Validation of cone-beam computed tomography as a predictor of osteoporosis using the Klemetti classification

Abstract This study aimed at evaluating the validity of cone-beam computed tomography (CBCT) for assessing mandibular bone quality using the Klemetti classification. The morphology of the endosteal mandibular cortex of 30 (60 hemi-mandibles) postmenopausal women between the ages of 45 and 80 years was evaluated based on the Klemetti classification in panoramic radiographs used as reference images. Afterwards, panoramic reconstruction and cross-sectional slices of CBCT examinations of these patients were analyzed and categorized according to the same classification. All the images were assessed by two oral radiologists. The McNemar-Bowker test compared the agreement between the CBCT images and the reference images. No differences were found between the diagnostic results based on panoramic radiography and panoramic reconstruction. However, the mean scores for the cross-sectional evaluation were higher, and the results, statistically different from the others. Based on the disagreement found between the panoramic radiographs and the CBCT cross-sectional slices, the Klemetti classification is not an adequate means of assessing bone quality with CBCT. On the other hand, the higher values found for the cross-sectional slices could be associated with better visibility on the CBCT images.

Disease Stage and Mode of Therapy Are Important Determinants of Treatment Outcomes for Medication-Related Osteonecrosis of the Jaw.

PURPOSE: The treatment of patients with medication-related osteonecrosis of the jaw (MRONJ) is challenging. The purpose of the present study was to estimate the frequency and identify the factors associated with clinical improvement during treatment. PATIENTS AND METHODS: We designed and implemented a retrospective cohort study and enrolled a sample of subjects diagnosed with MRONJ between 2004 and 2015. The primary predictor variables were a set of heterogeneous variables grouped into the following categories: demographic (age and gender) and clinical (location of necrosis, therapy duration, medication type, disease stage, and treatment type). The primary outcome variable was the treatment outcome, defined as stable or worse and improved or healed. The descriptive, bivariate, and multiple logistic statistics were computed, and statistical significance was defined as P < .05. RESULTS: The sample included 337 subjects with a mean age of 68.9 years. Of the 337 subjects, 256 were women (76%). A total of 143 patients (42.2%) experienced spontaneous necrosis. Twenty-four (7.1%) had had exposure to targeted antiangiogenic agents. Those with stage 1 or 2 disease were more likely to have better outcomes than those with stage 3 disease (stage 1, adjusted odds ratio [OR] 3.4, P = .005; stage 2, adjusted OR 2.2, P = .03). Treatment type was a significant variable. Subjects undergoing surgery were 28 times more likely to have a positive outcome than those receiving nonoperative therapy (adjusted OR 28.7, P < .0001). CONCLUSIONS: Subjects with MRONJ who presented with less severe disease or who underwent operative treatment were most likely to have improvement or complete healing of their MRONJ-related lesions.

Retrospective analysis of osteoradionecrosis of the mandible: proposing a novel clinical classification and staging system.

Osteoradionecrosis of the jaw is a common radiation-induced complication that may be observed in oral cancer patients. Several classifications and staging systems have been proposed for osteoradionecrosis of the mandible based on clinical symptoms, radiological findings, and/or the response to diverse treatments. However, none has been universally accepted because of their individual deficiencies. The aim of this study was to introduce a new clinical classification that can be applied to the treatment of osteoradionecrosis in an easier and more acceptable way, through a retrospective analysis of patients with osteoradionecrosis of the mandible. A review was conducted of 99 patients diagnosed with osteoradionecrosis of the mandible in the study institution between 2000 and 2013. A novel classification was established on the basis of bone necrosis and soft tissue defects. A new staging system with four different stages (stage 0, stage I, stage II, and stage III) is proposed. We believe that this new classification and staging system is easier and more acceptable for clinical evaluation than previous ones.

Osteoradionecrosis of the mandible: A ten year single-center retrospective study.

