Needle fracture as a complication of dental local anesthesia: recommendations for prevention and a comprehensive treatment algorithm based on literature from the past four decades.

OBJECTIVES: The aim of this publication is to provide a concept for prevention and a standardized step-by-step clinical approach to this rare but serious and potentially preventable complication of dental local anesthesia. MATERIALS AND METHODS: We collected data with a PUBMED search using the key words "local anesthesia," "dental anesthesia/anesthesia" OR "mandibular block anesthesia," "complication," "hypodermic needle," "needle breakage" OR "needle fracture," and "foreign body AND removal" OR "retrieval." The existing literature was systematically evaluated from 1980 to date using Microsoft Excel 2007 (Microsoft Corporation). RESULTS: After analysis of the literature, we included 36 reports documenting 59 needle breakage events and defined possible risk factors and preventive measures. All relevant reported parameters were listed in tabular form. The main result of this article is a treatment algorithm for this complication. CONCLUSIONS: Prevention of a needle fracture should be the main goal during local dental anesthesia. Use of longer hypodermic needle can obviate complex retrieval surgery. If immediate removal of the fragment fails, localization, planning, and the necessary surgical procedure should be arranged promptly. CLINICAL RELEVANCE: Following a strict algorithm, successful surgical handling of this complication will depend on minimizing risk and following treatment recommendations closely.

Stage-related treatment concept of medication-related osteonecrosis of the jaw-a case series.

OBJECTIVES: There is no general consensus for treatment of medication-related osteonecrosis of the jaw (MRONJ). A stage-related approach that primarily aims to minimize morbidity and preserve function was prospectively evaluated. PATIENTS AND METHODS: Treatment goals are stable mucosal closure and absence of clinical symptoms. Patients were enrolled between March 2010 and October 2011. MRONJ lesions were treated either by conservative means or surgically by debridement or resective surgery. RESULTS: In total, 38 patients were treated. Six patients were healed by undergoing conservative measures; nine were treated palliatively. Four patients dropped out after surgery in the recall phase. In 17 of 19 patients (89.5%) surgical treatment was successful. After a 1-year observation period, the success rate was 92% (23 of 25), including all patients treated as per protocol. CONCLUSION: In stage-related treatment, conservative means or surgical debridement can be successful at early stages. Extensive resection is solely indicated in cases of extended necrosis. CLINICAL RELEVANCE: The number of patients with MRONJ is steadily increasing. Guidelines to deal with this condition are helpful for both clinicians and dental practitioners.

Prevalence of bisphosphonate-associated osteonecrosis of the jaw after intravenous zoledronate infusions in patients with early breast cancer.

OBJECTIVES: The definite incidence rate of bisphosphonate-related osteonecrosis of the jaws (BRONJ) is still unknown. The aim of this study was to investigate prevalence of BRONJ in a group of breast cancer patients applying the classification of the Association of Oral and Maxillofacial Surgeons 2009. PATIENTS AND METHODS: Between 2000 and 2008, 63 premenopausal early breast cancer patients who were free of metastases were treated with 4 mg zoledronic acid every 6 months over 3 years as participants of a multicenter, randomized, controlled, adjuvant breast cancer medication trial. Patients were not informed about the risk of jaw necrosis. None reported tooth or jaw complaints during the breast cancer follow-up examinations. In 2010, 48 patients of this cohort were investigated concerning BRONJ by clinical and radiological examinations. RESULTS: No advanced stages (AAOMS 2009)were detected. However, five patients (10.4%) presented purulent (2) and nonpurulent (3) fistulas and radiological signs correlating to BRONJ stage 0. CONCLUSION: Although no case of advanced BRONJ was detected, the study revealed a high prevalence of BRONJ stage 0. This supports the need for tight cooperation between dentists and medical specialists prescribing bisphosphonates including dental pre-therapeutic and follow-up examinations. Adaption of the BRONJ classification taking account to bone exposure via fistulas is recommended. CLINICAL RELEVANCE: BRONJ is said to be a complication linked to high-dosage bisphosphonate therapy. The study demonstrates that even after application of zoledronate in a low-dose protocol, early BRONJ occurred. Radiological signs solely are not sufficient to confirm BRONJ; clinical signs are mandatory.

Influence of the Tube Angle on the Measurement Accuracy of Peri-Implant Bone Defects in Rectangular Intraoral X-ray Imaging.

