Endoperiodontal lesions: diagnosis first, then treatment and not always tooth extraction: a cross-sectional survey in Spain and a proposal of a clinical treatment protocol.

Background: Endoperiodontal lesion (EPL) is defined as a pathological communication between pulpal and periodontal tissues. Currently, accurate diagnosis and treatment of this pathology are challenging. This study aims to identify the different endoperiodontal therapies to propose a clinical protocol to simplify and unify the criteria for EPL treatment. Material and Methods: Observational cross-sectional study through an electronic survey. This study matches STROBE guidelines. The anonymous questionnaire contained open-ended and close-ended questions and was distributed to dentistry professors of the UPV/EHU and different professionals from Spanish associations and scientific societies. The data collected were analyzed using descriptive and analytical statistics. Results: A total of 128 responses were obtained, of which 120 were active professionals or had not been so for less than 5 years. The majority of professionals were women (65.6%) and from the Basque Country (63.9%). A total of 86.6% reported having complementary studies to a degree or a bachelor's degree. The treatments performed by these professionals were similar to those reported in the literature, which started with root canal treatment when there was an endodontic origin (91.5%), and with basic periodontal treatment when periodontal (51.3%). Conclusions: Considering the current scientific evidence and the clinical practice of professionals in the treatment of EPL, we designed a clinical protocol. This protocol needs validation in larger populations and with longer follow-ups. Key words:Clinical protocol, Dental pulp diseases, Periodontal diseases, Review, Surveys and questionnaires.

Comparative study of the modified VISTA technique (m-VISTA) versus the coronally advanced flap (CAF) in the treatment of multiple Miller class III/RT2 recessions: a randomized clinical trial.

OBJECTIVES: To compare the percentage of mean root coverage (MRC%) obtained in the treatment of multiple Miller class III/RT2 gingival recessions using the modified VISTA (m-VISTA) technique versus the coronally advanced flap (CAF) technique, using a connective tissue graft (CTG) in both cases. MATERIALS AND METHODS: Twenty-four patients were randomly treated with m-VISTA (test group (TG) = 12) or CAF (control group (CG) = 12). A calibrated, experienced, and blinded examiner collected data related to multiple periodontal clinical variables, especially the recession (REC) in order to calculate the MRC% at 6 and 12 months, which was the primary outcome of the study. Also, the radiological bone level, the characteristics of the CTG, and postsurgical incidences were assessed. Finally, a descriptive and an analytical statistical analysis of the variables and their associations was performed. RESULTS: The recessions (n = 84) were located mainly in the mandible (n = 65) and in posterior sectors (premolars: n = 35; molars: n = 8). At 6 months, the MRC% was 61% (2 mm) for both study groups, and at 12 months, it increased to 73.26% (2.11 mm) in the TG and decreased to 56.49% (1.78 mm) in the CG. CONCLUSION: When approaching multiple Miller class III/RT2 recessions, there were no statistically significant differences in the MRC% at 6 and 12 months between the group treated with the m-VISTA technique and the group treated with the CAF. CLINICAL RELEVANCE: The characteristics of the m-VISTA technique, such as the closed approach, the mobilization of the papilla, and the coronal stabilization of the CTG, could facilitate the maturation of the tissues in the treatment of Miller class III/RT2 recessions. This would favor better root coverage. TRIAL REGISTRATION: NCT03258996.

Single tooth restoration in the maxillary esthetic zone using a one-piece ceramic implant with 1 year of follow-up: case series.

