indicate a more aggressive behavior.