Ozone infiltration as an adjunctive treatment to piezoelectric surgery in the management of medication-related osteonecrosis of the jaws: case series of 29 patients.

PURPOSE: Medication-related osteonecrosis of the jaws has been reported to be associated with bisphosphonate and RANKL inhibitor medications. This prospective clinical study aimed to assess the outcomes of pre-operative ozone infiltration therapy in patients with established MRONJ. METHODS: The treatment protocol for ozone applications were designed as 20 applications ozone infiltration therapy followed by surgical interventions of necrotic tissue debridement using piezoelectric surgery instruments. The evaluation of the results based on the clinical and radiologic specifications considering the necrotic lesion reduction and healing. The study included 31 lesions in 29 patients. The mean follow-up was 23.6 months. RESULTS: 25 lesions out of 31 healed totally without any remissions. The outcomes were not affected by any variables such as gender, age, type of pharmacological treatment, lesion location, and MRONJ staging. The statistically significant results were found among the clinical condition of the patients (p = 0.01) and administration route of medications (p = 0.004). Healing was significantly less in patients that received intra-vascular administrations. Clinical conditions of the patients were divided as osteoporosis, oncologic, and arthritis. Significantly better results were obtained in osteoporosis patients. 38% of the population experienced spontaneous sequestration with signs of improvements and the surgical interventions were canceled. According to the results, total healing of MRONJ lesions was seen in 79% patients (81% lesions). CONCLUSION: Ozone therapy and debridement with Piezoelectric surgery can be considered as a safe and beneficial adjunctive treatment alternative for osteonecrosis lesions in cases of established MRONJ.

Guided Zygomatic Implantology for Oral Cancer Rehabilitation: A Case Report.

Oral rehabilitation after maxillary oncological resection is challenging. This case report presents the rehabilitation of a 65-year-old Caucasian male adenoid cystic carcinoma patient using a myo-cutaneous thigh flap, zygomatic implant placement, and an immediate fixed provisional prosthesis made with computer-aided technologies. The patient presented complaints of asymptomatic enlarged swelling of 5-mm on the right hard hemi-palate. There was an oro-antral communication deriving from a previous local excision. Preoperative radiographs showed the involvement of the right maxilla, maxillary sinus, and nose with a suspect involvement of the maxillary division of the trigeminal nerve. Treatment was planned through a fully digital workflow. A partial maxillectomy was performed endoscopically, and maxilla was reconstructed using an anterolateral thigh free flap. Two zygomatic implants were inserted simultaneously. A provisional fix full-arch prosthesis was manufactured preoperatively through a fully digital workflow and was placed in the operating room. Following post-operative radiotherapy, the patient received a final hybrid prosthesis. During the follow-up period of two years, the patient reported good function, aesthetics, and significant enhancement in quality of life. According to the results of this case, the protocol represented can be a promising alternative for oral cancer patients with large defects, and can lead to an improved quality of life.

Zygomatic Implant Insertion in MRONJ: A Case Report with a Follow-Up of 3 Years.

The oral rehabilitation of MRONJ patients represents a challenging situation. Conventional dental implant insertion is not indicated because of the risk of creating a new necrotic area. This case study describes the oral rehabilitation of a 78-year-old female patient, who developed an osteonecrotic lesion in the fourth year of bisphosphonate treatment. The patient underwent a series of surgeries, including resection of the necrotic tissue on the right maxillary region and removal of conventional implants. The patient had a large maxillary defect, and no other treatment modalities such as conventional prosthetic appliances and traditional dental implant insertions were applicable. The patient had a very poor quality of life and as a rehabilitation option, two zygomatic implant insertions were planned and performed as an anchorage for maxillary fixed prosthesis. Radiographic and clinical examination after three years of follow-up indicated that healing was achieved, and healthy tissues formed around zygomatic implants. The patient did not suffer from any additional necrotic tissues or other complications in the oral cavity. According to the results of this case report, zygomatic implantation after resective surgery might be considered as a promising alternative for MRONJ patients with large defects when other treatment alternatives fail or are not applicable.

Oral rehabilitation with unilateral zygomatic implants: A case series of 32 patients.