BACKGROUND: Oral implants have helped clinicians to improve the quality of life for many patients. The material of choice for dental implants currently remains titanium type IV, whose mechanical and biological properties have been proven throughout the history of implantology. Yet, this material is not exempt from complications. For these reasons, ceramic alternatives to titanium have emerged. Thus, the purpose of this study is to evaluate peri-implant hard and soft tissue stability with the use of a one-piece ceramic implant (Straumann® PURE Ceramic Implant) during 1 year of follow-up. STUDY DESIGN: One-piece all-ceramic zirconia (ZrO2) implants were placed to replace single missing teeth in the esthetic zone. Six to 8 weeks after the procedure, the definitive prosthesis was fabricated. At the time of prosthesis, placement (T0) photographs and periapical radiographs were taken, and the following clinical parameters were recorded: probing depth (PD), plaque index (PI), bleeding on probing (BOP), suppuration on probing (SOP), distance from gingival margin to incisal edge (GM-IE), and Jemt papilla index (JPI). Follow-up appointments were scheduled at 4 (T4), 8 (T8), and 12 (T12) months, when the same parameters were recorded. In addition, plaque control was reinforced and prophylaxis was carried out. In this last appointment, a final periapical radiograph was taken to assess marginal bone loss. RESULTS: A total of 32 zirconia implants were placed in 28 patients (16 women and 12 men, aged between 34 and 67 years). The survival and success rate were 96.9%. The increase in probing depth from baseline to 12 months was 0.78 mm. Assessments of plaque index and bleeding on probing showed a slight increase throughout the study. CONCLUSIONS: The results obtained with the Straumann® PURE Ceramic implants show them to exhibit very good clinical behavior. The survival rate of the implants of our pilot study was 96.9%. For these reasons, we can say that zirconia implants could be an alternative to titanium implants in the esthetic zone.

Complete root coverage in the treatment of Miller class III or RT2 gingival recessions: a systematic review and meta-analysis.

BACKGROUND: The primary objective of this systematic review and meta-analysis was to assess the evidence on complete root coverage (CRC) achieved by periodontal plastic techniques in the treatment of Miller class III/RT2 gingival recessions, comparing techniques developed along the twentieth century (pre-twenty-first) versus surgical approaches of the twenty-first century (21st). METHODS: An electronic bibliographic search was carried out in four databases up to December 2019, focusing on studies that reported CRC results in Miller class III or RT2 recessions treatment with at least a six-month follow-up. In addition, a random-effects models' meta-analysis was performed for the CRC, comparing pre-twenty-first versus twenty-first century techniques at 6 months, 12 months and more than 12 months. RESULTS: Thirty-seven publications were included. A total of 933 gingival recessions were treated, 298 with pre-twenty-first century surgical techniques and 635 with techniques from the twenty-first century. CRC was achieved at 6 months on half of the recessions (pre-twenty-first: 57.60% vs. 21st: 51.11%), but decreased markedly for twenty-first century techniques at 12 months (pre-twenty-first: 63.82% vs. 21st: 32.87%). Thereafter, this difference was the other way around (> 12 months: pre-twenty-first: 5.26% vs. 21st: 19.65%). The meta-analysis showed a high heterogeneity, with no significant differences amongst the techniques. CONCLUSIONS: Although CRC might be achievable by treating Miller class III or RT2 recessions with any of the described techniques, its long-term stability is not predictable. More randomized clinical trials with longer follow-ups and several visits, are needed. In addition, the patient's satisfaction should also be assessed.

Description of the modified vestibular incision subperiosteal tunnel access (m-VISTA) technique in the treatment of multiple Miller class III gingival recessions: a case series.

BACKGROUND: Gingival recession is a common finding in the adult population. It is considered a challenge for clinicians to obtain a complete root coverage of Miller class III recession. The aim of this case series was to assess the outcomes achieved with the use of modified VISTA technique (m-VISTA) in patients having multiple Miller class III recessions after 6 months. METHODS: Ten patients (six women and four men; mean age: 53 years), who showed multiple Miller class III recessions (depth ≥ 2 mm) and who met the established inclusion and exclusion criteria, were treated by postgraduate students with the use of m-VISTA technique. RESULTS: A total of 38 recessions were performed. The recessions were mainly located in the mandible (80%), which included six molars. The mean baseline recession was 3.12 mm. Post the intervention, a mean root coverage of 58.72% was achieved, with complete root coverage observed in 29% of the recessions. CONCLUSIONS: m-VISTA may offer several advantages in the treatment of Miller class III gingival recession. Nevertheless, more clinical trials with a longer follow-up period are needed to arrive at a concrete conclusion about its advantages. TRIAL REGISTRATION: NCT03258996. Data registration: 08/18/2017.

Treatment of Amalgam Tattoo With a New Technique: Mucoabrasion and Free Connective Tissue Graft.

