Christine Jacobsen

Osteopathology induced by bisphosphonates and dental implants: clinical observations

ObjectivesAlthough there are many reports about risk factors for the development of BP-associated osteonecrosis of the jaws, the role of dental implants as a local risk factor is still discussed, especially in patients with oral BP treatment. Until now, a few case reports and surveys display a possible minor risk in patients with oral BP therapy, whereas the avoidance of implant placement is generally accepted in patients with intravenous BP therapy.Patient and methodsIn this study, the cases of 14 patients with osteonecrosis of the jaws in association with BP therapy and dental implant placement were analyzed carefully with a detailed literature review.ResultsOf 14 patients, nine had underlying malignant disease and five patients had osteoporosis. In ten patients, implants were placed either in the posterior mandible or maxilla; the mean interval between implant insertion and disease onset was 20.9 months. Pain (n12) and signs of infection (n10) were the most common symptoms. Histologically, signs of infection were found in nine of 11 analyzed patients with presence of Actinomyces in six patients. Two patients turned out to have infiltration of underlying malignant disease.ConclusionsPosteriorly placed implants seem to be of higher risk of development of osteonecrosis of the jaws. Not only the implant placement but also the inserted implant itself seems to be a continuous risk factor.Clinical relevanceThe herein elaborated risk factors help dentists plan dental rehabilitation with implants in this high-risk group of patients and indicate careful and regular dental recall.

Surgical Navigation in Craniomaxillofacial Surgery: Expensive Toy or Useful Tool? A Classification of Different Indications

The complex 3-dimensional (3D) anatomy and geometry of the human skull and face combined with the need for precise symmetry poses challenges for reconstructive surgery of the region. Therefore, and with the technical improvements during the past 10 years or so, surgical navigation has become an established technique in craniomaxillofacial surgery. 1-4 Many technical problems have been solved, and the accuracy of multiple strategies of imaging and registration has been proved. 5 However, the procedure of preparing a patient for navigation is still linked to extra effort for the patient and surgeon. Even noninvasive registration procedures, such as a splint fixed to the upper jaw, as described by Schramm et al, 6 require dental impressions and additional imaging with the splint in situ. Insecurity surrounds surgical navigation of the lower jaw with different techniques available, such as mounting a dynamic reference frame to the mandible 7-9 or retaining the mandible in a defined position against the maxilla. 7,10-15 Thus, the state of surgical navigation of the mandible has been deemed unsatisfactory to date. 16 The aim of the present study was to evaluate the feasibility and limitations of surgical navigation. In addition, we determined the time and effort of the surgical team in relation to the benefit.

Bisphosphonate-Induced Osteonecrosis of the Jaw: Comparison of Disease Extent on Contrast-Enhanced MR Imaging, [18F] Fluoride PET/CT, and Conebeam CT imaging

BACKGROUND AND PURPOSE: Imaging of bisphosphonate-induced osteonecrosis of the jaw is essential for surgical planning. We compared the extent of BONJ on contrast-enhanced MR imaging, [18F] fluoride PET/CT, and panoramic views derived from standard conebeam CT with clinical pre- and intraoperative examinations. MATERIALS AND METHODS: Between February 2011 and January 2012, ten subjects with written informed consent (9 women; mean, 69.6 years; range, 53–88 years) were included in this prospective ethics-board-approved study. Patients underwent CEMR imaging, [18F] fluoride PET/CT, and CBCT and were clinically examined pre- and intraoperatively. Surgery was performed, and BONJ was histologically confirmed in 9 patients. Location and extent of BONJ on different modalities/examinations were graphically compared (0 = no pathologic finding, 1 = smallest, 5 = largest extent of BONJ). Rank tests were used to assess overall and paired differences of ratings in 9 patients. A P value <.05 was considered statistically significant. RESULTS: Significant differences in BONJ extent among different modalities and examinations were found (P < .001). The highest median rank was seen in PET/CT (4 ± 1.12) and CEMR imaging (4 ± 1.01), followed by intraoperative examinations (3 ± 0.71), CBCT (2 ± 0.33), and preoperative examinations (1 ± 0). No significant differences were found between PET/CT and CEMR imaging (P = .23), except when comparing PET/CT to either CBCT, pre- and intraoperative examinations (all P < .05). Preoperative examinations showed significantly less extensive disease than all other modalities/examinations (all P < .05). CONCLUSIONS: [18F] fluoride PET/CT and CEMR imaging revealed more extensive involvement of BONJ compared with panoramic views from CBCT and clinical examinations.