AIMS: Zygomatic implants are successful alternatives to conventional dental implants for oral rehabilitation of patients with severely atrophic maxillae; however, the use of unilateral zygomatic implants needs to be studied further to validate their efficacy. The present investigation aimed to evaluate unilateral zygomatic implant placement in the oral rehabilitation of partially edentulous patients with extremely atrophic maxillary bone and/or previous implant failures. MATERIALS AND METHODS: This retrospective clinical study included patients with partially edentulous maxillae who underwent unilateral zygomatic implant insertion. The primary outcome was implant survival. Intraoperative, postoperative and prosthetic complications were also assessed based on patients' clinical records. RESULTS: A total of 32 patients (34 zygomatic implants) with a mean age of 60.45 ± 8.74 years (range 47 to 78 years) were included in the study. The mean follow-up period was 34.3 ± 25.5 months, and the overall implant survival rate was 100%. No intraoperative or postoperative complications developed in any of the patients, and no prosthesis failures or complications were recorded. CONCLUSIONS: The results indicate that unilateral zygomatic implant insertion for oral rehabilitation of patients with partially edentulous posterior maxillae with severely atrophic bone and/or previous implant failures can be considered a successful alternative to use of conventional dental implants associated with advanced bone grafting procedures.

Oral Rehabilitation of Bilateral Cleft Lip and Palate Patient with Simultaneous LeFort I Osteotomy and Zygomatic Implants: A Case Report.

The aim of this study is to evaluate Le Fort I Osteotomy and zygomatic implantation without any graft placement for management of a cleft lip and palate patient. This case report describes oral rehabilitation of a 33-year-old patient with bilateral cleft lip-palate and oronasal fistula and atrophic pre-maxilla. As treatment, the patient received simultaneous Le Fort I osteotomy, palatoplasty and two zygomatic implant insertions. The prosthetic superstructure included zygomatic implant-supported removable hybrid prosthesis on bar locator and metal-ceramic fixed bridges in the posterior region. As conclusion, this protocol can be promising for management of patients with cleft lip-palate and malocclusion.

Simultaneous Le Fort I osteotomy and zygomatic implant placement.

The aim of this retrospective study was to evaluate the outcomes of simultaneous LeFort I osteotomy and zygomatic/dental implant placement for oral rehabilitation of patients with extremely atrophic/dysmorphic edentulous maxilla. Simultaneous LeFort I osteotomy and zygomatic/dental implant placement was performed with patient-specific anatomical models and surgical guides produced through three-dimensional virtual planning methods. All patients received their final prosthesis, with immediate loading, on the day after surgery. The primary outcome variables were the implant survival rate, and the incidence of intra/postoperative complications. In total, 15 zygomatic implants and 33 conventional dental implants were inserted in eight patients. The mean follow-up of the patients was 38.5 months. The implant survival rate was 93.3% for zygomatic implants and 100% for dental implants. No intra/postoperative complications were observed. Simultaneous LeFort I osteotomy associated with zygomatic/dental implant surgery can be considered as a valuable treatment option for rehabilitation of patients with extremely atrophic edentulous maxilla and esthetic issues of the face.

A Novel Guided Zygomatic and Pterygoid Implant Surgery System: A Human Cadaver Study on Accuracy.

The aim of this human cadaver study was to assess the accuracy of zygomatic/pterygoid implant placement using custom-made bone-supported laser sintered titanium templates. For this purpose, pre-surgical planning was done on computed tomography scans of each cadaver. Surgical guides were printed using direct metal laser sintering technology. Four zygomatic and two pterygoid implants were inserted in each case using the guided protocol and related tools. Post-operative computed tomography (CT) scans were obtained to evaluate deviations between the planned and inserted implants. Accuracy was measured by overlaying the real position in the post-operative CT on the virtual presurgical placement of the implant in a CT image. Descriptive and bivariate analyses of the data were performed. As a result, a total of 40 zygomatic and 20 pterygoid implants were inserted in 10 cadavers. The mean deviations between the planned and the placed zygomatic and pterygoid implants were respectively (mean ± SD): 1.69° ± 1.12° and 4.15° ± 3.53° for angular deviation. Linear distance deviations: 0.93 mm ± 1.23 mm and 1.35 mm ± 1.45 mm at platform depth, 1.35 mm ± 0.78 mm and 1.81 mm ± 1.47 mm at apical plane, 1.07 mm ± 1.47 mm and 1.22 mm ± 1.44 mm for apical depth. In conclusion, the surgical guide system showed accuracy for all the variables studied and allowed acceptable and accurate implant placement regardless of the case complexity.

