Osteoradionecrosis in a Torus Mandibularis Treated by Antimicrobial Photodynamic Therapy: A Case Report.

Background: Osteoradionecrosis (ORN) of the jaws is a late complication after radiotherapy to head and neck cancer. Objective: To describe a rare case of ORN of the torus mandibularis that was successfully managed exclusively with antimicrobial photodynamic therapy (aPDT). Case report: A 72-year-old man presented an exposed necrotic bone observed in the torus mandibularis, extending to the lingual alveolar ridge with no edema nor suppuration. The treatment provided a noninvasive treatment leading to spontaneous sequestrectomy of the torus in 2 weeks with complete mucosal repair in 5 weeks and absence of lesion signs and/or symptoms even after 6 months of follow-up. Conclusions: The aPDT indicated to be a satisfactory treatment for ORN affecting torus mandibularis, a region with surgical limitations, avoiding surgery.

Long-term follow-up of osteoradionecrosis of the mandible.

AIM: Investigating the prevalence of mandibular ORN in a single Swedish Oncology Center. METHODS: A total of 450 patients, treated with radiotherapy for squamous cell carcinoma in the oropharynx between 2004 and 2014 were included. Three different techniques of radiotherapy were studied. ORN diagnosis was set when clinical signs according to Marx were observed, or if radiological signs were staged according to Schwartz and Kagan. RESULTS: Using the staging system, 90 patients (20%) were diagnosed with ORN. The mean age of the ORN patients was 56.6 years, the older the patient the lower the risk of developing ORN (p = .01). The risk of developing ORN for patients receiving Intensity Modulated Radiotherapy was lower compared to patients treated with the other techniques in the multivariable analysis. Brachytherapy significantly increases the risk of ORN. The risk of ORN increased by 8% each year after radiation (p = .04). The mean time to the ORN diagnosis was 3.9 years. In the multivariate analysis, the risk of ORN increased by 13% each year after radiation (p = .0013). CONCLUSION: The mean radiation dose was of greater importance for the risk of ORN than the maximum dose. Elderly people with oropharyngeal cancer were less prone to develop ORN.

Evaluation of Anterolateral Thigh Fascia Lata Rescue Flap for Mandibular Osteoradionecrosis.

Importance: Mandibular osteoradionecrosis (ORN) is a progressive disease that can be difficult to treat. Conservative measures often fail, while conventional definitive management requires a morbid segmental resection with osteocutaneous reconstruction. Evidence of the anterolateral thigh fascia lata (ALTFL) rescue flap technique's safety, effectiveness, and long-term outcomes is needed. Objective: To determine the long-term outcomes of the ALTFL rescue flap procedure for treating patients with mandibular ORN. Design, Settings, and Participants: This was a retrospective medical record review performed at a single tertiary-level academic health care institution with patients who were appropriate candidates for the ALTFL procedure to treat mandibular ORN from March 3, 2011, to December 31, 2022. Data analyses were performed from January 1 to March 26, 2023. Main Outcomes and Measures: Patient characteristics, preoperative radiographic Notani staging, intraoperative defect size, length of stay, complication rates, and clinical and radiographic findings of progression-free intervals. Results: The study population of 43 patients (mean [SD] age, 66.1 [47-80] years; 24 [55.8%] male individuals) included 52 cases of mandibular ORN. The preoperative Notani staging of the study population was known for 46 of the 52 total cases: 11 cases (23.9%) were stage I; 21 (45.7%), stage II; and 14 (30.4%), stage III. The mean defect area was 20.9 cm2. Successful arrest of ORN disease progression was noted in the clinical and radiographic findings of 50 of the 52 (96.2%) cases, with only 2 (3.8%) cases subsequently requiring fibular free flap reconstruction. The major complication rate was 1.9% (1 case). Clinical and radiographic progression-free intervals were assessed, and no statistically significant differences were noted between Notani staging groups (log-rank P = .43 and P = .43, respectively); ie, patients with stage III disease had no significant difference in risk of clinical (HR, 0.866; 95% CI, 0.054-13.853) or radiographic (HR, 0.959; 95% CI, 0.059-15.474) progression vs those with stage I disease. Weibull profiling revealed 96.9%, 94.6%, and 93.1% successful mandibular ORN arrest at 1, 3, and 5 years, respectively. The major complication rate was 1.9%. Mean (SD) length of stay was 2.7 (0.0-7.0) days. Mean (SD) radiographic follow-up was 29.3 (30.7) months. Conclusions and Relevance: The findings of this large retrospective patient case series support the continued success of the ALTFL rescue flap technique, a safe and highly effective long-term treatment for mandibular ORN in carefully selected patients.