BACKGROUND: Intraoral radiography in the right-angle technique is the standard procedure to examine the peri-implant bone level in implant follow-up and implant-related studies. For the implementation of the right-angle or parallel technique, mostly ready-made image receptor holders are used. The aim of this experimental study is to analyze changes in the measurement of standardized peri-implant defects caused by a deviation in the position of the image receptor. METHODS: Eleven Xive® implants (Dentsply Sirona, Bensheim, Germany) were placed in bovine bone, and peri-implant defects of varying depths were created. The preparations were fixed in a specially made test stand, and intraoral radiographs were taken using the right-angle technique with standard film holders at various horizontal and vertical projection angles. Defect measurement was carried out with the imaging software Sidexis 4 V 4.3 (Dentsply Sirona, Bensheim, Germany). RESULTS: With increasing angular deviation, larger deviations between the measured and the real extent of the defect occurred. Vertical tilting caused significant distortion, while horizontal rotation showed less effect. CONCLUSION: Intraoral radiography only provides a valid representation of the peri-implant bone level for follow-up or as a tool in implant-related studies if a reproducible projection direction is assured.

Pulp Revascularization in an Autotransplanted Mature Tooth: Visualization with Magnetic Resonance Imaging and Histopathologic Correlation.

Autotransplantation of a mature tooth usually leads to pulpal necrosis. Root canal treatment is recommended to prevent related inflammatory complications a few weeks after surgery. Extraoral root-end resection may facilitate reperfusion and obviate root canal treatment, but cannot be pictured with conventional dental radiography at this point in time. In the case of a lower mature transplanted molar, contrast-enhanced magnetic resonance imaging proved to be a feasible method for visualizing pulp revascularization just 4 weeks after autotransplantation. Consequently, root canal treatment was obviated. Nevertheless, the tooth had to be extracted 18 months postoperatively due to external cervical root resorption, probably caused by the extraction trauma. This allowed the histological processing and examination of the newly generated intracanal tissue. Uninflamed fibrovascular connective tissue was found, while odontoblasts or cementoblast-like cells were absent. These findings indicated that it was most likely stem cells from the bone marrow and the periodontal ligament that drove the regeneration.

Evaluating a Periapical Lesion Detection CNN on a Clinically Representative CBCT Dataset-A Validation Study.

The aim of this validation study was to comprehensively evaluate the performance and generalization capability of a deep learning-based periapical lesion detection algorithm on a clinically representative cone-beam computed tomography (CBCT) dataset and test for non-inferiority. The evaluation involved 195 CBCT images of adult upper and lower jaws, where sensitivity and specificity metrics were calculated for all teeth, stratified by jaw, and stratified by tooth type. Furthermore, each lesion was assigned a periapical index score based on its size to enable a score-based evaluation. Non-inferiority tests were conducted with proportions of 90% for sensitivity and 82% for specificity. The algorithm achieved an overall sensitivity of 86.7% and a specificity of 84.3%. The non-inferiority test indicated the rejection of the null hypothesis for specificity but not for sensitivity. However, when excluding lesions with a periapical index score of one (i.e., very small lesions), the sensitivity improved to 90.4%. Despite the challenges posed by the dataset, the algorithm demonstrated promising results. Nevertheless, further improvements are needed to enhance the algorithm's robustness, particularly in detecting very small lesions and the handling of artifacts and outliers commonly encountered in real-world clinical scenarios.

Extraoral Root-End Resection May Promote Pulpal Revascularization in Autotransplanted Mature Teeth-A Retrospective Study.

Tooth germ autotransplantation of open apices of the teeth exhibits high pulpal healing rates, whereas that of mature permanent teeth normally causes irreversible pulpal necrosis. Extraoral root-end resection (EORER) during transplantation may promote pulpal revascularization (PRV) in transplanted mature teeth and reduce endodontic treatment requirement. This study compared the primary outcomes of survival rates, PRV, and root resorption and determined relevant confounders in autotransplanted mature and immature teeth. The medical charts of consecutive patients who underwent tooth autotransplantation between January 2017 and March 2021 were evaluated. Teeth with a documented follow-up of at least 1 year were included. During the study period, 59 teeth were transplanted in 44 patients. Overall, 2 teeth were excluded owing to missing data; 57 teeth were analyzed, including 25 mature teeth additionally treated with EORER. After a mean follow-up of 21.2 ± 16.1 months, no significant differences in primary outcomes were detected. Fifty-five teeth remained in situ (96.5%), and radiological signs of root resorption were detected in 9/57 teeth (15.8%). PRV was positive in 54/57 teeth (94.7%). Surgical duration and PRV failure were significantly associated with high incidences of root resorption. Mature teeth autotransplantation with EORER yielded similar results to immature teeth autotransplantation and is a feasible treatment option. Long surgery and failed revascularization increased root resorption rates. More factors should be evaluated in larger trials with longer observation periods.

