Virtual planning for mandible resection and reconstruction.

In mandibular reconstruction, computer-assisted procedures, including virtual surgical planning (VSP) and additive manufacturing (AM), have become an integral part of routine clinical practice. Especially complex cases with extensive defects after ablative tumor surgery benefit from a computer-assisted approach. Various CAD/CAM-manufactured tools such as surgical guides (guides for osteotomy, resection and predrilling) support the transition from virtual planning to surgery. Patient-specific implants (PSIs) are of particular value as they facilitate both osteosynthesis and the positioning of bone elements. Computer-based approaches may be associated with higher accuracy, efficiency, and superior patient outcomes. However, certain limitations should be considered, such as additional costs or restricted availability. In the future, automation of the planning process and augmented reality techniques, as well as MRI as a non-ionizing imaging modality, have the potential to further improve the digital workflow.

Evaluation of one-piece zirconia dental implants: An 8-year follow-up study.

OBJECTIVES: Long-term studies of modern zirconia implants are still insufficient. This prospective 8-year follow-up study investigated one-piece zirconia implants. MATERIALS AND METHODS: Patients who had received a one-piece zirconia dental implant (PURE ceramic implant, Institut Straumann GmbH, Basel, Switzerland) were included in this study. Next to the implant survival and success rates, the radiographic and clinical implant parameters were assessed. RESULTS: The overall survival rate of 67 zirconia implants in 39 patients was 100%. The overall success rate was 89.6%. Around the immediate zirconia implants, the success rate was 94.7%, and around the delayed implants, 87.5%. The immediate implants showed a significantly higher bone crest compared to the delayed implants (p = 0.0120). According to the pink esthetic score, the immediate implants revealed more favorable esthetic results compared to the delayed implants after an 8-year follow-up (p = 0.0002). CONCLUSIONS: After 8 years, the one-piece zirconia implants presented an 89.6% success rate. Regarding the timing of implantation, in individual cases, immediate implantation can have slight advantages over delayed implantation. CLINICAL RELEVANCE: Immediate implants can also be considered for zirconia implants and should not be excluded on principle.

The Global Impact of COVID-19 on Craniomaxillofacial Surgeons: A Follow-Up Survey After One Year.

Study Design: Comparative cross-sectional. Objective: To measure the impact that COrona VIrus Disease-19 (COVID-19) has had on craniomaxillofacial (CMF) surgeons after 1 year and compare it with 2020 data by (1) measuring access to adequate personal protective equipment (PPE), (2) performance of elective surgery, and (3) the vaccination status. This should be investigated because most CMF surgeons felt that hospitals did not provide them with adequate PPE. Methods: The investigators surveyed the international AO CMF membership using a 30-item online questionnaire and compared it to a previous study. The primary predictor variable was year of survey administration. Primary outcome variables were availability of adequate personal protective equipment (adequate/inadequate), performance of elective surgery (yes/no), and vaccination status (fully vaccinated/partly vaccinated/not vaccinated). Descriptive and analytic statistics were computed. Binary logistic regression models were created to measure the association between year and PPE availability. Statistical significance level was set at P < .05. Results: The sample was composed of 523 surgeons (2% response rate). Most surgeons reported access to adequate PPE (74.6%). The most adequate PPE was offered in Europe (87.8%) with the least offered in Africa (45.5%). Surgeons in 2021 were more likely to report adequate PPE compared to 2020 (OR 3.74, 95% CI [2.59-4.39]). Most of the respondents resumed elective surgery (79.5% vs 13.3% in 2020) and were fully vaccinated (59.1%). Conclusions: Most CMF surgeons now have access to adequate PPE, resumed elective surgery, and are either fully or partly vaccinated. Future studies should investigate the long-term impact of the fast-evolving COVID-19 pandemic on CMF surgeons.

Surgical treatment of medication-related osteonecrosis of the upper jaw: Case series.