Rates of osteoradionecrosis in resected oral cavity cancer reconstructed with free tissue transfer in the intensity-modulated radiotherapy era.

BACKGROUND: Resected oral cavity carcinoma defects are often reconstructed with osteocutaneous or soft-tissue free flaps, but risk of osteoradionecrosis (ORN) is unknown. METHODS: This retrospective study included oral cavity carcinoma treated with free-tissue reconstruction and postoperative IMRT between 2000 and 2019. Risk-regression assessed risk factors for grade ≥2 ORN. RESULTS: One hundred fifty-five patients (51% male, 28% current smokers, mean age 62 ± 11 years) were included. Median follow-up was 32.6 months (range, 1.0-190.6). Thirty-eight (25%) patients had fibular free flap for mandibular reconstruction, whereas 117 (76%) had soft-tissue reconstruction. Grade ≥2 ORN occurred in 14 (9.0%) patients, at a median 9.8 months (range, 2.4-61.5) after IMRT. Post-radiation teeth extraction was significantly associated with ORN. One-year and 10-year ORN rates were 5.2% and 10%, respectively. CONCLUSIONS: ORN risk was comparable between osteocutaneous and soft-tissue reconstruction for resected oral cavity carcinoma. Osteocutaneous flaps can be safely performed with no excess concern for mandibular ORN.

Malignant transformation of chronic osteomyelitis of mandible: A rare presentation.

ABSTRACT: Chronic osteomyelitis is a bone disease that is characterized by inflammatory processes, including necrosis of mineralized and marrow tissues, suppuration, resorption, sclerosis, and hyperplasia. The primary cause of chronic osteomyelitis is usually microbiologic, and it results from an odontogenic infection, postextraction complication, inadequate removal of necrotic bone, early termination of antibiotic therapy, inappropriate selection of antibiotics, diagnostic failure, trauma, inadequate treatment for a fracture, or irradiation to the mandible. The incidence of malignant transformation of chronic osteomyelitis in the head and neck region is very low and rare in developed countries. This is the first case report on the malignant transformation of chronic osteomyelitis of the mandible which discusses its etiopathogenesis and radiographic imaging.

Factors Associated with Treatment Outcomes and Pathological Features in Patients with Osteoradionecrosis: A Retrospective Study.

A standard treatment for osteoradionecrosis (ORN) has not yet been established because of the diversity. Therefore, identifying the risk factors for a poor prognosis is essential. This study retrospectively investigated the factors associated with the prognosis of ORN in 68 patients. Relevant clinical data of all patients were obtained. Of the patients, 16 who underwent extensive surgery underwent histopathological analysis. The necrotic changes of the anterior and posterior margins in the cortical and cancellous bones were investigated. Multivariate analyses showed statistically significant associations between poor prognosis in patients with ORN and high radiation dose (hazard ratio [HR] 1.15), orocutaneous fistula (HR 2.93), and absence of sequestration (HR 2.49). Histopathological analysis showed a viable anterior margin of the middle portion of the cortical bone for all recovered cases; in contrast, most cases (75%) with a poor prognosis showed necrotic changes. The anterior margin of the cancellous bone was viable and resilient to high irradiation, regardless of the prognosis. These results suggest that patients with orocutaneous fistula should receive early surgical intervention, even if the affected area is limited or asymptomatic. In extensive surgery, a sufficient safety margin of necrotic bone, particularly in the anterior region, is required to improve the prognosis.

Predictive factors of osteoradionecrosis necessitating segmental mandibulectomy: A descriptive study.

OBJECTIVE: The objective of this study was to assess characteristics of patients with mandibular osteoradionecrosis (ORN) of severity necessitating segmental mandibulectomy and osteocutaneous free flap reconstruction. STUDY DESIGN: This study is a retrospective review of patients who underwent free flap reconstruction of the mandible at the UCLA Medical Center between January 2016 and February 2020 secondary to ORN. RESULTS: Twenty-nine charts with detailed dental and medical records were identified. Hypertension was reported in 14 of 29 patients, diabetes in 2 of 29, osteoporosis in 2 of 29, antiresorptive use in 3 of 29, tobacco use in 15 of 29, and alcohol use in 19 of 29. Twenty-three patients initially had stage III-IV cancer. The median radiation dose was 68 Gy and median time to ORN was 5.2 years. Chemotherapy was given in 21 patients and 4 had previous mandibular surgery. Twelve of 29 patients had surgical procedures identified as the causative factor and 17 of 29 occurred spontaneously. Median decayed, missing, and filled teeth score was 17 and 17 of 29 patients had grade II-IV periodontitis. Periodontitis was present in 8 of 17 of spontaneous and 1 of 12 of surgery cases. Twenty-five of 29 cases occurred in the same oral sextant as the tumor. CONCLUSION: Severe ORN occurred at doses >60 Gy in most cases. Location of the primary tumor was predictive of site of ORN and only molars were involved when precipitated by tooth extraction. Risk of ORN persists indefinitely.