Cephalometric and three-dimensional assessment of the posterior airway space and imaging software reliability analysis before and after orthognathic surgery.

PURPOSE This study aimed to compare the reliability of three different imaging software programs for measuring the PAS and concurrently to investigate the morphological changes in oropharyngeal structures in mandibular prognathic patients before and after orthognathic surgery by using 2D and 3D analyzing technique. MATERIAL AND METHODS The study consists of 11 randomly chosen patients (8 females and 3 males) who underwent maxillomandibular treatment for correction of Class III anteroposterior mandibular prognathism at the University Hospital in Zurich. A set of standardized LCR and CBCT-scans were obtained from each subject preoperatively (T0), 3 months after surgery (T1) and 3 months to 2 years postoperatively (T2). Morphological changes in the posterior airway space (PAS) were evaluated longitudinally by two different observers with three different imaging software programs (OsiriX(®) 64-bit, Switzerland; Mimics(®), Belgium; BrainLab(®), Germany) and manually by analyzing cephalometric X-rays. RESULTS A significant increase in the upper airway dimensions before and after surgery occurred in all measured cases. All other cephalometric distances showed no statistically significant alterations. Measuring the volume of the PAS showed no significant changes in all cases. All three software programs showed similar outputs in both cephalometric analysis and 3D measuring technique. CONCLUSION A 3D design of the posterior airway seems to be far more reliable and precise phrasing of a statement of postoperative gradients than conventional radiography and is additionally higher compared to the corresponding manual method. In case of Class III mandibular prognathism treatment with bilateral split osteotomy of the mandible and simultaneous maxillary advancement, the negative effects of PAS volume decrease may be reduced and might prevent a developing OSAS.

Metastatic basal cell carcinoma: report of a case and review of the literature

BACKGROUND Metastatic basal cell carcinoma (MBCC) is defined as primary cutaneous basal cell carcinoma (BCC) that spreads to distant sites as histologically similar metastatic deposits of BCC. BCCs are semimalignant, destructive, and invasive. Metastases are very rare, with an incidence of 0.0028%-0.5%. CASE REPORT A female patient with Gorlin-Goltz syndrome and a rare case of a basal cell carcinoma with an additional regional lymph node metastasis is presented. CONCLUSIONS This case highlights the importance of a multidisciplinary approach to and frequent monitoring of patients with Gorlin-Goltz syndrome. Early diagnosis and surgical treatment are still the treatment of first choice.

Osteopathology associated with bone resorption inhibitors – which role does Actinomyces play? A presentation of 51 cases with systematic review of the literature

BACKGROUND Bone resorption inhibitor-related osteopathology of the jaw (BRIOJ) is a severe complication in patients treated with bisphosphonates or denosumab. However, the precise pathogenesis of BRIOJ is not yet fully understood. Recent studies discovered the presence of Actinomyces colonies in biopsy material from BRIOJ patients. The aim of this study was to analyze current knowledge concerning the impact of Actinomyces on the pathogenesis of this condition and to present data from our own patients. METHODS Data from 51 patients with histopathological diagnoses of BRIOJ were retrospectively analyzed. In addition, a systematic literature search for studies describing the presence of Actinomyces was performed. RESULTS Actinomyces was present in 86% of our cases and 63.3% of 371 cases presented in the literature. All of our patients and 85% of patients described in the literature had a clearly defined local focus in association with osteopathology. A clear picture of whether Actinomyces colonizes the previously necrotic bone or contributes to inflammation causing subsequent bone necrosis is lacking in the literature. CONCLUSION The pathogenesis of BRIOJ remains unknown; however, there seems to be a role for Actinomyces, and possibly other pathogens, in the development of osteopathology of the jaws, which is not exclusive to bisphosphonate therapy. This study supports the hypothesis that an infectious component is of utmost importance for the pathogenesis of BRIOJ.

Clinical reliability of radial forearm free-flap procedure in reconstructive head and neck surgery.

Objective: The purpose of the study was to evaluate the indications, reliability, and complications of the radial forearm fasciocutaneous flap (RFFF) procedure in reconstructive head and neck surgery. Methods: The records of 81 patients who were treated with an RFFF between 1998 and 2009 were systematically reviewed. Data of recipient localization, previous T status, and postoperative complications were analyzed. Results: From the 50 male and 31 female patients, 4 patients (3 men and 1 woman) experienced flap failure during the first 36 hours: in 1 patient because of arterial and in 3 patients because of venous complications. None of the 4 patients had preoperative radiotherapy. A dehiscence was observed in 2 patients without a need for further surgery. Conclusions: With a success rate of more than 95%, the RFFF is a reliable flap and a workhorse, particularly in defects where thinness is needed to substitute for the oral mucosa, such as on the floor of the mouth or the tongue.