BACKGROUND: Numerous factors have been associated with the development of osteoradionecrosis (ORN) of the jaws. The purpose of this study was to investigate the factors that are linked to the severity of mandibular ORN. METHODS: A retrospective study was conducted which included all ORN cases treated in the Department of Oral and Maxillofacial Surgery in Munich (LMU) between 2003 and 2012. The cases were categorized according to the necrosis stage and several variables were evaluated in order to identify possible correlation between them and the severity of the necrosis. RESULTS: A total of 115 patients with 153 osteonecrosis lesions were included in the study. Twenty-three cases were of stage I, 31 were of stage II and 99 were of stage III. The initial tumors were predominantly located in the floor of the mouth, the tongue or the pharynx. Diabetes mellitus (OR: 4.955, 95% Cl: 1.965-12.495), active smoking (OR: 13.542, 95% Cl: 2.085-87.947), excessive alcohol consumption (OR: 5.428, 95% Cl: 1.622-18.171) and dental treatment and/or local pathological conditions (OR: 0.237, 95% Cl: 0.086-0.655) were significant predictors for stage III necrosis. CONCLUSIONS: The aforementioned factors are predictive of ORN severity and can guide its prophylaxis and management.

Sclerosis in bisphosphonate-related osteonecrosis of the jaws and its correlation with the clinical stages: study of 43 cases.

We analysed the degree of sclerosis in the different stages of bisphosphonate-related osteonecrosis of the jaws (BRONJ) and studied the relation between the grade of sclerosis, the clinical symptoms, and the depth of lucency. We compared 43 patients with mandibular BRONJ with a control group of 40 cases with no bony lesions. The presence of sclerotic bone, cortical irregularities, radiolucency, fragmentation or sequestration, periostitis, and narrowing of the mandibular canal were studied from computed tomographic (CT) scans using the program ImageJ 1.47v (National Institute of Health, Bethesda, USA) to measure the radiolucency, width of the cortices, and degree of sclerosis. Patients with BRONJ had more severe sclerosis than controls (p<0.01). There was also a significant difference among the different stages of BRONJ, with the highest values found in stage III (p=0.02). The degree of sclerosis differed according to sex, type of bisphosphonate, and the clinical characteristics such as pain, or suppuration, but not significantly so (p>0.05). We conclude that the degree of sclerosis increases with the clinical stage of BRONJ, and is correlated with the depth of lucency.

Is mandibular asymmetry more frequent and severe with unilateral disc displacement?

PURPOSE: To investigate the prevalence of mandibular asymmetry (MA) within the symptomatic unilateral anterior disc displacement (ADD) patients, and analyze the influence TMJ factors of the MA severity. METHODS: Patients aged under 20 years old with symptomatic unilateral ADD and asymptomatic volunteers with normal disc-condyle relationship diagnosed by magnetic resonance imaging (MRI) were included in this study. Posteroanterior cephalometric radiographs were taken to measure MA. Condylar height, disc length and disc displacement were measured by MRI. The prevalence and severity of MA were compared between the ADD and the control groups. The correlation between the severity of MA with the amount of condylar height shortage, disc deformity and distance of disc displacement were also evaluated within the ADD group. RESULTS: There were 165 cases in the unilateral ADD group, and 156 cases in the control group. One hundred and nineteen cases had MA which accounted 72.12% (119/165) in the ADD group; while in the control group, only 25.64% (40/156) exhibited MA. The mean horizontal menton deviation and condylar height shortage in the unilateral ADD group were significantly larger than that in the control group (5.62 mm vs. 4.19 mm; 3.14 mm vs. 1.32 mm, p < 0.01). The severity of MA was significantly correlated with the amount of disc displacement, disc deformity and condylar height shortage (correlation coefficient: 0.80, 0.70, and 0.82). CONCLUSION: MA is much more common and severe in young unilateral ADD patients. The severity of MA is correlated with the height of condyle and the status of the disc.

Leucocyte-rich and platelet-rich fibrin for the treatment of bisphosphonate-related osteonecrosis of the jaw: a prospective feasibility study.

Our aim was to assess the feasibility of using leucocyte-rich and platelet-rich fibrin (L-PRF) for the treatment of bisphosphonate-related osteonecrosis of the jaw (BRONJ) in a single group study. After treatment with L-PRF, the response of each patient was recorded 1 month and 4 months postoperatively. Further assessments were made of the site, stage, concentration of c-terminal crosslinked telopepide of type 1 collagen, and actinomycosis. Among the total of 34 patients, 26 (77%) showed complete resolution, 6 (18%) had delayed resolution, and 2 (6%) showed no resolution. There was a significant association between the response to treatment and the stage of BRONJ (p=0.002) but no other significant associations were detected. This study has shown that it is feasible to use L-PRF for the treatment of BRONJ, but the effectiveness cannot be judged with this study design. Randomised prospective trials are needed to confirm this.