Long-term Follow-up for Apical Microsurgery of Teeth with Core and Post Restorations.

INTRODUCTION: Orthograde retreatment was recommended before apical surgery to achieve high success rates. The aim of this study was to determine the success rates of apicoectomy of core and post-restored teeth without prior root canal retreatment followed for up to 13 years. METHODS: Seventy-three patients with 87 teeth with apical periodontitis underwent apical microsurgery from 2004 to 2006 at the Department of Dental Medicine and Oral Health, Medical University of Graz, Graz, Austria. After 1.5-5 years and 10-13 years, 85 and 49 teeth, respectively, were followed up by 4 independent, calibrated examiners. Absolute and relative frequencies of the dichotomous outcome (healed vs nonhealed) were analyzed considering patient-, tooth-, and treatment-related factors. The significance of the obtained values was determined with the chi-square and Fisher exact tests. RESULTS: All of the 85 (100%) investigated teeth were in situ 1.5-5 years after surgery, whereas only 49 of 62 analyzed teeth (79%) remained after 10-13 years. Radiologically documented periapical healing was 97.6% (83/85 teeth) for the first follow-up period but decreased to 75.8% (47/62 teeth) by the second follow-up. Smokers showed significantly worse results after 10-13 years. None of the other investigated potential influencing factors significantly affected results. CONCLUSIONS: This clinical study showed that apical microsurgery on teeth with core and post restoration using Intermediate Restorative Material (Dentsply Caulk, Milford, DE) as filling material achieves excellent results after 1.5-5 years (97.6%) and still shows good results after 10-13 years (75.8%). Accordingly, it is a reliable alternative to root canal retreatment, eliminating the risk of post removal-related complications.

Potential risk factors for maxillary sinus membrane perforation and treatment outcome analysis.

BACKGROUND: Most common complication of sinus floor elevation (SFE) is sinus membrane perforation (SMP). PURPOSE: To investigate the correlation between SMP and potential risk factors and to evaluate SMP treatment outcomes. MATERIALS AND METHODS: This study included patients who had undergone a SFE at Division of Oral Surgery and Orthodontics, Medical University of Graz from 2013 to 2017. Analysis of patients' records and CBCT focused on patient-related risk factors (sinus contours, thickness of membrane and lateral sinus wall, interfering septa, crossing vessels, former oroantral communication) and intervention-related risk factors (surgical approach, sides, number of tooth units, and sites). The outcome of SMP treatment was analyzed in the recalls. RESULTS: In all, 121 patients underwent 137 SFE. There were 19 cases of SMP (13.9%). Two significant factors were identified: maxillary sinus contours (P = .001) and thickness of the sinus membrane (P = .005). The sinus membrane perforation rate was highest in narrow tapered sinus contours and when the sinus membrane was thinner than 1 mm. Among 19 cases with SMP, no complications were seen upon recall. CONCLUSIONS: Maxillary sinus contours and sinus membrane thickness seem to be relevant factors for SMP. Sinus membrane perforations were successfully treated by coverage with collagen membrane.

Influence of Extraoral Apicoectomy on Revascularization of an Autotransplanted Tooth: A Case Report.

Autotransplantation is considered a standard procedure with a poorer prognosis for mature than for immature teeth. In this case report, the root tip of an almost fully developed tooth was resected during autotransplantation to fit into a deficient recipient site. As a positive side effect, the apical foramen was enlarged, with potential improvement of the probability of revascularization. Clinical and radiologic follow-up examinations up to 18 months indicated revascularization and uneventful periodontal regeneration and thus successful autotransplantation. This case supports the hypothesis that intraoperative apicoectomy can improve the prognosis for revascularization of mature autotransplanted teeth. Further prospective controlled clinical studies are needed to confirm this innovative surgical approach.

Assessment of impacted and partially impacted lower third molars with panoramic radiography compared to MRI-a proof of principle study.