PURPOSE: The management of maxillary medication-related osteonecrosis of the jaw (MRONJ) is challenging. Therefore, identifying the proper treatment is important. This study aimed to evaluate the surgical treatment of maxillary MRONJ using single-layer closure with mucoperiosteal flap and double-layer closure with buccal fat pad flap (BFPF) and mucoperiosteal flap and to find the outcomes after rehabilitation with obturators. METHODS: A retrospective analysis was conducted and included all surgically treated and followed-up maxillary MRONJ cases in a single center. Demographics and clinical data, stage of MRONJ, surgical treatment, and treatment outcome were collected. RESULTS: Seventy-nine lesions were included. Removal of necrotic bone was followed by coverage with mucoperiosteal flap in 60 lesions and BFPF in 14 lesions. Seven lesions (five primarily and two following unsuccessful treatment with BFPF) underwent necrectomy and were reconstructed with obturators. Complete mucosal healing was achieved in 76.7% of the lesions covered with mucoperiosteal flap. BFPF led to complete mucosal healing in 85.7% of the lesions. No complications were observed in the defects rehabilitated with obturators. CONCLUSION: Removal of necrotic bone followed by closure with mucoperiosteal flap is reliable for MRONJ treatment. BFPF is effective for closure of MRONJ-related oroantral communications (OACs).

Clinical and pathologic parameters predicting recurrence of facial basal cell carcinoma: a retrospective audit in an advanced care center.

OBJECTIVES: This study was designed to investigate the associations between clinical, pathologic, and therapeutic parameters of facial basal cell carcinoma (BCC) and recurrence rates in patients treated at an advanced care center. METHODS: A retrospective cohort study was performed. Patients who presented to an advanced care center within a 6-year period with facial BCC and who received surgical treatment were included for further review according to predefined inclusion criteria. The predictor variable was defined as "negative-margin (R0) resection after the first surgery". The primary outcome variable was defined as "BCC recurrence". Descriptive and inferential statistics were computed. The significance level was set at P ≤ 0.05. RESULTS: A total of 71 patients (29 female, 42 male; average age: 71.76 years) were found to meet all of the study inclusion criteria. All BCCs had been referred, and 50.7% had been submitted to previous surgery. The mean ± standard deviation tumor diameter was 2.3 ± 1.8 cm. Recurrence of BCC was observed in 11 patients (15.5%). Large tumor diameters, increased patient age, and failure to achieve R0 resection at the first surgical appointment significantly increased recurrence rates. CONCLUSIONS: Complete facial BCC excision at the first surgical appointment is pivotal in reducing the likelihood of recurrence. The influence of the anatomic location of facial BCC on recurrence rates may be limited.

Iterations of computer- and template assisted mandibular or maxillary reconstruction with free flaps containing the lateral scapular border--Evolution of a biplanar plug-on cutting guide.

BACKGROUND: Computer-assisted planning and intraoperative implementation using templates have become appreciated modalities in craniofacial reconstruction with fibula and DCIA flaps due to saving in operation time, improved accuracy of osteotomies and easy insetting. Up to now, a similar development for flaps from the subscapular vascular system, namely the lateral scapular border and tip, has not been addressed in the literature. PATIENTS/METHOD: A cohort of 12 patients who underwent mandibular (n = 10) or maxillary (n = 2) reconstruction with free flaps containing the lateral scapular border and tip using computer-assisted planning, stereolithography (STL) models and selective laser sintered (SLS) templates for bone contouring and sub-segmentation osteotomies was reviewed focussing on iterations in the design of computer generated tools and templates. RESULTS: The technical evolution migrated from hybrid STL models over SLS templates for cut out as well as sub-segmentation with a uniplanar framework to plug-on tandem template assemblies providing a biplanar access for the in toto cut out from the posterior aspect in succession with contouring into sub-segments from the medial side. CONCLUSION: The latest design version is the proof of concept that virtual planning of bone flaps from the lateral scapular border can be successfully transferred into surgery by appropriate templates.

Are There Clinical or Pathological Parameters of Maxillary Oral Squamous Cell Carcinoma With an Influence on the Occurrence of Neck Node Metastasis? An Appraisal of 92 Patients.