Insertion of Zygomatic Implants with a Technical Modification of the Extrasinus Protocol: A Retrospective Case Series.

PURPOSE: The aim of this retrospective clinical case series report was to evaluate the outcomes of patients who underwent zygomatic implant surgery with a recent technical modification of the extrasinus surgical protocol. MATERIALS AND METHODS: The implant system presented in this study had a novel designed unthreaded body with a 12.5-mm sharp threaded apical end for obtaining maximum retention to the zygomatic bone. A total of 92 patients with severely atrophic maxillae were included in this study. All the patients were treated with a modification of the extrasinus protocol for insertion of 261 zygomatic implants. The mean follow-up of the patients was 34.5 ± 17.1 (SD) months (range: 6 to 72 months). The implant survival rate was the primary outcome. The intraoperative and postoperative complications were evaluated as additional criteria for success. RESULTS: The cumulative implant survival rate was 97.99%. Definitive or provisional prostheses were delivered on the same day of surgery, which resulted in an improvement in the quality of life of the patients. Five implants failed in four patients. No sinusitis or mucositis was seen in any of the patients. Eleven postoperative complications occurred in seven patients. CONCLUSION: The novel zygomatic surgery protocol introduced in this study can be an effective alternative to augmentation procedures and conventional implants, especially in cases of extremely atrophic posterior maxillae.

Zygomatic implant survival in 9 ectodermal dysplasia patients with 3.5- to 7-year follow-up.

OBJECTIVE: Ectodermal dysplasia syndrome is a complex group of genetic disorders identified by the abnormal development of the ectodermal structures. The aim of this retrospective clinical case series report was to evaluate the outcomes of the ectodermal dysplasia syndrome patients that underwent zygomatic implant surgery. MATERIALS AND METHODS: A total of 9 ectodermal dysplasia syndrome patients aged between 21 and 56 years (mean age 36.8) with severely atrophic maxilla were included in this study. All the patients were treated with a total of 19 zygomatic implants. The mean follow-up of the patients was 55 months (with a range of 44-84 months). The implant survival rate was evaluated as a primary outcome. The intra- and postoperative complications were evaluated as additional criteria for success. RESULTS: The overall implant survival rate was 100% without any complications. Final or provisional prosthesis was delivered on the same day of surgery, which resulted in an improvement of the quality of life of the patients. CONCLUSION: According to the results of this study, zygomatic surgery can be considered as a viable and safe alternative to conventional treatment modalities for oral rehabilitation of ectodermal dysplasia syndrome patients.

Clinical outcome of 302 zygomatic implants in 110 patients with a follow-up between 6 months and 7 years.

BACKGROUND: Zygomatic implant surgery is considered as a safe and successful alternative to the conventional implant surgery with bone grafts for patients with severe atrophic maxilla. PURPOSE: The aim of this retrospective clinical case series was to report clinical outcome of zygomatic implants with a follow-up between 6 months and 7 years. MATERIALS AND METHODS: A total of 110 patients with 302 zygomatic implants were included in this study. The intra and postoperative complications and survival rate of zygomatic implants were evaluated. RESULTS: The study included 110 consecutively treated patients with an age range of 21 to 76 years (mean 57.35 years, SD 10.42). The overall zygomatic implant survival rate was 98.34%. There were five implant failures in four patients. One intraoperative and 17 postoperative complications developed in 18 patients. There were no dropouts and the median follow-up of the patients was 41.75 months (with a range of 6-89 months). CONCLUSIONS: According to the results, in cases of severely atrophic posterior maxilla, zygomatic implant surgery can be considered as an effective and safe alternative to conventional implants and bone grafting procedures.