Occurrence of spontaneous periodontal disease in the SAMP1/YitFc murine model of Crohn disease.

BACKGROUND: Oral involvement is often associated with inflammatory bowel disease (IBD). Recent evidence suggests a high incidence of periodontal disease in patients with Crohn disease (CD). To the best of the authors' knowledge, no animal model of IBD that displays associated periodontal disease was reported previously. The aim of this study is to investigate the occurrence and progression of periodontal disease in SAMP1/YitFc (SAMP) mice that spontaneously develop a CD-like ileitis. In addition, the temporal correlation between the onset and progression of periodontal disease and the onset of ileitis in SAMP mice was studied. METHODS: At different time points, SAMP and parental AKR/J (AKR) control mice were sacrificed, and mandibles were prepared for stereomicroscopy and histology. Terminal ilea were collected for histologic assessment of inflammation score. Periodontal status, i.e., alveolar bone loss (ABL) and alveolar bone crest, was examined by stereomicroscopy and histomorphometry, respectively. RESULTS: ABL increased in both strains with age. SAMP mice showed greater ABL compared with AKR mice by 12 weeks of age, with maximal differences observed at 27 weeks of age. AKR control mice did not show the same severity of periodontal disease. Interestingly, a strong positive correlation was found between ileitis severity and ABL in SAMP mice, independent of age. CONCLUSIONS: The present results demonstrate the occurrence of periodontal disease in a mouse model of progressive CD-like ileitis. In addition, the severity of periodontitis strongly correlated with the severity of ileitis, independent of age, suggesting that common pathogenic mechanisms, such as abnormal immune response and dysbiosis, may be shared between these two phenotypes.

Staging of osteonecrosis of the jaw requires computed tomography for accurate definition of the extent of bony disease.

Management of osteonecrosis of the jaw associated with antiresorptive agents is challenging, and outcomes are unpredictable. The severity of disease is the main guide to management, and can help to predict prognosis. Most available staging systems for osteonecrosis, including the widely-used American Association of Oral and Maxillofacial Surgeons (AAOMS) system, classify severity on the basis of clinical and radiographic findings. However, clinical inspection and radiography are limited in their ability to identify the extent of necrotic bone disease compared with computed tomography (CT). We have organised a large multicentre retrospective study (known as MISSION) to investigate the agreement between the AAOMS staging system and the extent of osteonecrosis of the jaw (focal compared with diffuse involvement of bone) as detected on CT. We studied 799 patients with detailed clinical phenotyping who had CT images taken. Features of diffuse bone disease were identified on CT within all AAOMS stages (20%, 8%, 48%, and 24% of patients in stages 0, 1, 2, and 3, respectively). Of the patients classified as stage 0, 110/192 (57%) had diffuse disease on CT, and about 1 in 3 with CT evidence of diffuse bone disease was misclassified by the AAOMS system as having stages 0 and 1 osteonecrosis. In addition, more than a third of patients with AAOMS stage 2 (142/405, 35%) had focal bone disease on CT. We conclude that the AAOMS staging system does not correctly identify the extent of bony disease in patients with osteonecrosis of the jaw.

Outcomes of osseous free flap reconstruction in stage III bisphosphonate-related osteonecrosis of the jaw: systematic review and a new case series.

INTRODUCTION: There is currently no gold standard for the treatment of Stage III bisphosphonate-related osteonecrosis of the jaw (BRONJ). The question remains whether osseous reconstruction can offer an additional gain in outcome given the theoretical risk of non-union at the resection margins and recurrence in the osseous free flap. The objective was to conduct a systematic review of articles describing outcomes of osseous microsurgical reconstruction in cases of BRONJ with a minimum follow-up of 12 months, and to present the long-term outcomes of a new case series of three patients. MATERIAL AND METHODS: A multi-database QUORUM-based single-reviewer systematic review identified eight papers that fulfilled the selection criteria. There are only case series and case reports available (Level 4 of the Oxford Evidence-based medicine scale). A total of 31 patients were analysed including the cases described in this article. CONCLUSION: The limited overall rate of non-union at the resection margins and the 6.5% recurrence rate of BRONJ in the transplant counters the theoretical objections and advocates for considering osseous free flap reconstruction in the treatment of refractory BRONJ Stage III lesions. However, additional data derived from larger case series or case-control studies are imperative to support this hypothesis.