PURPOSE: To determine the proportion of patients with cervical metastases caused by maxillary oral squamous cell carcinoma (OSCC) and to identify any clinical or pathologic parameters that might be associated with the occurrence of metastatic neck disease. MATERIALS AND METHODS: A retrospective cohort study of all patients managed with primary surgical resection of maxillary OSCC at the authors' institution from 2006 through 2013 was performed. Cervical lymph node dissection and adjuvant therapy were performed as warranted by preoperative staging examinations or histopathologic evaluation or as recommended after multidisciplinary consultation, and regular follow-up protocols were followed. In this analysis, each maxillary OSCC was assigned to an anterior or a posterior anatomic group based on the location of the primary lesion, with the anatomic tumor location serving as the predictor variable and the occurrence of cervical lymph node metastases as the outcome variable. Descriptive and inferential statistics were calculated with a significance level set at a P value less than .05 and post hoc power analyses were performed. RESULTS: The study sample was composed of 92 patients (38 women, 54 men; average age, 60.9 yr). Overall, 27 patients developed cervical metastases (29.3%). Neck disease was present in 15 patients (16.3%) at initial presentation. Delayed cervical metastases were diagnosed in 12 patients (13%) and manifested after an average period of 11.17 months. The anatomic location of the OSCC within the maxillary structures (anterior vs posterior) and the histologic grade greatly influenced the occurrence of metastatic neck disease. No associations were found for the variables tumor size and resection status. CONCLUSION: In this series, cervical lymph node metastases were frequent and to some degree predictable based on anatomic location and tumor grade.

Maxillofacial Fractures: Midface and Internal Orbit-Part I: Classification and Assessment.

Fractures of the midface and internal orbit occur isolated or in combination with other injuries. Frequently, the patients are first seen in emergency rooms responsible for the coordination of initial diagnostic procedures, followed by the transfer to specialties for further treatment. It is, therefore, important for all physicians treating facial trauma patients to understand the basic principles of injuries to the midface. Thus, this article aims to describe the anatomy and the current classification systems in use, the related clinical symptoms, and the essential diagnostic measures to obtain precise information about the injury pattern.

Maxillofacial Fractures: Midface and Internal Orbit-Part II: Principles and Surgical Treatment.

Current clinical assessment and imaging techniques were described in part 1, and this article presents a systematic review of the surgical treatment principles in the management of midface and internal orbit fractures from initial care to definitive treatment, including illustrative case examples. New developments enabled limited surgical approaches by standardization of osteosynthesis principles regarding three-dimensional buttress reconstruction, by newly developed individualized implants such as titanium meshes and, especially for complex fracture patterns, by critical assessment of anatomical reconstruction through intraoperative endoscopy, as well as intra- and postoperative imaging. Resorbable soft tissue anchors can be used both for ligament and soft tissue resuspension to reduce ptosis effects in the cheeks and nasolabial area and to achieve facial aesthetics similar to those prior to the injury.

Basal cell carcinoma-treatments for the commonest skin cancer.

BACKGROUND: With an incidence of 70 to over 800 new cases per 100 000 persons per year, basal cell carcinoma (BCC) is a very common disease, accounting for about 80% of all cases of non-melanoma skin cancer. It very rarely metastasizes. A variety of treatments are available for the different subtypes and stages of BCC. METHOD: This review is based on pertinent literature retrieved by a selective search in the Medline database, as well as the American Cancer Society guidelines on BCC and the German guidelines on BCC and skin cancer prevention. RESULTS: The gold standard of treatment is surgical excision with histological control of excision margins, which has a 5-year recurrence rate of less than 3% on the face. For superficial BCC, approved medications such as imiquimod (total remission rate, 82-90%) and topical 5-fluorouracil (80%) are available, as is photodynamic therapy (71-87%). Other ablative methods (laser, cryosurgery) are applicable in some cases. Radiotherapy is an alternative treatment for invasive, inoperable BCC, with 5-year tumor control rates of 89-96%. Recently, drugs that inhibit an intracellular signaling pathway have become available for the treatment of locally advanced or metastatic BCC. Phase I and II clinical trials revealed that vismodegib was associated with objective response rates of 30-55% and tumor control rates of 80-90%. This drug was approved on the basis of a non-randomized trial with no control arm. It has side effects ranging from muscle cramps (71%) and hair loss (65%) to taste disturbances (55%) and birth defects. CONCLUSION: The established, standard treatments are generally highly effective. Vismodegib is a newly approved treatment option for locally advanced BCC that is not amenable to either surgery or radiotherapy.

