Dental implants placed into alveolar clefts reconstructed with tongue flaps and bone grafts.

OBJECTIVE: The aim of this study was to describe a case series using surgical and prosthodontic modifications of tongue flaps necessary to adapt them for use in the reconstruction of large cleft deformities refractory to customary measures using dental implants and to study their outcomes in patients with complex cleft lip and palate deformities. STUDY DESIGN: Five patients were treated with iliac crest bone grafts and covered by anteriorly based tongue flaps divided at either 3 or 4 weeks after surgery. The patients were followed clinically and radiographically for 3-12 years after placement of their dental implants to monitor implant survival and success. RESULTS: One of the 5 patients suffered a partial tongue flap detachment, graft dehiscence, and recurrence of an oronasal fistula, which was successfully treated by shifting the tongue flap tissue from its new location in the palate. A total of 18 dental implants were placed into bone-grafted tissue covered by the tongue flaps. There was 1 implant failure. There were no cases of periimplantitis or bone loss in the 17 surviving implants. CONCLUSIONS: Tongue flaps are rarely used clinical entities with a very narrow range of indications. Tongue flaps are useful in the preprosthetic reconstruction of select cases with large residual oronasal fistulae with soft tissue deficits due to scarring from previously failed surgery. Tongue flaps are extremely stressful procedures for patients to endure. Patient selection is of the utmost importance.

Bisphosphonate associated osteonecrosis of the jaw.

In 2003, the first reports describing osteonecrosis of the jaw (ONJ) in patients receiving bisphosphonates (BP) were published. These cases occurred in patients with cancer receiving high-dose intravenous BP; however, 5% of the cases were in patients with osteoporosis receiving low-dose bisphosphonate therapy. We present the results of a systematic review of the incidence, risk factors, diagnosis, prevention, and treatment of BP associated ONJ. We conducted a comprehensive literature search for relevant studies on BP associated ONJ in oncology and osteoporosis patients published before February 2008.All selected relevant articles were sorted by area of focus. Data for each area were abstracted by 2 independent reviewers. The results showed that the diagnosis is made clinically. Prospective data evaluating the incidence and etiologic factors are very limited. In oncology patients receiving high-dose intravenous BP, ONJ appears to be dependent on the dose and duration of therapy, with an estimated incidence of 1%-12% at 36 months of exposure. In osteoporosis patients, it is rare, with an estimated incidence < 1 case per 100,000 person-years of exposure. The incidence of ONJ in the general population is not known. Currently, there is insufficient evidence to confirm a causal link between low-dose BP use in the osteoporosis patient population and ONJ. We concluded BP associated ONJ is associated with high-dose BP therapy primarily in the oncology patient population. Prevention and treatment strategies are currently based on expert opinion and focus on maintaining good oral hygiene and conservative surgical intervention.

Canadian consensus practice guidelines for bisphosphonate associated osteonecrosis of the jaw.

OBJECTIVE: Following publication of the first reports of osteonecrosis of the jaw (ONJ) in patients receiving bisphosphonates in 2003, a call for national multidisciplinary guidelines based upon a systematic review of the current evidence was made by the Canadian Association of Oral and Maxillofacial Surgeons (CAOMS) in association with national and international societies concerned with ONJ. The purpose of the guidelines is to provide recommendations regarding diagnosis, identification of at-risk patients, and prevention and management strategies, based on current evidence and consensus. These guidelines were developed for medical and dental practitioners as well as for oral pathologists and related specialists. METHODS: The multidisciplinary task force established by the CAOMS reviewed all relevant areas of research relating to ONJ associated with bisphosphonate use and completed a systematic review of current literature. These evidence-based guidelines were developed utilizing a structured development methodology. A modified Delphi consensus process enabled consensus among the multidisciplinary task force members. These guidelines have since been reviewed by external experts and endorsed by national and international medical, dental, oral surgery, and oral pathology societies. RESULTS: RECOMMENDATIONS regarding diagnosis, prevention, and management of ONJ were made following analysis of all current data pertaining to this condition. ONJ has many etiologic factors including head and neck irradiation, trauma, periodontal disease, local malignancy, chemotherapy, and glucocorticoid therapy. High-dose intravenous bisphosphonates have been identified as a risk factor for ONJ in the oncology patient population. Low-dose bisphosphonate use in patients with osteoporosis or other metabolic bone disease has not been causally linked to the development of ONJ. Prevention, staging, and treatment recommendations are based upon collective expert opinion and current data, which has been limited to case reports, case series, surveys, retrospective studies, and 2 prospective observational studies. RECOMMENDATIONS: In all oncology patients, a thorough dental examination including radiographs should be completed prior to the initiation of intravenous bisphosphonate therapy. In this population, any invasive dental procedure is ideally completed prior to the initiation of high-dose bisphosphonate therapy. Non-urgent procedures are preferably delayed for 3 to 6 months following interruption of bisphosphonate therapy. Osteoporosis patients receiving oral or intravenous bisphosphonates do not require a dental examination prior to initiating therapy in the presence of appropriate dental care and good oral hygiene. Stopping smoking, limiting alcohol intake, and maintaining good oral hygiene should be emphasized for all patients receiving bisphosphonate therapy. Individuals with established ONJ are most appropriately managed with supportive care including pain control, treatment of secondary infection, removal of necrotic debris, and mobile sequestrate. Aggressive debridement is contraindicated. CONCLUSION: Our multidisciplinary guidelines, which provide a rational evidence-based approach to the diagnosis, prevention, and management of bisphosphonate-associated ONJ in Canada, are based on the best available published data and the opinion of national and international experts involved in the prevention and management of ONJ.