Full-Digital Workflow for Fabricating a Custom-Made Direct Metal Laser Sintering (DMLS) Mandibular Implant: A Case Report.

Direct Laser Metal Sintering (DLMS) is an additive manufacturing (AM) technique that is capable of manufacturing metal parts according to a three-dimensional (3D) design made using computer-assisted-design (CAD) software, thanks to a powerful laser beam that melts selectively micro-powder layers, one on top of the other, until the desired object is generated. With DMLS, it is now possible to fabricate custom-made titanium implants for oral and maxillofacial applications. We present the case of a 67-year-old woman diagnosed with a squamous cell carcinoma of the mandible. The patient underwent subtotal mandibular resection; conventional reconstruction procedures failed to rehabilitate the function of the mandible. A prosthesis replacing the resected mandible was designed and fabricated using a digital workflow. The extensive bone defect was rehabilitated with a prosthesis replacing the mandibular bone and supporting a morse-taper dental prosthesis. The masticatory function was reestablished.

Maxillary resection for cancer, zygomatic implants insertion, and palatal repair as single-stage procedure: report of three cases.

BACKGROUND: Oronasal/antral communication, loss of teeth and/or tooth-supporting bone, and facial contour deformity may occur as a consequence of maxillectomy for cancer. As a result, speaking, chewing, swallowing, and appearance are variably affected. The restoration is focused on rebuilding the oronasal wall, using either flaps (local or free) for primary closure, either prosthetic obturator. Postoperative radiotherapy surely postpones every dental procedure aimed to set fixed devices, often makes it difficult and risky, even unfeasible. Regular prosthesis, tooth-bearing obturator, and endosseous implants (in native and/or transplanted bone) are used in order to complete dental rehabilitation. Zygomatic implantology (ZI) is a valid, usually delayed, multi-staged procedure, either after having primarily closed the oronasal/antral communication or after left it untreated or amended with obturator. The present paper is an early report of a relatively new, one-stage approach for rehabilitation of patients after tumour resection, with palatal repair with loco-regional flaps and zygomatic implant insertion: supposed advantages are concentration of surgical procedures, reduced time of rehabilitation, and lowered patient discomfort. CASES PRESENTATION: We report three patients who underwent alveolo-maxillary resection for cancer and had the resulting oroantral communication directly closed with loco-regional flaps. Simultaneous zygomatic implant insertion was added, in view of granting the optimal dental rehabilitation. CONCLUSIONS: All surgical procedures were successful in terms of oroantral separation and implant survival. One patient had the fixed dental restoration just after 3 months, and the others had to receive postoperative radiotherapy; thus, rehabilitation timing was longer, as expected. We think this approach could improve the outcome in selected patients.

A case report of haemorrhagic-aneurismal bone cyst of the mandible.

Haemorrhagic-aneurismal bone cysts (HABCs) are quite rare, benign, non-neoplastic, expansive, and vascular locally destructive lesions. They are generally considered sequelae of an earlier trauma causing an overflow of blood into the bone. HABCs are classified as pseudocysts and they should be differentiated from true cysts because their treatment is different. Since few of these cysts involve subjective symptoms, most are discovered accidentally during radiography, while a sure diagnosis is likely to be obtained only during surgery, on discovery of a non-epithelialised cavity. Here, we report a typical case of a haemorrhagic-mandibular cyst in a 13-year-old girl, which was treated by opening the cavity and scraping its walls following diagnostic arteriography and post-operative transcutaneous intralesional embolization. No further complications were recorded in the post-operative period, although the convalescence lasted for a time longer than expected, because of anemia. No further surgery was performed. She has been disease-free for two years. Evaluation of intralesional blood flow is important for HABCs because of the hemorrhagic risk in surgery. Embolization seems to be a useful procedure in the treatment of HABCs and could be tried as the treatment modality in the standard protocol for the treatment of HABCs.

A case of lipoma of lateral anterior neck treated with surgical enucleation.