Clinicopathologic features of oral squamous cell carcinoma: do they vary in different age groups?

PURPOSE: To analyze clinicopathologic parameters of oral squamous cell carcinoma (OSCC) in different age groups. We hypothesized that clinical and pathologic parameters of OSCCs will vary in different age groups. MATERIALS AND METHODS: A retrospective cohort study was performed. All patients who were treated for a primary manifestation of OSCC at a single institution from 2001 to 2012 were reviewed and allocated to predefined age groups (predictor variable) as follows: young (≤40 years), middle-aged (40-80 years), and very elderly (≥80 years). The following outcome variables were recorded: demographic parameters, classic risk factors, tumor location and size, neck node involvement, histopathologic and therapeutic details, and association with human papillomavirus (HPV). The descriptive statistics were computed. Parametric and nonparametric tests were used for additional analysis. The significance level was set at P < .05. RESULTS: We reviewed 739 patients and identified 11 (1.4%) young (mean age 34.2 ± 2.8 years) and 17 (2.3%) very elderly patients (mean age 83.1 ± 1.2 years). The predilection site for OSCC was the oral tongue (63%) in young patients, the floor of the mouth (52%) in middle-aged patients, and the alveolar process (60%) in very elderly patients. One patient in the young group (9%) and 8 patients in the very elderly group (47%) had been exposed to risk factors; however, all of the examined middle-aged patients had had such exposure. The association of OSCC with HPV was distributed equally among the age groups. No age-related differences in the histopathologic parameters of OSCC were found. CONCLUSIONS: The features of OSCC that vary at different ages are the anatomic predilection site and the association with classic risk factors. HPV was not an age-related independent risk factor for OSCC development in the present study.

Complete mouth rehabilitation after transposition osteotomy based on intraoral scanning: an experimental approach.

This article describes the surgical and prosthodontic treatment of a patient with severe dysgnathia combined with amelogenesis imperfecta. To the authors' knowledge, this is the first treatment report to describe the application of intraoral scanning for a complete mouth reconstruction. After transposition osteotomy, the treatment included the simultaneous fabrication of antagonistic computer-aided design/computer-aided manufactured (CAD/CAM) long-term interim restorations for the maxilla and mandible and the establishment of a new centric relation position and adequate vertical dimension of occlusion. Particularly in complex situations, the major advantages of intraoral scanning can be identified as an extended magnification of the 3-dimensional digital data to control the preparation and impression at the dental office. However, the presented treatment revealed some deficiencies in the digital work flow that must be rectified. In combination with high-performance polymers, the CAD/CAM technology offers a wide range of new treatment options and simplifies the fabrication of long-term interim restorations. Although in the present treatment the esthetic and functional requirements of the patient were met, no published studies of this procedure have been based on intraoral scanning, and the approach has to be considered experimental.

Neurodevelopmental and esthetic results in children after surgical correction of metopic suture synostosis: a single institutional experience.

INTRODUCTION: Metopic suture synostosis leading to trigonocephaly is considered the second most frequent type of craniosynostosis. Besides esthetic results, we present 25 consecutive pediatric cases operated upon metopic suture synostosis with a focus on the child's motor, speech, and neurocognitive development. METHODS: Twenty-five children (aged 6 to 33 months; median 9.2 months) with trigonocephaly were operated upon between 2002 and 2012 with fronto-orbital advancement including frontal bone cranioplasty and fronto-orbital bandeau remodeling. Neurodevelopmental deficits were evaluated by a standardized questionnaire including gross motor function, manual coordination, speech, and cognitive function performed by independent pediatric/developmental neurologists before surgery and at 6 and 12 months of time interval postoperatively. RESULTS: Twenty-one (84 %) boys and four (16 %) girls were included in this study. Mean follow-up period was 33 ± 28 months. Outcome analysis for esthetic results showed a high degree of satisfaction by the parents and treating physicians in 23 cases (92 %). Preoperative evaluation revealed neurodevelopmental deficits in 10 children (40 %; six mild, four moderate degree). Twelve children (48 %) were proven to have a normal preoperative neuropediatric development. Mild or moderate developmental restraints were no longer apparent in 6/13, improved but still apparent in 3/13, and stable in 4/13, 6 months after cranial vault reconstruction. At 12 months of follow-up, deficits were no longer present in 9/13 and improved in 4/13. Apart from this cohort, two children were diagnosed with a syndromic form, and one child had a fetal valproate syndrome. In these three children, neurodevelopmental deficits were more pronounced. Neurocognitive progress was obvious, but was comparably slower, and major deficits were still apparent at last follow-up. All children with proven mild/moderate/severe deficits received intensive physiotherapy, logopedic, or neurobehavioral support. CONCLUSIONS: As shown in a single-center observation, surgical correction of metopic suture synostosis not only refines esthetic appearance but also might improve neurodevelopmental outcome if deficits are apparent, even in syndromic forms of the deformity under additional physiotherapy, logopedic, or neurobehavioral support.