Marble bone disease: a review of osteopetrosis and its oral health implications for dentists.

Osteopetrosis is one cause of osteosclerosis and may result in such serious oral complications as osteomyelitis and exposed necrotic bone. Dentists should be aware of patients with the disease because of its effect on osteoclast function, which results in impaired wound healing. The purpose of this paper is to review the causes, pathogenesis and differential diagnosis of osteopetrosis and to provide guidance to dentists on the management of patients with osteopetrosis.

Primary squamous cell carcinoma of the maxillary alveolus in a 10-year-old girl.

Oral squamous cell carcinoma is rare in the pediatric population. When it does occur, it is most commonly seen on the tongue or lip. In this article, we report a rare case of squamous cell carcinoma of the maxillary gingiva and alveolus in a 10-year-old girl and review the literature concerning oral squamous cell carcinoma in the pediatric population.

Metastatic mandibular retinoblastoma in a child reconstructed with soft tissue matrix expansion grafting: a preliminary report.

PURPOSE: Retinoblastoma is a congenital malignant neoplasm of retinal tissue. Reports of metastasis to the mandible are rare. Successful retinoblastoma management has led to a dramatic improvement in survival rates. Increasing numbers of surviving patients require reconstruction of the defects caused by the ablation of such metastasis. PATIENT AND METHODS: This article describes the management of a pediatric mandibular defect secondary to the resection of a metastatic retinoblastoma. RESULTS: A unique application of the soft tissue matrix expansion technique, otherwise known as the "tent-pole" graft, which has been previously described in adults with severe mandibular atrophy, was utilized in the pediatric patient. CONCLUSION: The soft tissue matrix expansion grafting technique can be successfully utilized in the reconstruction of ablative defects in pediatric patients.

An analysis of peripheral giant cell granuloma associated with dental implant treatment.

This report discusses the management of a 21-year-old male who developed a peripheral giant cell granuloma (PGCG) associated with dental implant therapy, and reviews 4 previously reported cases of PGCGs developing in association with dental implant treatment. The patient described in this report was treated with multiple dental implants to manage severe oligodontia. Six years after implant placement, with the patient lost to follow-up, he presented to his dentist complaining of increasing swelling in the right mandibular vestibule. The patient was noted to have a large exophytic, ovoid-shaped, firm, smooth-surfaced, maroon-colored lesion. The lesion was found to be a PGCG associated with a dental implant. The lesion was treated successfully by explantation of the dental implant, complete excision of the lesion, and curettage of the underlying bony defect. No evidence of recurrence was seen over 12 months of follow-up.

Cleidocranial dysplasia: 2 generations of management.

Patients with cleidocranial dysplasia (CCD) commonly present with significant dental problems, such as retention of multiple deciduous teeth, impaction or delay in eruption of permanent teeth and, often, the presence of supernumerary teeth. Several approaches have been described for the management of such patients. We report 2 cases illustrating the shift in the management paradigm from edentulation and prosthetic replacement to orthodontically assisted forced eruption and fixed appliance orthodontic treatment combined with orthognathic surgery.