INTRODUCTION: A new technique was performed for the removal of an amalgam tattoo (AT), consisting in mucoabrasion combined with a free connective tissue graft (FCTG). CASE PRESENTATION: A 59-year-old female presented with a large AT involving the alveolar mucosa and gingiva between teeth #7 and #8, where endodontic treatment and apicoectomy was performed 21 years ago. To avoid compromising esthetics, the lesion was managed with a new technique including mucoabrasion and an FCTG. At the 53-month follow-up, the patient exhibited a naturally appearing soft tissue with no evidence of the AT. CONCLUSION: When performing a one-stage treatment of removing ATs in areas of high esthetic demand, it is possible to achieve good results and ideal gingival color.

One-year results of a nonsurgical treatment protocol for peri-implantitis. A retrospective case series.

OBJECTIVES: The aim of this study was to assess the clinical outcomes of a nonsurgical treatment protocol for peri-implantitis and to evaluate the influence that some factors could have on the results of this treatment. MATERIAL AND METHODS: In this retrospective case series, patients with at least one implant with peri-implantitis, treated with a nonsurgical protocol and with a one-year follow-up, were included. Clinical parameters (probing depth, recession, bleeding, and/or suppuration on probing) were collected at baseline, 6 weeks, 3, 6, and 12 months. Radiographic bone levels were assessed in periapical radiographs taken at baseline and 12 months. An analysis of the factors significantly associated with marginal bone level changes was performed. Descriptive and analytic statistics were carried out at the patient and at the implant level, as well as a multiple linear regression analysis. RESULTS: Data from 37 patients with 70 implants were analyzed. There was a general and consistent improvement from baseline compared to all follow-up points in the clinical variables. A significant radiographic bone gain of 0.91 mm was observed. The factors significantly associated were baseline plaque index, sex, and age at patient level, and type of prosthesis and implant location at implant level. CONCLUSIONS: Within the limitations of this study, this nonsurgical treatment protocol might be considered as a first treatment option for peri-implantitis. More studies are needed, with larger sample sizes and longer follow-ups, to confirm these outcomes and their long-term stability.

Histologic and Clinical Study of Gingival Recession Treated with Subepithelial Connective Tissue Graft: A Case Report.

Subepithelial connective tissue graft (SCTG) is considered the gold standard for treatment of gingival recessions. For ethical reasons, most studies report only clinical and not histologic results. A 20-year-old woman presenting with a localized gingival recession of 5 mm in the mandibular left central incisor was treated with SCTG. According to the initial treatment plan, the tooth was extracted 11 months later and a histologic study was performed, revealing new attachment of connective tissue with collagen fibers that were directly inserted in a perpendicular way into dentin areas and new cement areas (1.37 mm).

Complications of harvesting a connective tissue graft from the palate. A retrospective study and description of a new technique.

BACKGROUND: Connective tissue graft (CTG) is considered as the gold standard for the treatment of gingival recessions (GR). There are few studies assessing the complications that can arise in the donor site when harvesting a connective tissue graft (CTG) and how the harvesting technique can influence those complications. MATERIAL AND METHODS: A retrospective clinical study was carried out in order to compare the complications observed in 40 patients with Miller class I, II and III GR ≥ 3 mm, after using the trap-door technique (TD) in the control group and a newly described technique, the "UPV/EHU technique", in the test group. Patients were consecutively allocated to each treatment group. Patients were monitored 14 days after surgery in order to evaluate post-operative complications in the donor site: presence of pain (P), bleeding (B), infection (I) and necrosis > 30%. RESULTS: Although morbidity was observed in both groups, it was less important in the test group (no pain and minimal pain in 30% and 35% of the cases, respectively, and absence of bleeding or infection and necrosis >30% in only 5% of the cases). CONCLUSIONS: Within the limits of this study, this newly described "UPV/EHU technique" should be considered as a treatment option when harvesting a CTG, with minimal morbidity for patients. Key words:Connective tissue graft, pain, gingival recessions, wound healing, cosmetic periodontal plastic surgery, trap-door technique, "UPV/EHU technique".

Prevalence of peri-implant inflammatory disease in patients with a history of periodontal disease who receive supportive periodontal therapy.