Diagnostic efficacy of cone-beam computed tomography for mandibular fractures.

OBJECTIVE: The aim of the study was to determine the clinical efficacy of maxillofacial cone-beam computed tomography (CBCT) for the diagnosis of suspected mandibular fractures and to evaluate whether findings would lead to a change in treatment. STUDY DESIGN: CBCT imaging was performed for 164 patients with suspected mandibular fractures (231 sites) but equivocal clinical and radiological findings (conventional radiography). Images were interpreted by oral and maxillofacial surgeons and treatment decisions based on pre and postimaging were compared. Linear regression analyses were performed. RESULTS: For 63.2% of sites (n = 146) the suspected diagnosis was confirmed by CBCT (P < .0001; R(2) = 0.93). For 4.33% of sites (n = 10) no fracture was identified. Additional fractures were identified in 17.75% (n = 41) and additional infractures in 14.72% (n = 34). The treatment plan was altered for 9.52% of sites (n = 22). CONCLUSIONS: CBCT imaging of suspected mandibular fractures resulted in a change in the treatment plan in 9.52%.

Pathologic fractures in bisphosphonate-related osteonecrosis of the jaw-review of the literature and review of our own cases.

Background Bisphosphonates are powerful drugs used for the management of osteoporosis and metastatic bone disease to avoid skeletal-related complications. Side effects are rare but potentially serious such as the bisphosphonate-related osteonecrosis of the jaws (BRONJ). BRONJ impairs the quality of life and can even lead to pathologic fractures of the mandible. Management of BRONJ is difficult per se. If complicated with pathologic mandibular fractures in advanced stages, the treatment options are controversially discussed. This review delineates the epidemiology and pathogenesis of BRONJ to put the various modalities for the treatment of pathologic mandible fractures into perspective. Methods Various case reports and case series in the literature were reviewed. Cases were reviewed of patients suffering from pathologic fracture due to bisphosphonate-related osteonecrosis of the jaw treated in the Department of Oral and Maxillofacial Surgery (Ludwig-Maximilians-University of Munich) from 2003 to 2010. Of 140 patients suffering from BRONJ, four were identified with pathologic fracture of the mandible. Results Management of pathologic mandibular fractures in patients suffering from BRONJ is an unsolved issue. At present there is a paucity of information to establish reliable therapy guidelines. The published strategies range from conservative treatment to major bone resections with or without internal or external fixation and with or without autogenous reconstruction. There is no evidence for the superiority of a single therapeutic mode, however. Conclusion Further understanding of BRONJ is mandatory to establish a sound rationale for the treatment of associated mandibular fractures.

MatrixMANDIBLE preformed reconstruction plates--a two-year two-institution experience in 71 patients.