Changing trends and the role of medical management on the outcome of patients treated for osteoradionecrosis of the mandible: experience from a regional head and neck unit.

This study is a retrospective review of treatment outcomes of osteoradionecrosis (ORN) of the mandible with specific reference to the evolving role of medical management with pentoxifylline, tocopherol, and doxycycline. We reviewed the presentation and management of 71 patients treated for ORN of the mandible at the regional head and neck unit during a 15-year period to January 2011, and categorised them into three grades using the Notani classification: grade I (n=28), grade II (n=16), and grade III (n=27). Twelve patients with grade I ORN, 3 with grade II, and 10 with grade III, were prescribed medical treatment. Of these, three with grade I, and two with grade II ORN were cured, and progression of the disease had halted and there was satisfactory control of symptoms in eight with grade I and four with grade III disease. Patients who failed to respond to conservative treatment were further analysed for the need for free flap reconstruction. Medical management was introduced as a standard treatment in January 2006. Of the 39 patients diagnosed before this, 20 (51%) required resection and free flap reconstruction compared with only 8/32 (25%) after it had been introduced.

A simple evaluation method for early detection of bisphosphonate-related osteonecrosis of the mandible using computed tomography.

OBJECTIVES: The aim of this study was to establish a simple method for the early detection of bisphosphonate-related osteonecrosis of the jaw (BRONJ) using computed tomography (CT). MATERIALS AND METHODS: CT images of the mandible were obtained from a total of 20 patients with BRONJ and 20 control subjects. BRONJ was classified into 2 groups, with bone exposure (Stage 1-3 BRONJ) or without (Stage 0 BRONJ). In each patient, 15 transaxial CT images were selected and 30 configured regions of interest (ROI) were identified. The ANOVA test was applied to test the relationship between the severity of systemic risk factors. RESULTS: Regarding the local status of the mandible, significant differences were observed among the Stage 0 BRONJ, Stage 1-3 BRONJ, non-BRONJ and control groups in the cancellous bone CT radiodensity values, but there were no significant differences between the Stage 0 and Stage 1-3 BRONJ groups. In the cortical bone widths, significant differences were observed only between BRONJ and the controls. CONCLUSIONS: Measuring cancellous bone CT radiodensity value has the potential to be a simple and quantitative method to detect the early stages of BRONJ.

A classification system for conditions causing condylar hyperplasia.

A classification system was developed to place patients with condylar hyperplasia (CH) into categories based on histology, clinical and imaging characteristics, effects on the jaws and facial structures, and rate of occurrence. Four major categories were defined. CH type 1 is an accelerated and prolonged growth aberration of the "normal" mandibular condylar growth mechanism, causing a predominantly horizontal growth vector, resulting in prognathism that can occur bilaterally (CH type 1A) or unilaterally (CH type 1B). CH type 2 refers to enlargement of the mandibular condyle caused by an osteochondroma, resulting in predominantly unilateral vertical overgrowth and elongation of the mandible and face. One of the forms has predominantly a vertical growth vector and condylar enlargement, but without exophytic tumor extensions (type 2A), whereas the other primary form grows vertically but develops horizontal exophytic tumor growth off of the condyle (CH type 2B). CH type 3 includes other rare, benign tumors and CH type 4 includes malignant conditions that originate in the mandibular condyle causing enlargement. The order of classification is based on occurrence rates and type of pathology, where CH type 1A is the most commonly occurring form and CH type 4 is the rarest. This classification system for CH pathology should help the clinician understand the nature of the pathology, progression if untreated, recommended ages for surgical intervention to minimize adverse effects on subsequent facial growth and development in younger patients, and the surgical protocols to comprehensively and predictably treat these conditions.

Soft diet causes greater alveolar osteopenia in the mandible than in the maxilla.