OBJECTIVES: To describe the status of implants in periodontally compromised patients who regularly receive supportive periodontal therapy (SPT) and to determine the factors associated to peri-implant inflammatory disease in those patients. MATERIAL AND METHODS: Clinical and radiographic data of implants in periodontal patients who, after being treated and included in a SPT programme, wore implant prostheses for at least 6 months were recorded. The implants were classified according to the criteria of the 6th European Workshop on Periodontology in health, mucositis and peri-implantitis. Logistic regression analysis was performed to analyse the individual and adjusted effects of each study variable on mucositis or peri-implantitis, using SUDAAN to account for clustering (multiple implants within the patient). RESULTS: A total of 786 implants were placed in 239 patients. At patient level, 60.3%, 24.7% and 15.1% were classified as healthy, mucositis and peri-implantitis patients, respectively. At implant level, the respective percentages were 77.4%, 12.8% and 9.8%. For mucositis, at implant level, the adjusted ORs indicate a significant association with plaque index (P = 0.050), type of periodontitis (P = 0.030) and location (P = 0.045). For peri-implantitis, the adjusted ORs indicate a significant association with plaque index (P < 0.001) and location (P = 0.002). CONCLUSIONS: The prevalence of peri-implant inflammatory disease in periodontal patients who regularly undergo SPT is clinically significant. The factors associated with peri-implant inflammatory disease were plaque index and implant location, and mucositis was also affected by the type of periodontitis the patient had.

Supportive periodontal therapy and periodontal biotype as prognostic factors in implants placed in patients with a history of periodontitis

OBJECTIVE: To evaluate bone loss around implants placed in patients with a history of treated chronic periodontitis and who did or did not attend supportive periodontal therapy, after one year in function. Furthermore, the influence of periodontal biotype and level of plaque was also evaluated. MATERIAL AND METHODS: Forty-nine patients participated voluntarily in the study. All subjects had a history of chronic periodontitis, which had been previously treated. After the active treatment, 27 patients attended supportive periodontal therapy (SPT) and the rest did not (No SPT). The O'Leary plaque index and periodontal biotype were recorded for each subject and 246 Astra Tech® Osseospeed TM implants were radiographically analysed (123 placed in SPT patients and 123 in No SPT patients) at the time of loading and one year later, measuring marginal bone loss with the program Dental Studio NX 6.0®. The statistical analysis was performed with Windows SPSS, applying Pearson's correlation index and the Kruskal-Wallis and U-Mann Whitney non-parametric tests. RESULTS: Six patients were found to have periimplantitis and sixteen mucositis. The survival rate was 99.59% (100% SPT and 99.18% No SPT). Mean bone loss was 0.39 mm (range [-0.71 - 8.05]). Among SPT patients, 95% of the implants had losses less than or equal to the mean (mean bone loss of 0.16 mm) compared to 53.7% for the No SPT group (mean bone loss of 0.62 mm). A statistically significant relationship was demonstrated between bone loss around the implant and the patient's periodontal biotype and plaque index. CONCLUSIONS: The marginal bone loss around implants in patients with treated chronic periodontitis is minimal if they are in a controlled SPT programme and there is individual control of plaque index. Moreover, the presence of a thin periodontal biotype represents a risk factor for additional bone loss (AU)

Supportive periodontal therapy and periodontal biotype as prognostic factors in implants placed in patients with a history of periodontitis.

OBJECTIVE: To evaluate bone loss around implants placed in patients with a history of treated chronic periodontitis and who did or did not attend supportive periodontal therapy, after one year in function. Furthermore, the influence of periodontal biotype and level of plaque was also evaluated. MATERIAL AND METHODS: Forty-nine patients participated voluntarily in the study. All subjects had a history of chronic periodontitis, which had been previously treated. After the active treatment, 27 patients attended supportive periodontal therapy (SPT) and the rest did not (No SPT). The O'Leary plaque index and periodontal biotype were recorded for each subject and 246 Astra Tech® OsseospeedTM implants were radiographically analysed (123 placed in SPT patients and 123 in No SPT patients) at the time of loading and one year later, measuring marginal bone loss with the program Dental Studio NX 6.0®. The statistical analysis was performed with Windows SPSS, applying Pearson's correlation index and the Kruskal-Wallis and U-Mann Whitney non-parametric tests. RESULTS: Six patients were found to have periimplantitis and sixteen mucositis. The survival rate was 99.59% (100% SPT and 99.18% No SPT). Mean bone loss was 0.39 mm (range [-0.71 - 8.05]). Among SPT patients, 95% of the implants had losses less than or equal to the mean (mean bone loss of 0.16 mm) compared to 53.7% for the No SPT group (mean bone loss of 0.62 mm). A statistically significant relationship was demonstrated between bone loss around the implant and the patient's periodontal biotype and plaque index. CONCLUSIONS: The marginal bone loss around implants in patients with treated chronic periodontitis is minimal if they are in a controlled SPT programme and there is individual control of plaque index. Moreover, the presence of a thin periodontal biotype represents a risk factor for additional bone loss.