Lipoma arise in almost 50% of all soft tumours. The neck lipomas are rare tumours that may present as painless masses with slow growth, in the lateral portions of the neck. Some lipomas, such as the one studied in our case, grow deep in the subcutaneous tissue, in close contact with muscles. Here, we report a case of lipoma extending from pre-tragal region up to the ascending branch of the mandible in a 62 year old man, treated with enucleation. The inferior margin of lipoma involved the pharyngeal and the superior margin was achieved by the top of the skull base. The mass of lipoma caused breathing difficulties in the patient, preventing regular sleep. No complication was recorded in the post-operative period and no further surgery was performed. The complete resolution after one year's follow-up, together with the rarity of the anatomical site, makes this case worthy of description. A correct diagnosis facilitated removal of this lesion with a surgical method.

A case of mandible osteonecrosis after a severe periimplant infection.

The term osteonecrosis has been applied to describe the presence of a persistent inflammation of the mouth, osteomyelitis, delayed healing of extraction sockets, development of sequestra or presence of fistulae from the mouth to the lower skin. Here, we document a case of mandible osteonecrosis that developed in a patient after a severe periimplant infection. Osteonecrosis, severe inflammatory osteolysis, and heavy bacterial colonization were found. Surgical toilette and hyperbaric oxygen therapy permitted complete healing of the case. No complication was recorded in the post-operative period and no further surgery was performed. The clinical follow up and the imaging after one year showed a complete 'restitution ad integrum' of the mandible. Although the risk of developing osteonecrosis of the jaw for oral implants is low, the devastating complications still require caution.

A rare case of rynopharyngeal melanoma.

Primary mucosal melanomas (MM) of the head and neck region constitute 0.5-2% of all malignant melanomas. The rynopharynx is a region that is less often involved by malignant melanomas. Because most of mucosal melanotic lesions are painless in their early stages, the diagnosis is unfortunately often delayed until symptoms resulting from ulceration, growth, and/or bleeding are noted. Here, we document the rare case of a malignant rynopharynx melanoma of a 43 year old woman. Its treatment and the pertinent literature are discussed. No complication was recorded in the post-operative period and no further surgery was performed. The follow up showed no recurrence in the same position and with the same characteristics, even after six years. Mucosal melanomas are aggressive tumours and the prognosis in these patients is poor. Clinicians must use treatment strategies that provide functional benefit, so as to maintain quality of life without excessive toxicity.

Computer planning and bone density evaluation of jaws reconstructed with bone grafts from living donors.

Bone augmentation to reconstruct atrophic jaws provides the base for sufficient functional and aesthetic implant-supported oral rehabilitation. Although autografts are the standard procedure for bone grafting, the use of homolog bone provides a reasonable alternative because it is safe, cheap, and available in adequate amount. Five patients were grafted with femur bone derived from living donors, and in 2 of them, 16 implants were inserted after 6 months. Pearson χ test was used to investigate the difference in bone density (BD) between native and grafted bone and between peri-implant and bone far from fixtures. The BD of the grafted bone is about double that of the native bone. Peri-implant BD is higher than BD far from fixtures, demonstrating that implant loading increase BD. Computed tomography is a valuable and accurate preoperative and follow-up method to obtain information about bone quality and quantity (ie, volume of available bone). Femur graft has a high density that improves under loading, thus suggesting that early implant loading should be performed whenever possible. However, a larger implant series and a longer observation period are mandatory to have a stronger support to these preliminary data.

Spiral implants bearing full-arch rehabilitation: analysis of clinical outcome.

