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.

Mechanisms of trigeminal nerve injuries.

Injuries to the trigeminal nerve branches are a known and accepted risk in oral and maxillofacial surgery. It is prudent for the practitioner to explain the risks to patients as part of the informed consent process and to recognize and document the presence of nerve injury postoperatively. Patients should be referred to a surgeon experienced in microsurgical techniques in a timely fashion for evaluation and possible surgical intervention if an injury is not resolving.

Outcomes of open versus closed treatment of mandibular subcondylar fractures.

OBJECTIVES: The purpose of this study was to compare the long-term treatment results of open reduction and rigid internal fixation (ORIF) with closed reduction and maxillomandibular fixation (CRMMF) for subcondylar fractures when guided by specific indications and contraindications. PATIENTS AND METHODS: A protocol for the treatment of condylar process fractures was developed that included absolute and relative indications and contraindications as well as a technique regimen. To evaluate the results of this protocol, 10 patients treated with CRMMF and 10 treated by ORIF were recalled after a minimum of 6 months and examined for gender, race, diagnosis, age at injury, time since operation, and cause of the fracture. Each group was assessed by 2 blinded investigators for maximum interincisal opening, right lateral excursion, left lateral excursion, protrusive movement, deviation on opening, scar perception, motor function, sensory perception, contour perception, occlusion, and perception of pain. Nonparametric data were compared for statistical significance with a chi-square analysis and parametric data with an independent samples t-test (P < .05). RESULTS: No statistically significant differences existed between the ORIF and CRMMF groups for gender, race, diagnosis, or cause. Moreover, no differences existed for age at injury, maximum interincisal opening, right lateral excursion, left lateral excursion, protrusive movement, deviation on opening, or occlusion. Differences were noted between groups for time since operation, scar perception, and perception of pain. Using the protocol outlined, there were no differences between the ORIF and CRMMF groups for ranges of motion, occlusion, contour, and motor or sensory function. The ORIF group was associated with perceptible scars. The CRMMF group was associated with chronic pain. CONCLUSIONS: Using a treatment protocol, there were few differences in outcomes between patients treated with CRMMF and ORIF for subcondylar fractures.

Synovial chondromatosis of the temporomandibular joint: varying presentation in 4 cases.

Synovial chondromatosis is a rare condition in which cartilage is formed in the synovial membrane of a joint. The manifestations of this benign neoplastic process can mimic many common temporomandibular joint and parotid diseases. Four cases of synovial chondromatosis are presented. In each case, atypical presentation, coexisting joint disease, or both caused diagnostic confusion. The histories and physical examinations were initially consistent with more common joint diseases in each case. Imaging provided some insight into diagnosis and was a definitive indication for surgical treatment. Treatment by subtotal synovectomy and by removal of chondromatous nodules were undertaken in each case. No patient in our series has had recurrence of disease or symptoms after surgical treatment.

The nonsubmerged osseointegrated dental implant.

Implant patients are seeking means of restoring their health and appearance with minimal side effects. Dental implant surgery must react to these demands by continuing to develop minimally invasive implant surgery techniques, imaging that customizes surgical procedures, and materials and drugs that reduce surgical costs and complications, shorten recovery, and increase the longevity of components, enabling patients to live active lifestyles. Nonsubmerged osseointegrated implants fit nicely into the future of dental surgery.

Treatment of comminuted fractures of the mandible.

Management of comminuted mandible fractures requires careful planning. Treatment is based on a thorough understanding of the medical management of severely injured patients, biology of these injuries, the biomechanics of the mandible, and principles of fracture fixation.

Orthodontic and temporomandibular joint considerations in treatment of patients with Ehlers-Danlos syndrome.

The gross clinical manifestations, the classifications of the syndrome, and a summary of the pathophysiology are presented. Dental manifestations are described with an emphasis on the orthodontic and temporomandibular joint problems found in the disease. Finally, there are short clinical reports of orthodontic and surgical temporomandibular joint treatments.

Craniomaxillofacial trauma in the elderly.

PURPOSE: Limited data are currently available regarding the nature of craniomaxillofacial fractures in the geriatric population. This retrospective study reviews 109 hospital records dating from 1981 to mid-1993. The goal of this study was to provide details relevant to these types of injuries. RESULTS: Most patients were injured in motor vehicle accidents (MVA) or fall-related episodes. Females sustained 43.9% of the fractures while males sustained 56.1%. In females, falls were the most common cause of fractures, while in males MVAs caused the majority of fractures (P < .01). Most fractures were found in the upper midface region (60.3%) and the mandible (27.5%). MVAs and falls were responsible for 82.7% of all mandibular fractures. The majority of fractures were treated nonsurgically (49.5%); however, 37.6% were treated with open reduction and internal fixation. The in-hospital mortality rate was 11.1%, and there were three postoperative complications. CONCLUSION: The geriatric craniomaxillofacial trauma patient is readily treatable with both aggressive surgical measures and more conservative approaches. Elderly patients often have an underlying medical condition that may subsequently alter the patient's treatment. The findings of this study also suggest that more preventive measures and methods of minimizing mortality and morbidity need to be implemented.