Immediate temporary restoration of single-tooth implants: Prospective clinical study

Purpose: The goal of this study is to ass ess the survival, marginal bone loss and complications around sing le-toothimplants on which immediate provisionalization was carried out.Patients and Methods: 78 implants were placed in 57 patients:56 after extraction and 22 in healed sockets. Immediatelyafter surgery provisional crowns were delivered without contacts in both centric and excursive jaw movements.The final crowns were inserted between 3 to 6 months later. During the study there were 3 x-rays takenper patient. The marginal bone loss was measured and complications were recorded. The statistical analys is of thedata was carried out with the STATA 10® software.Results: The mean duration of the study was 92 weeks. Survival rate was 98.7% (1 failure out of 78 implants). Themean mesial bone loss was 0.2±0.4 mm and the mean distal bone loss was 0.2±0.4 mm. No statistically significantdiff erences were found between immediate or delayed implants. 67 implants sh owed a bone loss less than 1 mm,and 36 did not sh ow any bone loss at all.The main complications were the uncementing of the crowns (11 crowns ), the presence of cement remnants (10crowns ) and the development of apical lesions around implants (6 implants).Conclusion: With the limitations of this study, it can be concluded by saying that immediate restoration withsing le-tooth implants and provisional crowns may be cons idered as a predictable technique (AU)

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Immediate temporary restoration of single-tooth implants: Prospective clinical study.

PURPOSE: The goal of this study is to assess the survival, marginal bone loss and complications around single-tooth implants on which immediate provisionalization was carried out. PATIENTS AND METHODS: 78 implants were placed in 57 patients: 56 after extraction and 22 in healed sockets. Immediately after surgery provisional crows were delivered without contacts in both centric and excursive jaw movements. The final crowns were inserted between 3 to 6 months later. During the study there were 3 x-rays taken per patient. The marginal bone loss was measured and complications were recorded. The statistical analysis of the data was carried out with the STATA 10® software. RESULTS: The mean duration of the study was 92 weeks. Survival rate was 98.7% (1 failure out of 78 implants). The mean mesial bone loss was 0.2 ± 0.4 mm and the mean distal bone loss was 0.2 ± 0.4 mm. No statistically significant differences were found between immediate or delayed implants. 67 implants showed a bone loss less than 1 mm, and 36 did not show any bone loss at all. The main complications were the uncementing of the crowns (11 crowns), the presence of cement remnants (10 crowns) and the development of apical lesions around implants (6 implants). CONCLUSION: With the limitations of this study, it can be concluded by saying that immediate restoration with single-tooth implants and provisional crowns may be considered as a predictable technique.

Bisphosphonates and oral pathology II. Osteonecrosis of the jaws: review of the literature before 2005.

Bisphosphonates are bone-turnover modulating drugs which are used in the management of a number of bone diseases ranging from osteoporosis to neoplasic pathology-associated osteolysis. In the last years a number of cases of osteonecrosis of the jaws associated with these drugs have been reported. In this review we analyze the cases published in the literature indexed from 2003 to December 2005. During this period 246 cases were reported, being more frequently associated with women in the sixth decade of life. More frequently associated bisphosphonates were the nitrogenated bisphosphonates (pamidronate, zolendronic acid) and the most common oral antecedent was a dental extraction. Nevertheless more than 25% of the cases were spontaneous. The most frequent site was the mandible and most of the cases presented clinical evidence of bone exposure and pain. Different treatments have been proposed with different antibiotic therapies with or without surgery, showing in general terms an uncertain prognosis with low healing rates.

Bisphosphonates and oral pathology I. General and preventive aspects.

Bisphosphonates constitute a group of drugs capable of modulating bone turnover, and reduce its remodelling when an excessive resorption occurs. This is why they are indicated in a large group of bone diseases like postmenopausal osteoporosis or osteolysis associated with breast cancer or multiple myeloma. Over the last years and due to their extensive use, many cases of complications associated with their use have been published. Among the most important possible adverse effects are the oral ones, with the appearance of ulcerations and, especially, osteonecrosis of the jaws associated with this therapy. In this paper, we have analyzed the general characteristics of these drugs and their mechanisms of action as well as the described adverse effects, especially oral and maxillofacial has been made special reference regarding the prevention of osteonecrosis of the jaws, heightened by cases described in medical and odontological literature. The preventive protocol backs up the fundamental role of the odontologist in the effective prevention of this process before, during and after the treatment.