A spiral implant (SPI) is a conical internal helix implant with a variable thread design which confers the characteristic of self drilling, self tapping, and self bone condensing. The effectiveness of this type of implant has been reported in several clinical situations. However, because there are no reports that specifically focus on one of the biggest challenges in oral rehabilitation, that is, full arch rehabilitation, it was decided to perform a retrospective study. The study population was composed of 23 patients (12 women and 11 men, median age 57 years) for evaluation and implant treatment between January 2005 and June 2009. Two-hundred six spiral family implants (SFIs) were inserted with a mean postloading follow-up of 23 months. Several variables were investigated: demographic (age and gender), anatomic (maxilla and mandible, tooth site), implant (type, length, and diameter), surgical (surgeon, postextractive, flapless technique, grafts), and prosthetic (implant/crown ratio, dentition in the antagonist arch, type of loading, and computerized tomography [CT] planning) variables. Implant loss and peri-implant bone resorption were evaluated. Univariate and multivariate tests were performed. Survival and success rates were 97.1% and 82.5%, respectively. Only implant length and implant/crown ratio showed statistical significance in determining a better clinical outcome. In conclusion, SFIs are a reliable tool for the most difficult cases of oral rehabilitation. No differences were detected among implant type. Length and implant/crown ratio can influence the crestal bone resorption with better result for longer fixtures and a higher implant/crown ratio. In addition, banked bone derived from living donors can be used to restore alveolar ridge augmentation without adverse effects. Finally, flapless and CT-planned surgery did not significantly increase the clinical outcome in most complex rehabilitation.

Implant treatment in grafted and native bone in patients affected by ectodermal dysplasia.

Ectodermal dysplasia (ED) is a congenital syndrome characterized chiefly by abnormalities of tissues of ectodermal origin, namely skin, nails, hair, and teeth. Dental treatment of patients with ED is necessary because it affords the opportunity to develop normal forms of speech, chewing, swallowing, and normal facial support. Because there are few reports focusing on implants inserted in bone grafted in patients with ED, we therefore performed a retrospective study on 44 implants inserted in 4 patients to detect those variables acting on survival and crestal bone remodeling around implant neck in such subjects. Forty-four fixtures were analyzed. Several patient-related (age and sex), anatomic (maxilla and mandible and tooth site), implant (type, length, and diameter), surgical (sites and types of grafts), and prosthetic (type of loading) variables were investigated. Implant failure and peri-implant bone resorption were considered as predictors of clinical outcome. Kaplan-Meier algorithm and Cox regression were then performed to detect those variables statistically associated with the clinical outcome. Implant length and diameter ranged from 11.5 to 15 mm and from 3.5 to 4.0 mm, respectively. Implants were inserted to replace 12 incisors, 12 cuspids, 11 premolars, and 9 molars. No implant was lost. On the contrary, implant's length, grafted sites, and type of loading affected univariate analysis, but these data were not confirmed by multivariate algorithm. Dental implants and bone grafts to orally rehabilitate patients with ED are valuable devices with no difference if compared with unaffected patients, at least in adults.

Implant rehabilitation in grafted and native bone in patients affected by ectodermal dysplasia: evaluation of 78 implants inserted in 8 patients.

OBJECTIVES: Ectodermal dysplasia (ED) is a congenital syndrome characterized chiefly by abnormalities of tissues of ectodermal origin, namely skin, nails, hair, and teeth. Dental treatment of patients with ED is necessary, because it affords the opportunity to develop normal forms of speech, chewing, swallowing, and normal facial support. Because there are few reports focusing on implants inserted in bone grafted in patients affected by ED. This is a retrospective study of 78 implants inserted in 8 patients to detect those variables acting on survival and crestal bone remodeling around the implant neck in such subjects. MATERIALS: Seventy-eight fixtures were analyzed. Several patient-related (age and gender), anatomical (maxilla and mandible, tooth site), implant (type, length, and diameter), surgical (sites and types of grafts), and prosthetic (type of loading and implant/crow ratio) variables were investigated. Implant failure and peri-implant bone resorption were considered as predictors of clinical outcome. Kaplan-Meier algorithm and Cox regression were then performed to detect those variables statistically associated with the clinical outcome. RESULTS: Implant length and diameter ranged from 11.5 to 18 mm and from 3.5 to 6.0 mm, respectively. Implants were inserted to replace 19 incisors, 19 cuspids, 21 premolars, and 19 molars. One implant was lost. On the contrary, implant' length, grafted sites, and type of loading have an impact on univariate analysis, but this datum was not confirmed by multivariate algorithm. CONCLUSION: The use of dental implants and bone grafts to orally rehabilitate patients affected by ED is a valuable service with no difference in the results compared with unaffected patients, at least in adults.