OBJECTIVES: Third molars often require surgical removal. Since three-dimensional radiological assessment is often indicated in difficult cases to avoid surgical complications, the radiation burden has to be considered. Here, MRI may offer a dose-free alternative to conventional X-ray techniques. The aim of this retrospective analysis was to evaluate the assessment quality of MRI compared to panoramic radiography in impacted and partially impacted lower third molars. METHODS: Panoramic radiographs and MRI scans of 28 Caucasian patients were assessed twice by four investigators. Wisdom teeth were classified according to Juodzbalys and Daugela 2013. RESULTS: When radiological lower third molar assessments with panoramic radiography and MRI were compared, staging concurred in 73% in the first round of assessments and 77% in the second. CONCLUSIONS: The presented study demonstrates that MRI not only provides much the same information that panoramic radiography usually does, but also has the advantages of a dose-free three-dimensional view. This may facilitate and shorten third molar surgery. Image interpretation, however, can differ depending on training and experience.

Immediate loading of four interforaminal implants supporting a locator-retained mandibular overdenture in the elderly. Results of a 3-year randomized, controlled, prospective clinical study.

BACKGROUND: Implant-retained overdentures have become a standard option for the prosthetic treatment of the edentulous mandible in the elderly. PURPOSE: This prospective study aimed to compare immediate and conventional loading of four interforaminal implants supporting a Locator-retained mandibular overdenture in elderly patients regarding implant survival, implant stability, and implant-related complications. MATERIAL AND METHODS: The study population comprised 20 completely edentulous patients (11 males) aged 60 years and older with severe mandible resorption. Each patient received four interforaminal implants (Neoss Ltd., Harrogate, UK). Following randomization, implants were loaded either immediately after dental implant surgery or 3 months after implant placement with the Locator-abutment system. At follow-up visits 3, 6 12, 24, and 36 months after loading, implant stability was evaluated with Periotest and Ostell. RESULTS: Twenty patients received 80 implants. In eight patients, 32 implants were loaded immediately. Two patients had to be switched from the immediate to the conventional loading group due to insufficient primary stability (≤30 Ncm). Implant survival was similar in both groups after 36 months. No implant was lost. Decreasing Periotest, and accordingly, increasing Ostell measurements indicated adequate osseointegration in both groups. The course of treatment was not significantly different in the two groups. There were comparable incidences of postoperative complaints like swelling, hematoma, or wound dehiscence, as well as need for prosthetic treatment due to abutment loosening or occlusal discrepancies. Incidence of pressure marks and number of patient visits were significantly higher in the conventional loading group. CONCLUSION: With sufficient primary stability, immediate loading of four interforaminal implants in the edentulous mandible might be the preferential choice in the elderly, reducing total treatment time, and number of patient visits.

Prevalence of Medication-Related Osteonecrosis of the Jaw in Patients with Breast Cancer, Prostate Cancer, and Multiple Myeloma.

Medication-related osteonecrosis of the jaw is a known side-effect of antiresorptive therapy in patients with malignant diseases. Nevertheless, the exact pathogenesis is still unknown and published prevalences show a significant range. The aim of the presented paper was to assess the prevalence of osteonecrosis (ONJ) in breast cancer, prostate cancer, and multiple myeloma patients receiving parenteral antiresorptive therapy. For this reason a PubMed search was performed and 69 matching articles comprising 29,437 patients were included in the analysis. Nine-hundred fifty-one cases of jaw necrosis were described. The overall ONJ-prevalence was 2.09% in the breast cancer group, 3.8% in the prostate cancer group, and 5.16% for multiple myeloma patients.

Bisphosphonate-associated osteonecrosis of the jaws: surgical treatment with ErCrYSGG-laser. Case report.

Bisphosphonates (BP) play an important role in concomitant therapy of certain types of cancer and multiple myeloma as well as in treatment of osteoporosis. The administration of BP has great therapeutic benefits, but correlates with a specific kind of osteonecrosis of the alveolar bone. The so-called bisphosphonate-related osteonecrosis of the jaws (BRONJ) is a rare, but often severe adverse side effect of high-dosage and long-term BP therapy. Thus far, no consensus for treatment of BRONJ has been achieved. All strategies have to take into account the insecure prognosis and danger of recurrence of clinically apparent necrosis and progression of disease. At the Department of Oral Surgery and Radiology, Medical University of Graz, an ErCrYSGG laser was successfully applied in surgical treatment of BRONJ. Stable mucosal coverage could be achieved in all of 5 cases. Laser surgery can be considered as a promising technique for the effective treatment of BRONJ.