Alteraciones osteoarticulares en el músico adulto mayor de instrumentos viento-madera / Osteoarticular alterations in the elderly musician of Wind-Wood Instruments

Objetivo: Valorar si existen cambios a nivel bucodental en adultos mayores, instrumentistas de viento-madera por el uso del instrumento a lo largo de más de 35 años de profesión y compararlos con un grupo control. Metodología: Estudio de tipo observacional, descriptivo de corte transversal, entre músicos profesionales, adultos mayores, de 60 años o más, con más de 35 años de profesión y que toquen instrumentos de "viento-madera". La muestra inicial de estudio estaba formada por 57 músicos. El instrumento de recogida de datos utilizado se ha elaborado de forma exclusiva. El análisis estadístico se llevó a cabo mediante SPSS Statistics 23.0. Resultados: Media de edad 63 ± 1,28 años, horas de estudio diario 3,47 ± 3,3 horas con experiencia profesional de 40,12 ± 12,98 años. Dependiendo del tipo de instrumento, embocadura, años de profesión y las fuerzas ejercidas por la lengua, labios, así como las de oclusión dental, aparecen distintas alteraciones en la articulación temporomandibular de los músicos, variaciones en el aparato estomatognático en músicos con instrumentos de lengüeta tipo bisel y maloclusiones junto a desgaste de los bordes incisales en los de lengüeta simple y doble. Es significativa la aparición de trastornos de la articulación temporomandibular entre instrumentistas de viento-madera y el grupo control (p = 0,0236). Conclusiones: Según el tipo de instrumento de viento y del contacto de la "boquilla" con el sistema estomatognático, este estudio ha demostrado que tocar un instrumento de viento-madera a nivel profesional durante más de 35 años afecta a la posición de los dientes y donde las horas de estudio y las fuerzas continuas e intermitentes necesarias para tocar son factores etiológicos predisponentes de maloclusión y de la aparición de alteraciones osteoarticulares en la cavidad oral de los músicos adultos mayores (AU)

Objectives: To assess whether there are changes at the oral level in older adults, woodwind players for the use of the instrument over more than 35 years of profession and compare them with a control group. Methodology: Observational, descriptive cross-sectional study, among professional musicians, seniors, 60 years of age or older, with more than 35 years of profession and playing "woodwind" instruments. The initial study sample was formed by 57 musicians. The data collection instrument used has been developed exclusively. The statistical analysis SPSS Statistics 23.0. Results: Mean age 63±1.28 years, daily study hours 3.47±3.3 hours with professional experience of 40.12±2.98 years. Depending on the type of instrument, mouthpiece, years of profession and the forces exerted by the tongue, lips, as well as those of dental occlusion, different alterations in the Temporomandibular Joint of musicians appear variations in the stomatognathic apparatus in musicians with type tongue instruments bevel and malocclusions with wear of the incisal edges in the single and double tongue. The appearance of temporomandibular joint disorders between woodwind players and the control group is significant (p=0.0236). Conclusions: Depending on the type of wind instrument and the contact of the "mouthpiece" with the stomatognathic system, this study has shown that playing a professional wind-wood instrument for more than 35 years affects the position of the teeth and where the hours of study and the continuous and intermittent forces necessary to play; they are predisposing etiological factors of malocclusion and the appearance of osteoarticular alterations in the oral cavity of older adult musicians (AU)

Normal Tissue Complication Probability (NTCP) Prediction Model for Osteoradionecrosis of the Mandible in Patients With Head and Neck Cancer After Radiation Therapy: Large-Scale Observational Cohort.