Acute cardiac care in dental practice.

Acute cardiac care in the dental office is always based on a limited patient data base and limited ability to intervene. The dentist must be aware that the parameters of these conditions are always the same. The dentist must recognize a problem in cardiac function, ensure tissue perfusion and oxygenation, restore cardiac function, influence the underlying cause, recognize promptly when additional acute medical intervention is necessary, and be able to activate the emergency medical system.

Tumor necrosis factor-alpha as a biochemical marker of pain and outcome in temporomandibular joints with internal derangements.

OBJECTIVE: Previous studies have demonstrated the presence of tumor necrosis factor-alpha (TNF) in human temporomandibular joint (TMJ) synovial fluid. The present study continues the investigation of the role of TNF in TMJs with internal derangements. MATERIALS AND METHODS: Synovial fluid was obtained from 18 TMJs in 12 patients undergoing either arthroscopy (14 joints) or arthrotomy (four joints) for internal derangements. Standardized clinical data were collected preoperatively, intraoperatively, and postoperatively. RESULTS: When pain on palpation was absent, the mean preoperative TNF level was 14 +/- 6 ng/mL. When pain on palpation was present, the mean TNF level was 42 +/- 39 ng/mL (significant difference at P = .05). When the surgical outcome was poor, the mean preoperative TNF level was 26 +/- 9 ng/mL. When the outcome was within the stated guidelines for a favorable result, the mean TNF level was 12 +/- 7 ng/mL (significant difference at P = .05). In addition, a significant reduction (P = .05) in TNF following joint lavage (preoperative, 48 ng/mL to postoperative, 7 ng/mL) was found. CONCLUSIONS: The finding of a positive correlation between preoperative pain and TNF values suggests a biochemical basis for the origin of the pain associated with internal derangements. The relationship between preoperative TNF levels and surgical outcome suggests that the prognosis for surgery may be predicted by measuring biochemical markers of joint disease.

Evaluation of rigid internal fixation of mandible fractures performed in the teaching laboratory.

Rigid internal fixation of mandible fractures is advocated as an effective means of providing undisturbed healing and immediate function. However, its application in the clinical setting has resulted in many technique-related failures. To determine the reasons for clinical failure and to help develop improved means of providing successful fixation, the results of plate application in the teaching laboratory were evaluated. Seventy-four surgeons taking the AO/Association for the Study of Internal Fixation (AO/ASIF) maxillofacial course in Davos, Switzerland and 56 surgeons taking the advanced AO/ASIF course in Naples, FL applied rigid internal fixation devices to a mandibular fracture model. Treatment was evaluated for anatomic morbidity and effectiveness. In Davos, 92 of 121 subcondylar, body, symphysis, and ramus fractures (76%) were treated effectively. This included 22 of 34 symphysis fractures (65%). In Naples, 11 of 28 symphyseal fractures (39%) were fixed effectively with lag screws without anatomic morbidity. Technique failure is a frequent event in the application of rigid internal fixation devices to mandible fractures. Lag screw fixation of symphyseal fractures had a particularly high rate of technique-related failure.

The double-reversing Z-plasty in primary palatoplasty: operative experience and early results.

The double-reversing Z-plasty of Furlow for closure of the soft palate was used in 34 children with various types of cleft palate. Mean age at repair was 12.8 months. Intraoperative experience was favorable, with acceptable operating time and blood loss. Length of hospitalization averaged 1.9 days. Postoperatively, two children experienced temporary stridor, which resolved within 24 to 48 hours. One child had dehiscence of the hard palate (Von Lagenbeck repair) 4 weeks postoperatively, and three children developed small oronasal fistulae. Early speech evaluation demonstrated adequate soft palate mobility in 33 of 34 patients, with observable velopharyngeal function. Twelve children had mild velar compromise, with eight exhibiting slight nasal air escape.

Clinical aspects of imaging in maxillofacial trauma.

Imaging of maxillofacial injuries serves as the principal means of qualifying the clinical diagnosis. Imaging assists in treatment planning of comprehensive surgical repair. The use of more invasive means of providing stable fixation of facial fractures has increased the demands made on fracture imaging. Clinical decision making depends on a thorough understanding of the clinical findings in an injury and its anatomic features as delineated on imaging.