Bisfosfonatos y Patología Oral I. Aspectos generales y preventivos / Bisphosphonates and Oral Pathology I. General and preventive aspects

Los bisfosfonatos constituyen un grupo de fármacos capaces de modular el recambio óseo y disminuir su remodelado cuando existe una reabsorción excesiva. Por ello están indicados en numerosas patologías óseas como la osteoporosis postmenopáusica o la osteolisis asociada al cáncer de mama o al mieloma múltiple. En los últimos años y a raíz de su utilización masiva se han ido publicando numerosos casos de complicaciones asociadas a su uso. Entre los posibles efectos adversos más importantes se encuentran los orales, con la aparición de ulceraciones y sobre todo los casos de osteonecrosis de los maxilares asociados a esta terapéutica. En esta revisión analizamos las características generales de estos medicamentos y su mecanismo de actuación, así como los efectos adversos descritos, especialmente los orales y maxilofaciales, haciendo una referencia especial sobre la prevención de la osteonecrosis de los maxilares, a la luz de los casos descritos en la literatura médica y odontológica. El protocolo preventivo refuerza el papel fundamental del odontólogo en la prevención efectiva de este proceso antes, durante y después del tratamiento

Bisphosphonates constitute a group of drugs capable of modulating bone turnover, and reduce its remodelling when an excessive resorption occurs. This is why they are indicated in a large group of bone diseases like postmenopausal osteoporosisor osteolisis associated with breast cancer or multiple myeloma. Over the last years and due to their extensive use, many cases of complications associated with their use have been published. Among the most important possible adeverse effects are the oral ones, with the appearance of ulcerations and, especially, osteonecrosis of the jaws associated with this therapy. In this paper, we have analyzed the general characteristics of these drugs and their mechanisms of actionas well as the described adverse effects, especially oral and maxillofacial has been made special reference regarding the prevention of osteonecrosis of the jaws, hightened by cases described in medical and odontological literature. The preventive protocol backs up the fundamental role of the odontologist in the effective prevention of this process before, during and after the treatment

Bisphosphonates and Oral Pathology II. Osteonecrosis of the jaws: review of the literature before 2005

Los bisfosfonatos son fármacos moduladores del recambio óseo que están indicados en numerosas patologías óseas desde la osteoporosis a la osteolisis asociada a patología neoplásica. En los últimos años se han ido publicando numerososcasos de osteonecrosis de los maxilares asociada a la toma de estos medicamentos. En esta revisión se analizan los casos publicados en la literatura indexada desde el inicial del 2003 hasta diciembre del 2005. Durante este periodo se han publicado 246 casos, afectando más a las mujeres y sobre todo en la sexta década de vida. Los bisfosfonatos más frecuentemente asociados han sido los nitrogenados (pamidronato-ácido zoledrónico) y el antecedente oral más común la exodoncia. No obstante, más del 25% correspondieron a casos “espontáneos”. La localización mas frecuente fue la mandíbula y clínicamente la mayoría de los casos mostraban exposición ósea y dolor asociado. La terapéutica ha sido muy diversa con diferentes pautas antibióticas con o sin cirugía, mostrando en general un pronóstico incierto con bajos índices de curación

Bisphosphonates are bone-turnover modulating drugs which are used in the management of a number of bone diseases ranging from osteoporosis to neoplasic pathology-associated osteolysis. In the last years a number of cases of osteonecrosis of the jaws associated with these drugs have been reported. In this review we analyze the cases published in the literature indexed from 2003 to December 2005. During this period 246 cases were reported, being more frequently associated with women in the sixth decade of life. More frequently associated bisphosphonates were the nitrogenated bisphosphonates (pamidronate, zolendronic acid) and the most common oral antecedent was a dental extraction. Nevertheless more than 25% of the cases were spontaneous. The most frequent site was the mandible and most of the cases presented clinical evidence of bone exposure and pain. Different treatments have been proposed with different antibiotic therapies with or without surgery, showing in general terms an uncertain prognosis with low healing rates