PURPOSE: Osteoradionecrosis (ORN) of the mandible represents a severe, debilitating complication of radiation therapy (RT) for head and neck cancer (HNC). At present, no normal tissue complication probability (NTCP) models for risk of ORN exist. The aim of this study was to develop a multivariable clinical/dose-based NTCP model for the prediction of ORN any grade (ORNI-IV) and grade IV (ORNIV) after RT (±chemotherapy) in patients with HNC. METHODS AND MATERIALS: Included patients with HNC were treated with (chemo-)RT between 2005 and 2015. Mandible bone radiation dose-volume parameters and clinical variables (ie, age, sex, tumor site, pre-RT dental extractions, chemotherapy history, postoperative RT, and smoking status) were considered as potential predictors. The patient cohort was randomly divided into a training (70%) and independent test (30%) cohort. Bootstrapped forward variable selection was performed in the training cohort to select the predictors for the NTCP models. Final NTCP model(s) were validated on the holdback test subset. RESULTS: Of 1259 included patients with HNC, 13.7% (n = 173 patients) developed any grade ORN (ORNI-IV primary endpoint) and 5% (n = 65) ORNIV (secondary endpoint). All dose and volume parameters of the mandible bone were significantly associated with the development of ORN in univariable models. Multivariable analyses identified D30% and pre-RT dental extraction as independent predictors for both ORNI-IV and ORNIV best-performing NTCP models with an area under the curve (AUC) of 0.78 (AUCvalidation = 0.75 [0.69-0.82]) and 0.81 (AUCvalidation = 0.82 [0.74-0.89]), respectively. CONCLUSIONS: This study presented NTCP models based on mandible bone D30% and pre-RT dental extraction that predict ORNI-IV and ORNIV (ie, needing invasive surgical intervention) after HNC RT. Our results suggest that less than 30% of the mandible should receive a dose of 35 Gy or more for an ORNI-IV risk lower than 5%. These NTCP models can improve ORN prevention and management by identifying patients at risk of ORN.

[Predictive factors for mandibular osteoradionecrosis after irradiation of head and neck cancers]. / Facteurs prédictifs de l'ostéoradionécrose mandibulaire après irradiation des cancers des voies aérodigestives supérieures.

The identification of the different risk factors for mandibular osteoradionecrosis (ORN) must be done before and after the management of patients with head and neck cancer. Various clinical criteria for this severe radiation-induced complication are related to the patient (intrinsic radiosensitivity, malnutrition associated with thin weight loss, active smoking intoxication, microcapillary involvement, precarious oral status, hyposalivation) and/or related to the disease (oral cavity, large tumor size, tumor mandibular invasion). Therapeutic risk factors are also associated with a higher risk of ORN (primary tumor surgery, concomitant radio-chemotherapy, post-irradiation dental avulsion, preventive non-observance with the absence of stomatological follow-up and daily installation of gutters fluoride and, non-observance curative healing treatments). Finally, various dosimetric studies have specified the parameters in order to target the dose values distributed in the mandible, which increases the risk of ORN. An mean mandibular dose greater than 48-54Gy and high percentages of mandibular volume receiving 40 to 60Gy appear to be discriminating in the risk of developing an ORN.

Surgical management of garre's osteomyelitis in an 8-year-old child.

Chronic non-suppurative osteomyelitis, also known as Garre's osteomyelitis is a well-described pathologic entity in dental literature. We present here a case report of a unilateral hard bony swelling of the lower jaw associated with infection. Radiograph revealed the pathognomic feature of 'onion skin' appearance. Surgical recontouring of the lower jaw was performed since there was no evidence of bone remodelling after removal of the infected tooth.

Is Adjunctive Hyperbaric Oxygen Treatment Alone or with Surgery the Proper Management for Active and Persistent Osteoradionecrosis?

ABSTRACT: This study enrolled patients with stage 3 osteoradionecrosis. There were three treatment modalities: antibiotics, hyperbaric oxygen therapy (HBOT), and surgery. Complete healing was the primary outcome. Multiple logistic regression analysis demonstrated that surgery with HBOT improved wound healing better than HBOT alone.

Does the administration of meloxicam before head and neck radiotherapy reduce the risk of mandibular osteoradionecrosis? An animal model study.

OBJECTIVE: To assess whether the administration of meloxicam before head and neck radiotherapy reduces the risk of mandibular osteoradionecrosis in rats. MATERIAL AND METHODS: Sixty male Wistar rats were randomly divided into 6 groups (n = 10) according to the meloxicam administration and radiation therapy: control (C), irradiated (I), single dose of meloxicam (M1), single dose of meloxicam and irradiated (M1I), triple dose of meloxicam (M3), triple dose of meloxicam and irradiated (M3I). Meloxicam was administrated (20 mg/kg per dose) 1 h before the radiation therapy (single dose of 20 Gy) and 24 h and 48 h after the radiation therapy for groups with two additional doses. Ten days after the radiation therapy, the three right mandibular molars were extracted from all rats, who were euthanatized after 21 or 35 days (n = 5 per group). The mandibles were assessed by macroscopic evaluation and micro-CT analysis. RESULTS: The right hemimandibles of the irradiated groups revealed macroscopic signs of osteoradionecrosis, and those of the non-irradiated groups revealed complete gingival healing. A significant delay in alveolar socket healing in all irradiated groups was observed in the micro-CT assessment regardless meloxicam treatment. CONCLUSION: The administration of meloxicam before head and neck radiotherapy does not reduce the risk of mandibular osteoradionecrosis when associated to dental extractions. CLINICAL RELEVANCE: Since meloxicam has been shown to be a potential radiation-protective agent, and osteoradionecrosis physiopathology is believed to be related to an inflammatory process, possible interactions are relevant to be investigated.