Osteopathology of the jaw associated with bone resorption inhibitors: what have we learned in the last 8 years?

QUESTIONS UNDER STUDY 8 years after discovery of osteonecrosis of the jaw associated with bisphosphonate therapy a lot of experience has been garnered in treating 112 patients with this disease. This disease, although uncommon, is still a burden for the patient as well as the treating specialists and an adequate standardised classification as well as therapy does not exist. This article presents a summary of collected patient data, garnered experience and consequential changes in knowledge, in diagnostic measures and therapy. METHODS The data of in total 112 patients referred to the Special Clinics for patients with bisphosphonate-associated lesions of the jaw was retrospectively analysed and compared with data from the literature. RESULTS In total, 110 patients, 70% women, were included in the data analysis. A quarter of those patients had osteoporosis as the underlying disease, more than half of all patients had extractions as the local influencing factor. The lesion was localised in the mandible in three quarters of all patients and almost all patients showed clinical signs of infection. In total, 58% of all patients were treated surgically with a complete remission rate of 78% over 7 years. CONCLUSIONS This summary of patient data and literature shows that knowledge about bisphosphonate-associated osteopathology of the jaw becomes more and more specific. The range of drugs associated with this disease has increased, but also therapeutic options show more and more success. Classifications, published shortly after the discovery of BRONJ need to be revised and new knowledge included.

Is mandibular reconstruction using vascularized fibula flaps and dental implants a reasonable treatment

PURPOSE this study retrospectively analyzed the rate of screwed implant insertion and risk factors in patients undergoing mandibular reconstruction with microsurgical revascularized fibula flaps. METHODS This study retrospectively analyzed all patients with microvascularized fibula grafts between 1997 and 2005. Collected data included general data and risk factors (e.g., smoking, alcohol use), and irradiation was the main predictor variable. The number of patients rehabilitated with dental implants and the implant success rate were evaluated, possible influencing factors were identified, and the results were compared with previously published data. RESULTS The sample included 33 patients (17 men, 16 women; mean age: 52 years); 76% were smokers, 42% drank alcohol regularly, and 73% had undergone mandible irradiation. Twenty-three patients received 140 screw-retained implants for dental rehabilitation. Twenty-three implants were lost. Overall 1- and 5-year implant survival rates were 94% and 83%, respectively. Implant survival rates were 86% in non-irradiated mandibular bone, 86% in non-irradiated grafted fibular bone, 82% in irradiated mandibular bone, and 38% in irradiated grafted fibular bone. CONCLUSION This study showed that the use of dental implants in patients with fibula flaps is an appropriate and successful option for dental rehabilitation, even in those with risk factors such as smoking, alcohol use, and irradiation. Implant placement in irradiated grafted bone seems to be a high-risk procedure.

Surgical navigation in cranio-maxillofacial surgery: an evaluation on a child with a cranio-facio-orbital tumour

Surgical navigation, though well-established, is often associated with extra effort for both patient and surgeon, and with additional exposure to radiation as a result of the necessary extra imaging. Osteoblastoma is a benign bone tumour, malignant transformation of which is rare but possible, and so resection is indicated. The orbit with surrounding structures is a challenging region for accurate three-dimensional reconstruction. A virtual plan based on the patients mirrored anatomy realised by intraoperative navigation can assist in achieving perfect results. An 8-year-old boy presented with a huge osteoblastoma of the frontal and temporal skull. The tumour had extracranial and intracranial parts, and reached into the orbital roof and the sphenoid and ethmoid bones. The ethmoid sinus was involved, the eye was displaced, and he had functional problems. Virtual planning and navigation were prepared without the need for any additional imaging. The tumour was resected through a coronal approach, and immediately reconstructed with an autologous calvarial split graft, designed and positioned under navigation with a preoperative plan that was based on the mirrored healthy side. Surgical navigation based on a virtual plan can achieve symmetrical results, particularly when dealing with complex three-dimensional anatomy. Navigation does not necessarily mean additional procedures or imaging. We think that virtual planning and navigation are useful for selected cases.