OBJECTIVE: To investigate changes in the bony microstructure of the upper and lower alveolar bone during masticatory loading induced by soft diet feeding in growing rats. DESIGN: Three-week-old male Wistar rats were randomly divided into two groups. Rats were fed with either pellets [control group (n=6)] or a soft diet [experimental group (n=6)] for nine weeks. 3D-microstructure of the alveolar bone of the first molar region (M1) was examined by micro-CT analysis. RESULTS: Micro-CT images showed increased marrow spaces of the inter-radicular alveolar bone around the rat mandibular M1 in the experimental group compared with that in the control group. The bone volume/tissue volume ratio, trabecular thickness, trabecular number, mean intercept length, trabecular width and trabecular star volume for the mandibular M1 inter-radicular alveolar bone were lower in the experimental group than in the control group. Marrow space star volume was increased in the experimental group compared with the control group. CONCLUSIONS: These results suggest that alveolar osteopenia is more extensive in the mandible than the maxilla in rats that experience low masticatory loading during growth.

Comparative evaluation of guided tissue regeneration with use of collagen-based barrier freeze-dried dura mater allograft for mandibular class 2 furcation defects (a comparative controlled clinical study).

AIM: The aim of periodontal surgery is complete regeneration. The present study was designed to evaluate and compare clinically soft tissue changes in form of probing pocket depth, gingival shrinkage, attachment level and hard tissue changes in form of horizontal and vertical bone level using resorbable membranes. MATERIALS AND METHODS: Twelve subjects with bilateral class 2 furcation defects were selected. After initial phase one treatment, open debridement was performed in control site while freezedried dura mater allograft was used in experimental site. Soft and hard tissue parameters were registered intrasurgically. Nine months reentry ensured better understanding and evaluation of the final outcome of the study. RESULTS: Guided tissue regeneration is a predictable treatment modality for class 2 furcation defect. There was statistically significant reduction in pocket depth as compared to control (p < 0.01). There is statistically significant increase in periodontal attachment level within control and experimental sites showed better results (p < 0.01). For hard tissue parameter, significant defect fill resulted in experimental group, while in control group, less significant defect fill was found in horizontal direction and nonsignificant defect fill was found in vertical direction. CONCLUSION: The results showed statistically significant improvement in soft and hard tissue parameters and less gingival shrinkage in experimental sites compared to control site. CLINICAL SIGNIFICANCE: The use of FDDMA in furcation defects helps us to achieve predictable results. This cross-linked collagen membrane has better handling properties and ease of procurement as well as economic viability making it a logical material to be used in regenerative surgeries.

Odontogenic keratocyst: a case report and review of an old lesion with new classification.

The odontogenic keratocyst (OKC) is distinctive among jaw cysts given its tendency toward recurrence and aggressive clinical behavior. This paper presents a well-documented case of OKC and a review of the diagnostic features, treatment modalities and new evidence supporting the reclassification and renaming of this unique pathologic process.

Giant cell lesions of the jaws: does the level of vascularity and angiogenesis correlate with behavior?

PURPOSE: To compare vascularity and angiogenic activity in aggressive and nonaggressive giant cell lesions (GCLs) of the jaws. MATERIALS AND METHODS: This is a retrospective study of 14 GCLs treated at the University of California, San Francisco. Immunohistochemistry was used to determine of the expression of vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), CD34, and CD31. VEGF and bFGF expression in giant cells (GCs) and surrounding mononuclear stroma was classified into 1) high immunoreactivity (>50% staining) and 2) low immunoreactivity (<50% staining). CD31- and CD34-stained vessels were counted at 200× magnification. Clinical and radiographic records were reviewed to classify lesions as aggressive or nonaggressive. RESULTS: Of the lesions, 8 were aggressive and 6 were nonaggressive. High VEGF expression was found within the GCs in 4 of 8 aggressive lesions compared with 1 of 6 nonaggressive lesions. The stroma in both groups had low staining. High staining of the GCs for bFGF was found in 6 of 8 aggressive lesions compared with 3 of 6 nonaggressive lesions. The stroma of all aggressive cases showed high expression of bFGF compared with 3 of 6 nonaggressive cases. The aggressive group had a mean of 20.1 ± 5.4 vessels/high-powered field (hpf) stained for CD31 compared with 11.5 ± 5.6 vessels/hpf in the nonaggressive group. The aggressive group had 24.6 ± 7.0 vessels/hpf stained with CD34 compared with 18.5 ± 4.0 vessels/hpf in the nonaggressive group. CONCLUSIONS: The vascularity and level of angiogenesis within aggressive GCLs are higher than those in nonaggressive lesions.