Effects of the Association of Periodontitis and Type 1 Diabetes Mellitus Induced on Periodontal Tissues and the Duodenal Mucosa of Wistar Rats.

Forty Wistar rats were used: (1) control group (CG); (2) group of periodontal disease (PD); (3) type 1 diabetes mellitus group (T1DM); (4) type 1 diabetes mellitus + periodontal disease group (T1DM + PD). In groups T1DM and T1DM + PD, T1DM induction was performed with the administration of streptozotocin (STZ) 80 mg/kg intraperitoneal body weight. The PD and T1DM + PD groups were submitted to PD induction with ligation. After the experimental phase and euthanasia, histological, radiographic, and morphological analyses were performed. For data analysis, was used the one-way ANOVA and post-test Tukey. The T1DM + PD group had a significantly higher level of fasting blood glucose compared to the other groups. In radiographic and histomorphometric analyses, the T1DM + PD group showed greater alveolar bone loss compared to the control group. The T1DM + PD group showed greater osteoclastic activity compared to the control, T1DM, and PD groups and exhibited an intense inflammatory infiltrate, most of which were PMN, being that the amount of this group of cells (PMN) was significantly greater than the PD group. The heights of the intestinal villi were statistically higher in the PD, T1DM, T1DM + PD groups, compared to the control. Regarding the height of the crypt, only the T1DM and T1DM + PD groups were significantly higher compared to the other groups. Association of diabetes and periodontal inflammation increased the deleterious effects on bone tissue and adverse effect on the permeability of the duodenal mucosa.

Surgical Treatment of Bilateral Atrophic Mandible Fracture.

Poor proprioception, weakness, and impaired reflexes increase the incidence of facial fracture in the elderly. Mandibular fractures in these people range from 10.1% to 56%. Fragment reduction and fracture consolidation are difficult due to bone atrophy, decreased capacity for bone regeneration, and lack of anatomical landmarks to guide the alignment of the fragments. This study reports 2 patients with different conducts regarding the treatment of bilateral fractures in atrophic mandible. The first patient refers to the removal of plates of the 2.4 mm system with low profile, which failed during the mandibular function, being replaced by the 2.4 mm system with high profile. The 2nd clinical reports the use of the 2.0 mm system only to simplify the mandibular fracture, and then reconstructing that with a 2.4-mm system with high profile, using the load bearing principles. Regarding mandibular fractures, an important goal is to neutralize the muscle action aiming the bone stability. There are several methods to treat that the indication should consider the load bearing and load sharing concepts. The incorrect fixation choice in these patients can result in complications as bad union, material failure, infection, and consequent treatment failure.

Dental assessment of odontogenic maxillary sinusitis, aided by Cone Beam Computed Tomography.

OBJECTIVES: To identify tooth diseases as potential causative factors in the development of maxillary sinus lesions, with the aid of clinical examination combined with Cone Beam Computed Tomography (CBCT), in the patients with persistent sinus-like ailments, unresponsive to routine treatment offered by otolaryngologists. MATERIALS AND METHODS: In 44 patients with suspected odontogenic maxillary sinusitis, a dental examination with tooth vitality test was carried out, in conjunction with CBCT. The study involved 29 women and 15 men (age range 19-69 years, mean age 43 (SD = 13.9) years). RESULTS: In 15 (34.1%) patients the odontogenic lesions were encountered in maxillary sinuses. A total of 33 causative teeth were identified, of which 13 (39%) were after root canal treatment (RCT). Only one of the teeth had a properly reconstructed crown, and only one tooth had the root canals properly filled-in. Most frequently, the lesions in the sinuses were attributed to the inflammation of periapical tissues; the first molar having been established as the most common causative tooth. CONCLUSIONS: A detailed dental examination, pursued in conjunction with CBCT analysis, allow to diagnose odontogenic maxillary lesions. The incidence of long-term ailments originating in the maxillary sinuses should prompt a detailed assessment of the teeth, especially those after RCT.