PURPOSE: To evaluate handling, complication rates, clinical and treatment outcomes of the MatrixMANDIBLE Preformed Reconstruction Plates (MMPRPs), in particular with regard to the frequency of fatigue fractures and operative time. PATIENTS AND METHODS: A cohort of 71 subjects with an indication for a load-bearing osteosynthesis of the mandible was enrolled in the present study. The indications for plate use were defects due to tumor, trauma, or osteonecrosis. The outcome variables were fitting accuracy, application time, and postoperative complications, defined as plate exposure, loosening of plates or screws, plate fracture, and orocutaneous fistulas. Additionally, the feasibility of a transoral approach was tested. RESULTS: The sample included 71 subjects with a mean age of 54.8 ± 15.0 years, including 43 men (60.6%). MMPRPs could be placed in 70 of the 71 patients. In 10 patients a transoral approach for plate application was successfully performed. The mean time investment to contour the plates was 13.1 minutes. The fitting accuracies of the nonbendable sections were satisfying. No plate fracture was observed within an average follow-up period of 11.8 months. Postoperative complications occurred in 19 (27.1%) of the 70 patients. Plate removal was required in 11 (15.7%) of 70 patients. CONCLUSIONS: The results of the present study suggest that the use of MMPRPs coincides with a reduced operative time and a minimized risk of fatigue fractures. Thus, MMPRPs seem to be a useful standard device in a scope of indications for load-bearing osteosynthesis of the anterolateral division of the mandible, additionally facilitating a transoral approach for application.

Incidence of maxillary sinusitis and oro-antral fistulae in bisphosphonate-related osteonecrosis of the jaw.

OBJECTIVE: Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a serious side-effect of bisphosphonate therapy. In the majority of cases BRONJ occurs in the mandible. As a consequence a detailed investigation of BRONJ of the maxilla and in particular of involvement of the maxillary sinus has largely so far been neglected. The aim of this study was to analyse the frequency of maxillary sinusitis and oro-antral fistulae in BRONJ of the maxilla. SUBJECTS AND METHODS: A retrospective multicentre analysis was carried out in three Departments of Oral and Maxillofacial Surgery focussing on patients suffering from BRONJ in the maxilla. The role of involvement of the maxillary sinus, in particular sinusitis and oro-antral fistula, was analysed. RESULTS: Out of a total of 170 patients suffering from BRONJ 53 cases (31.2%) with involvement of the maxilla were identified. At least one sign of maxillary sinusitis was present in 43.6% (23/53) and an oro-antral fistula in the course of the disease was detected in 35.8% (19/53) of those patients. The mean length of time of bisphosphonate intake was 36.16±16.32 months. Zoledronate was most frequently associated (60.4%) with symptoms, followed by the combination of Zoledronate/Ibandronate (13.2%), and Zoledronate/Pamidronate or Pamidronate alone (both 7.5%). CONCLUSION: Maxillary sinusitis and oro-antral fistulae are associated with a BRONJ manifestation in the upper jaw in approximately 44%. The involvement of the maxillary sinus should be given special attention and three-dimensional imaging modalities might be necessary, not only to evaluate the extent of necrosis, but also to exclude involvement of the maxillary sinus.

Bisphosphonate-related osteonecrosis of the jaws - characteristics, risk factors, clinical features, localization and impact on oncological treatment.

INTRODUCTION: Osteonecrosis of the jaw (ONJ) is a serious side-effect of intravenous nitrogen-containing bisphosphonate therapy frequently used in the treatment of malignant diseases. Despite numerous case series published so far studies with detailed investigations into risk factors, the precise localization of ONJ and impact of ONJ on the oncological treatment remain sparse. PATIENTS AND METHODS: This single-centre study collated medical records (2003-2009) of all patients that suffered from ONJ within the Department of Oral and Maxillofacial Surgery, Ludwig-Maximilians-University of Munich, Germany. In total, 126 patients fulfilled the case criteria of ONJ and were examined clinically. The complete medical history including detailed questionnaires was collected of 66 patients, focussing in particular on the identification of underlying risk factors, clinical features, ONJ localization as well as the impact on the oncological treatment. RESULTS: The majority of ONJ cases occurred in patients suffering from malignant diseases (n=117; 92.8%), in particular breast cancer (n=57; 45.2%), multiple myeloma (n=37; 29.4%) and prostate cancer (n=13; 10.3%), all received nitrogen-containing bisphosphonates intravenously. ONJ was also diagnosed in 9 patients (7.1%) suffering from osteoporosis or rheumatoid arthritis. The most prevalent clinical feature was exposed necrotic bone (93.9%) in the oral cavity which was accompanied in 78.8% of cases by pain. A predilection for the mandible and in particular for molar and premolar regions in both jaws was shown. Although no recommendation concerning the oncologic treatment was made, the manifestation of ONJ resulted (in a significant proportion of the patients) in a change of medication and schedule. The most frequent co-medications were steroids and anti-angiogenetic drugs, such as thalidomide. DISCUSSION: The predilection for mandibular molar and premolar regions, and the infectious conditions that often precede the onset of ONJ support recent pathogenesis theories stating that local inflammation and associated pH-changes may trigger the release and activation of nitrogen-containing bisphosphonates ultimately resulting in necrosis. CONCLUSION: The development of ONJ has a multi-factorial aetiology and the clinical presentation can vary markedly. ONJ cannot only impair the quality of life but also the treatment of the underlying disease.