Florid osseous dysplasia: report of two cases and a review of the literature / Displasia ósea florida: reporte de dos casos y revisión de la literatura

Florid osseous dysplasia (FOD) is a benign condition of the jaws in which the normal architecture of bone is replaced by a fibrous tissue containing a variable amount of bone and cementum-like tissue. This lesion is most commonly seen in middle aged black women. FOD appears as dense, lobulated masses, often symmetrically located in the mandible, rarely in the maxilla. The lesion is usually asymptomatic and benign. However, a secondary infection may occur and its treatment can be difficult and complicated. This paper reports the case of two patients. The first one is a white woman aged 65 and the second one is a black woman aged 70, both diagnosed with FOD, revealed by secondary infections. The diagnosis was based on clinical and radiographic findings, as biopsy is contraindicated. Radiological and clinical features of FOD and its management will be also discussed on the basis of recent literature.

La displasia ósea florida (DOF) es una patología benigna del maxilar y mandíbula en la que se sustituye la arquitectura normal del hueso por un tejido fibroso que contiene una cantidad variable de tejido óseo y cementoide. Esta lesión es más frecuente en mujeres negras de edad media. La DOF aparece como una masa densa, lobulada, a menudo situada simétricamente en la mandíbula, rara vez en el maxilar. La lesión suele ser asintomática y benigna. Sin embargo, una infección secundaria puede ocurrir y su tratamiento puede ser difícil y complicarse. Este artículo reporta el caso de dos pacientes. La primera es una mujer blanca de 65 años y la segunda es una mujer negra de 70 años, ambas diagnosticadas con DOF, revelada por infecciones secundarias. El diagnóstico se basó en los hallazgos clínicos y radiológicos, ya que la biopsia está contraindicada. Las características clínicas y radiológicas de la DOF y su manejo son discutidos en base a la literatura reciente.

Free flap reconstruction of osteoradionecrosis of the mandible: a 10-year review and defect classification.

BACKGROUND: The purpose of this study was to evaluate outcomes of free flap reconstruction for advanced osteoradionecrosis (ORN) defects and develop an algorithm to guide surgical planning. METHODS: All cases involving free flap reconstruction for ORN of the mandible between 1998 and 2008 were reviewed. A defect classification scheme was developed. Flap selection and outcomes were analyzed and evaluated by defect type. RESULTS: Seventy-five free flaps and 13 pedicle flaps were performed in 63 patients. Total flap loss was 5%. Overall surgical complication was 32%. Complication rates were higher with bone flaps than with soft tissue flaps (p = .018). A full oral diet was tolerated in 57% of patients, whereas 26% required partial tube feeding, and 16% were tube-feeding dependent. CONCLUSION: Free flap reconstruction of advanced ORN defects can be safely performed in a variety of flap configurations with good outcomes. The classification scheme may assist in flap selection.

Expansive osseous dysplasia: report of 9 lesions in an African population sample and a review of the literature.

OBJECTIVES: The aim of this study was to report on the clinicopathologic features of osseous dysplasias (ODs) that manifest with gross expansion in a black South African hospital population sample. STUDY DESIGN: The files of 9 histology-verified expansive ODs in 8 patients were reviewed. The clinical records and radiographs were analyzed and compared with reports in the literature. RESULTS: The main complaint of all patients was related to expansion of the jaw. All except 1 were female, with ages between 26 and 71 years and sizes of the lesions ranging from 4 to 15 cm. No history of similar lesions in family members was obtained. All lesions occurred in the mandible and 6 crossed the midline. The expansive growth pattern was associated with persistence of radiolucent areas in the lesions which microscopically consisted of cellular fibro-osseous tissue. Resorption of mineralized deposits by osteoclasts was prominent in the radiolucent parts of the lesion. Maturation with enlargement of the radiodense component was associated with a decrease in osteoclast activity and the formation of lobular bone masses and confluent psammomatous mineralized deposits. CONCLUSION: We propose the term "expansive osseous dysplasia" for the rare albeit important clinical subcategory of ODs that manifest with progressive jaw expansion. Suspension of osteoclast activity plays an important role in the maturation of the lesions into dense mineralized masses.