Bevacizumab-Associated Implant Presence-Triggered Osteonecrosis: A Case Report and Literature Review.

The effect of bevacizumab-related osteonecrosis of the jaw on previously osseointegrated dental implants has not been adequately studied. Here, we report a case of osteonecrosis of the jaw detected around dental implants placed before bevacizumab therapy. A 66-year-old woman undergoing bevacizumab therapy for metastatic triple-negative breast cancer developed malocclusion after buccal gingival swelling and pain in the #18, #19, and #20 tooth region. The patient visited a local dental clinic, where existing implants in relation to #19 and #20 were removed. Subsequently, the patient visited our department, and intraoral examination revealed necrotic bone in the region corresponding to #19 and #20. Radiographic examination showed a pathologic fracture in this region that was considered to result from osteonecrosis of the jaw. Bevacizumab therapy was suspended temporarily until the acute inflammation had subsided. In addition, treatment with antibacterial agents and conservative surgery was considered. Complete soft tissue coverage was observed 14 days after surgery. In recent years, the number of patients receiving bevacizumab treatment has increased. Because bevacizumab-related osteonecrosis of the jaw could occur around previously osseointegrated dental implants as well, this case report suggests an effective treatment regimen based on a combination of antibacterial agents and conservative surgery.

Does inflammatory dental disease affect the development of medication-related osteonecrosis of the jaw in patients using high-dose bone-modifying agents?

OBJECTIVES: High-dose bone-modifying agents (BMAs), such as bisphosphonates and denosumab, are essential for the treatment of cancer patients with bone metastases. The incidence of medication-related osteonecrosis of the jaw (MRONJ) is increasing. Inflammatory dental diseases could lead to MRONJ, and hence, they should be managed appropriately. Tooth extractions are commonly advised to prevent dental inflammation; however, the accurate indications for tooth extractions before starting BMA therapy have not been established. Hence, we assessed teeth with inflammatory dental diseases to identify indicators for prophylactic extraction before starting BMA therapy. MATERIALS AND METHODS: We included 745 teeth with inflammatory dental diseases of 212 cancer patients on high-dose BMA therapy. We assessed the relationship between inflammatory dental disease and risk of MRONJ development. Multivariate Cox regression analysis was used for statistical analysis. The cumulative occurrence rate of MRONJ was calculated using the Kaplan-Meier method. RESULTS: MRONJ occurred in 43 of 745 teeth. Teeth characteristics significantly correlated with MRONJ occurrence were mandible (p = 0.009), molar region (p = 0.005), radiopaque changes in bone surrounding the root on orthopantograms obtained at patients' first visits (p < 0.001), and tooth extractions after starting BMA therapy (p < 0.001). CONCLUSIONS: Radiopaque changes in bone surrounding the root are an important radiographic finding that indicates the need for prophylactic tooth extractions before starting BMA therapy. CLINICAL RELEVANCE: Our results suggest that the prophylactic extraction of teeth with radiopaque changes in bone surrounding the root before starting BMA therapy could prevent the onset of MRONJ.

Study of Treatment Methods for Surrounding Soft Tissues of Implants Following Mandibular Reconstructions with Fibula-Free Flaps.

In maxillofacial reconstruction implant treatment, unsatisfactory soft tissue treatment of the area around the implant may lead to inflammation. As a result, appropriate soft tissue treatment is critical. To the best of our knowledge, there are no studies that compare the different tissue treatment methods available. Hence, in this study, we compare three soft tissue treatment methods around implants after mandibular reconstruction is achieved with a fibula-free flap. Out of 33 patients who underwent mandible reconstruction using fibula-free flaps between 2006 and 2015, 5 were selected for this study. A total of 17 implants were used for treatment by the final prosthetics of the five patients. Three soft tissue treatment methods with free gingival graft (FGG) were evaluated, namely, installing a splint in a modified abutment to protect the wounded area during a palatal mucosa transplant (method 1), installing a splint or dentures to a locator abutment (method 2), and the use of screw-in fixed dentures (method 3). The method that could guarantee the widest keratinized mucosa was the screw-in fixed denture method. The results of our study indicated that employing screw-in fixed dentures for FGG may be a useful soft tissue treatment for mandible reconstruction implants.