Osteoporosis and bisphosphonates-related osteonecrosis of the jaw: not just a sporadic coincidence--a multi-centre study.

INTRODUCTION: Bisphosphonates (BPs) are powerful drugs that inhibit bone metabolism. Adverse side effects are rare but potentially severe such as bisphosphonate-related osteonecrosis of the jaw (BRONJ). To date, research has primarily focused on the development and progression of BRONJ in cancer patients with bone metastasis, who have received high dosages of BPs intravenously. However, a potential dilemma may arise from a far larger cohort, namely the millions of osteoporosis patients on long-term oral BP therapy. PATIENTS AND METHODS: This current study assessed 470 cases of BRONJ diagnosed between 2004 and 2008 at eleven different European clinical centres and has resulted in the identification of a considerable cohort of osteoporosis patients suffering from BRONJ. Each patient was clinically examined and a detailed medical history was raised. RESULTS: In total, 37/470 cases (7.8%) were associated with oral BP therapy due to osteoporosis. The majority (57%) of affected individuals did not have any risk factors for BRONJ as defined by the American Association of Oral and Maxillofacial Surgery. The average duration of BP intake of patients without risk factors was longer and the respective patients were older compared to patients with risk factors, but no statistical significant difference was found. In 78% of patients the duration of oral BP therapy exceeded 3 years prior to BRONJ diagnosis. DISCUSSION: The results from this study suggest that the relative frequency of osteoporosis patients on oral BPs suffering from BRONJ is higher than previously reported. There is an urgent need to substantiate epidemiological characteristics of BRONJ in large cohorts of individuals.

Fluorescence-guided bone resection in bisphosphonate-related osteonecrosis of the jaws: first clinical results of a prospective pilot study.

PURPOSE: Surgical debridement is the therapy of choice in advanced stages of bisphosphonate-related osteonecrosis of the jaws (BRONJ). However, the therapy is currently only loosely standardized because no suitable imaging modalities exist. This study aims to redress this by exploring the suitability and reproducibility of applying a fluorescence-guided bone resection to patients with BRONJ. PATIENTS AND METHODS: This prospective pilot study comprised 15 patients with 20 BRONJ lesions (only stages II and III) with a history of intravenous bisphosphonate treatment for metastatic bone diseases. Before surgical treatment, each patient received a 10-day administration of doxycycline. Fluorescence-guided resection of necrotic bone was performed by means of a certified fluorescence lamp. Success of the procedure was proclaimed if mucosal closure was observed and symptoms were absent 4 weeks postoperatively. RESULTS: The 4-week postoperative follow-up identified a mucosal closure in 17 of 20 BRONJ lesions (85%). These patients were free of any symptoms. Failure as defined by mucosal dehiscence and exposed bone was observed in 3 of 20 BRONJ lesions (15%). CONCLUSION: The success rate of this surgical regimen of BRONJ was respectable, and thus fluorescence-guided bone resection can be considered an effective treatment for stage II and stage III BRONJ. Furthermore, the reproducibility of the technique offers an opportunity to standardize the surgical therapy. Further studies are called for that compare the fluorescence-guided bone resection with conventional surgical approaches, as well as surgical versus conservative treatment in the early stages (stages 0 and I) of BRONJ.